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1 處方藥物清單 藥物清單 CareMore Cal MediConnect Plan (Medicare-Medicaid Plan) 洛杉磯郡 加州 2016 請查閱 本文件包含本計劃中給付藥物的相關資訊 本處方藥物清單更新日期 10/05/2016. 如果您有任何疑問 請致電 CareMore Cal MediConnect Plan 會員服務部 電話號碼 (TTY 711), 太平洋時間週一至週五上午 8點至下午 8點 如需更多資訊 請瀏覽網站 duals.caremore.com. H6629_16_25137_T_001_CTCMS Approved 08/26/2015 處方藥物 ID: 版本 22 發佈時間 1/1/2016

2 H6629_16_25137_T_001_CT CMS Approved 09/01/2015 CareMore Cal MediConnect Plan (Medicare-Medicaid Plan) 2016 給付藥物清單 ( 處方藥物清單 ) 這是會員可於 CareMore Cal MediConnect Plan (Medicare-Medicaid Plan) 取得的藥物清單 CareMore Cal MediConnect Plan 是一個同時與 Medicare 和 Medi-Cal 訂立合約的醫療保健 計劃, 從而為參保人提供這兩個計劃的福利 CareMore 代表 CareMore 的附屬公司執行合 約 CareMore 是 CareMore Health System 的註冊商標 給付藥物清單 及 / 或藥局與醫療服務提供者網路全年之中都會有所變更 在我們執行影 響您的變更前, 我們會向您寄送通知 福利和 / 或共付費用可能於每年 1 月 1 日進行變動 您可以隨時瀏覽網站 duals.caremore.com, 線上查看 CareMore Cal MediConnect Plan 的最 新 給付藥物清單, 或致電 (TTY 711) 您可以免費獲得其他格式的資料, 如大型字體版本或音訊版本 請撥打電話 (TTY 711) 此為免費電話 條件及限制可能適用 有關更多資訊, 請致電 CareMore Cal MediConnect Plan 會員服務部, 或閱讀 CareMore Cal MediConnect Plan 會員手冊 您可以免費取得此資訊的其他語言版本 請致電 (TTY 711), 週一至週五, 上午 8 點至下午 8 點 此為免費電話 Դուք կարող եք ստանալ այս ձեռնարկն անվճար է այլ լեզուներով: Call երկուշաբթի - ուրբաթ `8:00 - ից 8:00 - ին: TTY օգտվողները պետք է զանգահարել 711. Կանչի ազատ է 您可以免費取得本手冊其他語言版本 請致電, 週一至週五, 上午 8:00 至晚上 8:00 TTY 使用者可撥打 711 此為免費電話 الخط الخاص بإمكانك الحصول على هذه المعلومات مجانا بلغات أخرى. اتصل على الرقم 8 من يوم االثنين لغاية يوم الجمعة ومن الساعة 711 TTY باالعضاء ممن لديهم ضعف في السمع أو النظر. مساءا. هذه المكالمة مجانية 8 صباحا لغاية 8:00 می توانید این دفترچه را به طور رایگان به سایر زبان ها دریافت کنید. از دوشنبه تا جمعه و از ساعت " تماس بگیرند. 711 باید با شماره TTY تماس بگیرید. کاربران شب با شماره 8:00 صبح تا " این تماس رایگان است 귀하께서는이안내서를다른언어로무료로받아보실수있습니다. 주중 ( 월 - 금 ) 오전 8:00 시 에서오후 8:00 시사이에번으로전화해주십시오. TTY 사용자는 711 로전화해주십시오. 통 화는무료입니다. Этот справочник можно бесплатно получить в переводе на другие языки. Звоните по телефону, линия работает с понедельника по пятницу с 8:00 до 20:00. Если вы пользуетесь устройством TTY, звоните по телефону 711. Звонки бесплатные. Puedes recibir este manual en otros idiomas sin cargo. Llama al de lunes a viernes, de 8.00 a.m. a 8.00 p.m. Los usuarios de TTY deben llamar al 711. La llamada es gratuita. Makukuha ninyo nang libre ang handbook na ito sa ibang wika. Tawagan ang, Lunes hanggang Biyernes 8:00 a.m. hanggang 8:00 p.m. Ang mga gumagamit ng TTY ay dapat tawagan ang 711. Libre ang pagtawag. Quy vi co thê nhâṇ sô tay naỳ miêñ phi băǹg cać ngôn ngư khać. Haỹ goị sô, tư Thư Hai đêń Thư Saú, từ 8 giơ sańg đêń 8 giơ tôí. Ngươì duǹg TTY câǹ goị đêń sô 711. Cuô c goị được miêñ phi. (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全 天候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 1

3 常見問題 (FAQ) 如果您對本 給付藥物清單 有疑問, 您可以在此尋找解答 您可閱讀所有常見問題 (Frequently Asked Questions, FAQ) 以了解更多資訊, 或僅查詢某問題的解答 1. 給付藥物清單 中有哪些處方藥物 ( 我們將 給付藥物清單 簡稱為 藥物清單 ) 藥物清單 中列出了 CareMore Cal MediConnect Plan 給付的藥物 您可在本計劃網路內的藥房 取得這些藥物 本計劃網路內的藥房是與本計劃簽訂協議, 並與本計劃合作為您提供服務的藥房 我們稱這些藥房為 網路藥房 CareMore Cal MediConnect Plan 在以下情況下給付 藥物清單 上的所有具有醫療必要性的藥 物 : 您的醫師或其他處方醫師表示您需要這些藥物使病情好轉或保持健康, 以及 您可以到 CareMore Cal MediConnect Plan 網路內藥房領取藥物 在某些情況下, 您必須在領取藥物之前採取一些行動 ( 請參閱後面的問題 5) 您也可以瀏覽我們的網站 duals.caremore.com 或撥打會員服務部電話 (TTY 711), 查看我們給付的最新藥物清單 2. 藥物清單 的內容會變更嗎 是 CareMore Cal MediConnect Plan 可能會在年度內增加或刪除 藥物清單 上的某些藥物 一 般而言, 藥物清單 的內容僅有在下列情況下才會變更 : 價格較低且功效與現在 藥物清單 中之藥物相當的藥物出現, 或 我們得知該藥物不安全 我們也可能會變更本計劃的藥物相關規定 例如, 我們可以 : 決定某藥物是否需要事先批准 ( 事先批准是在取得藥物前獲得 CareMore Cal MediConnect Plan 的許可 ) 增加或變更您可領取的藥量 ( 稱為 供藥量限制 ) 新增或變更某藥物的漸進式治療限制 ( 漸進式治療表示您必須先使用某種藥物, 然後我們 才給付另外一種藥物 ) ( 如需了解關於這些藥物規定的更多資訊, 請參閱第 4 頁上的內容 ) 當我們將您正在服用的藥物自 藥物清單 中移除時, 我們將會告知您 當我們變更本計劃的藥物 給付規定時, 我們亦會告知您 以下的問題 3 4 和 7 將會提供更多有關 藥物清單 變更事宜的 資訊 您可以隨時瀏覽網站 duals.caremore.com, 線上查看 CareMore Cal MediConnect Plan 的最 新 藥物清單 您還可以撥打會員服務部電話 (TTY 711), 查看目前 藥 物清單 (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全 天候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 2

4 3. 當有價格較低且功效與現在 藥物清單 中之藥物相當的藥物出現時將會 如何 如您正在服用的藥物因出現價格較低且功效相當的藥物而被移除, 我們會告知您 我們會在將其從 藥物清單 中移除或重新領取藥物之前至少 60 天告知您 那麼您能在藥物被從藥物清單移除前 獲得 60 天的供藥量 如果在年度內對藥物清單做出非例行性變更, 我們將寄信告知您 我們將在 網站上刊登通知信 4. 如果我們發現某項藥物並不安全將會如何 如果 Food and Drug Administration (FDA) 表示您正在服用的藥物並不安全, 我們會立刻將該藥物 自 藥物清單 中移除 我們亦會寄信給您告知您此事宜 如果您收到關於不安全藥物的通知, 請 立即致電您的醫師 您的醫師可以幫助您確定最適合您的其他藥物 5. 藥物的給付範圍是否有任何限制或上限 或者在領取某些藥物之前是否有 任何必須採取的行動 是, 部分藥物有給付規定或您可領取的藥量限制 在某些情況下, 您的醫師或其他處方醫師必須採 取一些行動, 您才能領取藥物 例如 : 事先批准 ( 或事先授權 ): 針對某些藥物, 在領取處方藥物之前, 您或您的醫師或者其他處 方醫師必須取得 CareMore Cal MediConnect Plan 的批准 如果您未得到批准,CareMore Cal MediConnect Plan 可能不給付藥物 供藥量限制 : 有時候,CareMore Cal MediConnect Plan 設定了您可以領取的藥物限制 漸進式治療 : 有時候,CareMore Cal MediConnect Plan 會要求您接受漸進式治療 這表示 您必須按一定的順序嘗試使用適用於您病況的藥物 您可能必須先試用某種藥物, 而後我們 才會給付其他藥物 如果您的醫師認為第一種藥物對您沒有療效, 那麼我們將會給付第二種 藥物 您可以查看第 頁上的表格, 查詢所需藥物是否有任何額外要求或限制 您也可以瀏覽我們的 網站 duals.caremore.com 了解更多資訊 我們已在網站上發佈文件, 解釋我們的事先授權限制 您亦可要求我們寄送一份副本給您 您可以要求對這些限制做出例外處理 請參閱問題 11 以了解更多有關例外處理的資訊 如果您住在療養院或其他長期照護機構且您需要不在 藥物清單 中的藥物, 或者您無法輕 易取得您所需的藥物, 我們可協助您 不管您是否是 CareMore Cal MediConnect Plan 新會 員, 我們將給付您所需要藥物的 31 天緊急供藥量 ( 除非您的處方規定更少天數的供藥量 ) 這將讓您有時間可以和您的醫師或其他處方開立者商量 其可協助您決定 藥物清單 中是 否有類似的藥物可以取代您服用的藥物, 或者協助您決定是否應該申請例外處理 請參閱問 題 11 以了解更多有關例外處理的資訊 6. 您該如何知道您需要的藥物是否有限制或您是否需要在領取藥物之前採取 任何行動 T 第 6 頁的 給付藥物清單 中有一欄標為 必須採取的行動 限制, 或使用限制 (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全 天候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 3

5 7. 如果我們變更本計劃部分藥物的給付方式將會如何 ( 例如, 我們新增了 某項藥物的事先授權 ( 批准 ) 供藥量限制和 / 或漸進式治療限制 ) 如果我們新增了某項藥物的事先批准 供藥量限制和 / 或漸進式治療限制, 我們將會告知您 我們 將會在新增限制前的至少 60 天內或在您下次要求藥房續配處方時告知您 而後, 您將可在給付規 定變更之前獲得該藥物 60 天的供藥量 這將讓您有時間和您的醫師或其他處方開立者商量下一步 該怎麼做 8. 您該如何在 藥物清單 中尋找藥物 尋找藥物的方式有兩種 : 您可按字母順序搜尋 ( 如您知道藥物如何拼寫 ), 或 您可按醫療的病症搜尋 如按字母順序搜尋, 請前往按字母順序的名單部分 您可以使用藥物名稱的首字母查找 如按醫療病症搜尋, 請找到第 9 頁的 按醫療病症分類的藥物清單 部分內容 本部分中的藥物根 據用於治療疾病的類型, 被分類到不同的類別 例如, 如果您患有心臟病, 您應該查看類別 心血 管 高血壓 / 血脂藥治療物 您將可在該類別中找到治療心臟病症的藥物 9. 如果您欲服用的藥物不在 藥物清單 中該怎麼辦 如果您在 藥物清單 上找不到您的藥物, 請撥打電話 (TTY 711) 諮詢會員服務 部 如果您了解到 CareMore Cal MediConnect Plan 不給付該藥物, 您可以執行以下操作之一 : 向會員服務部索取與您欲服用之藥物的類似藥物清單 然後將該清單交給您的醫師或其他處 方開立者 其可開立 藥物清單 中與您欲服用之藥物類似的藥物 ; 或 您可要求保健計劃進行例外處理以給付您的藥物 請參閱問題 11 以了解更多有關例外處理的 資訊 10. 如果您是 CareMore Cal MediConnect Plan 新會員, 而且在 藥物清單 上找不到您的藥物或在獲取藥物方面存在問題, 您該怎麼辦 我們會為您提供協助 我們在您成為 CareMore Cal MediConnect Plan 會員後前 90 天給付暫時性 的 30 天供藥量 這將讓您有時間可以和您的醫師或其他處方開立者商量 其可協助您決定 藥物 清單 中是否有類似的藥物可以取代您服用的藥物, 或者協助您決定是否應該申請例外處理 我們在以下情況下為您給付 30 天的供藥量 : 您正在服用的藥物不在我們的 藥物清單 中, 或 保健計劃規定不允許您領取處方醫師指定的藥量, 或 該藥物需要 CareMore Cal MediConnect Plan 事先批准, 或 您正在服用的藥物是屬於漸進式治療限制中的藥物 (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全 天候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 4

6 如果您居住在療養院或其他長期照護機構, 您可以重新領取長達 天的處方藥物 在該計劃的 前 90 天中, 您可以多次重新領取藥物 這將能夠讓您的處方醫師有時間將您的藥物變更為 藥物 清單 上的藥物或者申請例外處理 如果您的照護級別發生變更, 需要您轉移機構或者治療中心, 您可能有資格領取一次性臨時處方藥 物供應 例如, 如果您從醫院出院並且根據醫院處方獲得出院藥物清單, 您可以一次性領取藥物 您可以臨時一次性例外領取藥物, 不管您是否處於加入計劃的前 90 天 請讓您的處方醫師致電我 們了解詳情 11. 您可以申請例外處理以使您的藥物獲得給付嗎 是 您可以要求 CareMore Cal MediConnect Plan 例外給付不在 藥物清單 上的藥物 您也可要求本計劃變更您藥物的相關規定 例如,CareMore Cal MediConnect Plan 可能會限制我們給付藥物的藥量 假如您的藥物具 有藥量限制, 您可以要求我們更改限制並給付更多的數量 其他範例 : 您可要求本計劃取消漸進式治療限制或事先批准規定 12. 例外處理申請需要多久時間 首先, 我們必須收到支持您例外處理申請的醫師或其他處方醫師的聲明 在我們收到聲明後, 我們 將會在 72 小時內告知您我們針對您例外處理申請所做的決定 如果您或您的處方開立者認為等待 72 小時將會使您的健康受損, 您可申請加速例外處理 這表示 您將可更快得到決定 如果您的處方開立者有為您的急件申請提供佐證, 我們將會在收到您處方開 立者所提供之支持聲明後的 24 小時內告知您我們的決定 13. 您該如何提出例外處理申請 如需提出例外處理申請, 請致電會員服務部 會員服務部將與您及您的醫療服務提供者合作, 幫助 您申請例外處理 14. 什麼是一般藥物 一般藥物的構成成份與原廠藥物一樣 一般藥物的價格通常比品牌藥低, 且一般藥物的名稱通常較 不廣為人知 一般藥物是經 Food and Drug Administration (FDA) 批准的藥物 CareMore Cal MediConnect Plan 給付原廠藥物和一般藥物 15. 什麼是非處方藥物 (OTC) OTC 全稱是 over-the-counter 當您的醫療服務提供者為您開具非處方藥物時,CareMore Cal MediConnect Plan 也給付這些藥物 您可以參閱 CareMore Cal MediConnect Plan 藥物清單, 了解所給付的 OTC 藥物 (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全 天候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 5

7 16. CareMore Cal MediConnect Plan 是否給付 OTC 非藥物產品 當您的醫療服務提供者為您開具 OTC 非藥物產品時,CareMore Cal MediConnect Plan 也給付這 些產品 您可以參閱 CareMore Cal MediConnect Plan 藥物清單, 了解所給付的 OTC 非藥物產品 17. 您需支付多少共付費用 您可以參閱 CareMore Cal MediConnect Plan 藥物清單, 了解每種藥物的共付費用 住在療養院或其他長期照護機構的 CareMore Cal MediConnect Plan 會員無需支付共付費用 一些 在社區中取得長期照護服務的會員也無需支付共付費用 共付費用按級別列出 同一級別的藥物群組具有相同的共付費用 第 1 級藥物為一般藥物 此級別藥物的共付費用為 $0 第 2 級藥物為原廠藥物 此級別藥物的共付費用為 $0 第 3 級藥物為 Medi-Cal 給付的處方藥物 此級別藥物的共付費用為 $0 第 4 級藥物為 Medi-Cal 給付的非處方 (OTC) 藥物 此級別藥物的共付費用為 $0 給付藥物清單 以下給付藥物清單為您提供 CareMore Cal MediConnect Plan 給付的藥物資訊 假如您在清單中 查找藥物時有困難, 請翻到從第 146 頁開始的索引 表格第一欄所列的是藥物名稱 原廠藥物的名稱為大寫 ( 例如 BRAND NAME EXAMPLE), 一般 藥物則為小寫斜體字 ( 例如 generic example) 透過 必須採取的行動 限制, 或使用限制 欄的資訊, 您將了解 CareMore Cal MediConnect Plan 對於給付您的藥物是否有任何規定 以下是我們使用的縮寫清單.. 縮寫 B/D HI LA PAR 描述 B 部分與 D 部分決定 居家點滴 限制供應 郵購藥物 需要事先授權 解釋 根據實際狀況, 該處方藥物可由 Medicare B 部分或 D 部分給 付 可能需要呈交藥物使用和設置的資訊, 以進行判定 我們的醫療福利給付本處方藥物 如需更多資訊, 請聯絡會員 服務部, 電話 (TTY 711) 本處方藥物僅在特定的藥房供應 如需更多資訊, 請聯絡會員 服務部, 電話 (TTY 711) 該處方藥物透過我們的郵購服務以及網路內零售藥房提供 考 慮透過郵購服務來取得長期使用的 ( 維持性 ) 藥物 ( 比如高血 壓藥物 ) 網路內零售藥房可能更適合於取得短期服用的處方 藥物 ( 比如抗生素 ) 此計劃要求您或您的醫師取得某些處方藥物的預先批准 這意 味著您需要在配藥前先取得批准 如果您沒有取得批准, 我們 可能不會給付此藥物 (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全 天候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 6

8 QLL ST 供藥量限 漸進式治療 對于某些藥物, 此計劃會限制給付藥物的數量 您必須先嘗試另一種藥物, 才可取得此藥物 請注意 : 藥物旁邊的星號 (*) 意味著該藥物並非 D 部分藥物 您不需要支付這些藥物的共付費 用 這類藥物也有不同的上訴規定 上訴是在您認為我們有錯誤的情況下, 要求我們審查我們對您 的給付福利做出之決定, 並要求我們做出變更的一種正式的方式 例如, 我們可能決定某項您欲取 得的藥物不屬於或不再屬於 Medicare 或 Medi-Cal 的給付範圍 如果您或您的醫師不同意我們的 決定, 您可以提出上訴 如果您有任何疑問, 請撥打會員服務部電話 (TTY 711) 您也可參閱 會員手冊 以了解針對我們的決定提出上訴的方式 (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全 天候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 7

9 按醫療病症分類的藥物清單 本部分中的藥物根據用於治療疾病的類型, 被分類到不同的類別 例如, 如果您患有心臟病, 您應該查看 類別 心血管 高血壓 / 血脂藥治療物 您將可在該類別中找到治療心臟病症的藥物 藥物名稱 ANTI - INFECTIVES ANTIFUNGAL AGENTS ABELCET AMBISOME amphotericin b CANCIDAS clotrimazole mucous membrane ERAXIS(WATER DILUENT) fluconazole fluconazole in dextrose(iso-o) fluconazole in nacl (iso-osm) intravenous piggyback 100 mg/50 ml, 400 mg/200 ml fluconazole in nacl (iso-osm) intravenous piggyback 200 mg/100 ml flucytosine griseofulvin microsize oral suspension griseofulvin ultramicrosize itraconazole ketoconazole oral NOXAFIL ORAL SUSPENSION nystatin oral suspension nystatin oral tablet terbinafine hcl oral B/D; ; HI B/D; B/D; B/D; PAR; ; QLL (630 per 30 days) ; QLL (30 per 30 days) 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/2016 8

10 voriconazole intravenous voriconazole oral suspension for reconstitution voriconazole oral tablet 200 mg voriconazole oral tablet 50 mg ANTIVIRALS abacavir abacavir-lamivudine-zidovudine acyclovir oral capsule acyclovir oral suspension 200 mg/5 ml acyclovir oral tablet acyclovir sodium intravenous solution adefovir amantadine hcl oral capsule amantadine hcl oral tablet APTIVUS ORAL CAPSULE APTIVUS ORAL SOLUTION ATRIPLA BARACLUDE ORAL SOLUTION COMPLERA CRIXIVAN ORAL CAPSULE 200 MG CRIXIVAN ORAL CAPSULE 400 MG DESCOVY didanosine oral capsule,delayed release(dr/ec) 125 mg PAR; ; QLL (300 per 30 days) PAR; ; QLL (60 per 30 days) PAR; ; QLL (120 per 30 days) ; QLL (60 per 30 days) ; QLL (60 per 30 days) B/D; ; QLL (120 per 30 days) QLL (390 per 30 days) ; QLL (30 per 30 days) PAR; ; QLL (600 per 30 days) ; QLL (30 per 30 days) ; QLL (360 per 30 days) ; QLL (180 per 30 days) QLL (30 per 30 days) ; QLL (90 per 30 days) (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 9

11 didanosine oral capsule,delayed release(dr/ec) 200 mg didanosine oral capsule,delayed release(dr/ec) 250 mg, 400 mg EDURANT EMTRIVA ORAL CAPSULE EMTRIVA ORAL SOLUTION entecavir EPCLUSA EPIVIR HBV ORAL SOLUTION EPIVIR ORAL SOLUTION EPZICOM EVOTAZ famciclovir oral tablet 125 mg, 250 mg famciclovir oral tablet 500 mg foscarnet FUZEON SUBCUTANEOUS RECON SOLN ganciclovir sodium GENVOYA HARVONI INTELENCE ORAL TABLET 100 MG INTELENCE ORAL TABLET 200 MG INTELENCE ORAL TABLET 25 MG INVIRASE ORAL CAPSULE INVIRASE ORAL TABLET ISENTRESS ORAL POWDER IN PACKET ISENTRESS ORAL TABLET ; QLL (60 per 30 days) ; QLL (30 per 30 days) ; QLL (30 per 30 days) ; QLL (30 per 30 days) ; QLL (870 per 30 days) PAR; ; QLL (30 per 30 days) PAR; QLL (30 per 30 days) ; QLL (960 per 30 days) ; QLL (30 per 30 days) ; QLL (30 per 30 days) ; QLL (60 per 30 days) ; QLL (21 per 7 days) B/D ; QLL (60 per 30 days) ; QLL (30 per 30 days) PAR; ; QLL (28 per 28 days) ; QLL (120 per 30 days) ; QLL (60 per 30 days) ; QLL (480 per 30 days) ; QLL (300 per 30 days) ; QLL (120 per 30 days) ; QLL (120 per 30 days) 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/

12 ISENTRESS ORAL TABLET,CHEWABLE 100 MG ISENTRESS ORAL TABLET,CHEWABLE 25 MG KALETRA ORAL SOLUTION KALETRA ORAL TABLET MG KALETRA ORAL TABLET MG lamivudine oral solution lamivudine oral tablet 100 mg lamivudine oral tablet 150 mg lamivudine oral tablet 300 mg lamivudine-zidovudine LEXIVA ORAL SUSPENSION LEXIVA ORAL TABLET DERIBA nevirapine oral suspension nevirapine oral tablet nevirapine oral tablet extended release 24 hr 100 mg nevirapine oral tablet extended release 24 hr 400 mg NORVIR ORAL CAPSULE NORVIR ORAL SOLUTION NORVIR ORAL TABLET ODEFSEY OLYSIO PREZCOBIX ; QLL (180 per 30 days) ; QLL (720 per 30 days) ; QLL (480 per 30 days) ; QLL (300 per 30 days) ; QLL (120 per 30 days) ; QLL (900 per 30 days) ; QLL (60 per 30 days) ; QLL (30 per 30 days) ; QLL (60 per 30 days) ; QLL (1800 per 30 days) ; QLL (120 per 30 days) ; QLL (1200 per 30 days) ; QLL (60 per 30 days) ; QLL (30 per 30 days) ; QLL (360 per 30 days) ; QLL (480 per 30 days) ; QLL (360 per 30 days) QLL (30 per 30 days) PAR; ; QLL (30 per 30 days) (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 11

13 PREZISTA ORAL SUSPENSION PREZISTA ORAL TABLET 150 MG PREZISTA ORAL TABLET 600 MG, 800 MG PREZISTA ORAL TABLET 75 MG RELENZA DISKHALER RESCRIPTOR ORAL TABLET RESCRIPTOR ORAL TABLET, DISPERSIBLE RETROVIR INTRAVENOUS REYATAZ ORAL CAPSULE 150 MG, 200 MG REYATAZ ORAL CAPSULE 300 MG REYATAZ ORAL POWDER IN PACKET ribasphere oral capsule ribasphere oral tablet 200 mg ribavirin oral capsule ribavirin oral tablet 200 mg rimantadine SELZENTRY SOVALDI stavudine oral capsule 15 mg, 20 mg stavudine oral capsule 30 mg, 40 mg stavudine oral recon soln STRIBILD SUSTIVA ORAL CAPSULE 200 MG SUSTIVA ORAL CAPSULE 50 MG SUSTIVA ORAL TABLET SYNAGIS TAMIFLU ; QLL (420 per 30 days) ; QLL (180 per 30 days) ; QLL (60 per 30 days) ; QLL (300 per 30 days) ; QLL (60 per 180 days) ; QLL (180 per 30 days) ; QLL (360 per 30 days) ; QLL (60 per 30 days) ; QLL (30 per 30 days) ; QLL (240 per 30 days) ; QLL (120 per 30 days) PAR; ; QLL (120 per 30 days) ; QLL (60 per 30 days) ; QLL (2400 per 30 days) ; QLL (30 per 30 days) ; QLL (120 per 30 days) ; QLL (360 per 30 days) ; QLL (30 per 30 days) PAR; ; LA 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/

14 TECHNIVIE TIVICAY ORAL TABLET 10 MG, 25 MG TIVICAY ORAL TABLET 50 MG TRIUMEQ TRIZIVIR TRUVADA ORAL TABLET MG, MG, MG TRUVADA ORAL TABLET MG TYBOST TYZEKA valacyclovir valganciclovir oral tablet VIDEX 2 GRAM PEDIATRIC VIDEX 4 GRAM PEDIATRIC VIEKIRA PAK VIEKIRA XR VIRACEPT ORAL TABLET 250 MG VIRACEPT ORAL TABLET 625 MG VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 HR 100 MG VIRAZOLE VIREAD ORAL POWDER VIREAD ORAL TABLET VITEKTA ZEPATIER ZIAGEN ORAL SOLUTION PAR; ; QLL (56 per 28 days) QLL (60 per 30 days) ; QLL (60 per 30 days) ; QLL (30 per 30 days) ; QLL (60 per 30 days) QLL (30 per 30 days) ; QLL (30 per 30 days) ; QLL (30 per 30 days) ; QLL (30 per 2 days) ; QLL (1200 per 30 days) ; QLL (1200 per 30 days) PAR; PAR ; QLL (300 per 30 days) ; QLL (120 per 30 days) PAR; ; QLL (240 per 30 days) ; QLL (30 per 30 days) ; QLL (30 per 30 days) PAR; ; QLL (30 per 30 days) ; QLL (960 per 30 days) (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 13

15 zidovudine oral capsule zidovudine oral syrup zidovudine oral tablet CEPHALOSPORINS cefaclor oral capsule cefaclor oral suspension for reconstitution 125 mg/5 ml cefaclor oral suspension for reconstitution 250 mg/5 ml, 375 mg/5 ml cefaclor oral tablet extended release 12 hr cefadroxil oral capsule cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml cefadroxil oral tablet cefazolin in dextrose (iso-os) intravenous piggyback 1 gram/50 ml cefazolin injection recon soln 1 gram cefazolin injection recon soln 10 gram, 100 gram, 20 gram, 300 g cefazolin injection recon soln 500 mg cefazolin intravenous cefdinir cefepime cefoxitin in dextrose, iso-osm cefoxitin intravenous recon soln 1 gram ; QLL (180 per 30 days) ; QLL (1920 per 30 days) ; QLL (60 per 30 days) ; HI HI ; HI ; HI HI ; HI 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/

16 cefoxitin intravenous recon soln 10 gram, 2 gram cefpodoxime cefprozil ceftazidime injection recon soln 1 gram, 2 gram ceftazidime injection recon soln 6 gram ceftriaxone in dextrose,iso-os ceftriaxone injection recon soln 1 gram, 2 gram, 250 mg, 500 mg ceftriaxone injection recon soln 10 gram ceftriaxone intravenous cefuroxime axetil oral tablet cefuroxime sodium intravenous vial injection recon soln 1.5 gram, 750 mg cefuroxime sodium intravenous vial intravenous recon soln 7.5 gram cephalexin oral capsule 250 mg, 500 mg cephalexin oral suspension for reconstitution cephalexin oral tablet HI ; HI HI ; HI HI ; HI ; HI HI TEFLARO ERYTHROMYCINS / OTHER MACROLIDES azithromycin intravenous recon soln 500 mg (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 15

17 azithromycin intravenous recon soln 500 mg (2 mg/ml) azithromycin oral suspension for reconstitution azithromycin oral tablet clarithromycin oral suspension for reconstitution clarithromycin oral tablet clarithromycin oral tablet extended release 24 hr ery-tab oral tablet,delayed release (dr/ec) 250 mg, 333 mg ERY-TAB ORAL TABLET,DELAYED RELEASE (DR/EC) 500 MG erythrocin (as stearate) oral tablet 250 mg ERYTHROCIN INTRAVENOUS RECON SOLN 500 MG erythromycin ethylsuccinate oral tablet ; QLL (28 per 2 days) erythromycin oral tablet MISCELLANEOUS ANTIINFECTIVES ALBENZA ALINIA ORAL SUSPENSION FOR RECONSTITUTION ALINIA ORAL TABLET amikacin injection solution 1,000 mg/4 ml, 500 mg/2 ml atovaquone atovaquone-proguanil oral tablet mg ; QLL (180 per 3 days) PAR; 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/

18 AZACTAM AZACTAM IN DEXTROSE (ISO-OSM) baciim bacitracin intramuscular BILTRICIDE CAPASTAT CAYSTON chloramphenicol sod succinate chloroquine phosphate oral clindamycin hcl clindamycin phosphate injection clindamycin phosphate intravenous solution 300 mg/2 ml, 900 mg/6 ml clindamycin phosphate intravenous solution 600 mg/4 ml COARTEM colistin (colistimethate na) CUBICIN DAPSONE daptomycin DARAPRIM ethambutol gentamicin injection gentamicin sulfate (ped) (pf) gentamicin sulfate (pf) intravenous solution 100 mg/10 ml ; HI HI PAR; ; LA ; HI (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 17

19 GENTAMICIN SULFATE (PF) INTRAVENOUS SOLUTION 60 MG/6 ML gentamicin sulfate (pf) intravenous solution 80 mg/8 ml hydroxychloroquine oral imipenem-cilastatin INVANZ INJECTION isoniazid oral linezolid oral suspension for reconstitution linezolid oral tablet mefloquine meropenem metro i.v. metronidazole in nacl (iso-os) metronidazole oral MYCOBUTIN NEBUPENT neomycin paromomycin PASER PENTAM PRIFTIN PRIMAQUINE pyrazinamide quinine sulfate rifampin RIFATER ; HI ; HI PAR; ; QLL (1800 per 2 days) ; QLL (28 per 2 days) ; HI B/D; PAR; 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/

20 SIRTURO STREPTOMYCIN INTRAMUSCULAR STROMECTOL SYNERCID TOBI tobramycin sulfate injection recon soln tobramycin sulfate injection solution TRECATOR TYGACIL XIFAXAN ORAL TABLET 550 MG ZYVOX INTRAVENOUS PARENTERAL SOLUTION 200 MG/100 ML ZYVOX INTRAVENOUS PARENTERAL SOLUTION 600 MG/300 ML ZYVOX ORAL SUSPENSION FOR RECONSTITUTION PENICILLINS amoxicillin oral capsule amoxicillin oral suspension for reconstitution amoxicillin oral tablet amoxicillin oral tablet,chewable 125 mg, 250 mg amoxicillin-pot clavulanate ampicillin ampicillin sodium injection PAR; ; LA PAR; ; QLL (280 per 28 days) HI ; HI ; HI PAR; ; QLL (84 per 28 days) HI ; HI PAR; ; QLL (1800 per 2 days) ; HI (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 19

21 ampicillin sodium intravenous recon soln 1 gram ampicillin sodium intravenous recon soln 2 gram ampicillin-sulbactam injection recon soln 1.5 gram, 3 gram ampicillin-sulbactam injection recon soln 15 gram ampicillin-sulbactam intravenous recon soln 3 gram BICILLIN C-R INTRAMUSCULAR SYRINGE 1, 200,000 UNIT/ 2 ML(600K/600K) dicloxacillin nafcillin injection recon soln 1 gram, 10 gram nafcillin injection recon soln 2 gram nafcillin intravenous recon soln 2 gram oxacillin injection recon soln 1 gram, 2 gram oxacillin injection recon soln 10 gram oxacillin intravenous recon soln 1 gram oxacillin intravenous recon soln 2 gram PENICILLIN G POT IN DEXTROSE INTRAVENOUS PIGGYBACK 1 MILLION UNIT/ 50 ML PENICILLIN G POT IN DEXTROSE INTRAVENOUS PIGGYBACK 2 MILLION UNIT/ 50 ML, 3 MILLION UNIT/50 ML HI ; HI HI ; HI ; HI HI HI 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/

22 penicillin g potassium injection recon soln 20 million unit penicillin g potassium injection recon soln 5 million unit penicillin g procaine intramuscular syringe 1.2 million unit/2 ml penicillin g procaine intramuscular syringe 600,000 unit/ml penicillin g sodium penicillin v potassium piperacillin-tazobactam ZOSYN IN DEXTROSE (ISO-OSM) INTRAVENOUS PIGGYBACK 2.25 GRAM/50 ML ZOSYN IN DEXTROSE (ISO-OSM) INTRAVENOUS PIGGYBACK GRAM/50 ML, 4.5 GRAM/100 ML QUINOLONES ciprofloxacin er ciprofloxacin hcl oral ciprofloxacin lactate intravenous solution 200 mg/20 ml ciprofloxacin lactate intravenous solution 400 mg/40 ml levofloxacin intravenous levofloxacin oral ofloxacin oral tablet 400 mg ; HI ; HI ; HI HI ; HI (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 21

23 SULFA'S / RELATED AGENTS sulfadiazine oral sulfamethoxazole-trimethoprim TETRACYCLINES demeclocycline DOXY-100 doxycycline hyclate intravenous doxycycline hyclate oral capsule doxycycline hyclate oral tablet 100 mg, 20 mg doxycycline hyclate oral tablet 50 mg doxycycline hyclate oral tablet, delayed release (dr/ec) 100 mg, 150 mg, 75 mg doxycycline monohydrate oral capsule doxycycline monohydrate oral tablet minocycline oral capsule minocycline oral tablet morgidox oral capsule 100 mg morgidox oral capsule 50 mg tetracycline URINARY TRACT AGENTS MACRODANTIN ORAL CAPSULE 25 MG, 50 MG methenamine hippurate trimethoprim VANCOMYCIN vancomycin in 0.9% sodium cl intravenous piggyback 1 gram/200 ml 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/

24 VANCOMYCIN IN 0.9% SODIUM CL INTRAVENOUS PIGGYBACK 500 MG/100 ML, 750 MG/150 ML vancomycin in dextrose 5 % intravenous piggyback 1 gram/200 ml VANCOMYCIN IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK 500 MG/100 ML, 750 MG/150 ML vancomycin intravenous recon soln 1, 000 mg, 10 gram, 500 mg, 750 mg vancomycin intravenous recon soln 5 gram vancomycin oral capsule 125 mg ; HI PAR; ; QLL (40 per 2 days) vancomycin oral capsule 250 mg PAR; ; QLL (80 per 2 days) ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ADJUNCTIVE AGENTS amifostine crystalline dexrazoxane hcl intravenous recon soln 250 mg dexrazoxane hcl intravenous recon soln 500 mg ELITEK INTRAVENOUS RECON SOLN 1.5 MG elitek intravenous recon soln 7.5 mg FUSILEV KEPIVANCE leucovorin calcium injection recon soln 100 mg, 200 mg, 350 mg, 50 mg leucovorin calcium injection recon soln 500 mg PAR; PAR; (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 23

25 leucovorin calcium oral levoleucovorin calcium intravenous recon soln mesna MESNEX ORAL XGEVA PAR; ; QLL (1.7 per 28 days) ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ABRAXANE AFINITOR AFINITOR DISPERZ ALECENSA ALIMTA anastrozole ARRANON ARZERRA ASTAGRAF XL AVASTIN INTRAVENOUS SOLUTION 25 MG/ ML AVASTIN INTRAVENOUS SOLUTION 25 MG/ ML (16 ML) azacitidine AZASAN azathioprine azathioprine sodium BELEODAQ BENDEKA bexarotene bicalutamide PAR; PAR; ; QLL (30 per 30 days) B/D; B/D; B/D; B/D PAR; ; QLL (4 per 30 days) PAR; ; QLL (300 per 30 days) 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/

26 BICNU bleo 15k bleomycin BLINCYTO BOSULIF ORAL TABLET 100 MG BOSULIF ORAL TABLET 500 MG BUSULFEX CABOMETYX ORAL TABLET 20 MG CABOMETYX ORAL TABLET 40 MG, 60 MG CAPRELSA ORAL TABLET 100 MG CAPRELSA ORAL TABLET 300 MG carboplatin intravenous solution CELLCEPT INTRAVENOUS cisplatin cladribine CLOLAR COMETRIQ ORAL CAPSULE 100 MG/DAY(80 MG X1-20 MG X1) COMETRIQ ORAL CAPSULE 140 MG/DAY(80 MG X1-20 MG X3) COMETRIQ ORAL CAPSULE 60 MG/DAY (20 MG X 3/DAY) COTELLIC cyclophosphamide oral capsule cyclosporine intravenous cyclosporine modified PAR; PAR; ; QLL (120 per 30 days) PAR; ; QLL (30 per 30 days) B/D PAR; LA; QLL (90 per 30 days) PAR; LA; QLL (30 per 30 days) PAR; ; LA; QLL (90 per 30 days) PAR; ; LA; QLL (30 per 30 days) B/D; PAR; ; QLL (56 per 28 days) PAR; ; QLL (112 per 28 days) PAR; ; QLL (84 per 28 days) PAR; ; LA; QLL (90 per 30 days) B/D; B/D B/D; (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 25

27 cyclosporine oral capsule CYRAMZA INTRAVENOUS SOLUTION 10 MG/ ML CYRAMZA INTRAVENOUS SOLUTION 10 MG/ ML (50 ML) cytarabine cytarabine (pf) injection solution 100 mg/5 ml (20 mg/ml), 2 gram/20 ml (100 mg/ml) cytarabine (pf) injection solution 20 mg/ml dacarbazine DACOGEN DARZALEX daunorubicin intravenous solution decitabine DOCEFREZ INTRAVENOUS RECON SOLN 20 MG docetaxel intravenous solution 10 mg/ ml, 160 mg/16 ml (10 mg/ml), 160 mg/8 ml (20 mg/ml), 20 mg/2 ml (10 mg/ml) docetaxel intravenous solution 20 mg/ ml (1 ml), 80 mg/4 ml (20 mg/ml), 80 mg/ 8 ml (10 mg/ml) doxorubicin intravenous recon soln doxorubicin intravenous solution doxorubicin, peg-liposomal DROXIA EMCYT EMPLICITI B/D; PAR; PAR ; LA B/D; 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/

28 epirubicin intravenous solution 200 mg/100 ml epirubicin intravenous solution 50 mg/ 25 ml ERBITUX ERIVEDGE ERWINAZE ETOPOPHOS etoposide intravenous EVOMELA exemestane FARESTON FARYDAK ORAL CAPSULE 10 MG FARYDAK ORAL CAPSULE 15 MG, 20 MG FASLODEX FIRMAGON KIT W DILUENT SYRINGE fludarabine intravenous recon soln fludarabine intravenous solution fluorouracil intravenous flutamide FOLOTYN GAZYVA gemcitabine intravenous recon soln 1 gram, 200 mg gemcitabine intravenous recon soln 2 gram PAR; PAR; ; QLL (30 per 30 days) ; QLL (60 per 30 days) ; QLL (30 per 30 days) PAR; ; QLL (60 per 30 days) PAR; ; QLL (30 per 30 days) PAR; (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 27

29 gemcitabine intravenous solution 1 gram/26.3 ml (38 mg/ml), 200 mg/5.26 ml (38 mg/ml) gemcitabine intravenous solution 2 gram/52.6 ml (38 mg/ml) gengraf oral capsule 100 mg, 25 mg gengraf oral capsule 50 mg gengraf oral solution GILOTRIF GLEEVEC ORAL TABLET 100 MG GLEEVEC ORAL TABLET 400 MG GLEOSTINE HALAVEN HERCEPTIN HEXALEN hydroxyurea IBRANCE ICLUSIG ORAL TABLET 15 MG ICLUSIG ORAL TABLET 45 MG idarubicin ifosfamide intravenous recon soln ifosfamide intravenous solution imatinib oral tablet 100 mg imatinib oral tablet 400 mg IMBRUVICA INLYTA ORAL TABLET 1 MG INLYTA ORAL TABLET 5 MG IRESSA B/D; B/D B/D; PAR; ; QLL (30 per 30 days) PAR; ; QLL (240 per 30 days) PAR; ; QLL (60 per 30 days) PAR; PAR; ; QLL (30 per 30 days) PAR; ; QLL (60 per 30 days) PAR; ; QLL (30 per 30 days) PAR; ; QLL (240 per 30 days) PAR; ; QLL (60 per 30 days) PAR; ; QLL (120 per 30 days) PAR; ; QLL (240 per 30 days) PAR; ; QLL (120 per 30 days) 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/

30 irinotecan intravenous solution 100 mg/5 ml, 40 mg/2 ml irinotecan intravenous solution 500 mg/25 ml ISTODAX IXEMPRA JAKAFI ORAL TABLET 10 MG JAKAFI ORAL TABLET 15 MG JAKAFI ORAL TABLET 20 MG JAKAFI ORAL TABLET 25 MG JAKAFI ORAL TABLET 5 MG JEVTANA KADCYLA KEYTRUDA LENVIMA ORAL CAPSULE 10 MG/DAY (10 MG X 1/DAY) LENVIMA ORAL CAPSULE 14 MG/DAY(10 MG X 1-4 MG X 1), 20 MG/DAY (10 MG X 2) LENVIMA ORAL CAPSULE 18 MG/DAY (10 MG X 1-4 MG X2) LENVIMA ORAL CAPSULE 24 MG/DAY(10 MG X 2-4 MG X 1) LENVIMA ORAL CAPSULE 8 MG/DAY (4 MG X 2), 8 MG/DAY (4 MG X 2) (60 PACK) letrozole LEUKERAN leuprolide subcutaneous kit PAR; ; QLL (150 per 30 days) PAR; ; QLL (100 per 30 days) PAR; ; QLL (75 per 30 days) PAR; ; QLL (60 per 30 days) PAR; ; QLL (300 per 30 days) PAR; PAR; PAR; ; QLL (30 per 30 days) PAR; ; QLL (60 per 30 days) PAR; QLL (90 per 30 days) PAR; ; QLL (90 per 30 days) PAR; QLL (60 per 30 days) ; QLL (30 per 30 days) (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 29

31 LONSURF LUPRON DEPOT (3 NTH) INTRAMUSCULAR SYRINGE KIT 22.5 MG LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 3.75 MG LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 7.5 MG LYNPARZA LYSODREN MARQIBO MATULANE megestrol oral suspension 400 mg/10 ml (10 ml), 800 mg/20 ml (20 ml) megestrol oral suspension 400 mg/10 ml (40 mg/ml) megestrol oral tablet MEKINIST ORAL TABLET 0.5 MG MEKINIST ORAL TABLET 2 MG melphalan hcl mercaptopurine methotrexate sodium methotrexate sodium (pf) injection recon soln methotrexate sodium (pf) injection solution mitomycin mitoxantrone MUSTARGEN mycophenolate mofetil PAR; PAR; PAR; ; QLL (1 per 28 days) PAR; PAR; ; QLL (480 per 30 days) PAR; QLL (90 per 30 days) PAR; QLL (30 per 30 days) B/D; 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/

32 mycophenolate sodium NEXAVAR NILANDRON NINLARO NIPENT NULOJIX octreotide acetate ODOMZO ONCASPAR OPDIVO oxaliplatin intravenous recon soln 100 mg oxaliplatin intravenous recon soln 50 mg oxaliplatin intravenous solution paclitaxel PERJETA POMALYST ORAL CAPSULE 1 MG POMALYST ORAL CAPSULE 2 MG POMALYST ORAL CAPSULE 3 MG, 4 MG PORTRAZZA PROGRAF INTRAVENOUS PURIXAN RAPAMUNE REVLIMID ORAL CAPSULE 10 MG B/D; PAR; ; LA; QLL (120 per 30 days) ; QLL (30 per 30 days) PAR; ; QLL (3 per 28 days) B/D; PAR; PAR; ; LA; QLL (30 per 30 days) PAR; PAR; ; QLL (120 per 30 days) PAR; ; QLL (60 per 30 days) PAR; ; QLL (30 per 30 days) B/D; PAR; B/D; ; LA; QLL (60 per 30 days) (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 31

33 REVLIMID ORAL CAPSULE 15 MG, 2.5 MG, 20 MG, 25 MG REVLIMID ORAL CAPSULE 5 MG RITUXAN SANDIMMUNE ORAL SOLUTION SIGNIFOR SIMULECT INTRAVENOUS RECON SOLN 10 MG SIMULECT INTRAVENOUS RECON SOLN 20 MG sirolimus SOLTAX SOMATULINE DEPOT SPRYCEL STIVARGA SUTENT ORAL CAPSULE 12.5 MG SUTENT ORAL CAPSULE 25 MG, 37.5 MG, 50 MG SYNRIBO TABLOID tacrolimus oral TAFINLAR TAGRISSO ORAL TABLET 40 MG TAGRISSO ORAL TABLET 80 MG tamoxifen TARCEVA ORAL TABLET 100 MG, 150 MG TARCEVA ORAL TABLET 25 MG TARGRETIN ORAL ; LA; QLL (30 per 30 days) ; LA; QLL (150 per 30 days) PAR; B/D; B/D B/D; B/D; ; QLL (30 per 30 days) PAR; ; QLL (120 per 30 days) ; QLL (90 per 30 days) ; QLL (30 per 30 days) B/D; PAR; QLL (120 per 30 days) PAR; ; LA; QLL (60 per 30 days) PAR; ; LA; QLL (30 per 30 days) ; QLL (30 per 30 days) ; QLL (90 per 30 days) PAR; ; QLL (300 per 30 days) 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/

34 TARGRETIN TOPICAL TASIGNA TECENTRIQ THALOMID ORAL CAPSULE 100 MG, 50 MG THALOMID ORAL CAPSULE 150 MG, 200 MG thiotepa toposar topotecan intravenous recon soln topotecan intravenous solution TORISEL TREANDA INTRAVENOUS RECON SOLN TRELSTAR DEPOT TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION TRELSTAR INTRAMUSCULAR SYRINGE MG/2 ML, 3.75 MG/2 ML TRELSTAR INTRAMUSCULAR SYRINGE 22.5 MG/2 ML TRELSTAR LA tretinoin (chemotherapy) TREXALL TRISENOX TYKERB UNITUXIN VECTIBIX VELCADE PAR; ; QLL (120 per 30 days) LA; QLL (20 per 21 days) ; QLL (30 per 30 days) ; QLL (60 per 30 days) ; QLL (1 per 168 days) ; QLL (1 per 168 days) ; LA; QLL (180 per 30 days) PAR; (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 33

35 VENCLEXTA ORAL TABLET 10 MG VENCLEXTA ORAL TABLET 100 MG VENCLEXTA ORAL TABLET 50 MG VENCLEXTA STARTING PACK vinblastine intravenous solution VINCASAR PFS INTRAVENOUS SOLUTION 1 MG/ML vincasar pfs intravenous solution 2 mg/2 ml vincristine vinorelbine VOTRIENT XALKORI XTANDI YERVOY YONDELIS ZALTRAP ZANOSAR ZELBORAF ZOLINZA ZORTRESS ZYDELIG ZYKADIA PAR; LA; QLL (60 per 30 days) PAR; LA; QLL (120 per 30 days) PAR; LA; QLL (30 per 30 days) PAR; LA; QLL (42 per 365 days) ; QLL (120 per 30 days) PAR; ; QLL (60 per 30 days) PAR; ; QLL (120 per 30 days) PAR; PAR; ; QLL (240 per 30 days) ; QLL (120 per 30 days) B/D; PAR; ; QLL (60 per 30 days) PAR; ; QLL (150 per 30 days) ZYTIGA PAR; ; QLL (120 per 30 days) AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH ANTICONVULSANTS APTIOM BANZEL ORAL SUSPENSION PAR; ; QLL (2400 per 30 days) 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/

36 BANZEL ORAL TABLET 200 MG BANZEL ORAL TABLET 400 MG BRIVIACT INTRAVENOUS BRIVIACT ORAL SOLUTION BRIVIACT ORAL TABLET 10 MG BRIVIACT ORAL TABLET 100 MG, 75 MG BRIVIACT ORAL TABLET 25 MG BRIVIACT ORAL TABLET 50 MG carbamazepine oral capsule, er multiphase 12 hr carbamazepine oral suspension 100 mg/ 5 ml carbamazepine oral suspension 200 mg/ 10 ml carbamazepine oral tablet carbamazepine oral tablet extended release 12 hr 100 mg carbamazepine oral tablet extended release 12 hr 200 mg, 400 mg carbamazepine oral tablet,chewable CELONTIN ORAL CAPSULE 300 MG clonazepam oral tablet 0.5 mg clonazepam oral tablet 1 mg clonazepam oral tablet 2 mg clonazepam oral tablet,disintegrating mg PAR; ; QLL (480 per 30 days) PAR; ; QLL (240 per 30 days) PAR PAR; QLL (600 per 30 days) PAR; QLL (600 per 30 days) PAR; QLL (60 per 30 days) PAR; QLL (240 per 30 days) PAR; QLL (120 per 30 days) ; QLL (1200 per 30 days) ; QLL (600 per 30 days) ; QLL (300 per 30 days) ; QLL (4800 per 30 days) (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 35

37 clonazepam oral tablet,disintegrating 0.25 mg clonazepam oral tablet,disintegrating 0.5 mg clonazepam oral tablet,disintegrating 1 mg clonazepam oral tablet,disintegrating 2 mg diazepam rectal kit mg diazepam rectal kit 2.5 mg, mg DILANTIN DILANTIN EXTENDED ORAL CAPSULES 100 MG DILANTIN INFATABS divalproex epitol EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 100 MG EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 200 MG EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 300 MG ethosuximide felbamate fosphenytoin FYCOMPA ORAL SUSPENSION FYCOMPA ORAL TABLET 10 MG, 12 MG FYCOMPA ORAL TABLET 2 MG FYCOMPA ORAL TABLET 4 MG ; QLL (2400 per 30 days) ; QLL (1200 per 30 days) ; QLL (600 per 30 days) ; QLL (300 per 30 days) ; QLL (2 per 2 days) ; QLL (480 per 30 days) ; QLL (240 per 30 days) ; QLL (180 per 30 days) QLL (720 per 30 days) ; QLL (30 per 30 days) ; QLL (180 per 30 days) ; QLL (90 per 30 days) 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/

38 FYCOMPA ORAL TABLET 6 MG FYCOMPA ORAL TABLET 8 MG gabapentin oral capsule 100 mg gabapentin oral capsule 300 mg gabapentin oral capsule 400 mg gabapentin oral solution 250 mg/5 ml gabapentin oral solution 250 mg/5 ml (5 ml), 300 mg/6 ml (6 ml) gabapentin oral tablet 600 mg gabapentin oral tablet 800 mg GABITRIL ORAL TABLET 12 MG, 16 MG lamotrigine oral tablet lamotrigine oral tablet, chewable dispersible levetiracetam intravenous levetiracetam oral solution 100 mg/ml levetiracetam oral solution 500 mg/5 ml (5 ml) levetiracetam oral tablet levetiracetam oral tablet extended release 24 hr 500 mg levetiracetam oral tablet extended release 24 hr 750 mg LYRICA ORAL CAPSULE 100 MG LYRICA ORAL CAPSULE 150 MG LYRICA ORAL CAPSULE 200 MG LYRICA ORAL CAPSULE 225 MG, 300 MG ; QLL (60 per 30 days) ; QLL (45 per 30 days) ; QLL (1080 per 30 days) ; QLL (360 per 30 days) ; QLL (270 per 30 days) ; QLL (2160 per 30 days) QLL (2160 per 30 days) ; QLL (180 per 30 days) ; QLL (135 per 30 days) ; QLL (180 per 30 days) ; QLL (120 per 30 days) ; QLL (180 per 30 days) ; QLL (120 per 30 days) ; QLL (90 per 30 days) ; QLL (60 per 30 days) (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 37

39 LYRICA ORAL CAPSULE 25 MG LYRICA ORAL CAPSULE 50 MG LYRICA ORAL CAPSULE 75 MG LYRICA ORAL SOLUTION ONFI ORAL SUSPENSION ONFI ORAL TABLET 10 MG ONFI ORAL TABLET 20 MG oxcarbazepine oral tablet OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR 150 MG OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR 300 MG OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR 600 MG PEGANONE phenobarbital oral elixir phenobarbital oral tablet 100 mg phenobarbital oral tablet 15 mg phenobarbital oral tablet 16.2 mg phenobarbital oral tablet 30 mg phenobarbital oral tablet 32.4 mg phenobarbital oral tablet 60 mg phenobarbital oral tablet 64.8 mg phenobarbital oral tablet 97.2 mg phenytoin oral suspension 100 mg/4 ml phenytoin oral suspension 125 mg/5 ml phenytoin oral tablet,chewable phenytoin sodium extended ; QLL (720 per 30 days) ; QLL (360 per 30 days) ; QLL (240 per 30 days) ; QLL (900 per 30 days) PAR; ; QLL (480 per 30 days) PAR; ; QLL (120 per 30 days) PAR; ; QLL (60 per 30 days) ; QLL (480 per 30 days) ; QLL (240 per 30 days) ; QLL (120 per 30 days) ; QLL (3000 per 30 days) ; QLL (120 per 30 days) ; QLL (800 per 30 days) ; QLL (741 per 30 days) ; QLL (400 per 30 days) ; QLL (370 per 30 days) ; QLL (200 per 30 days) ; QLL (185 per 30 days) ; QLL (123 per 30 days) 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/

40 phenytoin sodium intravenous solution POTIGA ORAL TABLET 200 MG, 300 MG, 400 MG POTIGA ORAL TABLET 50 MG primidone roweepra SABRIL SPRITAM ORAL TABLET FOR SUSPENSION 1, 000 MG, 250 MG, 500 MG SPRITAM ORAL TABLET FOR SUSPENSION 750 MG tiagabine topiramate oral capsule, sprinkle topiramate oral tablet 100 mg topiramate oral tablet 200 mg topiramate oral tablet 25 mg topiramate oral tablet 50 mg TRILEPTAL ORAL SUSPENSION valproate sodium valproic acid valproic acid (as sodium salt) oral solution 250 mg/5 ml valproic acid (as sodium salt) oral solution 250 mg/5 ml (5 ml), 500 mg/10 ml (10 ml) VIMPAT INTRAVENOUS VIMPAT ORAL SOLUTION ; QLL (90 per 30 days) ; QLL (270 per 30 days) ; LA; QLL (180 per 30 days) QLL (60 per 30 days) QLL (120 per 30 days) ; QLL (480 per 30 days) ; QLL (240 per 30 days) ; QLL (1920 per 30 days) ; QLL (960 per 30 days) QLL (1200 per 30 days) ; QLL (1200 per 30 days) (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 39

41 VIMPAT ORAL TABLET 100 MG VIMPAT ORAL TABLET 150 MG VIMPAT ORAL TABLET 200 MG VIMPAT ORAL TABLET 50 MG zonisamide ANTIPARKINSONISM AGENTS APOKYN AZILECT benztropine oral bromocriptine carbidopa-levodopa entacapone NEUPRO pramipexole oral tablet ropinirole oral tablet selegiline hcl tolcapone ; QLL (120 per 30 days) ; QLL (80 per 30 days) ; QLL (60 per 30 days) ; QLL (240 per 30 days) PAR; ; LA PAR; ; QLL (30 per 30 days) trihexyphenidyl MIGRAINE / CLUSTER HEADACHE THERAPY ERGOMAR MIGRANAL rizatriptan sumatriptan succinate oral sumatriptan succinate subcutaneous cartridge sumatriptan succinate subcutaneous pen injector 4 mg/0.5 ml, 6 mg/0.5 ml ; QLL (8 per 28 days) ; QLL (12 per 30 days) ; QLL (9 per 30 days) ; QLL (4 per 30 days) ; QLL (4 per 30 days) 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/

42 sumatriptan succinate subcutaneous pen injector 6 mg/0.5 ml (autoinjector) sumatriptan succinate subcutaneous solution sumatriptan succinate subcutaneous syringe 6 mg/0.5 ml zolmitriptan QLL (4 per 30 days) ; QLL (4 per 30 days) QLL (4 per 30 days) ; QLL (9 per 30 days) ZOMIG NASAL MISCELLANEOUS NEUROLOGICAL THERAPY ; QLL (6 per 30 days) AMPYRA COPAXONE SUBCUTANEOUS SYRINGE 20 MG/ ML COPAXONE SUBCUTANEOUS SYRINGE 40 MG/ ML donepezil oral tablet 10 mg donepezil oral tablet 5 mg donepezil oral tablet,disintegrating 10 mg donepezil oral tablet,disintegrating 5 mg EXELON TRANSDERMAL galantamine oral capsule,ext rel. pellets 24 hr galantamine oral solution galantamine oral tablet GILENYA GLATOPA PAR; ; LA; QLL (60 per 30 days) PAR; ; QLL (30 per 30 days) PAR; ; QLL (12 per 28 days) ; QLL (30 per 30 days) ; QLL (30 per 30 days) ; QLL (30 per 30 days) ; QLL (30 per 30 days) ; QLL (180 per 30 days) ; QLL (60 per 30 days) PAR; ; QLL (30 per 30 days) PAR; ; QLL (30 per 30 days) (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 41

43 memantine oral solution memantine oral tablet 10 mg memantine oral tablet 5 mg NAMENDA ORAL SOLUTION NAMENDA ORAL TABLET 10 MG NAMENDA ORAL TABLET 5 MG NAMENDA TITRATION PAK NAMENDA XR ORAL CAP,SPRINKLE,ER 24HR DOSE PACK NAMENDA XR ORAL CAPSULE,SPRINKLE,ER 24HR NUEDEXTA rivastigmine rivastigmine tartrate tetrabenazine oral tablet 12.5 mg tetrabenazine oral tablet 25 mg TYSABRI XENAZINE ORAL TABLET 12.5 MG ; QLL (300 per 30 days) ; QLL (60 per 30 days) ; QLL (90 per 30 days) ; QLL (300 per 30 days) ; QLL (60 per 30 days) ; QLL (90 per 30 days) ; QLL (60 per 30 days) ; QLL (56 per 365 days) ; QLL (30 per 30 days) ; QLL (60 per 30 days) ; QLL (30 per 30 days) ; QLL (60 per 30 days) PAR; ; QLL (240 per 30 days) PAR; ; QLL (120 per 30 days) PAR; ; LA PAR; ; LA; QLL (240 per 30 days) XENAZINE ORAL TABLET 25 MG PAR; ; LA; QLL (120 per 30 days) MUSCLE RELAXANTS / ANTISPASDIC THERAPY AMRIX baclofen dantrolene MESTINON ORAL SYRUP MESTINON TIMESPAN pyridostigmine bromide tizanidine oral tablet PAR; 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/

44 NARCOTIC ANALGESICS ABSTRAL acetaminophen-codeine oral solution 120 mg-12 mg /5 ml (5 ml), 240 mg-24 mg /10 ml (10 ml), 300 mg-30 mg /12.5 ml acetaminophen-codeine oral solution mg/5 ml acetaminophen-codeine oral tablet mg acetaminophen-codeine oral tablet mg acetaminophen-codeine oral tablet mg buprenorphine hcl injection solution buprenorphine hcl injection syringe buprenorphine hcl sublingual tablet 2 mg buprenorphine hcl sublingual tablet 8 mg butalbital-acetaminop-caf-cod oral capsule mg duramorph (pf) injection solution 0.5 mg/ml duramorph (pf) injection solution 1 mg/ml endocet oral tablet mg, mg, mg fentanyl citrate PAR; ; QLL (120 per 30 days) QLL (4500 per 30 days) ; QLL (4500 per 30 days) ; QLL (390 per 30 days) ; QLL (360 per 30 days) ; QLL (180 per 30 days) ; QLL (150 per 30 days) QLL (150 per 30 days) PAR; ; QLL (240 per 30 days) PAR; ; QLL (60 per 30 days) ; QLL (180 per 30 days) ; QLL (180 per 30 days) QLL (180 per 30 days) ; QLL (360 per 30 days) PAR; ; QLL (120 per 30 days) (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 43

45 fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr FENTORA hydrocodone-acetaminophen oral solution mg/15 ml(15 ml), mg/5 ml, mg/7.5ml(7.5ml) hydrocodone-acetaminophen oral solution mg/15 ml hydrocodone-acetaminophen oral tablet mg, mg, mg hydrocodone-acetaminophen oral tablet mg, mg, mg hydrocodone-ibuprofen oral tablet mg hydromorphone oral tablet 2 mg, 4 mg hydromorphone oral tablet 8 mg LAZANDA NASAL SPRAY,NON-AEROSOL 100 MCG/SPRAY, 400 MCG/SPRAY LAZANDA NASAL SPRAY,NON-AEROSOL 300 MCG/SPRAY levorphanol tartrate LORCET (HYDROCODONE) LORCET HD LORCET PLUS ORAL TABLET MG LORTAB LORTAB LORTAB methadone injection methadone intensol ; QLL (15 per 30 days) PAR; ; QLL (120 per 30 days) QLL (2700 per 30 days) ; QLL (2700 per 30 days) ; QLL (390 per 30 days) ; QLL (360 per 30 days) ; QLL (480 per 30 days) ; QLL (360 per 30 days) ; QLL (180 per 30 days) PAR; ; QLL (30 per 30 days) PAR; QLL (30 per 30 days) ; QLL (180 per 30 days) ; QLL (360 per 30 days) ; QLL (360 per 30 days) ; QLL (360 per 30 days) ; QLL (360 per 30 days) ; QLL (360 per 30 days) ; QLL (360 per 30 days) QLL (150 per 30 days) ; QLL (180 per 30 days) 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/

46 methadone oral concentrate methadone oral solution 10 mg/5 ml methadone oral solution 5 mg/5 ml methadone oral tablet 10 mg methadone oral tablet 5 mg methadose oral concentrate morphine (pf) injection solution 0.5 mg/ml morphine (pf) injection solution 1 mg/ ml morphine (pf) intravenous patient control.analgesia soln 150 mg/30 ml morphine (pf) intravenous patient control.analgesia soln 30 mg/30 ml morphine concentrate oral solution morphine intravenous cartridge 2 mg/ ml RPHINE INTRAVENOUS CARTRIDGE 8 MG/ ML morphine intravenous solution 10 mg/ ml, 50 mg/ml morphine intravenous solution 100 mg/ 4 ml, 25 mg/ml, 250 mg/10 ml RPHINE INTRAVENOUS SOLUTION 4 MG/ ML, 8 MG/ML morphine intravenous syringe 2 mg/ml, 4 mg/ml morphine oral capsule, er multiphase 24 hr 30 mg, 60 mg ; QLL (180 per 30 days) ; QLL (900 per 30 days) ; QLL (1800 per 30 days) ; QLL (180 per 30 days) ; QLL (360 per 30 days) ; QLL (180 per 30 days) ; QLL (180 per 30 days) ; QLL (120 per 30 days) B/D; QLL (180 per 30 days) ; QLL (270 per 30 days) QLL (120 per 30 days) QLL (120 per 30 days) ; QLL (120 per 30 days) QLL (120 per 30 days) ; QLL (180 per 30 days) QLL (120 per 30 days) ; QLL (30 per 30 days) (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 45

47 morphine oral capsule,extend.release pellets 100 mg, 20 mg, 30 mg, 50 mg, 60 mg, 80 mg morphine oral solution 10 mg/5 ml morphine oral solution 20 mg/5 ml (4 mg/ml) morphine oral tablet 15 mg morphine oral tablet 30 mg morphine oral tablet extended release 100 mg, 15 mg, 30 mg, 60 mg morphine oral tablet extended release 200 mg NORCO oxycodone oral capsule oxycodone oral concentrate oxycodone oral tablet 10 mg, 5 mg oxycodone oral tablet 15 mg oxycodone oral tablet 20 mg, 30 mg oxycodone-acetaminophen oral solution oxycodone-acetaminophen oral tablet mg, mg, mg, mg oxycodone-aspirin SUBSYS vicodin vicodin es vicodin hp XODOL 10/300 XODOL 5/300 ; QLL (60 per 30 days) ; QLL (2700 per 30 days) ; QLL (1350 per 30 days) ; QLL (360 per 30 days) ; QLL (180 per 30 days) ; QLL (90 per 30 days) ; QLL (60 per 30 days) ; QLL (360 per 30 days) ; QLL (360 per 30 days) ; QLL (360 per 30 days) ; QLL (360 per 30 days) ; QLL (540 per 30 days) ; QLL (180 per 30 days) QLL (1800 per 30 days) ; QLL (360 per 30 days) ; QLL (360 per 30 days) PAR; ; QLL (120 per 30 days) ; QLL (390 per 30 days) ; QLL (390 per 30 days) ; QLL (390 per 30 days) ; QLL (390 per 30 days) ; QLL (390 per 30 days) 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/

48 XODOL 7.5/300 NON-NARCOTIC ANALGESICS ACEPHEN RECTAL SUPPOSITORY 650 MG ACETAMINOPHEN EXTRA STRENGTH ORAL CAPSULE 500 MG ACETAMINOPHEN EXTRA STRENGTH ORAL CAPSULE 500 MG ACETAMINOPHEN EXTRA STRENGTH ORAL LIQUID 500 MG/15 ML ACETAMINOPHEN EXTRA STRENGTH ORAL LIQUID 500 MG/15 ML ACETAMINOPHEN EXTRA STRENGTH ORAL SUSPENSION 160 MG/5 ML ACETAMINOPHEN LIQUID acetaminophen oral suspension 160 mg/ 5 ml acetaminophen oral tablet 500 mg ACETAMINOPHEN PAIN RELIEF acetaminophen rectal suppository 650 mg ADDED STRENGTH PAIN RELIEVER ADULT LOW DOSE ASPIRIN ALL DAY RELIEF ASPIR-LOW ASPIRIN LOW DOSE aspirin oral tablet ASPIRIN ORAL TABLET 325 MG aspirin oral tablet,chewable ; QLL (390 per 30 days) ; ; ; ; ; ; ; ; ; ; (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 47

49 ASPIRIN ORAL TABLET,DELAYED RELEASE (DR/EC) 325 MG ASPIRIN ORAL TABLET,DELAYED RELEASE (DR/EC) 325 MG aspirin oral tablet,delayed release (dr/ec) 325 mg, 81 mg BETATEMP buprenorphine-naloxone sublingual tablet mg buprenorphine-naloxone sublingual tablet 8-2 mg butorphanol tartrate injection solution 1 mg/ml butorphanol tartrate injection solution 2 mg/ml butorphanol tartrate nasal diclofenac potassium diclofenac sodium oral diflunisal ECOTRIN LOW STRENGTH ENTERIC COATED ASPIRIN etodolac fenoprofen oral tablet FEVER REDUCER AN PAIN RELIEVER ORAL SUSPENSION FEVERALL RECTAL SUPPOSITORY 650 MG FLANAX (NAPROXEN) flurbiprofen HEADACHE RELIEF (ASA-ACET-CAF) ; ; PAR; ; QLL (360 per 30 days) PAR; ; QLL (90 per 30 days) ; QLL (240 per 30 days) ; QLL (120 per 30 days) ; QLL (5 per 28 days) ; 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/

50 I-PRIN IBUPROFEN IB ORAL TABLET ibuprofen oral capsule ibuprofen oral suspension ibuprofen oral tablet 200 mg ibuprofen oral tablet 400 mg, 600 mg, 800 mg MAPAP EXTRA STRENGTH MASOPHEN ORAL TABLET 500 MG meclofenamate oral MEDIPROXEN meloxicam oral suspension meloxicam oral tablet MENSTRUAL RELIEF MIGRAINE FORMULA MIGRAINE RELIEF nabumetone nalbuphine injection solution 10 mg/ml nalbuphine injection solution 20 mg/ml naloxone naltrexone oral naproxen naproxen sodium oral capsule naproxen sodium oral tablet 220 mg naproxen sodium oral tablet 275 mg, 550 mg ; ; ; QLL (300 per 30 days) ; QLL (30 per 30 days) ; QLL (180 per 30 days) ; QLL (90 per 30 days) ; (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 49

51 NARCAN NON-ASPIRIN ORAL SUSPENSION oxaprozin PAIN AND FEVER ORAL TABLET 500 MG PAIN RELIEF (ACETAMIN-ASP-CAF) PAIN RELIEF EXTRA STRENGTH PAIN RELIEF ORAL TABLET PAIN RELIEVER (ACETAM-ASPIRIN) PAIN RELIEVER EXTRA STRENGTH PAIN RELIEVER ORAL CAPSULE PAIN RELIEVER ORAL TABLET 500 MG PAIN RELIEVER PLUS PAIN-OFF PAMPRIN MAX PHARBETOL ORAL TABLET 500 MG piroxicam PROVIL Q-PAP EXTRA STRENGTH Q-PAP ORAL TABLET 500 MG sulindac oral SUPER PAIN RELIEF tolmetin tramadol oral tablet tramadol-acetaminophen VOLTAREN TOPICAL GEL 1 % PSYCHOTHERAPEUTIC DRUGS ABILIFY MAINTENA ; ; ; ; ; QLL (240 per 30 days) ; QLL (240 per 30 days) ; QLL (1000 per 30 days) ; QLL (1 per 28 days) 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/

52 ADASUVE alprazolam oral tablet amitriptyline amoxapine aripiprazole oral solution aripiprazole oral tablet 10 mg aripiprazole oral tablet 15 mg aripiprazole oral tablet 2 mg aripiprazole oral tablet 20 mg, 30 mg aripiprazole oral tablet 5 mg aripiprazole oral tablet, disintegrating 10 mg aripiprazole oral tablet, disintegrating 15 mg ARISTADA INTRAMUSCULAR SUSPENSION, EXTENDED REL SYRING 441 MG/1.6 ML ARISTADA INTRAMUSCULAR SUSPENSION, EXTENDED REL SYRING 662 MG/2.4 ML ARISTADA INTRAMUSCULAR SUSPENSION, EXTENDED REL SYRING 882 MG/3.2 ML bupropion hcl oral tablet 100 mg bupropion hcl oral tablet 75 mg bupropion hcl oral tablet extended release 100 mg bupropion hcl oral tablet extended release 150 mg, 200 mg bupropion hcl oral tablet extended release 24 hr 150 mg ; QLL (90 per 30 days) ; QLL (900 per 30 days) ; QLL (90 per 30 days) ; QLL (60 per 30 days) ; QLL (450 per 30 days) ; QLL (30 per 30 days) ; QLL (180 per 30 days) ; QLL (90 per 30 days) ; QLL (60 per 30 days) PAR; ; QLL (1.6 per 30 days) PAR; ; QLL (2.4 per 30 days) PAR; ; QLL (3.2 per 30 days) ; QLL (135 per 30 days) ; QLL (180 per 30 days) ; QLL (120 per 30 days) ; QLL (60 per 30 days) ; QLL (90 per 30 days) (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 51

53 bupropion hcl oral tablet extended release 24 hr 300 mg buspirone chlorpromazine citalopram oral solution citalopram oral tablet 10 mg citalopram oral tablet 20 mg citalopram oral tablet 40 mg clomipramine clorazepate dipotassium clozapine oral tablet 100 mg clozapine oral tablet 200 mg clozapine oral tablet 25 mg clozapine oral tablet 50 mg clozapine oral tablet,disintegrating 100 mg clozapine oral tablet,disintegrating 12.5 mg clozapine oral tablet,disintegrating 150 mg clozapine oral tablet,disintegrating 200 mg clozapine oral tablet,disintegrating 25 mg desipramine oral DESVENLAFAXINE FUMARATE ORAL TABLET EXTENDED RELEASE 24HR 100 MG DESVENLAFAXINE FUMARATE ORAL TABLET EXTENDED RELEASE 24HR 50 MG ; QLL (45 per 30 days) ; QLL (600 per 30 days) ; QLL (120 per 30 days) ; QLL (60 per 30 days) ; QLL (30 per 30 days) ; QLL (120 per 30 days) ; QLL (270 per 30 days) ; QLL (135 per 30 days) ; QLL (1080 per 30 days) ; QLL (540 per 30 days) QLL (270 per 30 days) QLL (2160 per 30 days) QLL (180 per 30 days) QLL (135 per 30 days) QLL (1080 per 30 days) ; QLL (120 per 30 days) ; QLL (240 per 30 days) 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/

54 DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE 24 HR 100 MG DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE 24 HR 50 MG DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE 24HR 100 MG DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE 24HR 50 MG dextroamphetamine oral capsule, extended release 10 mg, 5 mg dextroamphetamine oral capsule, extended release 15 mg dextroamphetamine oral tablet 10 mg dextroamphetamine oral tablet 5 mg dextroamphetamine-amphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 5 mg, 7.5 mg dextroamphetamine-amphetamine oral tablet 30 mg diazepam injection solution diazepam injection syringe diazepam intensol diazepam oral concentrate diazepam oral solution 5 mg/5 ml (1 mg/ ml) diazepam oral solution 5 mg/5 ml (1 mg/ ml, 5 ml) diazepam oral tablet 10 mg diazepam oral tablet 2 mg ; QLL (120 per 30 days) ; QLL (240 per 30 days) QLL (120 per 30 days) QLL (240 per 30 days) ; QLL (60 per 30 days) ; QLL (120 per 30 days) PAR; ; QLL (180 per 30 days) PAR; ; QLL (90 per 30 days) ; QLL (90 per 30 days) ; QLL (60 per 30 days) ; QLL (240 per 30 days) ; QLL (240 per 30 days) ; QLL (1200 per 30 days) QLL (1200 per 30 days) ; QLL (120 per 30 days) ; QLL (600 per 30 days) (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 53

55 diazepam oral tablet 5 mg doxepin oral duloxetine oral capsule,delayed release(dr/ec) 20 mg duloxetine oral capsule,delayed release(dr/ec) 30 mg duloxetine oral capsule,delayed release(dr/ec) 40 mg duloxetine oral capsule,delayed release(dr/ec) 60 mg EMSAM ergoloid escitalopram oxalate oral solution escitalopram oxalate oral tablet 10 mg escitalopram oxalate oral tablet 20 mg escitalopram oxalate oral tablet 5 mg FANAPT ORAL TABLET 1 MG FANAPT ORAL TABLET 10 MG FANAPT ORAL TABLET 12 MG FANAPT ORAL TABLET 2 MG FANAPT ORAL TABLET 4 MG FANAPT ORAL TABLET 6 MG FANAPT ORAL TABLET 8 MG FANAPT ORAL TABLETS,DOSE PACK FAZACLO ORAL TABLET,DISINTEGRATING 100 MG ; QLL (240 per 30 days) ; QLL (180 per 30 days) ; QLL (120 per 30 days) ; QLL (90 per 30 days) ; QLL (60 per 30 days) ; QLL (30 per 30 days) ; QLL (600 per 30 days) ; QLL (60 per 30 days) ; QLL (30 per 30 days) ; QLL (120 per 30 days) QLL (720 per 30 days) QLL (72 per 30 days) ; QLL (60 per 30 days) ; QLL (360 per 30 days) ; QLL (180 per 30 days) ; QLL (120 per 30 days) ; QLL (90 per 30 days) ; QLL (16 per 365 days) QLL (270 per 30 days) 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/

56 FAZACLO ORAL TABLET,DISINTEGRATING 12.5 MG FAZACLO ORAL TABLET,DISINTEGRATING 25 MG FETZIMA ORAL CAPSULE,EXT REL 24HR DOSE PACK FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR 120 MG, 80 MG FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR 20 MG FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR 40 MG fluoxetine oral capsule 10 mg fluoxetine oral capsule 20 mg fluoxetine oral capsule 40 mg fluoxetine oral solution fluoxetine oral tablet 10 mg fluoxetine oral tablet 20 mg fluphenazine decanoate fluphenazine hcl fluvoxamine oral tablet 100 mg fluvoxamine oral tablet 25 mg fluvoxamine oral tablet 50 mg GEODON INTRAMUSCULAR guanidine haloperidol haloperidol decanoate QLL (2160 per 30 days) QLL (1080 per 30 days) PAR; ; QLL (56 per 365 days) PAR; ; QLL (30 per 30 days) PAR; ; QLL (180 per 30 days) PAR; ; QLL (90 per 30 days) ; QLL (240 per 30 days) ; QLL (120 per 30 days) ; QLL (60 per 30 days) ; QLL (600 per 30 days) ; QLL (240 per 30 days) ; QLL (120 per 30 days) ; QLL (90 per 30 days) ; QLL (360 per 30 days) ; QLL (180 per 30 days) (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 55

57 haloperidol lactate HETLIOZ imipramine hcl INTUNIV ER INVEGA ORAL TABLET EXTENDED RELEASE 24HR 1.5 MG INVEGA ORAL TABLET EXTENDED RELEASE 24HR 3 MG INVEGA ORAL TABLET EXTENDED RELEASE 24HR 6 MG INVEGA ORAL TABLET EXTENDED RELEASE 24HR 9 MG INVEGA SUSTENNA INVEGA TRINZA INTRAMUSCULAR SYRINGE 273 MG/0.875 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 410 MG/1.315 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 546 MG/1.75 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 819 MG/2.625 ML KHEDEZLA ORAL TABLET EXTENDED RELEASE 24HR 100 MG KHEDEZLA ORAL TABLET EXTENDED RELEASE 24HR 50 MG LATUDA ORAL TABLET 120 MG LATUDA ORAL TABLET 20 MG LATUDA ORAL TABLET 40 MG LATUDA ORAL TABLET 60 MG LATUDA ORAL TABLET 80 MG PAR; ; QLL (30 per 30 days) ; QLL (30 per 30 days) ; QLL (240 per 30 days) ; QLL (120 per 30 days) ; QLL (60 per 30 days) ; QLL (30 per 30 days) ; QLL (2 per 28 days) ; QLL (0.875 per 90 days) ; QLL (1.315 per 90 days) ; QLL (1.75 per 90 days) ; QLL (2.625 per 90 days) ; QLL (120 per 30 days) ; QLL (240 per 30 days) ; QLL (30 per 30 days) ; QLL (240 per 30 days) ; QLL (120 per 30 days) ; QLL (75 per 30 days) ; QLL (60 per 30 days) 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/

58 lithium carbonate lithium citrate oral solution 8 meq/5 ml LORAZEPAM INTENSOL lorazepam oral tablet loxapine succinate LUNESTA maprotiline oral tablet 25 mg maprotiline oral tablet 50 mg maprotiline oral tablet 75 mg MARPLAN METADATE ER methylphenidate oral capsule, er biphasic mg methylphenidate oral capsule, er biphasic mg methylphenidate oral capsule,er biphasic mg methylphenidate oral capsule,er biphasic mg methylphenidate oral tablet methylphenidate oral tablet extended release methylphenidate oral tablet extended release 24hr 18 mg mirtazapine oral tablet 15 mg mirtazapine oral tablet 30 mg ; QLL (90 per 30 days) ; QLL (90 per 30 days) ; QLL (30 per 30 days) ; QLL (270 per 30 days) ; QLL (135 per 30 days) ; QLL (90 per 30 days) ; QLL (60 per 30 days) ; QLL (30 per 30 days) ; QLL (60 per 30 days) ; QLL (30 per 30 days) ; QLL (90 per 30 days) ; QLL (90 per 30 days) ; QLL (90 per 30 days) ; QLL (45 per 30 days) (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 57

59 mirtazapine oral tablet 45 mg mirtazapine oral tablet 7.5 mg mirtazapine oral tablet,disintegrating 15 mg mirtazapine oral tablet,disintegrating 30 mg mirtazapine oral tablet,disintegrating 45 mg modafinil oral tablet 100 mg modafinil oral tablet 200 mg molindone nefazodone oral tablet 100 mg nefazodone oral tablet 150 mg nefazodone oral tablet 200 mg nefazodone oral tablet 250 mg nefazodone oral tablet 50 mg nortriptyline NUPLAZID olanzapine intramuscular olanzapine oral tablet 10 mg olanzapine oral tablet 15 mg olanzapine oral tablet 2.5 mg olanzapine oral tablet 20 mg olanzapine oral tablet 5 mg olanzapine oral tablet 7.5 mg olanzapine oral tablet,disintegrating 10 mg olanzapine oral tablet,disintegrating 15 mg ; QLL (30 per 30 days) ; QLL (180 per 30 days) ; QLL (90 per 30 days) ; QLL (45 per 30 days) ; QLL (30 per 30 days) PAR; ; QLL (30 per 30 days) PAR; ; QLL (60 per 30 days) ; QLL (180 per 30 days) ; QLL (120 per 30 days) ; QLL (90 per 30 days) ; QLL (72 per 30 days) ; QLL (360 per 30 days) PAR; LA; QLL (60 per 30 days) ; QLL (60 per 30 days) ; QLL (60 per 30 days) ; QLL (40 per 30 days) ; QLL (240 per 30 days) ; QLL (30 per 30 days) ; QLL (120 per 30 days) ; QLL (80 per 30 days) ; QLL (60 per 30 days) ; QLL (40 per 30 days) 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/

60 olanzapine oral tablet,disintegrating 20 mg olanzapine oral tablet,disintegrating 5 mg olanzapine-fluoxetine oral capsule mg, mg, 6-50 mg olanzapine-fluoxetine oral capsule 3-25 mg, 6-25 mg ORAP paliperidone oral tablet extended release 24hr 1.5 mg paliperidone oral tablet extended release 24hr 3 mg paliperidone oral tablet extended release 24hr 6 mg paliperidone oral tablet extended release 24hr 9 mg paroxetine hcl oral tablet 10 mg paroxetine hcl oral tablet 20 mg paroxetine hcl oral tablet 30 mg paroxetine hcl oral tablet 40 mg paroxetine hcl oral tablet extended release 24 hr 12.5 mg paroxetine hcl oral tablet extended release 24 hr 25 mg paroxetine hcl oral tablet extended release 24 hr 37.5 mg PAXIL ORAL SUSPENSION perphenazine ; QLL (30 per 30 days) ; QLL (120 per 30 days) ; QLL (30 per 30 days) ; QLL (90 per 30 days) ; QLL (240 per 30 days) ; QLL (120 per 30 days) ; QLL (60 per 30 days) ; QLL (30 per 30 days) ; QLL (180 per 30 days) ; QLL (90 per 30 days) ; QLL (60 per 30 days) ; QLL (45 per 30 days) ; QLL (180 per 30 days) ; QLL (90 per 30 days) ; QLL (60 per 30 days) ; QLL (900 per 30 days) (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 59

61 phenelzine PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 100 MG PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 25 MG PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 50 MG protriptyline quetiapine oral tablet 100 mg quetiapine oral tablet 200 mg quetiapine oral tablet 25 mg quetiapine oral tablet 300 mg quetiapine oral tablet 400 mg quetiapine oral tablet 50 mg REXULTI ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG REXULTI ORAL TABLET 3 MG, 4 MG RISPERDAL CONSTA INTRAMUSCULAR SYRINGE 12.5 MG/2 ML, 25 MG/2 ML, 37.5 MG/2 ML RISPERDAL CONSTA INTRAMUSCULAR SYRINGE 50 MG/2 ML risperidone oral solution risperidone oral tablet 0.25 mg risperidone oral tablet 0.5 mg risperidone oral tablet 1 mg risperidone oral tablet 2 mg risperidone oral tablet 3 mg risperidone oral tablet 4 mg ; QLL (120 per 30 days) ; QLL (480 per 30 days) ; QLL (240 per 30 days) ; QLL (240 per 30 days) ; QLL (120 per 30 days) ; QLL (960 per 30 days) ; QLL (80 per 30 days) ; QLL (60 per 30 days) ; QLL (480 per 30 days) PAR; ; QLL (60 per 30 days) PAR; ; QLL (30 per 30 days) ; QLL (2 per 28 days) ; QLL (480 per 30 days) ; QLL (1920 per 30 days) ; QLL (960 per 30 days) ; QLL (480 per 30 days) ; QLL (240 per 30 days) ; QLL (150 per 30 days) ; QLL (120 per 30 days) 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/

62 risperidone oral tablet,disintegrating 0.25 mg risperidone oral tablet,disintegrating 0.5 mg risperidone oral tablet,disintegrating 1 mg risperidone oral tablet,disintegrating 2 mg risperidone oral tablet,disintegrating 3 mg risperidone oral tablet,disintegrating 4 mg ROZEREM SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 10 MG SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 2.5 MG SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 5 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 150 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 200 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 300 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 400 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 50 MG ; QLL (1920 per 30 days) ; QLL (960 per 30 days) ; QLL (480 per 30 days) ; QLL (240 per 30 days) ; QLL (150 per 30 days) ; QLL (120 per 30 days) ; QLL (30 per 30 days) ; QLL (60 per 30 days) ; QLL (240 per 30 days) ; QLL (120 per 30 days) ; QLL (150 per 30 days) ; QLL (120 per 30 days) ; QLL (80 per 30 days) ; QLL (60 per 30 days) ; QLL (480 per 30 days) (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 61

63 sertraline oral concentrate sertraline oral tablet 100 mg sertraline oral tablet 25 mg sertraline oral tablet 50 mg SLEEP AID (DOXYLAMINE) STRATTERA ORAL CAPSULE 10 MG, 18 MG, 25 MG, 40 MG STRATTERA ORAL CAPSULE 100 MG, 60 MG, 80 MG SURNTIL temazepam oral capsule 15 mg, 22.5 mg, 30 mg thioridazine thiothixene tranylcypromine trazodone trifluoperazine trintellix oral tablet 10 mg trintellix oral tablet 20 mg trintellix oral tablet 5 mg ULTRA SLEEP (DOXYLAMINE SUCC) venlafaxine oral capsule,extended release 24hr 150 mg venlafaxine oral capsule,extended release 24hr 37.5 mg venlafaxine oral capsule,extended release 24hr 75 mg venlafaxine oral tablet 100 mg venlafaxine oral tablet 25 mg ; QLL (300 per 30 days) ; QLL (60 per 30 days) ; QLL (240 per 30 days) ; QLL (120 per 30 days) ; QLL (60 per 30 days) ; QLL (30 per 30 days) ; QLL (30 per 30 days) QLL (60 per 30 days) QLL (30 per 30 days) QLL (120 per 30 days) ; QLL (60 per 30 days) ; QLL (180 per 30 days) ; QLL (90 per 30 days) ; QLL (113 per 30 days) ; QLL (450 per 30 days) 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/

64 venlafaxine oral tablet 37.5 mg venlafaxine oral tablet 50 mg venlafaxine oral tablet 75 mg venlafaxine oral tablet extended release 24hr 150 mg venlafaxine oral tablet extended release 24hr 37.5 mg venlafaxine oral tablet extended release 24hr 75 mg VERSACLOZ VIIBRYD ORAL TABLET 10 MG VIIBRYD ORAL TABLET 20 MG VIIBRYD ORAL TABLET 40 MG VRAYLAR ORAL CAPSULE VRAYLAR ORAL CAPSULE,DOSE PACK XYREM zaleplon oral capsule 10 mg zaleplon oral capsule 5 mg zenzedi oral tablet 10 mg zenzedi oral tablet 5 mg ziprasidone hcl oral capsule 20 mg ziprasidone hcl oral capsule 40 mg ziprasidone hcl oral capsule 60 mg, 80 mg ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 210 MG, 405 MG ; QLL (300 per 30 days) ; QLL (225 per 30 days) ; QLL (150 per 30 days) ; QLL (60 per 30 days) ; QLL (180 per 30 days) ; QLL (90 per 30 days) QLL (600 per 30 days) ; QLL (120 per 30 days) ; QLL (60 per 30 days) ; QLL (30 per 30 days) PAR; QLL (30 per 30 days) PAR; QLL (7 per 365 days) PAR; ; LA; QLL (540 per 30 days) ; QLL (60 per 30 days) ; QLL (30 per 30 days) PAR; ; QLL (180 per 30 days) PAR; ; QLL (90 per 30 days) ; QLL (240 per 30 days) ; QLL (120 per 30 days) ; QLL (60 per 30 days) QLL (2 per 28 days) (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 63

65 ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 300 MG CARDIOVASCULAR, HYPERTENSION / LIPIDS ANTIARRHYTHMIC AGENTS ; QLL (2 per 28 days) amiodarone intravenous solution amiodarone intravenous syringe amiodarone oral dofetilide flecainide lidocaine (pf) intravenous solution lidocaine (pf) intravenous syringe 100 mg/5 ml (2 %) mexiletine MULTAQ pacerone oral tablet 100 mg, 200 mg, 400 mg procainamide injection solution 100 mg/ml procainamide injection solution 500 mg/ml propafenone oral tablet quinidine gluconate oral quinidine sulfate oral tablet sorine oral tablet 120 mg, 160 mg, 80 mg sorine oral tablet 240 mg sotalol af sotalol oral TIKOSYN B/D; B/D ; QLL (60 per 30 days) 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/

66 ANTIHYPERTENSIVE THERAPY acebutolol afeditab cr amiloride amiloride-hydrochlorothiazide amlodipine besylate oral tablet 10 mg, 2.5 mg amlodipine besylate oral tablet 5 mg amlodipine-benazepril atenolol atenolol-chlorthalidone benazepril benazepril-hydrochlorothiazide betaxolol oral bisoprolol fumarate bisoprolol-hydrochlorothiazide bumetanide candesartan oral tablet 16 mg, 4 mg, 8 mg candesartan oral tablet 32 mg candesartan-hydrochlorothiazid oral tablet mg candesartan-hydrochlorothiazid oral tablet mg, mg captopril captopril-hydrochlorothiazide cartia xt ; QLL (30 per 30 days) ; QLL (45 per 30 days) ; QLL (60 per 30 days) ; QLL (30 per 30 days) ; QLL (60 per 30 days) ; QLL (30 per 30 days) (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 65

67 carvedilol chlorothiazide chlorthalidone oral tablet 25 mg, 50 mg clonidine hcl oral tablet clonidine transdermal patch DEMSER dilt-xr diltiazem hcl intravenous solution diltiazem hcl oral capsule, extended release 120 mg, 180 mg, 240 mg, 300 mg, 360 mg diltiazem hcl oral capsule,ext release degradable diltiazem hcl oral capsule,extended release 12 hr diltiazem hcl oral capsule,extended release 24hr diltiazem hcl oral tablet diltiazem hcl oral tablet extended release 24 hr doxazosin enalapril maleate enalapril-hydrochlorothiazide eplerenone eprosartan felodipine oral er fosinopril fosinopril-hydrochlorothiazide ; QLL (4 per 28 days) ; QLL (30 per 30 days) 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/

68 furosemide injection solution furosemide oral solution 10 mg/ml, 40 mg/5 ml (8 mg/ml) furosemide oral tablet hydralazine hydrochlorothiazide indapamide irbesartan labetalol intravenous solution labetalol oral lisinopril lisinopril-hydrochlorothiazide losartan oral tablet 100 mg losartan oral tablet 25 mg, 50 mg losartan-hydrochlorothiazide matzim la methyclothiazide methyldopa methyldopa-hydrochlorothiazide methyldopate metolazone metoprolol succinate metoprolol ta-hydrochlorothiaz metoprolol tartrate intravenous solution ; QLL (30 per 30 days) ; QLL (30 per 30 days) ; QLL (60 per 30 days) ; QLL (30 per 30 days) (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 67

69 metoprolol tartrate intravenous syringe metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg minoxidil oral nadolol nadolol-bendroflumethiazide nicardipine oral nifedical xl nifedipine oral tablet extended release nifedipine oral tablet extended release 24hr pindolol prazosin oral propranolol intravenous propranolol oral propranolol-hydrochlorothiazid quinapril quinapril-hydrochlorothiazide ramipril spironolacton-hydrochlorothiaz spironolactone taztia xt telmisartan oral tablet 20 mg, 40 mg telmisartan oral tablet 80 mg terazosin timolol maleate oral ; QLL (30 per 30 days) ; QLL (60 per 30 days) 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/

70 torsemide oral trandolapril triamterene-hydrochlorothiazid oral capsule mg triamterene-hydrochlorothiazid oral tablet valsartan oral tablet 160 mg valsartan oral tablet 320 mg valsartan oral tablet 40 mg, 80 mg valsartan-hydrochlorothiazide verapamil intravenous solution verapamil oral capsule, 24 hr er pellet ct verapamil oral capsule,ext rel. pellets 24 hr verapamil oral tablet verapamil oral tablet extended release 120 mg (24 hours) verapamil oral tablet extended release 120 mg, 180 mg, 240 mg CARDIAC GLYCOSIDES digox oral tablet 125 mcg digoxin injection solution digoxin oral solution 50 mcg/ml digoxin oral tablet 125 mcg LANOXIN ORAL TABLET 125 MCG, 62.5 MCG ; QLL (60 per 30 days) ; QLL (30 per 30 days) ; QLL (90 per 30 days) ; QLL (30 per 30 days) (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 69

71 COAGULATION THERAPY AGGRENOX BRILINTA cilostazol clopidogrel oral tablet 300 mg clopidogrel oral tablet 75 mg EFFIENT ELIQUIS ORAL TABLET 2.5 MG ELIQUIS ORAL TABLET 5 MG enoxaparin subcutaneous solution enoxaparin subcutaneous syringe 100 mg/ml, 150 mg/ml enoxaparin subcutaneous syringe 120 mg/0.8 ml, 80 mg/0.8 ml enoxaparin subcutaneous syringe 30 mg/0.3 ml enoxaparin subcutaneous syringe 40 mg/0.4 ml enoxaparin subcutaneous syringe 60 mg/0.6 ml fondaparinux subcutaneous syringe 10 mg/0.8 ml fondaparinux subcutaneous syringe 2.5 mg/0.5 ml fondaparinux subcutaneous syringe 5 mg/0.4 ml fondaparinux subcutaneous syringe 7.5 mg/0.6 ml ; QLL (60 per 30 days) ; QLL (60 per 30 days) ; QLL (1 per 30 days) ; QLL (30 per 30 days) ; QLL (30 per 30 days) ; QLL (60 per 30 days) ; QLL (74 per 30 days) ; QLL (84 per 30 days) ; QLL (28 per 30 days) ; QLL (22.4 per 30 days) ; QLL (8.4 per 30 days) ; QLL (11.2 per 30 days) ; QLL (16.8 per 30 days) ; QLL (24 per 30 days) ; QLL (15 per 30 days) ; QLL (12 per 30 days) ; QLL (18 per 30 days) 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/

72 FRAGMIN SUBCUTANEOUS SYRINGE 2,500 ANTI-XA UNIT/0.2 ML, 5,000 ANTI-XA UNIT/ 0.2 ML heparin (porcine) in 5 % dex intravenous parenteral solution 12, 500 unit/250 ml heparin (porcine) in 5 % dex intravenous parenteral solution 25, 000 unit/250 ml(100 unit/ml), 25,000 unit/500 ml (50 unit/ml) heparin (porcine) in nacl (pf) intravenous parenteral solution 1,000 unit/500 ml, 2,000 unit/1,000 ml heparin (porcine) injection cartridge heparin (porcine) injection solution HEPARIN FLUSH heparin lock flush intravenous kit 100 unit/ml heparin lock flush intravenous solution 10 unit/ml, 100 unit/ml heparin lock flush intravenous syringe 10 unit/ml HEPARIN LOCK FLUSH INTRAVENOUS SYRINGE 100 UNIT/ML HEPARIN LOCKFLUSH(PORCINE)(PF) HEPARIN(PORCINE) IN 0.45% NACL INTRAVENOUS PARENTERAL SOLUTION 12, 500 UNIT/250 ML $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) B/D; HI B/D; ; HI B/D; HI B/D; ; HI B/D; ; HI ; B/D; ; B/D; B/D; ; B/D; ; B/D (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 71

73 heparin(porcine) in 0.45% nacl intravenous parenteral solution 25, 000 unit/250 ml, 25,000 unit/500 ml heparin, porcine (pf) injection solution heparin, porcine (pf) intravenous solution 100 unit/ml (1 ml) HEPARIN, PORCINE (PF) INTRAVENOUS SYRINGE 1 UNIT/ML heparin, porcine (pf) intravenous syringe 10 unit/ml, 100 unit/ml jantoven MEPHYTON NOJECT PREFILL (PF) pentoxifylline PRADAXA ORAL CAPSULE 110 MG PRADAXA ORAL CAPSULE 150 MG, 75 MG PROMACTA ORAL TABLET 12.5 MG, 25 MG, 75 MG PROMACTA ORAL TABLET 50 MG tranexamic acid intravenous warfarin XARELTO ORAL TABLET 10 MG, 20 MG XARELTO ORAL TABLET 15 MG $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) B/D; B/D; B/D; B/D; B/D; ; ; B/D; ; QLL (60 per 30 days) PAR; ; LA; QLL (30 per 30 days) PAR; ; LA; QLL (60 per 30 days) ; QLL (30 per 30 days) ; QLL (42 per 30 days) XARELTO ORAL TABLETS,DOSE PACK LIPID/CHOLESTEROL LOWERING AGENTS ; QLL (102 per 365 days) atorvastatin cholestyramine (with sugar) cholestyramine light ; QLL (30 per 30 days) 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/

74 colestipol fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg fenofibrate nanocrystallized 48 mg, 145 mg fenofibrate oral tablet 160 mg, 54 mg gemfibrozil oral JUXTAPID KYNAMRO lovastatin oral tablet 10 mg, 20 mg lovastatin oral tablet 40 mg niacin oral capsule, extended release 250 mg, 500 mg niacin oral tablet 100 mg, 50 mg, 500 mg NIACIN ORAL TABLET 250 MG niacin oral tablet extended release 24 hr 1,000 mg, 750 mg niacin oral tablet extended release 24 hr 500 mg niacin oral tablet extended release 250 mg, 750 mg NIACOR NIASPAN EXTENDED-RELEASE ORAL TABLET EXTENDED RELEASE 24 HR 1,000 MG, 750 MG NIASPAN EXTENDED-RELEASE ORAL TABLET EXTENDED RELEASE 24 HR 500 MG omega-3 acid ethyl esters ; QLL (30 per 30 days) ; QLL (30 per 30 days) PAR; ; LA PAR; ; LA ; QLL (30 per 30 days) ; QLL (60 per 30 days) ; ; ; ; QLL (60 per 30 days) ; QLL (30 per 30 days) ; ; QLL (60 per 30 days) ; QLL (30 per 30 days) (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 73

75 PRALUENT PEN PRALUENT SYRINGE pravastatin prevalite REPATHA PUSHTRONEX REPATHA SURECLICK REPATHA SYRINGE simvastatin WELCHOL PAR; ; QLL (2 per 28 days) PAR; ; QLL (2 per 28 days) ; QLL (30 per 30 days) PAR; QLL (3.5 per 28 days) PAR; ; QLL (3 per 28 days) PAR; ; QLL (3 per 28 days) ; QLL (30 per 30 days) ZETIA MISCELLANEOUS CARDIOVASCULAR AGENTS ; QLL (30 per 30 days) RANEXA VECAMYL NITRATES isosorbide dinitrate oral isosorbide mononitrate nitro-bid nitroglycerin intravenous nitroglycerin sublingual nitroglycerin transdermal patch 24 hour B/D NITROSTAT DERMATOLOGICALS/TOPICAL THERAPY ANTIPSORIATIC / ANTISEBORRHEIC calcipotriene scalp calcipotriene topical selenium sulfide topical lotion ; QLL (60 per 30 days) ; QLL (120 per 30 days) 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/

76 SORIATANE ORAL CAPSULE 10 MG, 17.5 MG, 25 MG VECTICAL BURN THERAPY silver sulfadiazine ssd thermazene KERATOLYTICS SALICYLIC ACID TOPICAL LIQUID 3 % SCALP RELIEF HYDROCORTISONE TOPICAL LIQUID 3 % MISCELLANEOUS DERMATOLOGICALS 8-P AMLACTIN TOPICAL LOTION ammonium lactate AMNIUM LACTATE TOPICAL LOTION 12 % AMNIUM LACTATE TOPICAL LOTION 5 % calamine CALAMINE-ZINC OXIDE TOPICAL LOTION 8-8 % diclofenac sodium topical gel 3 % ELIDEL fluorouracil topical cream 5 % GORMEL TEN imiquimod methoxsalen rapid PAR; ; ; ; PAR; ; QLL (100 per 30 days) PAR; ; QLL (100 per 90 days) PAR; (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 75

77 OXSORALEN PANRETIN PICATO podofilox PROTOPIC SKIN TREATMENT urea topical cream 10 %, 20 % urea topical lotion 10 % UREACIN-20 UVADEX VALCHLOR THERAPY FOR ACNE ACNE TREATMENT (BENZOYL PEROX) TOPICAL GEL ACNE-CLEAR benzoyl peroxide topical gel 10 %, 5 % BP clindamycin phosphate topical DIFFERIN TOPICAL GEL 0.3 % DIFFERIN TOPICAL GEL WITH PUMP ery pads erythromycin with ethanol erythromycin-benzoyl peroxide metronidazole topical cream metronidazole topical gel 0.75 % metronidazole topical lotion PERSA-GEL rosadan topical cream PAR; ; QLL (100 per 90 days) ; ; ; 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/

78 TAZORAC tretinoin topical cream tretinoin topical gel 0.01 %, % TOPICAL ANESTHETICS lidocaine (pf) injection solution 10 mg/ml (1 %), 20 mg/ml (2 %), 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 %) lidocaine hcl injection solution 5 mg/ ml (0.5 %) lidocaine hcl laryngotracheal lidocaine hcl mucous membrane lidocaine hcl urethral lidocaine topical adhesive patch, medicated lidocaine topical ointment lidocaine viscous lidocaine-prilocaine topical cream TOPICAL ANTIBACTERIALS ANTIBIOTIC (NEOMY-BACIT-POLYM) ANTIBIOTIC-PAIN RELIEF (BACIT) bacitracin topical ointment BACITRACIN TOPICAL PACKET BACITRACIN ZINC TOPICAL PACKET ; QLL (45 per 30 days) ; QLL (45 per 30 days) PAR; ; QLL (90 per 30 days) ; (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 77

79 bacitracin-polymyxin b topical ointment bacitracin-polymyxin b topical packet BACITRAYCIN PLUS TOPICAL OINTMENT 500 UNIT/GRAM DOUBLE ANTIBIOTIC gentamicin topical mupirocin topical ointment NEOSPORIN PLUS PAINRELIEF(BAC) POLY BACITRACIN sulfacetamide sodium (acne) SULFAMYLON TRI-BIOZENE TRIPLE ANTIBIOTIC (PRAM) EXTRA TRIPLE ANTIBIOTIC PLUS TRIPLE ANTIBIOTIC TOPICAL OINTMENT TRIPLE ANTIBIOTIC TOPICAL OINTMENT IN PACKET TRIPLE ANTIBIOTIC-PAIN RELIEF TOPICAL ANTIFUNGALS ANTI-FUNGAL MICONAZOLE POWDER TOPICAL POWDER 2 % ANTIFUNGAL (CLOTRIMAZOLE) ANTIFUNGAL (TOLNAFTATE) TOPICAL AEROSOL,SPRAY ANTIFUNGAL (TOLNAFTATE) TOPICAL CREAM ANTIFUNGAL MICONAZOLE CREAM ATHLETE'S FOOT (TERBINAFINE) ; ; ; 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/

80 ATHLETE'S FOOT (TOLNAFTATE) ATHLETE'S FOOT AF ciclodan topical solution ciclopirox topical cream ciclopirox topical gel ciclopirox topical shampoo ciclopirox topical solution ciclopirox topical suspension CLOTRIMAZOLE AF CLOTRIMAZOLE ANTIFUNGAL clotrimazole topical clotrimazole-betamethasone DESENEX TOPICAL POWDER econazole topical FUNGOID-D INZO ANTIFUNGAL JOCK ITCH JOCK ITCH (CLOTRIMAZOLE) JOCK ITCH (TERBINAFINE) ketoconazole topical LAMISIL AT TOPICAL CREAM LOTRIMIN AF TOPICAL CREAM LOTRIMIN AF TOPICAL POWDER MICATIN miconazole nitrate topical cream MICONAZORB AF PAR; PAR; ; ; ; ; ; (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 79

81 MICRO-GUARD nyamyc nystatin topical nystatin-triamcinolone nystop ODOR CONTROL FOOT-SNEAKER RINGWORM SECURA ANTIFUNGAL SECURA ANTIFUNGAL EXTRA THICK terbinafine hcl topical TINACTIN TOPICAL AEROSOL POWDER tolnaftate topical aerosol powder tolnaftate topical cream ZEASORB (MICONAZOLE) TOPICAL ANTIVIRALS acyclovir topical DENAVIR TOPICAL CORTICOSTEROIDS ala-cort topical cream alclometasone amcinonide ANTI-ITCH (HC) TOPICAL CREAM ANTI-ITCH (HC) TOPICAL OINTMENT BETA-HC betamethasone dipropionate betamethasone valerate topical cream betamethasone valerate topical lotion ; ; ; ; ; ; QLL (30 per 30 days) ; QLL (5 per 2 days) ; 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/

82 betamethasone valerate topical ointment betamethasone, augmented topical cream betamethasone, augmented topical lotion betamethasone, augmented topical ointment CAPEX clobetasol scalp clobetasol topical cream clobetasol topical gel clobetasol topical ointment clobetasol-emollient topical cream cormax scalp CORTISONE (HYDROCORTISONE) TOPICAL CREAM CORTIZONE-10 PLUS CORTIZONE-10 TOPICAL CREAM CORTIZONE-10 TOPICAL OINTMENT desonide desoximetasone diflorasone ECZEMA ANTI-ITCH fluocinolone fluocinolone and shower cap fluocinonide topical cream 0.05 % (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 81

83 fluocinonide topical gel fluocinonide topical ointment fluocinonide topical solution fluocinonide-e topical cream 0.05 % fluticasone topical cream fluticasone topical ointment halobetasol propionate HALOG hydrocortisone acetate topical HYDROCORTISONE PLUS hydrocortisone topical cream 0.5 % hydrocortisone topical cream 1 %, 2.5 % hydrocortisone topical lotion 1 % hydrocortisone topical lotion 2.5 % hydrocortisone topical ointment 0.5 % hydrocortisone topical ointment 1 %, 2.5 % hydrocortisone valerate hydrocortisone-min oil-wht pet HYDROCREAM HYDROSKIN TOPICAL LOTION LOKARA mometasone topical NEOSPORIN ANTI-ITCH NOBLE FORMULA HC TOPICAL CREAM RECORT PLUS ; ; ; 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/

84 SCALP RELIEF HYDROCORTISONE TOPICAL SOLUTION 1 % SCALPICIN ANTI-ITCH SOOTHING CARE (HYDROCORTISONE) triamcinolone acetonide topical cream triamcinolone acetonide topical lotion triamcinolone acetonide topical ointment %, 0.1 %, 0.5 % trianex triderm topical cream TOPICAL ENZYMES ; SANTYL TOPICAL SCABICIDES / PEDICULICIDES ; QLL (30 per 30 days) COMPLETE LICE TREATMENT LICE BEDDING SPRAY LICE COMPLETE KIT LICE CREAM RINSE LICE KILLING LICE KILLING (PERMETHRIN) LICE PYRINYL SHAMPOO LICE SOLUTION LICE TREATMENT (PERMETHRIN) LICE TREATMENT TOPICAL LIQUID 1 % LICE TREATMENT TOPICAL SHAMPOO lindane topical shampoo permethrin topical cream (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 83

85 permethrin topical liquid RID COMPLETE LICE ELIM KIT TOPICAL ; STOP LICE DIAGNOSTICS / MISCELLANEOUS AGENTS ANOREXIANTS benzphetamine oral tablet 50 mg phentermine ANTIDOTES acetylcysteine intravenous IRRIGATING SOLUTIONS lactated ringers irrigation neomycin-polymyxin b gu ringers irrigation MISCELLANEOUS AGENTS acamprosate ADAGEN alendronate oral tablet 40 mg anagrelide ARALAST NP BUPHENYL ORAL TABLET CARBAGLU cevimeline CLINIMIX 4.25%/D5W SULFIT FREE CLINIMIX E 2.75%/D10W SUL FREE CLINIMIX E 2.75%/D5W SULF FREE d10 %-0.45 % sodium chloride d2.5 %-0.45 % sodium chloride $0 (Tier 3) $0 (Tier 3) PAR; ; PAR; ; B/D; B/D; ; QLL (30 per 30 days) PAR; ; LA PAR; PAR; ; LA B/D; HI B/D; HI B/D; HI HI HI 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/

86 d5 % and 0.9 % sodium chloride d5 %-0.45 % sodium chloride DEX4 GLUCOSE ORAL TABLET,CHEWABLE DEX4 GLUCOSE POUCH PACK DEX4 GLUCOSE QUICK DISSOLVE dextrose 10 % and 0.2 % nacl dextrose 10 % in water (d10w) dextrose 25 % in water (d25w) dextrose 30 % in water (d30w) dextrose 40 % in water (d40w) dextrose 5 % in water (d5w) dextrose 5 %-lactated ringers dextrose 5%-0.2 % sod chloride dextrose 5%-0.3 % sod.chloride dextrose 50 % in water (d50w) intravenous parenteral solution dextrose 50 % in water (d50w) intravenous syringe dextrose 70 % in water (d70w) dextrose oral gel dextrose with sodium chloride disulfiram EXJADE FERRIPROX ORAL SOLUTION FERRIPROX ORAL TABLET GLUCO BURST ; HI ; HI ; HI ; HI ; HI ; HI HI HI B/D; HI PAR; ; LA PAR PAR; (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 85

87 GLUCOSE GEL glucose oral tablet,chewable 4 gram GLUTOSE 15 GLUTOSE 45 INCRELEX INSTA-GLUCOSE kionex (with sorbitol) levocarnitine (with sugar) levocarnitine oral tablet midodrine ORFADIN ORAL CAPSULE 10 MG, 2 MG, 5 MG ORFADIN ORAL CAPSULE 20 MG ORFADIN ORAL SUSPENSION pilocarpine hcl oral RAVICTI RENAGEL RENVELA ORAL POWDER IN PACKET 0.8 GRAM RENVELA ORAL POWDER IN PACKET 2.4 GRAM RENVELA ORAL TABLET riluzole sodium chloride 0.9 % intravenous sodium chloride irrigation sodium polystyrene (sorb free) sodium polystyrene sulfonate oral powder sodium polystyrene sulfonate oral suspension ; ; ; PAR; ; LA ; B/D; LA LA PAR; ; QLL (525 per 30 days) ; QLL (180 per 30 days) ; QLL (90 per 30 days) ; QLL (270 per 30 days) ; HI 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/

88 sodium polystyrene sulfonate rectal enema 30 gram/120 ml SODIUM POLYSTYRENE SULFONATE RECTAL ENEMA 50 GRAM/200 ML sps (with sorbitol) oral sps (with sorbitol) rectal SYPRINE water for irrigation, sterile ZEMAIRA SKING DETERRENTS bupropion hcl (smoking deter) CHANTIX CHANTIX CONTINUING NTH BOX CHANTIX STARTING NTH BOX NICORELIEF nicotine (polacrilex) NICOTINE TRANSDERMAL nicotine transdermal system transdermal patch 24 hour 14 mg/24 hr, 21 mg/24 hr, 7 mg/24 hr nicotine transdermal system transdermal patch, td daily, sequential mg/24 hr NICOTROL NS QUIT 2 QUIT 4 BUCCAL GUM STOP SKING AID PAR; ; LA ; QLL (60 per 30 days) ; QLL (60 per 30 days) ; QLL (56 per 28 days) ; QLL (106 per 365 days) ; ; ; ; ; QLL (120 per 30 days) (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 87

89 EAR, NOSE / THROAT MEDICATIONS MISCELLANEOUS AGENTS ASTEPRO NASAL SPRAY,NON-AEROSOL azelastine nasal aerosol,spray chlorhexidine gluconate mucous membrane ipratropium bromide nasal NASAL MIST oralone paroex oral rinse periogard STERILE SALINE NASAL triamcinolone acetonide dental ; QLL (30 per 25 days) ; QLL (30 per 25 days) ; QLL (30 per 30 days) TYZINE NASAL DROPS 0.05 % MISCELLANEOUS OTIC PREPARATIONS acetic acid otic acetic acid-aluminum acetate fluocinolone acetonide oil hydrocortisone-acetic acid ofloxacin otic OTIC STEROID / ANTIBIOTIC CIPRODEX COLY-MYCIN S neomycin-polymyxin-hc otic ENDOCRINE/DIABETES ADRENAL HORNES ACTHAR H.P. cortisone PAR; 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/

90 dexamethasone dexamethasone sodium phos (pf) dexamethasone sodium phosphate injection fludrocortisone hydrocortisone oral methylprednisolone acetate methylprednisolone oral tablets methylprednisolone sodium succ injection recon soln 125 mg, 40 mg methylprednisolone sodium succ intravenous prednisolone oral solution 15 mg/5 ml prednisolone sodium phosphate oral solution 15 mg/5 ml (3 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml) prednisolone sodium phosphate oral tablet,disintegrating prednisone intensol prednisone oral triamcinolone acetonide injection suspension 10 mg/ml triamcinolone acetonide injection suspension 40 mg/ml ANTITHYROID AGENTS methimazole oral tablet 10 mg, 5 mg propylthiouracil (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 89

91 DIABETES THERAPY acarbose oral tablet 100 mg acarbose oral tablet 25 mg acarbose oral tablet 50 mg alcohol pads BYDUREON BYETTA SUBCUTANEOUS PEN INJECTOR 10 MCG/DOSE(250 MCG/ML) 2.4 ML BYETTA SUBCUTANEOUS PEN INJECTOR 5 MCG/DOSE (250 MCG/ML) 1.2 ML CONDOMS, LATEX, LUBRICATED CONDOMS, LATEX, LUBRICATED DEVICE CONDOMS, LATEX, NON-LUBRICATED DEVICE CYCLOSET FREESTYLE INSULINX STRIP FREESTYLE INSULINX TEST STRIPS FREESTYLE LANCETS FREESTYLE LITE STRIPS FREESTYLE TEST GAUZE PADS 2 X 2 glimepiride oral tablet 1 mg glimepiride oral tablet 2 mg glimepiride oral tablet 4 mg glipizide oral tablet 10 mg glipizide oral tablet 5 mg glipizide oral tablet extended release 24hr 10 mg ; QLL (90 per 30 days) ; QLL (360 per 30 days) ; QLL (180 per 30 days) ; QLL (4 per 28 days) ; QLL (2.4 per 30 days) ; QLL (1.2 per 30 days) ; QLL (180 per 30 days) ; ; QLL (100 per 30 days) ; ; QLL (100 per 30 days) ; ; ; QLL (100 per 30 days) ; ; QLL (100 per 30 days) ; QLL (240 per 30 days) ; QLL (120 per 30 days) ; QLL (60 per 30 days) ; QLL (120 per 30 days) ; QLL (240 per 30 days) ; QLL (60 per 30 days) 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/

92 glipizide oral tablet extended release 24hr 2.5 mg glipizide oral tablet extended release 24hr 5 mg glipizide-metformin oral tablet mg glipizide-metformin oral tablet mg, mg GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT (HUMAN) insulin pen needle INSULIN SYRINGE (DISP) U ML, 1 ML, 1/2 ML INVOKANA ORAL TABLET 100 MG INVOKANA ORAL TABLET 300 MG JANUMET JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 100-1,000 MG JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 50-1,000 MG, MG JANUVIA ORAL TABLET 100 MG JANUVIA ORAL TABLET 25 MG JANUVIA ORAL TABLET 50 MG JARDIANCE LANTUS LANTUS SOLOSTAR LEVEMIR ; QLL (240 per 30 days) ; QLL (120 per 30 days) ; QLL (240 per 30 days) ; QLL (120 per 30 days) PAR; ; QLL (90 per 30 days) PAR; ; QLL (30 per 30 days) ; QLL (60 per 30 days) ; QLL (30 per 30 days) ; QLL (60 per 30 days) ; QLL (30 per 30 days) ; QLL (120 per 30 days) ; QLL (60 per 30 days) PAR; ; QLL (30 per 30 days) (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 91

93 LEVEMIR FLEXTOUCH metformin oral tablet 1,000 mg metformin oral tablet 500 mg metformin oral tablet 850 mg metformin oral tablet extended release 24 hr 500 mg metformin oral tablet extended release 24 hr 750 mg metformin oral tablet extended release 24hr 1,000 mg nateglinide oral tablet 120 mg nateglinide oral tablet 60 mg needles, insulin disp.,safety NOVOLIN 70/30 NOVOLIN N NOVOLIN R NOVOLOG NOVOLOG FLEXPEN NOVOLOG MIX NOVOLOG MIX FLEXPEN NOVOLOG PENFILL pioglitazone oral tablet 15 mg pioglitazone oral tablet 30 mg pioglitazone oral tablet 45 mg pioglitazone-metformin PROGLYCEM repaglinide oral tablet 0.5 mg repaglinide oral tablet 1 mg ; QLL (76 per 30 days) ; QLL (153 per 30 days) ; QLL (90 per 30 days) ; QLL (120 per 30 days) ; QLL (80 per 30 days) ; QLL (75 per 30 days) ; QLL (90 per 30 days) ; QLL (180 per 30 days) ; QLL (90 per 30 days) ; QLL (45 per 30 days) ; QLL (30 per 30 days) ; QLL (90 per 30 days) ; QLL (960 per 30 days) ; QLL (480 per 30 days) 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/

94 repaglinide oral tablet 2 mg SYMLINPEN 120 SYMLINPEN 60 TOUJEO SOLOSTAR VICTOZA 2-PAK VICTOZA 3-PAK MISCELLANEOUS HORNES ALDURAZYME ANDRODERM ANDROGEL TRANSDERMAL GEL IN METERED- DOSE PUMP MG/1.25 GRAM (1.62 %) ANDROGEL TRANSDERMAL GEL IN PACKET 1 % (25 MG/2.5GRAM) ANDROGEL TRANSDERMAL GEL IN PACKET 1 % (50 MG/5 GRAM) ANDROGEL TRANSDERMAL GEL IN PACKET 1.62 % (20.25 MG/1.25 GRAM) ANDROGEL TRANSDERMAL GEL IN PACKET 1.62 % (40.5 MG/2.5 GRAM) androxy AXIRON cabergoline calcitonin (salmon) calcitriol intravenous solution 1 mcg/ ml calcitriol oral capsule CEREZYME INTRAVENOUS RECON SOLN 400 UNIT ; QLL (240 per 30 days) ; QLL (11 per 30 days) ; QLL (6 per 30 days) ; QLL (9 per 30 days) ; QLL (9 per 30 days) PAR; ; QLL (30 per 30 days) ; QLL (150 per 30 days) ; QLL (225 per 30 days) ; QLL (300 per 30 days) ; QLL (112.5 per 30 days) ; QLL (150 per 30 days) PAR; ; QLL (180 per 30 days) ; QLL (4 per 30 days) B/D; B/D; PAR; (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 93

95 danazol oral desmopressin injection desmopressin nasal aerosol,spray desmopressin nasal spray,non-aerosol desmopressin oral ELAPRASE FABRAZYME KORLYM KUVAN ORAL TABLET,SOLUBLE MIACALCIN INJECTION MYOZYME NAGLAZYME NATPARA oxandrolone oral tablet 10 mg oxandrolone oral tablet 2.5 mg pamidronate SENSIPAR ORAL TABLET 30 MG, 60 MG SENSIPAR ORAL TABLET 90 MG SOMAVERT SUBCUTANEOUS RECON SOLN 10 MG, 15 MG, 20 MG SOMAVERT SUBCUTANEOUS RECON SOLN 25 MG, 30 MG STIMATE SYNAREL TESTIM testosterone cypionate testosterone enanthate VPRIV PAR; PAR; PAR; PAR; B/D; PAR; ; LA PAR; ; LA ; QLL (60 per 30 days) ; QLL (120 per 30 days) B/D; ; QLL (60 per 30 days) ; QLL (120 per 30 days) PAR; ; LA PAR; PAR; ; QLL (300 per 30 days) PAR; 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/

96 ZAVESCA zoledronic acid intravenous recon soln 4 mg zoledronic acid intravenous solution 4 mg/5 ml ZOMETA INTRAVENOUS SOLUTION 4 MG/100 ML THYROID HORNES levothyroxine oral levoxyl oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg liothyronine oral SYNTHROID PAR; ; LA UNITHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG GASTROENTEROLOGY ANTIDIARRHEALS / ANTISPASDICS ANTI-DIARRHEAL (LOPERAMIDE) ORAL LIQUID 1 MG/5 ML atropine injection syringe 0.05 mg/ml, 0.1 mg/ml BISMATROL ORAL SUSPENSION 262 MG/15 ML BISMATROL ORAL SUSPENSION 525 MG/15 ML BISMATROL ORAL TABLET,CHEWABLE BISMUTH ; (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 95

97 BISMUTH MAXIMUM STRENGTH DIARRHEA RELIEF (BISMUTH SUBS) dicyclomine oral capsule dicyclomine oral solution dicyclomine oral tablet DIOTAME diphenoxylate-atropine glycopyrrolate oral K-PEC ANTIDIARRHEAL (BISM SUB) KAO-TIN (BISMUTH SUBSALICYLAT) KAOPECTATE (BISMUTH SUBSALICY) KAOPECTATE EX STR (BISMUTH SS) loperamide oral capsule loperamide oral liquid 1 mg/5 ml PEPTIC RELIEF PEPTO-BISL ORAL TABLET,CHEWABLE PEPTO-BISL TO-GO PINK BISMUTH MAXIMUM STRENGTH PINK BISMUTH ORAL SUSPENSION PINK BISMUTH ORAL TABLET PINK BISMUTH ORAL TABLET,CHEWABLE SOOTHE (BISMUTH SUBSALICYLATE) SOOTHE REGULAR STRENGTH STOMACH RELIEF STOMACH RELIEF MAX STRENGTH STOMACH RELIEF ORIGINAL ; ; ; ; 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/

98 MISCELLANEOUS GASTROINTESTINAL AGENTS ACID GONE ANTACID E.STRENGTH ADVANCED ANTACID-ANTIGAS ALOPHEN alosetron ALUMINA AND MAGNESIUM ANTACID ORAL SUSPENSION MG/15 ML ALUMINA AND MAGNESIUM ANTACID ORAL TABLET,CHEWABLE MG ALUMINA, MAGNESIA, SIMETHICONE SUSPENSION ORAL SUSPENSION MG/5 ML, MG/5 ML aluminum hydroxide gel oral suspension 320 mg/5 ml aluminum hydroxide gel oral suspension 600 mg/5 ml ANTACID ANTACID ANTI-GAS ANTACID ANTI-GAS DOUBLE STR ANTACID EXST (MAG CARB-AL HYD) ANTACID EXTRA-STRENGTH ORAL SUSPENSION MG/5 ML ANTACID LIQUID ANTACID MAXIMUM STRENGTH ANTACID PLUS ANTI-GAS ANTACID REGULAR STRENGTH ANTACID WITH SIMETHICONE ANTACID-ANTIGAS ; QLL (60 per 30 days) ; (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 97

99 ANTACID-SIMETHICONE APRISO ASACOL HD balsalazide BISA-LAX BISAC-EVAC bisacodyl oral bisacodyl rectal BISCOLAX budesonide oral CALCIUM CARBONATE AND MAGNESIA ANTACID ORAL SUSPENSION MG/5 ML, MG/5 ML CALCIUM CARBONATE AND MAGNESIA ANTACID ORAL TABLET,CHEWABLE MG CANASA CITRATE OF MAGNESIA CITROMA CLEARLAX COL-RITE colocort COMFORT GEL COMFORT GEL EXTRA STRENGTH compro constulose CREON CYSTADANE ; ; ; ; ; 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/

100 DELZICOL ORAL CAPSULE (WITH DEL REL TABLETS) DIOCTO ORAL LIQUID DIOCTO ORAL SYRUP DIOCTYL DIPENTUM DOC-Q-LACE DOCU DOCUPRENE docusate calcium docusate sodium oral capsule 100 mg docusate sodium oral capsule 250 mg docusate sodium oral liquid docusate sodium oral tablet DOCUSIL DOK ORAL CAPSULE 100 MG DOK ORAL CAPSULE 250 MG DOK ORAL TABLET DRAMAMINE LESS DROWSY dronabinol DSS DUCODYL DULCOLAX STOOL SOFTENER (DSS) EMEND ORAL CAPSULE 125 MG EMEND ORAL CAPSULE 40 MG EMEND ORAL CAPSULE 80 MG ; ; ; ; ; ; ; ; ; B/D; ; QLL (120 per 30 days) ; B/D; ; QLL (5 per 30 days) B/D; ; QLL (1 per 2 days) B/D; ; QLL (10 per 30 days) (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 99

101 EMEND ORAL CAPSULE,DOSE PACK EMEND ORAL SUSPENSION FOR RECONSTITUTION enulose FLANAX ANTACID FLEET GLYCERIN (ADULT) FLEET LAXATIVE GAS RELIEF 80 GAS RELIEF ULTRA STRENGTH GATTEX 30-VIAL GATTEX ONE-VIAL GAVILAX ORAL POWDER gavilyte-c gavilyte-g gavilyte-n generlac GENTLE LAXATIVE GENTLELAX GERI-LANTA GERI-X ANTACID-ANTIGAS glycerin (adult) GLYCOLAX ORAL POWDER HEALTHYLAX HEARTBURN ANTACID HEARTBURN RELIEF hydrocortisone rectal cream 2.5 % hydrocortisone rectal enema KAO-TIN (DOCUSATE CALCIUM) B/D; ; QLL (15 per 30 days) B/D; QLL (15 per 30 days) ; 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/

102 lactulose LAXA CLEAR LAXATIVE (BISACODYL) ORAL TABLET, DELAYED RELEASE (DR/EC) LAXATIVE (BISACODYL) RECTAL LAXATIVE PEG 3350 ORAL POWDER LINZESS LIQUID ANTACID MAALOX MAXIMUM STRENGTH MAG-AL PLUS MAG-AL PLUS EXTRA STRENGTH magnesium citrate oral solution MASANTI DOUBLE STRENGTH meclizine oral tablet 12.5 mg, 25 mg meclizine oral tablet,chewable MEDI-MECLIZINE MESALAMINE ORAL mesalamine rectal mesalamine with cleansing wipe metoclopramide hcl injection solution metoclopramide hcl injection syringe metoclopramide hcl oral solution metoclopramide hcl oral tablet MI-ACID GAS RELIEF MILK OF MAGNESIA MILK OF MAGNESIA CONCENTRATED ; ; ; ; (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 101

103 MINERAL OIL EXTRA HEAVY MINERAL OIL HEAVY ORAL MINERAL OIL LAXATIVE mineral oil oral mineral oil rectal MINTOX MINTOX MAXIMUM STRENGTH MINTOX PLUS MIRALAX ORAL POWDER IN PACKET TION RELIEF (MECLIZINE) TION SICKNESS (MECLIZINE) TION SICKNESS RELIEF(MECLIZ) VIPREP MYTAB GAS MYTAB GAS MAXIMUM STRENGTH ondansetron hcl (pf) injection solution ondansetron hcl (pf) injection syringe ondansetron hcl intravenous ondansetron hcl oral solution ondansetron hcl oral tablet 24 mg ondansetron hcl oral tablet 4 mg, 8 mg ondansetron odt ORAL SALINE LAXATIVE ORAL LIQUID PANCREAZE peg 3350-electrolytes oral recon soln gram ; ; ; ; ; ; ; B/D; ; QLL (450 per 30 days) B/D; QLL (30 per 30 days) B/D; ; QLL (90 per 30 days) B/D; ; QLL (90 per 30 days) 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/

104 peg 3350-electrolytes oral recon soln gram peg-electrolyte soln PENTASA PHOSPHATE LAXATIVE ORAL LIQUID polyethylene glycol 3350 oral powder polyethylene glycol 3350 oral powder in packet POWDERLAX prochlorperazine edisylate injection solution 10 mg/2 ml (5 mg/ml) prochlorperazine maleate oral tablet 10 mg, 5 mg prochlorperazine maleate rectal procto-pak proctosol hc proctozone-hc PROLAXIN PURELAX READY-TO-USE ENEMA (MIN OIL) RELISTOR SUBCUTANEOUS SOLUTION REMICADE RI-GEL RI-GEL II RI-X SANI-SUPP (ADULT) SILACE ORAL LIQUID ; PAR; PAR; ; ; (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 103

105 SILACE ORAL SYRUP SIMETHICONE ORAL CAPSULE 125 MG, 180 MG simethicone oral capsule 180 mg simethicone oral tablet,chewable SIMETHICONE ORAL TABLET,CHEWABLE 125 MG SIMETHICONE ORAL TABLET,CHEWABLE 125 MG, 80 MG SOTHLAX SOF-LAX STOOL SOFTENER ORAL CAPSULE 100 MG, 240 MG, 250 MG STOOL SOFTENER ORAL CAPSULE 50 MG STOOL SOFTENER ORAL LIQUID STOOL SOFTENER ORAL SYRUP STOOL SOFTENER ORAL TABLET sulfasalazine SUPPOSITORY ADULT SUPREP BOWEL PREP KIT SURFAK THE MAGIC BULLET TRANSDERM-SCOP TRAVEL SICKNESS (MECLIZINE) ursodiol WOMAN'S LAXATIVE ORAL TABLET,DELAYED RELEASE (DR/EC) WOMEN'S GENTLE LAXATIVE(BISAC) ; ; ; ; ; QLL (4 per 12 days) ; 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/

106 WOMEN'S LAXATIVE (BISACODYL) ORAL TABLET,DELAYED RELEASE (DR/EC) ULCER THERAPY ACID CONTROL (RANITIDINE) ORAL TABLET 150 MG ACID REDUCER (FATIDINE) ACID REDUCER (RANITIDINE) DEXILANT famotidine (pf) famotidine (pf)-nacl (iso-os) famotidine intravenous famotidine oral suspension famotidine oral tablet 10 mg famotidine oral tablet 20 mg, 40 mg HEARTBURN PREVENTION HEARTBURN RELIEF (FATIDINE) HEARTBURN RELIEF (RANITIDINE) lansoprazole oral capsule,delayed release(dr/ec) misoprostol omeprazole oral capsule,delayed release(dr/ec) OMEPRAZOLE ORAL TABLET,DELAYED RELEASE (DR/EC) pantoprazole PEPCID AC ORAL TABLET 20 MG PROTONIX INTRAVENOUS ; QLL (30 per 30 days) ; ; QLL (30 per 30 days) ; ; (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 105

107 ranitidine hcl oral syrup ranitidine hcl oral tablet 150 mg, 300 mg ranitidine hcl oral tablet 75 mg ; sucralfate oral tablet IMMUNOLOGY, VACCINES / BIOTECHNOLOGY BIOTECHNOLOGY DRUGS ACTIMMUNE ARANESP (IN POLYSORBATE) INJECTION SOLUTION 100 MCG/ML, 200 MCG/ML, 25 MCG/ML, 300 MCG/ML, 40 MCG/ML, 60 MCG/ ML ARANESP (IN POLYSORBATE) INJECTION SYRINGE 10 MCG/0.4 ML, 200 MCG/0.4 ML, 40 MCG/0.4 ML ARANESP (IN POLYSORBATE) INJECTION SYRINGE 100 MCG/0.5 ML ARANESP (IN POLYSORBATE) INJECTION SYRINGE 150 MCG/0.3 ML, 60 MCG/0.3 ML ARANESP (IN POLYSORBATE) INJECTION SYRINGE 25 MCG/0.42 ML ARANESP (IN POLYSORBATE) INJECTION SYRINGE 300 MCG/0.6 ML ARANESP (IN POLYSORBATE) INJECTION SYRINGE 500 MCG/ML ARCALYST AVONEX (WITH ALBUMIN) AVONEX INTRAMUSCULAR PEN INJECTOR KIT AVONEX INTRAMUSCULAR SYRINGE AVONEX INTRAMUSCULAR SYRINGE KIT PAR; PAR; ; QLL (4 per 28 days) PAR; ; QLL (1.6 per 28 days) PAR; ; QLL (2 per 28 days) PAR; ; QLL (1.2 per 28 days) PAR; ; QLL (1.68 per 28 days) PAR; ; QLL (2.4 per 28 days) PAR; ; QLL (4 per 28 days) PAR; PAR; ; QLL (4 per 28 days) PAR; ; QLL (4 per 28 days) PAR; ; QLL (4 per 28 days) PAR; ; QLL (4 per 28 days) 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/

108 BETASERON SUBCUTANEOUS KIT GENOTROPIN GENOTROPIN MINIQUICK HUMATROPE INJECTION CARTRIDGE 12 MG (36 UNIT), 24 MG (72 UNIT) ILARIS (PF) INTRON A INJECTION LEUKINE INJECTION RECON SOLN ZOBIL NEULASTA SUBCUTANEOUS SYRINGE NEUPOGEN NORDITROPIN FLEXPRO SUBCUTANEOUS PEN INJECTOR 10 MG/1.5 ML (6.7 MG/ML), 15 MG/1.5 ML (10 MG/ML), 5 MG/1.5 ML (3.3 MG/ML) PEGINTRON PEGINTRON REDIPEN PROCRIT PROLEUKIN REBIF (WITH ALBUMIN) REBIF REBIDOSE REBIF TITRATION PACK PAR; PAR; PAR; PAR; PAR; ; LA PAR; PAR; PAR; ; QLL (2 per 28 days) PAR; PAR; PAR; PAR; ; QLL (4 per 28 days) PAR; ; QLL (12 per 28 days) PAR; PAR; PAR; SYLATRON PAR; VACCINES / MISCELLANEOUS IMMUNOLOGICALS ACTHIB (PF) ADACEL(TDAP ADOLESN/ADULT)(PF) ATGAM B/D (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 107

109 BCG VACCINE, LIVE (PF) BEXSERO (PF) BOOSTRIX TDAP CARIMUNE NF NANOFILTERED INTRAVENOUS RECON SOLN 12 GRAM, 6 GRAM CERVARIX VACCINE (PF) DAPTACEL (DTAP PEDIATRIC) (PF) ENGERIX-B (PF) ENGERIX-B PEDIATRIC (PF) FLEBOGAMMA DIF GAMASTAN S/D GAMMAGARD LIQUID GAMMAGARD S-D (IGA < 1 MCG/ML) GAMUNEX-C GARDASIL (PF) GARDASIL 9 (PF) HAVRIX (PF) INTRAMUSCULAR SUSPENSION HAVRIX (PF) INTRAMUSCULAR SYRINGE 1, 440 ELISA UNIT/ML HAVRIX (PF) INTRAMUSCULAR SYRINGE 720 ELISA UNIT/0.5 ML HIBERIX (PF) IVAX RABIES VACCINE (PF) INFANRIX (DTAP) (PF) INTRAMUSCULAR SUSPENSION IPOL INJECTION SUSPENSION IXIARO (PF) M-M-R II (PF) PAR; B/D; B/D; PAR; PAR; PAR; PAR; PAR; 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/

110 MENACTRA (PF) INTRAMUSCULAR SOLUTION MENOMUNE - A/C/Y/W-135 MENOMUNE - A/C/Y/W-135 (PF) MENVEO A-C-Y-W-135-DIP (PF) PEDVAX HIB (PF) PENTACEL ACTHIB COMPONENT (PF) PROQUAD (PF) QUADRACEL (PF) RABAVERT (PF) RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 10 MCG/ML RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 5 MCG/0.5 ML ROTARIX ROTATEQ VACCINE tetanus,diphtheria tox ped(pf) TETANUS-DIPHTHERIA TOXOIDS-TD THYGLOBULIN TICE BCG TRUMENBA TWINRIX (PF) TYPHIM VI INTRAMUSCULAR SOLUTION TYPHIM VI INTRAMUSCULAR SYRINGE VAQTA (PF) $0 (Tier 3) B/D; B/D; B/D B/D (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 109

111 VARIVAX (PF) VARIZIG YF-VAX (PF) ZOSTAVAX (PF) MUSCULOSKELETAL / RHEUMATOLOGY GOUT THERAPY allopurinol colchicine-probenecid COLCRYS probenecid OSTEOPOROSIS THERAPY alendronate oral tablet 10 mg, 5 mg alendronate oral tablet 35 mg, 70 mg BONIVA INTRAVENOUS FORTEO ibandronate intravenous ibandronate oral PROLIA raloxifene OTHER RHEUMATOLOGICALS ACTEMRA INTRAVENOUS VIAL BENLYSTA DEPEN TITRATABS ENBREL SUBCUTANEOUS RECON SOLN ENBREL SUBCUTANEOUS SYRINGE 25 MG/ 0.5ML (0.51) ENBREL SUBCUTANEOUS SYRINGE 50 MG/ ML (0.98 ML) ; QLL (30 per 30 days) ; QLL (4 per 28 days) B/D; PAR; ; QLL (3 per 28 days) B/D; ; QLL (1 per 28 days) PAR; ; QLL (2 per 365 days) ; QLL (30 per 30 days) PAR; PAR; PAR; ; QLL (8 per 28 days) PAR; ; QLL (4.08 per 28 days) PAR; ; QLL (8 per 28 days) 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/

112 ENBREL SURECLICK HUMIRA PEDIATRIC CROHN'S START SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML HUMIRA PEDIATRIC CROHN'S START SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML (6 PACK) HUMIRA PEN HUMIRA PEN CROHN'S-UC-HS START HUMIRA PEN PSORIASIS-UVEITIS HUMIRA SUBCUTANEOUS SYRINGE KIT 10 MG/0.2 ML, 20 MG/0.4 ML HUMIRA SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML KINERET leflunomide ORENCIA ORENCIA (WITH MALTOSE) ORENCIA CLICKJECT RIDAURA SAVELLA ORAL TABLET 100 MG SAVELLA ORAL TABLET 12.5 MG SAVELLA ORAL TABLET 25 MG SAVELLA ORAL TABLET 50 MG SAVELLA ORAL TABLETS,DOSE PACK OBSTETRICS / GYNECOLOGY ESTROGENS / PROGESTINS camila PAR; ; QLL (8 per 28 days) PAR; ; QLL (4.8 per 365 days) PAR; QLL (4.8 per 365 days) PAR; ; QLL (3.2 per 28 days) PAR; ; QLL (9.6 per 365 days) PAR; ; QLL (3.2 per 28 days) PAR; ; QLL (2 per 28 days) PAR; ; QLL (3.2 per 28 days) PAR; ; QLL (28 per 28 days) PAR; ; QLL (4 per 28 days) PAR; PAR; QLL (4 per 28 days) ; QLL (60 per 30 days) ; QLL (480 per 30 days) ; QLL (240 per 30 days) ; QLL (120 per 30 days) ; QLL (110 per 365 days) (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 111

113 DEBLITANE DEPO-PROVERA INTRAMUSCULAR SOLUTION 400 MG/ML errin ESTRACE VAGINAL estradiol oral estradiol transdermal patch weekly ESTRING heather hydroxyprogesterone caproate jencycla jolivette lyza medroxyprogesterone intramuscular medroxyprogesterone oral MENEST nora-be norethindrone (contraceptive) norethindrone acetate NORLYROC PREMARIN PREMPHASE PREMPRO SHAROBEL VAGIFEM VIVELLE-DOT MISCELLANEOUS OB/GYN 3-DAY VAGINAL ; QLL (4 per 28 days) ; QLL (1 per 90 days) ; QLL (1 per 90 days) ; QLL (8 per 28 days) ; 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/

114 clindamycin phosphate vaginal CLOTRIMAZOLE 3 DAY clotrimazole vaginal cream CLOTRIMAZOLE-3 CLOTRIMAZOLE-7 metronidazole vaginal MICONAZOLE 3 DAY VAGINAL CREAM MICONAZOLE 7 miconazole nitrate vaginal comb pack, prefill appl, cream miconazole nitrate vaginal cream miconazole nitrate vaginal suppository MICONAZOLE-3 VAGINAL KIT miconazole-3 vaginal suppository NUVARING terconazole tranexamic acid oral VAGINAL CONTRACEPTIVE FOAM ; ; ; ; QLL (6 per 30 days) VAGISTAT-3 ORAL CONTRACEPTIVES / RELATED AGENTS AFTERA altavera (28) alyacen 1/35 (28) alyacen 7/7/7 (28) apri (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 113

115 aranelle (28) AUBRA aviane azurette (28) balziva (28) briellyn caziant (28) cryselle (28) cyclafem 7/7/7 (28) dasetta 7/7/7 (28) DELYLA (28) desog-e.estradiol/e.estradiol drospirenone-ethinyl estradiol oral tablet mg ECONTRA EZ elinest ELLA enpresse FALLBACK SOLO falmina (28) gildagia gildess 1.5/30 (21) jolessa junel 1.5/30 (21) junel 1/20 (21) junel fe 1.5/30 (28) junel fe 1/20 (28) JUNEL FE 24 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/

116 kariva (28) kelnor 1/35 (28) kurvelo LARIN 1.5/30 (21) LARIN FE 1/20 (28) lessina levonest (28) levonorg-eth estrad triphasic levonorgestrel oral tablet 1.5 mg levonorgestrel-ethinyl estrad oral tablet mg-mcg, mg levonorgestrel-ethinyl estrad oral tablets,dose pack,3 month low-ogestrel (28) lutera (28) marlissa MICROGESTIN 1.5/30 (21) MICROGESTIN 1/20 (21) MICROGESTIN FE 1.5/30 (28) MICROGESTIN FE 1/20 (28) MIRCETTE (28) mono-linyah mononessa (28) MY WAY myzilra necon 0.5/35 (28) (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 115

117 necon 1/35 (28) necon 10/11 (28) necon 7/7/7 (28) NEXT CHOICE ONE DOSE norethindrone-e.estradiol-iron norgestimate-ethinyl estradiol oral tablet 0.18/0.215/0.25 mg-35 mcg (28), mg-mcg nortrel 0.5/35 (28) nortrel 1/35 (21) nortrel 1/35 (28) nortrel 7/7/7 (28) ocella ogestrel (28) OPCICON ONE-STEP orsythia philith PIMTREA (28) pirmella portia previfem reclipsen (28) sprintec (28) sronyx syeda TAKE ACTION TARINA FE 1/20 (28) tri-estarylla 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/

118 tri-linyah tri-previfem (28) tri-sprintec (28) trinessa (28) trivora (28) velivet triphasic regimen (28) viorele (28) VYFEMLA (28) zarah zenchent (28) zovia 1/35e (28) zovia 1/50e (28) OPHTHALLOGY ANTIBIOTICS bacitracin ophthalmic bacitracin-polymyxin b ophthalmic ciprofloxacin hcl ophthalmic erythromycin ophthalmic gentak ophthalmic ointment gentamicin ophthalmic NATACYN neo-polycin neomycin-bacitracin-polymyxin neomycin-polymyxin-gramicidin ofloxacin ophthalmic polycin (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 117

119 polymyxin b sulf-trimethoprim tobramycin VIGAX ANTIVIRALS trifluridine ZIRGAN BETA-BLOCKERS betaxolol ophthalmic carteolol levobunolol ophthalmic drops 0.5 % metipranolol timolol maleate ophthalmic CHOLINESTERASE INHIBITOR MIOTICS PHOSPHOLINE IODIDE CYCLOPLEGIC MYDRIATICS atropine ophthalmic drops MISCELLANEOUS OPHTHALLOGICS AKWA TEARS (POLYVINYL ALCOHOL) ALAWAY ALLERGY EYE (KETOTIFEN) ARTIFICIAL TEARS (PF) OPHTHALMIC DROPPERETTE % ARTIFICIAL TEARS (POLYVIN ALC) ARTIFICIAL TEARS(GLYCERIN-PEG) ARTIFICIAL TEARS(PG-HYPM-GLYC) ARTIFICIAL TEARS(PVALCH-POVID) azelastine ophthalmic BION TEARS (PF) ; ; ; ; 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/

120 COLLYRIUM cromolyn ophthalmic DRY EYE RELIEF EYE DROP TEARS EYE IRRIGATING SOLUTION EYE ITCH RELIEF EYE STREAM EYE WASH EYE WASH STERILE ITCHY EYE DROPS KETOTIFEN FUM 0.025% EYE DROPS ketotifen fumarate LIQUITEARS LUBRICANT EYE (PG-PEG 400) LUBRICANT EYE DROPS LUBRICANT EYE DROPS (GLYC-PG) LUBRICATING PLUS MEDIWASH MEDIWASH EYE IRRIGANT ISTURE DROPS NATURAL TEARS (PF) OCUSOFT IRRIGATING OPHTH SOLN olopatadine ophthalmic PATADAY PATANOL PAZEO ; ; ; ; ; ; ; (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 119

121 polyvinyl alcohol RESTASIS REVIVE PLUS STERILE EYE WASH TEARS AGAIN (PVA) TEARS NATURALE FREE (PF) ; QLL (60 per 30 days) ; ; ULTRA FRESH NON-STEROIDAL ANTI-INFLAMMATORY AGENTS flurbiprofen ophthalmic drops ILEVRO ketorolac ophthalmic NEVANAC ORAL DRUGS FOR GLAUCOMA acetazolamide acetazolamide sodium methazolamide oral OTHER GLAUCOMA DRUGS AZOPT COMBIGAN dorzolamide dorzolamide-timolol latanoprost LUMIGAN OPHTHALMIC DROPS 0.01 % TRAVATAN Z travoprost (benzalkonium) STEROID-ANTIBIOTIC COMBINATIONS neo-polycin hc 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/

122 neomycin-bacitracin-poly-hc neomycin-polymyxin b-dexameth neomycin-polymyxin-hc ophthalmic tobramycin-dexamethasone opthalmic suspension STEROID-SULFONAMIDE COMBINATIONS BLEPHAMIDE S.O.P. sulfacetamide-prednisolone STEROIDS dexamethasone sodium phosphate ophthalmic DUREZOL fluorometholone prednisolone acetate prednisolone sodium phosphate ophthalmic SULFONAMIDES sulfacetamide sodium ophthalmic drops SYMPATHOMIMETICS ALPHAGAN P OPHTHALMIC DROPS 0.1 % apraclonidine brimonidine ophthalmic drops 0.2 % VASOCONSTRICTOR DECONGESTANTS LUBRICANT REDNESS RELIEVER OPHTHALMIC DROPS % MAXIMUM REDNESS RELIEF REDNESS RELIEVER LUBRICANT (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 121

123 STERILE EYE DROPS OPHTHALMIC DROPS %, % RESPIRATORY AND ALLERGY ANTIHISTAMINE / ANTIALLERGENIC AGENTS ACTA-TABS PE ADULT TUSSIN CHEST CONGESTION ADULT TUSSIN COUGH CONGEST DM ALA-HIST DM ALAVERT ALKA-SELTZER PLUS ALLERGY ALL DAY ALLERGY (CETIRIZINE) ORAL TABLET ALL DAY ALLERGY RELIEF(CETIR) ALLER-G-TIME ALLER-TEC ALLERGY (DIPHENHYDRAMINE) ALLERGY AND SINUS RELIEF ALLERGY RELIEF (CETIRIZINE) ORAL TABLET ALLERGY RELIEF (CLEMASTINE) ALLERGY RELIEF (LORATADINE) ORAL TABLET ALLERGY RELIEF (LORATADINE) ORAL TABLET,DISINTEGRATING ALLERGY RELIEF(DIPHENHYDRAMIN) AP-HIST DM APRODINE arbinoxa BANOPHEN ALLERGY ; ; ; QLL (30 per 30 days) ; QLL (30 per 30 days) ; ; ; ; 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/

124 BANOPHEN ORAL CAPSULE 25 MG BANOPHEN ORAL CAPSULE 50 MG BANOPHEN ORAL LIQUID BANOPHEN ORAL TABLET benzonatate oral capsule 100 mg, 200 mg BIOCOTRON brompheniramin-phenylephrin-dm oral liquid mg/5 ml cetirizine oral tablet CHERATUSSIN AC clemastine oral tablet 1.34 mg clemastine oral tablet 2.68 mg codeine-guaifenesin COLD AND ALLERGY COLD AND ALLERGY PE COMPLETE ALLERGY COMPLETE ALLERGY MEDICINE COUGH CONTROL (GUAIFENESIN) COUGH CONTROL DM ORAL LIQUID COUGH SYRUP cyproheptadine oral tablet DAYHIST ALLERGY DIABETIC SILTUSSIN DAS-NA DIABETIC SILTUSSIN-DM $0 (Tier 3) ; ; ; ; ; QLL (30 per 30 days) ; ; ; (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 123

125 DIABETIC TUSSIN DM ORAL LIQUID MG/5 ML DIABETIC TUSSIN EX DIPHEDRYL ALLERGY DIPHEDRYL ORAL CAPSULE DIPHEDRYL ORAL LIQUID DIPHEDRYL ORAL TABLET DIPHENHIST ORAL CAPSULE DIPHENHIST ORAL LIQUID DIPHENHIST ORAL TABLET 25 MG diphenhydramine hcl injection solution 50 mg/ml diphenhydramine hcl injection syringe diphenhydramine hcl oral capsule diphenhydramine hcl oral elixir diphenhydramine hcl oral liquid diphenhydramine hcl oral syrup diphenhydramine hcl oral tablet 25 mg DIPHENHYDRAMINE ORAL CAPSULE 25 MG, 50 MG DIPHENHYDRAMINE ORAL ELIXIR 12.5 MG/5 ML DIPHENHYDRAMINE ORAL LIQUID 12.5 MG/5 ML DIPHENHYDRAMINE ORAL SYRUP 12.5 MG/5 ML ED A-HIST ORAL TABLET ED A-HIST PSE ENTRE-HIST PSE ; ; ; ; ; ; ; ; 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/

126 epinephrine injection syringe 0.1 mg/ ml EPIPEN 2-PAK EPIPEN JR 2-PAK EXPECTORANT COUGH SYRUP EXPECTORANT ORAL LIQUID G-TRON GERI-TUSSIN GUAIFENESIN AC guaifenesin oral liquid GUAIFENESIN-DM hydrocodone-chlorpheniramine hydrocodone-homatropine oral syrup mg/5 ml HYDROCODONE-HOMATROPINE ORAL SYRUP MG/5 ML (5 ML) hydrocodone-homatropine oral tablet HYDROMET IOPHEN C-NR IOPHEN DM-NR IOPHEN-NR levocetirizine oral tablet LOHIST-DM LORADAMED loratadine oral tablet loratadine oral tablet,disintegrating $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) ; QLL (2 per 2 days) ; QLL (2 per 2 days) ; ; ; ; ; ; ; ; QLL (30 per 30 days) ; ; ; ; (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 125

127 M-CLEAR WC NASAL DECONGESTANT (PSEUDOEPH) ORAL LIQUID NASAL DECONGESTANT (PSEUDOEPH) ORAL TABLET NASAL DECONGESTANT (PSEUDOEPH) ORAL TABLET EXTENDED RELEASE NIGHTIME SLEEP NIGHTTIME SLEEP AID (DIPHEN) ORAL CAPSULE 50 MG NIGHTTIME SLEEP AID (DIPHEN) ORAL TABLET NON-DROWSY ALLERGY phenadoz PHENYLEPHRINE HCL/DIPHENHYDRAMINE HCL promethazine oral tablet PROMETHAZINE VC-CODEINE promethazine-codeine promethazine-dm promethazine-phenyleph-codeine promethegan rectal suppository 12.5 mg PSEUDOEPHEDRINE 120 MG ER pseudoephedrine hcl oral liquid pseudoephedrine hcl oral tablet 30 mg pseudoephedrine hcl oral tablet 60 mg pseudoephedrine hcl oral tablet extended release $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) ; PAR; ; ; ; ; ; ; ; 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/

128 PSEUDOEPHEDRINE HCL/ CHLORPHENIRAMINE MALEATE ORAL TABLET 4-10 MG, 4-60 MG PSEUDOEPHEDRINE HCL/ CHLORPHENIRAMINE MALEATE TABLET PSEUDOEPHEDRINE HCL/TRIPROLIDINE HCL ORAL TABLET Q-DRYL ORAL CAPSULE Q-DRYL ORAL LIQUID Q-TUSSIN RELCOF C REST SIMPLY NIGHTTIME SLEEP RESTFULLY SLEEP RI-TUSSIN ROBAFEN ROBAFEN DM COUGH RYDEX SCOT-TUSSIN EXPECTORANT SILADRYL SA SILTUSSIN DM DAS SILTUSSIN SA SINUS 12 HOUR SINUS AND ALLERGY PE SINUS-ALLERGY (PHENYLEPHRINE) SLEEP AID (DIPHENHYDRAMINE) ORAL CAPSULE 50 MG ; ; ; (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 127

129 SLEEP AID (DIPHENHYDRAMINE) ORAL TABLET SLEEP AID MAX STR (DIPHENHYDR) SLEEP TABLET (DIPHENHYDRAMINE) SLEEP-TABS SUDOGEST SUDOGEST 12-HOUR SUDOGEST COLD AND ALLERGY SUDOGEST SINUS AND ALLERGY SUPHEDRIN SUPHEDRIN 12 HOUR SUPHEDRINE SUPHEDRINE 12 HOUR SUPHEDRINE PE COLD AND ALLERGY SUPHEDRINE PE SINUS ANDALLERGY TUSNEL DIABETIC TUSSI PRES-B ORAL LIQUID MG/5 ML TUSSIGON TUSSIN CHEST CONGESTION TUSSIN COUGH-CHEST CONGESTION TUSSIN DM COUGH AND CHEST ORAL LIQUID MG/5 ML TUSSIN DM ORAL LIQUID TUSSIN EXPECTORANT TUSSIN HONEY TUSSIN ORAL LIQUID VALU-DRYL ALLERGY ORAL CAPSULE $0 (Tier 3) ; ; ; 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/

130 VIRTUSSIN AC PULNARY AGENTS acetylcysteine ADEMPAS ADVAIR DISKUS ADVAIR HFA albuterol sulfate inhalation solution for nebulization 0.63 mg/3 ml, 1.25 mg/ 3 ml, 2.5 mg /3 ml (0.083 %) albuterol sulfate inhalation solution for nebulization 2.5 mg/0.5 ml, 5 mg/ml albuterol sulfate oral ATROVENT HFA budesonide inhalation suspension for nebulization 0.25 mg/2 ml, 0.5 mg/2 ml CINRYZE COMBIVENT RESPIMAT cromolyn inhalation DALIRESP DULERA ESBRIET FIRAZYR FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 250 MCG/ACTUATION, 50 MCG/ ACTUATION ; B/D; PAR; ; LA ; QLL (60 per 30 days) ; QLL (12 per 30 days) B/D; ; QLL (360 per 30 days) B/D; ; QLL (60 per 30 days) ; QLL (26 per 30 days) B/D; ; QLL (120 per 30 days) PAR; ; QLL (8 per 30 days) B/D; ; QLL (240 per 30 days) PAR; ; QLL (30 per 30 days) ; QLL (13 per 30 days) PAR; QLL (270 per 30 days) ; QLL (60 per 30 days) ; QLL (240 per 30 days) (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 129

131 FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 220 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 44 MCG/ACTUATION flunisolide nasal spray,non-aerosol 25 mcg (0.025 %) fluticasone nasal FORADIL AEROLIZER ipratropium bromide inhalation ipratropium-albuterol KALYDECO ORAL TABLET LETAIRIS levalbuterol hcl inhalation solution for nebulization 0.31 mg/3 ml, 1.25 mg/ 0.5 ml, 1.25 mg/3 ml levalbuterol hcl inhalation solution for nebulization 0.63 mg/3 ml metaproterenol montelukast PROAIR HFA PROAIR RESPICLICK PULZYME QVAR INHALATION AEROSOL 40 MCG/ ACTUATION QVAR INHALATION AEROSOL 80 MCG/ ACTUATION SEREVENT DISKUS sildenafil oral ; QLL (12 per 30 days) ; QLL (24 per 30 days) ; QLL (11 per 30 days) ; QLL (75 per 30 days) ; QLL (16 per 30 days) ; QLL (60 per 30 days) B/D; B/D; ; QLL (540 per 30 days) PAR; ; QLL (60 per 30 days) PAR; ; LA; QLL (30 per 30 days) B/D; ; QLL (270 per 30 days) B/D; ; QLL (540 per 30 days) ; QLL (30 per 30 days) ; QLL (18 per 30 days) ; QLL (2 per 30 days) B/D; ; QLL (9 per 30 days) ; QLL (18 per 30 days) ; QLL (60 per 30 days) PAR; ; QLL (90 per 30 days) 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/

132 sodium chloride inhalation solution for nebulization 0.9 %, 3 % SPIRIVA RESPIMAT SPIRIVA WITH HANDIHALER SYMBICORT terbutaline oral terbutaline subcutaneous theophylline oral tablet extended release 12 hr theophylline oral tablet extended release 24 hr TRACLEER TUDORZA PRESSAIR INHALATION AEROSOL POWDR BREATH ACTIVATED 400 MCG/ ACTUATION TUDORZA PRESSAIR INHALATION AEROSOL POWDR BREATH ACTIVATED 400 MCG/ ACTUATION (30 ACTUAT) VENTAVIS VENTOLIN HFA VOSPIRE ER XOLAIR $0 (Tier 3) ; ; QLL (4 per 30 days) ; QLL (30 per 30 days) ; QLL (11 per 30 days) PAR; ; LA; QLL (60 per 30 days) ; QLL (1 per 30 days) QLL (1 per 30 days) PAR; ; QLL (36 per 30 days) PAR; ; LA; QLL (6 per 28 days) zafirlukast UROLOGICALS ANTICHOLINERGICS / ANTISPASDICS ; QLL (60 per 30 days) MYRBETRIQ oxybutynin chloride oral syrup oxybutynin chloride oral tablet ; QLL (30 per 30 days) ; QLL (600 per 30 days) ; QLL (120 per 30 days) (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 131

133 oxybutynin chloride oral tablet extended release 24hr 10 mg, 15 mg oxybutynin chloride oral tablet extended release 24hr 5 mg tolterodine oral capsule,extended release 24hr tolterodine oral tablet TOVIAZ ; QLL (60 per 30 days) ; QLL (30 per 30 days) ; QLL (30 per 30 days) ; QLL (60 per 30 days) ; QLL (30 per 30 days) VESICARE ; QLL (30 per 30 days) BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPY alfuzosin AVODART dutasteride dutasteride-tamsulosin finasteride oral tablet 5 mg JALYN tamsulosin CHOLINERGIC STIMULANTS bethanechol chloride MISCELLANEOUS UROLOGICALS CYSTAGON potassium citrate oral tablet extended release 10 meq (1,080 mg), 5 meq (540 mg) URINARY ANESTHETICS URINARY PAIN RELIEF ORAL TABLET 95 MG URINARY TRACT ; QLL (30 per 30 days) ; QLL (30 per 30 days) ; QLL (30 per 30 days) ; QLL (30 per 30 days) ; QLL (60 per 30 days) ; LA 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/

134 VITAMINS, HEMATINICS / ELECTROLYTES ELECTROLYTES ALCALAK ANTACID (CALCIUM CARBONATE) ANTACID EXT STR (CALCIUM CARB) ANTACID EXTRA-STRENGTH ORAL TABLET, CHEWABLE 168 MG (420 MG), 300 MG (750 MG) CAL-GEST ANTACID CALCI-CHEW CALCIONATE CALCITRATE CALCIUM 500 CALCIUM D (D3) CALCIUM D ORAL TABLET 500 MG(1, 250MG) -200 UNIT CALCIUM D ORAL TABLET 500 MG(1, 250MG) -400 UNIT CALCIUM D ORAL TABLET,CHEWABLE CALCIUM 500 WITH D CALCIUM 600 CALCIUM D(3) ORAL TABLET 600 MG (1,500MG) -200 UNIT, 600 MG(1,500MG) UNIT CALCIUM 600 WITH VITAMIN D3 ORAL TABLET calcium acetate oral capsule calcium acetate oral tablet 667 mg ; ; ; ; ; ; ; ; (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 133

135 CALCIUM ANTACID ORAL TABLET,CHEWABLE 200 MG CALCIUM (500 MG) CALCIUM ANTACID ORAL TABLET,CHEWABLE 300 MG (750 MG), 400 MG (1,000 MG) CALCIUM ANTACID TROPICAL CALCIUM ANTACID ULTRA MAX ST calcium carbonate - d3 oral tablet 500 mg(1,250mg) -125 unit, 500 mg(1,250mg) -200 unit, 500 mg(1,250mg) -400 unit, 500mg (1,250mg) -600 unit calcium carbonate - d3 oral tablet 600 mg(1,500mg) -200 unit, 600 mg(1,500mg) -400 unit, 600 mg(1,500mg) -800 unit calcium carbonate - d3 oral tablet, chewable 500 mg(1,250mg) -400 unit CALCIUM CARBONATE - D3 ORAL TABLET, CHEWABLE MG-UNIT CALCIUM CARBONATE ANTACID ORAL TABLET,CHEWABLE 400 MG (1,000 MG) CALCIUM CARBONATE ORAL SUSPENSION calcium carbonate oral tablet 500 mg calcium (1,250 mg), 600 mg (1,500 mg) calcium carbonate oral tablet,chewable 200 mg calcium (500 mg), 400 mg (1,000 mg), 500 mg calcium (1,250 mg) CALCIUM CITRATE + D calcium citrate oral tablet 200 mg (950 mg) CALCIUM CITRATE ORAL TABLET 250 MG CALCIUM ; ; ; ; ; ; ; 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/

136 calcium citrate-vitamin d3 oral tablet 200 mg calcium -250 unit, 250 mg calcium- 200 unit calcium citrate-vitamin d3 oral tablet mg-unit, mg-unit CALCIUM GLUCONATE ORAL TABLET 45 MG (500 MG) CALCIUM GLUCONATE ORAL TABLET 60 MG (650 MG) CALCIUM LACTATE ORAL TABLET 84 MG (648 MG) CALCIUM WITH VITAMIN D calcium-magnesium-zinc oral tablet CALCIUM-MAGNESIUM-ZINC ORAL TABLET MG CERASPORT ORAL LIQUID CITRUS CALCIUM ORAL TABLET 200 MG CALCIUM -250 UNIT CITRUS CALCIUM ORAL TABLET MG-UNIT dextrose-kcl-nacl HI-CAL PLUS VIT D KLOR-CON 10 KLOR-CON 8 klor-con m10 KLOR-CON M15 KLOR-CON M20 lactated ringers intravenous ; ; ; ; B/D; HI ; HI (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 135

137 MAGNESIUM OXIDE ORAL CAPSULE 500 MG magnesium sulfate in water intravenous parenteral solution magnesium sulfate in water intravenous piggyback 2 gram/50 ml (4 %), 4 gram/50 ml (8 %) magnesium sulfate in water intravenous piggyback 4 gram/100 ml (4 %) magnesium sulfate injection solution magnesium sulfate injection syringe NORSOL-R NORSOL-R IN 5 % DEXTROSE OYSCO 500/D ORAL TABLET OYSCO D OYSCO-500 OYST-CAL-500 OYSTER SHELL + D3 OYSTER SHELL CALCIUM OYSTER SHELL CALCIUM 500 OYSTER SHELL CALCIUM-VIT D3 OYSTERCAL-D potassium chlorid-d5-0.45%nacl intravenous parenteral solution 10 meq/l, 30 meq/l, 40 meq/l potassium chlorid-d5-0.45%nacl intravenous parenteral solution 20 meq/l HI HI ; ; ; ; ; ; HI ; HI 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/

138 potassium chloride in 0.9%nacl intravenous parenteral solution 20 meq/l potassium chloride in 5 % dex intravenous parenteral solution 20 meq/l, 40 meq/l potassium chloride in 5 % dex intravenous parenteral solution 30 meq/l potassium chloride in lr-d5 intravenous parenteral solution 20 meq/l potassium chloride in lr-d5 intravenous parenteral solution 40 meq/l potassium chloride intravenous piggyback 10 meq/100 ml, 20 meq/100 ml, 20 meq/50 ml, 40 meq/100 ml potassium chloride intravenous piggyback 10 meq/50 ml potassium chloride intravenous piggyback 30 meq/100 ml potassium chloride intravenous solution potassium chloride oral capsule, extended release potassium chloride oral tablet extended release potassium chloride oral tablet,er particles/crystals potassium chloride-0.45 % nacl HI HI ; HI HI ; HI ; HI HI (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 137

139 potassium chloride-d5-0.2%nacl intravenous parenteral solution 20 meq/l potassium chloride-d5-0.2%nacl intravenous parenteral solution 40 meq/l potassium chloride-d5-0.3%nacl intravenous parenteral solution 20 meq/l potassium chloride-d5-0.9%nacl intravenous parenteral solution 20 meq/l potassium chloride-d5-0.9%nacl intravenous parenteral solution 40 meq/l ringers intravenous SOTH ANTACID sodium chloride 0.45 % intravenous parenteral solution sodium chloride 0.45 % intravenous piggyback sodium chloride 3 % sodium chloride 5 % sodium chloride intravenous parenteral solution 2.5 meq/ml sodium chloride intravenous parenteral solution 4 meq/ml SUPER CALCIUM TPN ELECTROLYTES TUMS ULTRA ORAL TABLET,CHEWABLE 400 MG (1,000 MG) ; HI HI ; HI HI B/D; HI ; HI HI ; HI HI ; HI HI ; 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/

140 ULTRA STRENGTH ANTACID ULTRA STRENGTH CALCIUM ANTACID MISCELLANEOUS NUTRITION PRODUCTS AMINOSYN 8.5 % AMINOSYN 8.5 %-ELECTROLYTES AMINOSYN II 10 % AMINOSYN II 7 % AMINOSYN II 8.5 % AMINOSYN II 8.5 %-ELECTROLYTES AMINOSYN M 3.5 % AMINOSYN-HBC 7% AMINOSYN-PF 10 % AMINOSYN-PF 7 % (SULFITE-FREE) CLINIMIX 5%/D15W SULFITE FREE CLINIMIX 5%/D25W SULFITE-FREE CLINIMIX 2.75%/D5W SULFIT FREE CLINIMIX 4.25%-D20W SULF-FREE CLINIMIX 4.25%-D25W SULF-FREE CLINIMIX 4.25%/D10W SULF FREE CLINIMIX 5%-D20W(SULFITE-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 CLINISOL SF 15 % B/D B/D; HI B/D; HI B/D; HI B/D; HI B/D; HI B/D; HI B/D; HI B/D; HI B/D; HI B/D; HI B/D; HI B/D; HI B/D; HI B/D; HI B/D; HI B/D; HI B/D; HI B/D; HI B/D; HI B/D; HI B/D; HI B/D; ; HI (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 139

141 freamine iii 10 % HEPATAMINE 8% intralipid intravenous emulsion 20 % NORSOL-M IN 5 % DEXTROSE NORSOL-R PH 7.4 PLASMA-LYTE 148 PLASMA-LYTE-56 IN 5 % DEXTROSE travasol 10 % TROPHAMINE 10 % TROPHAMINE 6% VITAMINS / HEMATINICS ascorbic acid (vitamin c) oral capsule, extended release ascorbic acid (vitamin c) oral tablet 1,000 mg B-12 DOTS C-500 ORAL TABLET C-500 ORAL TABLET,CHEWABLE CA-D3-MAG OX-ZINC-COP-MANG-BOR ORAL TABLET,CHEWABLE 600 MG CALCIUM- 400 UNIT-40 MG CALCIUM MINERALS calcium carbonate-vit d3-min oral tablet CALCIUM FOR WOMEN CALCIUM SOFT CHEW ORAL TABLET, CHEWABLE MG-UNIT-MCG, MG-UNIT-MCG calcium-vitamin d3-vitamin k oral tablet,chewable mg-unit-mcg B/D B/D; HI B/D; HI HI HI HI B/D; ; HI B/D; ; HI B/D; HI ; ; 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/

142 cholecalciferol (vitamin d3) oral capsule 1,000 unit, 5,000 unit cholecalciferol (vitamin d3) oral capsule 2,000 unit, 400 unit cholecalciferol (vitamin d3) oral drops 400 unit/ml cholecalciferol (vitamin d3) oral tablet 1,000 unit, 5,000 unit cholecalciferol (vitamin d3) oral tablet 2,000 unit, 400 unit CLASSIC PRENATAL cyanocobalamin (vitamin b-12) injection cyanocobalamin (vitamin b-12) oral tablet 1,000 mcg, 100 mcg, 500 mcg cyanocobalamin (vitamin b-12) oral tablet extended release cyanocobalamin (vitamin b-12) sublingual tablet 1,000 mcg cyanocobalamin (vitamin b-12) sublingual tablet 2,500 mcg D-VI-SOL D-VITA D DAILY PRENATAL DELTA D3 DIALYVITE 800 DIALYVITE VITAMIN D $0 (Tier 3) ; ; ; ; ; ; ; ; ; ; ; (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 141

143 ergocalciferol (vitamin d2) oral capsule ergocalciferol (vitamin d2) oral tablet 400 unit EZFE 200 FEOSOL ORAL TABLET 325 MG (65 MG IRON) FERATE ORAL TABLET 240 MG (27 MG IRON) FEROSUL ORAL TABLET FERRETTS FERREX 150 FERRO-TIME ferrous gluconate oral tablet 240 mg (27 mg iron) ferrous gluconate oral tablet 256 mg (28 mg iron) FERROUS GLUCONATE ORAL TABLET 324 MG (36 MG IRON), 324 MG (37.5 MG IRON), 324 MG (38 MG IRON) ferrous sulfate oral tablet 325 mg (65 mg iron) FERROUS SULFATE ORAL TABLET,DELAYED RELEASE (DR/EC) 324 MG (65 MG IRON) ferrous sulfate oral tablet,delayed release (dr/ec) 325 mg (65 mg iron) FERROUSUL folic acid oral tablet 1 mg folic acid oral tablet 400 mcg, 800 mcg FULL SPECTRUM B-VITAMIN C HIGH POTENCY IRON IFEREX 150 $0 (Tier 3) $0 (Tier 3) ; ; ; ; ; ; ; ; ; ; ; ; ; ; ; ; ; 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/

144 IRON (DRIED) IRON (FERROUS SULFATE) IRON HIGH POTENCY IRON ORAL TABLET 325 MG (65 MG IRON) KPN MYFERON 150 ONE DAILY PRENATAL ORAL COMBO PACK MG-MCG-MG OYSTER SHELL CALCIUM-VIT D2 ORAL TABLET 250 (625)-125 MG-UNIT POLY-IRON POLY-VITA POLY-VITAMIN polysaccharide iron complex PRENATAL FORMULA ORAL TABLET 28 MG IRON- 800 MCG PRENATAL ONE DAILY PRENATAL TABLET PRENATAL VITAMIN ORAL CAPSULE MG prenatal vitamin oral tablet PRENATAL VITAMIN ORAL TABLET, MG, 28 MG IRON- 800 MCG PRENATAL VITAMIN ORAL TABLET 27 MG IRON- 800 MCG prenatal vitamin oral tablet 28 mg iron- 800 mcg ; ; ; ; ; (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 143

145 pyridoxine (vitamin b6) oral tablet 100 mg, 25 mg, 50 mg RENA-VITE RISACAL-D SLOW RELEASE IRON ORAL TABLET EXTENDED RELEASE 160 MG (50 MG IRON), 250 MG (50 MG IRON), 47.5 MG IRON sodium fluoride oral tablet sodium fluoride oral tablet,chewable 1 mg fluoride (2.2 mg) STRAWBERRY C THERA-D thiamine hcl (vitamin b1) oral tablet 100 mg, 250 mg, 50 mg thiamine mononitrate (vit b1) VITAMIN A PALMITATE ORAL CAPSULE VITAMIN A PALMITATE ORAL TABLET 10,000 UNIT vitamin a palmitate oral tablet 15,000 unit VITAMIN B-1 VITAMIN B-1 (NONITRATE) VITAMIN B-12 ORAL TABLET 1,000 MCG, 100 MCG, 250 MCG, 500 MCG VITAMIN B-12 ORAL TABLET EXTENDED RELEASE 1,000 MCG VITAMIN B-12 ORAL TABLET EXTENDED RELEASE 2,000 MCG VITAMIN B-12 SUBLINGUAL TABLET 2,500 MCG ; ; ; ; ; ; 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/

146 VITAMIN B-2 VITAMIN B-6 ORAL TABLET 100 MG, 25 MG, 50 MG VITAMIN C ORAL CAPSULE, EXTENDED RELEASE VITAMIN C ORAL TABLET 1,000 MG, 250 MG, 500 MG VITAMIN C ORAL TABLET,CHEWABLE 250 MG, 500 MG VITAMIN C WITH ROSE HIPS ORAL TABLET VITAMIN D2 VITAMIN D3 ORAL CAPSULE 1,000 UNIT, 2, 000 UNIT, 400 UNIT VITAMIN D3 ORAL TABLET 1,000 UNIT, 2, 000 UNIT, 400 UNIT VITAMIN D3 ORAL TABLET 5,000 UNIT VITAMIN E (DL, ACETATE) ORAL CAPSULE 100 UNIT vitamin e oral capsule 1,000 unit, 200 unit, 400 unit vitamin e oral capsule 100 unit $0 (Tier 3) ; ; ; ; ; ; ; ; ; ; ; (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 145

147 索引 3 3-DAY VAGINAL P A abacavir... 9 abacavir-lamivudinezidovudine... 9 ABELCET... 8 ABILIFY MAINTENA ABRAXANE ABSTRAL acamprosate acarbose oral tablet 100 mg acarbose oral tablet 25 mg acarbose oral tablet 50 mg acebutolol ACEPHEN RECTAL SUPPOSITORY 650 MG ACETAMINOPHEN EXTRA STRENGTH ORAL CAPSULE 500 MG ACETAMINOPHEN EXTRA STRENGTH ORAL CAPSULE 500 MG ACETAMINOPHEN EXTRA STRENGTH ORAL LIQUID 500 MG/15 ML ACETAMINOPHEN EXTRA STRENGTH ORAL LIQUID 500 MG/15 ML ACETAMINOPHEN EXTRA STRENGTH ORAL SUSPENSION 160 MG/5 ML ACETAMINOPHEN LIQUID acetaminophen oral suspension 160 mg/5 ml acetaminophen oral tablet 500 mg ACETAMINOPHEN PAIN RELIEF acetaminophen rectal suppository 650 mg acetaminophen-codeine oral solution 120 mg-12 mg /5 ml (5 ml), 240 mg-24 mg /10 ml (10 ml), 300 mg-30 mg /12.5 ml acetaminophen-codeine oral solution mg/5 ml acetaminophen-codeine oral tablet mg acetaminophen-codeine oral tablet mg acetaminophen-codeine oral tablet mg acetazolamide acetazolamide sodium acetic acid otic acetic acid-aluminum acetate acetylcysteine acetylcysteine intravenous ACID CONTROL (RANITIDINE) ORAL TABLET 150 MG ACID GONE ANTACID E.STRENGTH ACID REDUCER (FATIDINE) ACID REDUCER (RANITIDINE) ACNE TREATMENT (BENZOYL PEROX) TOPICAL GEL ACNE-CLEAR ACTA-TABS PE ACTEMRA INTRAVENOUS VIAL ACTHAR H.P ACTHIB (PF) ACTIMMUNE acyclovir oral capsule... 9 acyclovir oral suspension 200 mg/5 ml... 9 acyclovir oral tablet... 9 acyclovir sodium intravenous solution... 9 acyclovir topical ADACEL(TDAP ADOLESN/ ADULT)(PF) ADAGEN ADASUVE ADDED STRENGTH PAIN RELIEVER adefovir... 9 ADEMPAS ADULT LOW DOSE ASPIRIN ADULT TUSSIN CHEST CONGESTION ADULT TUSSIN COUGH CONGEST DM ADVAIR DISKUS ADVAIR HFA ADVANCED ANTACID- ANTIGAS afeditab cr AFINITOR AFINITOR DISPERZ AFTERA AGGRENOX AKWA TEARS (POLYVINYL ALCOHOL) ala-cort topical cream (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全 天候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 146

148 ALA-HIST DM ALAVERT ALAWAY ALBENZA albuterol sulfate inhalation solution for nebulization 0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 mg /3 ml (0.083 %) albuterol sulfate inhalation solution for nebulization 2.5 mg/0.5 ml, 5 mg/ml albuterol sulfate oral ALCALAK alclometasone alcohol pads ALDURAZYME ALECENSA alendronate oral tablet 10 mg, 5 mg alendronate oral tablet 35 mg, 70 mg alendronate oral tablet 40 mg alfuzosin ALIMTA ALINIA ORAL SUSPENSION FOR RECONSTITUTION ALINIA ORAL TABLET ALKA-SELTZER PLUS ALLERGY ALL DAY ALLERGY RELIEF (CETIR) ALL DAY ALLERGY (CETIRIZINE) ORAL TABLET ALL DAY RELIEF ALLER-G-TIME ALLER-TEC ALLERGY AND SINUS RELIEF ALLERGY EYE (KETOTIFEN) ALLERGY RELIEF (CETIRIZINE) ORAL TABLET ALLERGY RELIEF (CLEMASTINE) ALLERGY RELIEF (LORATADINE) ORAL TABLET ALLERGY RELIEF (LORATADINE) ORAL TABLET, DISINTEGRATING ALLERGY RELIEF (DIPHENHYDRAMIN) ALLERGY (DIPHENHYDRAMINE) allopurinol ALOPHEN alosetron ALPHAGAN P OPHTHALMIC DROPS 0.1 % alprazolam oral tablet altavera (28) ALUMINA AND MAGNESIUM ANTACID ORAL SUSPENSION MG/15 ML ALUMINA AND MAGNESIUM ANTACID ORAL TABLET, CHEWABLE MG ALUMINA, MAGNESIA, SIMETHICONE SUSPENSION ORAL SUSPENSION MG/5 ML, MG/5 ML aluminum hydroxide gel oral suspension 320 mg/5 ml aluminum hydroxide gel oral suspension 600 mg/5 ml alyacen 1/35 (28) alyacen 7/7/7 (28) amantadine hcl oral capsule... 9 amantadine hcl oral tablet... 9 AMBISOME... 8 amcinonide amifostine crystalline amikacin injection solution 1,000 mg/4 ml, 500 mg/2 ml amiloride amiloridehydrochlorothiazide AMINOSYN 8.5 % AMINOSYN 8.5 %- ELECTROLYTES AMINOSYN II 10 % AMINOSYN II 7 % AMINOSYN II 8.5 % AMINOSYN II 8.5 %- ELECTROLYTES AMINOSYN M 3.5 % AMINOSYN-HBC 7% AMINOSYN-PF 10 % AMINOSYN-PF 7 % (SULFITE- FREE) amiodarone intravenous solution amiodarone intravenous syringe amiodarone oral amitriptyline AMLACTIN TOPICAL LOTION amlodipine besylate oral tablet 10 mg, 2.5 mg amlodipine besylate oral tablet 5 mg amlodipine-benazepril ammonium lactate AMNIUM LACTATE TOPICAL LOTION 12 % AMNIUM LACTATE TOPICAL LOTION 5 % amoxapine amoxicillin oral capsule amoxicillin oral suspension for reconstitution (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全 天候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 147

149 amoxicillin oral tablet amoxicillin oral tablet, chewable 125 mg, 250 mg amoxicillin-pot clavulanate amphotericin b... 8 ampicillin ampicillin sodium injection ampicillin sodium intravenous recon soln 1 gram ampicillin sodium intravenous recon soln 2 gram ampicillin-sulbactam injection recon soln 1.5 gram, 3 gram ampicillin-sulbactam injection recon soln 15 gram ampicillin-sulbactam intravenous recon soln 3 gram AMPYRA AMRIX anagrelide anastrozole ANDRODERM ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP MG/1.25 GRAM (1.62 %) ANDROGEL TRANSDERMAL GEL IN PACKET 1 % (25 MG/ 2.5GRAM) ANDROGEL TRANSDERMAL GEL IN PACKET 1 % (50 MG/5 GRAM) ANDROGEL TRANSDERMAL GEL IN PACKET 1.62 % (20.25 MG/ 1.25 GRAM) ANDROGEL TRANSDERMAL GEL IN PACKET 1.62 % (40.5 MG/2.5 GRAM) androxy ANTACID ANTACID ANTI-GAS ANTACID ANTI-GAS DOUBLE STR ANTACID EXST (MAG CARB-AL HYD) ANTACID EXT STR (CALCIUM CARB) ANTACID EXTRA-STRENGTH ORAL SUSPENSION MG/5 ML ANTACID EXTRA-STRENGTH ORAL TABLET,CHEWABLE 168 MG (420 MG), 300 MG (750 MG) ANTACID LIQUID ANTACID MAXIMUM STRENGTH ANTACID PLUS ANTI-GAS ANTACID REGULAR STRENGTH ANTACID WITH SIMETHICONE ANTACID (CALCIUM CARBONATE) ANTACID-ANTIGAS ANTACID-SIMETHICONE ANTI-DIARRHEAL (LOPERAMIDE) ORAL LIQUID 1 MG/5 ML ANTI-FUNGAL MICONAZOLE POWDER TOPICAL POWDER 2 % ANTI-ITCH (HC) TOPICAL CREAM ANTI-ITCH (HC) TOPICAL OINTMENT ANTIBIOTIC (NEOMY-BACIT- POLYM) ANTIBIOTIC-PAIN RELIEF (BACIT) ANTIFUNGAL MICONAZOLE CREAM ANTIFUNGAL (CLOTRIMAZOLE) ANTIFUNGAL (TOLNAFTATE) TOPICAL AEROSOL,SPRAY ANTIFUNGAL (TOLNAFTATE) TOPICAL CREAM AP-HIST DM APOKYN apraclonidine apri APRISO APRODINE APTIOM APTIVUS ORAL CAPSULE... 9 APTIVUS ORAL SOLUTION... 9 ARALAST NP aranelle (28) ARANESP (IN POLYSORBATE) INJECTION SOLUTION 100 MCG/ ML, 200 MCG/ML, 25 MCG/ML, 300 MCG/ML, 40 MCG/ML, 60 MCG/ML ARANESP (IN POLYSORBATE) INJECTION SYRINGE 10 MCG/0.4 ML, 200 MCG/0.4 ML, 40 MCG/ 0.4 ML ARANESP (IN POLYSORBATE) INJECTION SYRINGE 100 MCG/ 0.5 ML ARANESP (IN POLYSORBATE) INJECTION SYRINGE 150 MCG/ 0.3 ML, 60 MCG/0.3 ML ARANESP (IN POLYSORBATE) INJECTION SYRINGE 25 MCG/ 0.42 ML ARANESP (IN POLYSORBATE) INJECTION SYRINGE 300 MCG/ 0.6 ML (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全 天候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 148

150 ARANESP (IN POLYSORBATE) INJECTION SYRINGE 500 MCG/ ML arbinoxa ARCALYST aripiprazole oral solution aripiprazole oral tablet 10 mg aripiprazole oral tablet 15 mg aripiprazole oral tablet 2 mg aripiprazole oral tablet 20 mg, 30 mg aripiprazole oral tablet 5 mg aripiprazole oral tablet, disintegrating 10 mg aripiprazole oral tablet, disintegrating 15 mg ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 441 MG/1.6 ML ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 662 MG/2.4 ML ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 882 MG/3.2 ML ARRANON ARTIFICIAL TEARS (PF) OPHTHALMIC DROPPERETTE % ARTIFICIAL TEARS (POLYVIN ALC) ARTIFICIAL TEARS(GLYCERIN- PEG) ARTIFICIAL TEARS(PG-HYPM- GLYC) ARTIFICIAL TEARS(PVALCH- POVID) ARZERRA ASACOL HD ascorbic acid (vitamin c) oral capsule, extended release ascorbic acid (vitamin c) oral tablet 1,000 mg ASPIR-LOW ASPIRIN LOW DOSE aspirin oral tablet ASPIRIN ORAL TABLET 325 MG aspirin oral tablet, chewable ASPIRIN ORAL TABLET,DELAYED RELEASE (DR/EC) 325 MG ASPIRIN ORAL TABLET,DELAYED RELEASE (DR/EC) 325 MG aspirin oral tablet,delayed release (dr/ec) 325 mg, 81 mg ASTAGRAF XL ASTEPRO NASAL SPRAY,NON- AEROSOL atenolol atenololchlorthalidone ATGAM ATHLETE'S FOOT AF ATHLETE'S FOOT (TERBINAFINE) ATHLETE'S FOOT (TOLNAFTATE) atorvastatin atovaquone atovaquone-proguanil oral tablet mg ATRIPLA... 9 atropine injection syringe 0.05 mg/ml, 0.1 mg/ml atropine ophthalmic drops ATROVENT HFA AUBRA AVASTIN INTRAVENOUS SOLUTION 25 MG/ML AVASTIN INTRAVENOUS SOLUTION 25 MG/ML (16 ML) aviane AVODART AVONEX INTRAMUSCULAR PEN INJECTOR KIT AVONEX INTRAMUSCULAR SYRINGE AVONEX INTRAMUSCULAR SYRINGE KIT AVONEX (WITH ALBUMIN) AXIRON azacitidine AZACTAM AZACTAM IN DEXTROSE (ISO- OSM) AZASAN azathioprine azathioprine sodium azelastine nasal aerosol, spray azelastine ophthalmic AZILECT azithromycin intravenous recon soln 500 mg azithromycin intravenous recon soln 500 mg (2 mg/ ml) azithromycin oral suspension for reconstitution azithromycin oral tablet AZOPT azurette (28) B B-12 DOTS (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全 天候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 149

151 baciim bacitracin intramuscular bacitracin ophthalmic bacitracin topical ointment BACITRACIN TOPICAL PACKET BACITRACIN ZINC TOPICAL PACKET bacitracin-polymyxin b ophthalmic bacitracin-polymyxin b topical ointment bacitracin-polymyxin b topical packet BACITRAYCIN PLUS TOPICAL OINTMENT 500 UNIT/GRAM baclofen balsalazide balziva (28) BANOPHEN ALLERGY BANOPHEN ORAL CAPSULE 25 MG BANOPHEN ORAL CAPSULE 50 MG BANOPHEN ORAL LIQUID BANOPHEN ORAL TABLET BANZEL ORAL SUSPENSION BANZEL ORAL TABLET 200 MG BANZEL ORAL TABLET 400 MG BARACLUDE ORAL SOLUTION... 9 BCG VACCINE, LIVE (PF) BELEODAQ benazepril benazeprilhydrochlorothiazide BENDEKA BENLYSTA benzonatate oral capsule 100 mg, 200 mg benzoyl peroxide topical gel 10 %, 5 % benzphetamine oral tablet 50 mg benztropine oral BETA-HC betamethasone dipropionate betamethasone valerate topical cream betamethasone valerate topical lotion betamethasone valerate topical ointment betamethasone, augmented topical cream betamethasone, augmented topical lotion betamethasone, augmented topical ointment BETASERON SUBCUTANEOUS KIT BETATEMP betaxolol ophthalmic betaxolol oral bethanechol chloride bexarotene BEXSERO (PF) bicalutamide BICILLIN C-R INTRAMUSCULAR SYRINGE 1,200,000 UNIT/ 2 ML (600K/600K) BICNU BILTRICIDE BIOCOTRON BION TEARS (PF) BISA-LAX BISAC-EVAC bisacodyl oral bisacodyl rectal BISCOLAX BISMATROL ORAL SUSPENSION 262 MG/15 ML BISMATROL ORAL SUSPENSION 525 MG/15 ML BISMATROL ORAL TABLET, CHEWABLE BISMUTH BISMUTH MAXIMUM STRENGTH bisoprolol fumarate bisoprololhydrochlorothiazide bleo 15k bleomycin BLEPHAMIDE S.O.P BLINCYTO BONIVA INTRAVENOUS BOOSTRIX TDAP BOSULIF ORAL TABLET 100 MG BOSULIF ORAL TABLET 500 MG BP briellyn BRILINTA brimonidine ophthalmic drops 0.2 % BRIVIACT INTRAVENOUS BRIVIACT ORAL SOLUTION BRIVIACT ORAL TABLET 10 MG BRIVIACT ORAL TABLET 100 MG, 75 MG BRIVIACT ORAL TABLET 25 MG BRIVIACT ORAL TABLET 50 MG bromocriptine (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全 天候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 150

152 brompheniraminphenylephrin-dm oral liquid mg/5 ml budesonide inhalation suspension for nebulization 0.25 mg/2 ml, 0.5 mg/2 ml budesonide oral bumetanide BUPHENYL ORAL TABLET buprenorphine hcl injection solution buprenorphine hcl injection syringe buprenorphine hcl sublingual tablet 2 mg buprenorphine hcl sublingual tablet 8 mg buprenorphine-naloxone sublingual tablet mg buprenorphine-naloxone sublingual tablet 8-2 mg bupropion hcl oral tablet 100 mg bupropion hcl oral tablet 75 mg bupropion hcl oral tablet extended release 100 mg bupropion hcl oral tablet extended release 150 mg, 200 mg bupropion hcl oral tablet extended release 24 hr 150 mg bupropion hcl oral tablet extended release 24 hr 300 mg bupropion hcl (smoking deter) buspirone BUSULFEX butalbital-acetaminop-cafcod oral capsule mg butorphanol tartrate injection solution 1 mg/ ml butorphanol tartrate injection solution 2 mg/ ml butorphanol tartrate nasal BYDUREON BYETTA SUBCUTANEOUS PEN INJECTOR 10 MCG/DOSE(250 MCG/ML) 2.4 ML BYETTA SUBCUTANEOUS PEN INJECTOR 5 MCG/DOSE (250 MCG/ML) 1.2 ML C C-500 ORAL TABLET C-500 ORAL TABLET, CHEWABLE CA-D3-MAG OX-ZINC-COP-MANG- BOR ORAL TABLET,CHEWABLE 600 MG CALCIUM- 400 UNIT-40 MG cabergoline CABOMETYX ORAL TABLET 20 MG CABOMETYX ORAL TABLET 40 MG, 60 MG CAL-GEST ANTACID calamine CALAMINE-ZINC OXIDE TOPICAL LOTION 8-8 % CALCI-CHEW CALCIONATE calcipotriene scalp calcipotriene topical calcitonin (salmon) CALCITRATE calcitriol intravenous solution 1 mcg/ml calcitriol oral capsule CALCIUM CALCIUM D ORAL TABLET 500 MG(1,250MG) -200 UNIT CALCIUM D ORAL TABLET 500 MG(1,250MG) -400 UNIT CALCIUM D ORAL TABLET, CHEWABLE CALCIUM D (D3) CALCIUM 500 WITH D CALCIUM CALCIUM D(3) ORAL TABLET 600 MG(1,500MG) -200 UNIT, 600 MG(1,500MG) -400 UNIT CALCIUM MINERALS CALCIUM 600 WITH VITAMIN D3 ORAL TABLET calcium acetate oral capsule calcium acetate oral tablet 667 mg CALCIUM ANTACID ORAL TABLET,CHEWABLE 200 MG CALCIUM (500 MG) CALCIUM ANTACID ORAL TABLET,CHEWABLE 300 MG (750 MG), 400 MG (1,000 MG) CALCIUM ANTACID TROPICAL CALCIUM ANTACID ULTRA MAX ST calcium carbonate - d3 oral tablet 500 mg(1,250mg) -125 unit, 500 mg(1,250mg) -200 unit, 500 mg(1,250mg) -400 (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全 天候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 151

153 unit, 500mg (1,250mg) -600 unit calcium carbonate - d3 oral tablet 600 mg(1,500mg) -200 unit, 600 mg(1,500mg) -400 unit, 600 mg(1,500mg) -800 unit calcium carbonate - d3 oral tablet,chewable 500 mg(1, 250mg) -400 unit CALCIUM CARBONATE - D3 ORAL TABLET,CHEWABLE MG- UNIT CALCIUM CARBONATE AND MAGNESIA ANTACID ORAL SUSPENSION MG/5 ML, MG/5 ML CALCIUM CARBONATE AND MAGNESIA ANTACID ORAL TABLET,CHEWABLE MG CALCIUM CARBONATE ANTACID ORAL TABLET,CHEWABLE 400 MG (1,000 MG) CALCIUM CARBONATE ORAL SUSPENSION calcium carbonate oral tablet 500 mg calcium (1,250 mg), 600 mg (1,500 mg) calcium carbonate oral tablet,chewable 200 mg calcium (500 mg), 400 mg (1, 000 mg), 500 mg calcium (1, 250 mg) calcium carbonate-vit d3-min oral tablet CALCIUM CITRATE + D calcium citrate oral tablet 200 mg (950 mg) CALCIUM CITRATE ORAL TABLET 250 MG CALCIUM calcium citrate-vitamin d3 oral tablet 200 mg calcium unit, 250 mg calcium- 200 unit calcium citrate-vitamin d3 oral tablet mg-unit, mg-unit CALCIUM FOR WOMEN CALCIUM GLUCONATE ORAL TABLET 45 MG (500 MG) CALCIUM GLUCONATE ORAL TABLET 60 MG (650 MG) CALCIUM LACTATE ORAL TABLET 84 MG (648 MG) CALCIUM SOFT CHEW ORAL TABLET,CHEWABLE MG-UNIT-MCG, MG- UNIT-MCG CALCIUM WITH VITAMIN D calcium-magnesium-zinc oral tablet CALCIUM-MAGNESIUM-ZINC ORAL TABLET MG calcium-vitamin d3-vitamin k oral tablet,chewable mg-unit-mcg camila CANASA CANCIDAS... 8 candesartan oral tablet 16 mg, 4 mg, 8 mg candesartan oral tablet 32 mg candesartanhydrochlorothiazid oral tablet mg candesartanhydrochlorothiazid oral tablet mg, mg CAPASTAT CAPEX CAPRELSA ORAL TABLET 100 MG CAPRELSA ORAL TABLET 300 MG captopril captoprilhydrochlorothiazide CARBAGLU carbamazepine oral capsule, er multiphase 12 hr carbamazepine oral suspension 100 mg/5 ml carbamazepine oral suspension 200 mg/10 ml carbamazepine oral tablet carbamazepine oral tablet extended release 12 hr 100 mg carbamazepine oral tablet extended release 12 hr 200 mg, 400 mg carbamazepine oral tablet, chewable carbidopa-levodopa carboplatin intravenous solution CARIMUNE NF NANOFILTERED INTRAVENOUS RECON SOLN 12 GRAM, 6 GRAM carteolol cartia xt carvedilol CAYSTON caziant (28) cefaclor oral capsule cefaclor oral suspension for reconstitution 125 mg/ 5 ml (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全 天候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 152

154 cefaclor oral suspension for reconstitution 250 mg/ 5 ml, 375 mg/5 ml cefaclor oral tablet extended release 12 hr cefadroxil oral capsule cefadroxil oral suspension for reconstitution 250 mg/ 5 ml, 500 mg/5 ml cefadroxil oral tablet cefazolin in dextrose (isoos) intravenous piggyback 1 gram/50 ml cefazolin injection recon soln 1 gram cefazolin injection recon soln 10 gram, 100 gram, 20 gram, 300 g cefazolin injection recon soln 500 mg cefazolin intravenous cefdinir cefepime cefoxitin in dextrose, isoosm cefoxitin intravenous recon soln 1 gram cefoxitin intravenous recon soln 10 gram, 2 gram cefpodoxime cefprozil ceftazidime injection recon soln 1 gram, 2 gram ceftazidime injection recon soln 6 gram ceftriaxone in dextrose,isoos ceftriaxone injection recon soln 1 gram, 2 gram, 250 mg, 500 mg ceftriaxone injection recon soln 10 gram ceftriaxone intravenous cefuroxime axetil oral tablet cefuroxime sodium intravenous vial injection recon soln 1.5 gram, 750 mg cefuroxime sodium intravenous vial intravenous recon soln 7.5 gram CELLCEPT INTRAVENOUS CELONTIN ORAL CAPSULE 300 MG cephalexin oral capsule 250 mg, 500 mg cephalexin oral suspension for reconstitution cephalexin oral tablet CERASPORT ORAL LIQUID CEREZYME INTRAVENOUS RECON SOLN 400 UNIT CERVARIX VACCINE (PF) cetirizine oral tablet cevimeline CHANTIX CHANTIX CONTINUING NTH BOX CHANTIX STARTING NTH BOX CHERATUSSIN AC chloramphenicol sod succinate chlorhexidine gluconate mucous membrane chloroquine phosphate oral chlorothiazide chlorpromazine chlorthalidone oral tablet 25 mg, 50 mg cholecalciferol (vitamin d3) oral capsule 1,000 unit, 5, 000 unit cholecalciferol (vitamin d3) oral capsule 2,000 unit, 400 unit cholecalciferol (vitamin d3) oral drops 400 unit/ml cholecalciferol (vitamin d3) oral tablet 1,000 unit, 5,000 unit cholecalciferol (vitamin d3) oral tablet 2,000 unit, 400 unit cholestyramine light cholestyramine (with sugar) ciclodan topical solution ciclopirox topical cream ciclopirox topical gel ciclopirox topical shampoo ciclopirox topical solution ciclopirox topical suspension cilostazol CINRYZE CIPRODEX ciprofloxacin er ciprofloxacin hcl ophthalmic ciprofloxacin hcl oral ciprofloxacin lactate intravenous solution 200 mg/20 ml (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全 天候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 153

155 ciprofloxacin lactate intravenous solution 400 mg/40 ml cisplatin citalopram oral solution citalopram oral tablet 10 mg citalopram oral tablet 20 mg citalopram oral tablet 40 mg CITRATE OF MAGNESIA CITROMA CITRUS CALCIUM ORAL TABLET 200 MG CALCIUM -250 UNIT CITRUS CALCIUM ORAL TABLET MG-UNIT cladribine clarithromycin oral suspension for reconstitution clarithromycin oral tablet clarithromycin oral tablet extended release 24 hr CLASSIC PRENATAL CLEARLAX clemastine oral tablet 1.34 mg clemastine oral tablet 2.68 mg clindamycin hcl clindamycin phosphate injection clindamycin phosphate intravenous solution 300 mg/2 ml, 900 mg/6 ml clindamycin phosphate intravenous solution 600 mg/4 ml clindamycin phosphate topical clindamycin phosphate vaginal CLINIMIX 2.75%/D5W SULFIT FREE CLINIMIX 4.25%-D20W SULF- FREE CLINIMIX 4.25%-D25W SULF- FREE CLINIMIX 4.25%/D10W SULF FREE CLINIMIX 4.25%/D5W SULFIT FREE CLINIMIX 5%-D20W(SULFITE- FREE) CLINIMIX 5%/D15W SULFITE FREE CLINIMIX 5%/D25W SULFITE- FREE CLINIMIX E 2.75%/D10W SUL FREE CLINIMIX E 2.75%/D5W SULF 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 CLINISOL SF 15 % clobetasol scalp clobetasol topical cream clobetasol topical gel clobetasol topical ointment clobetasol-emollient topical cream CLOLAR clomipramine clonazepam oral tablet 0.5 mg clonazepam oral tablet 1 mg clonazepam oral tablet 2 mg clonazepam oral tablet, disintegrating mg clonazepam oral tablet, disintegrating 0.25 mg clonazepam oral tablet, disintegrating 0.5 mg clonazepam oral tablet, disintegrating 1 mg clonazepam oral tablet, disintegrating 2 mg clonidine hcl oral tablet clonidine transdermal patch clopidogrel oral tablet 300 mg clopidogrel oral tablet 75 mg clorazepate dipotassium CLOTRIMAZOLE 3 DAY CLOTRIMAZOLE AF CLOTRIMAZOLE ANTIFUNGAL clotrimazole mucous membrane... 8 clotrimazole topical clotrimazole vaginal cream CLOTRIMAZOLE CLOTRIMAZOLE (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全 天候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 154

156 clotrimazolebetamethasone clozapine oral tablet 100 mg clozapine oral tablet 200 mg clozapine oral tablet 25 mg clozapine oral tablet 50 mg clozapine oral tablet, disintegrating 100 mg clozapine oral tablet, disintegrating 12.5 mg clozapine oral tablet, disintegrating 150 mg clozapine oral tablet, disintegrating 200 mg clozapine oral tablet, disintegrating 25 mg COARTEM codeine-guaifenesin COL-RITE colchicine-probenecid COLCRYS COLD AND ALLERGY COLD AND ALLERGY PE colestipol colistin (colistimethate na) COLLYRIUM colocort COLY-MYCIN S COMBIGAN COMBIVENT RESPIMAT COMETRIQ ORAL CAPSULE 100 MG/DAY(80 MG X1-20 MG X1) COMETRIQ ORAL CAPSULE 140 MG/DAY(80 MG X1-20 MG X3) COMETRIQ ORAL CAPSULE 60 MG/DAY (20 MG X 3/DAY) COMFORT GEL COMFORT GEL EXTRA STRENGTH COMPLERA... 9 COMPLETE ALLERGY COMPLETE ALLERGY MEDICINE COMPLETE LICE TREATMENT compro CONDOMS, LATEX, LUBRICATED CONDOMS, LATEX, LUBRICATED DEVICE CONDOMS, LATEX, NON- LUBRICATED DEVICE constulose COPAXONE SUBCUTANEOUS SYRINGE 20 MG/ML COPAXONE SUBCUTANEOUS SYRINGE 40 MG/ML cormax scalp cortisone CORTISONE (HYDROCORTISONE) TOPICAL CREAM CORTIZONE-10 PLUS CORTIZONE-10 TOPICAL CREAM CORTIZONE-10 TOPICAL OINTMENT COTELLIC COUGH CONTROL DM ORAL LIQUID COUGH CONTROL (GUAIFENESIN) COUGH SYRUP CREON CRIXIVAN ORAL CAPSULE 200 MG... 9 CRIXIVAN ORAL CAPSULE 400 MG... 9 cromolyn inhalation cromolyn ophthalmic cryselle (28) CUBICIN cyanocobalamin (vitamin b- 12) injection cyanocobalamin (vitamin b- 12) oral tablet 1,000 mcg, 100 mcg, 500 mcg cyanocobalamin (vitamin b- 12) oral tablet extended release cyanocobalamin (vitamin b- 12) sublingual tablet 1,000 mcg cyanocobalamin (vitamin b- 12) sublingual tablet 2,500 mcg cyclafem 7/7/7 (28) cyclophosphamide oral capsule CYCLOSET cyclosporine intravenous cyclosporine modified cyclosporine oral capsule cyproheptadine oral tablet CYRAMZA INTRAVENOUS SOLUTION 10 MG/ML CYRAMZA INTRAVENOUS SOLUTION 10 MG/ML (50 ML) CYSTADANE CYSTAGON cytarabine cytarabine (pf) injection solution 100 mg/5 ml (20 mg/ (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全 天候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 155

157 ml), 2 gram/20 ml (100 mg/ ml) cytarabine (pf) injection solution 20 mg/ml D D-VI-SOL D-VITA d10 %-0.45 % sodium chloride d2.5 %-0.45 % sodium chloride D d5 % and 0.9 % sodium chloride d5 %-0.45 % sodium chloride dacarbazine DACOGEN DAILY PRENATAL DALIRESP danazol oral dantrolene DAPSONE DAPTACEL (DTAP PEDIATRIC) (PF) daptomycin DARAPRIM DARZALEX dasetta 7/7/7 (28) daunorubicin intravenous solution DAYHIST ALLERGY DEBLITANE decitabine DELTA D DELYLA (28) DELZICOL ORAL CAPSULE (WITH DEL REL TABLETS) demeclocycline DEMSER DENAVIR DEPEN TITRATABS DEPO-PROVERA INTRAMUSCULAR SOLUTION 400 MG/ML DESCOVY... 9 DESENEX TOPICAL POWDER desipramine oral desmopressin injection desmopressin nasal aerosol, spray desmopressin nasal spray, non-aerosol desmopressin oral desog-e.estradiol/ e.estradiol desonide desoximetasone DESVENLAFAXINE FUMARATE ORAL TABLET EXTENDED RELEASE 24HR 100 MG DESVENLAFAXINE FUMARATE ORAL TABLET EXTENDED RELEASE 24HR 50 MG DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE 24 HR 100 MG DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE 24 HR 50 MG DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE 24HR 100 MG DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE 24HR 50 MG DEX4 GLUCOSE ORAL TABLET, CHEWABLE DEX4 GLUCOSE POUCH PACK DEX4 GLUCOSE QUICK DISSOLVE dexamethasone dexamethasone sodium phos (pf) dexamethasone sodium phosphate injection dexamethasone sodium phosphate ophthalmic DEXILANT dexrazoxane hcl intravenous recon soln 250 mg dexrazoxane hcl intravenous recon soln 500 mg dextroamphetamine oral capsule, extended release 10 mg, 5 mg dextroamphetamine oral capsule, extended release 15 mg dextroamphetamine oral tablet 10 mg dextroamphetamine oral tablet 5 mg dextroamphetamineamphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 5 mg, 7.5 mg dextroamphetamineamphetamine oral tablet 30 mg dextrose 10 % and 0.2 % nacl dextrose 10 % in water (d10w) dextrose 25 % in water (d25w) dextrose 30 % in water (d30w) dextrose 40 % in water (d40w) dextrose 5 % in water (d5w) (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全 天候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 156

158 dextrose 5 %-lactated ringers dextrose 5%-0.2 % sod chloride dextrose 5%-0.3 % sod.chloride dextrose 50 % in water (d50w) intravenous parenteral solution dextrose 50 % in water (d50w) intravenous syringe dextrose 70 % in water (d70w) dextrose oral gel dextrose with sodium chloride dextrose-kcl-nacl DIABETIC SILTUSSIN DAS- NA DIABETIC SILTUSSIN-DM DIABETIC TUSSIN DM ORAL LIQUID MG/5 ML DIABETIC TUSSIN EX DIALYVITE DIALYVITE VITAMIN D DIARRHEA RELIEF (BISMUTH SUBS) diazepam injection solution diazepam injection syringe diazepam intensol diazepam oral concentrate diazepam oral solution 5 mg/ 5 ml (1 mg/ml) diazepam oral solution 5 mg/ 5 ml (1 mg/ml, 5 ml) diazepam oral tablet 10 mg diazepam oral tablet 2 mg diazepam oral tablet 5 mg diazepam rectal kit mg diazepam rectal kit 2.5 mg, mg diclofenac potassium diclofenac sodium oral diclofenac sodium topical gel 3 % dicloxacillin dicyclomine oral capsule dicyclomine oral solution dicyclomine oral tablet didanosine oral capsule, delayed release(dr/ec) 125 mg... 9 didanosine oral capsule, delayed release(dr/ec) 200 mg didanosine oral capsule, delayed release(dr/ec) 250 mg, 400 mg DIFFERIN TOPICAL GEL 0.3 % DIFFERIN TOPICAL GEL WITH PUMP diflorasone diflunisal digox oral tablet 125 mcg digoxin injection solution digoxin oral solution 50 mcg/ ml digoxin oral tablet 125 mcg DILANTIN DILANTIN EXTENDED ORAL CAPSULES 100 MG DILANTIN INFATABS dilt-xr diltiazem hcl intravenous solution diltiazem hcl oral capsule, extended release 120 mg, 180 mg, 240 mg, 300 mg, 360 mg diltiazem hcl oral capsule, ext release degradable diltiazem hcl oral capsule, extended release 12 hr diltiazem hcl oral capsule, extended release 24hr diltiazem hcl oral tablet diltiazem hcl oral tablet extended release 24 hr DIOCTO ORAL LIQUID DIOCTO ORAL SYRUP DIOCTYL DIOTAME DIPENTUM DIPHEDRYL ALLERGY DIPHEDRYL ORAL CAPSULE DIPHEDRYL ORAL LIQUID DIPHEDRYL ORAL TABLET DIPHENHIST ORAL CAPSULE DIPHENHIST ORAL LIQUID DIPHENHIST ORAL TABLET 25 MG diphenhydramine hcl injection solution 50 mg/ ml diphenhydramine hcl injection syringe (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全 天候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 157

159 diphenhydramine hcl oral capsule diphenhydramine hcl oral elixir diphenhydramine hcl oral liquid diphenhydramine hcl oral syrup diphenhydramine hcl oral tablet 25 mg DIPHENHYDRAMINE ORAL CAPSULE 25 MG, 50 MG DIPHENHYDRAMINE ORAL ELIXIR 12.5 MG/5 ML DIPHENHYDRAMINE ORAL LIQUID 12.5 MG/5 ML DIPHENHYDRAMINE ORAL SYRUP 12.5 MG/5 ML diphenoxylateatropine disulfiram divalproex DOC-Q-LACE DOCEFREZ INTRAVENOUS RECON SOLN 20 MG docetaxel intravenous solution 10 mg/ml, 160 mg/16 ml (10 mg/ml), 160 mg/8 ml (20 mg/ml), 20 mg/2 ml (10 mg/ ml) docetaxel intravenous solution 20 mg/ml (1 ml), 80 mg/4 ml (20 mg/ml), 80 mg/8 ml (10 mg/ml) DOCU DOCUPRENE docusate calcium docusate sodium oral capsule 100 mg docusate sodium oral capsule 250 mg docusate sodium oral liquid docusate sodium oral tablet DOCUSIL dofetilide DOK ORAL CAPSULE 100 MG DOK ORAL CAPSULE 250 MG DOK ORAL TABLET donepezil oral tablet 10 mg donepezil oral tablet 5 mg donepezil oral tablet, disintegrating 10 mg donepezil oral tablet, disintegrating 5 mg dorzolamide dorzolamide-timolol DOUBLE ANTIBIOTIC doxazosin doxepin oral doxorubicin intravenous recon soln doxorubicin intravenous solution doxorubicin, pegliposomal DOXY doxycycline hyclate intravenous doxycycline hyclate oral capsule doxycycline hyclate oral tablet 100 mg, 20 mg doxycycline hyclate oral tablet 50 mg doxycycline hyclate oral tablet,delayed release (dr/ ec) 100 mg, 150 mg, 75 mg doxycycline monohydrate oral capsule doxycycline monohydrate oral tablet DRAMAMINE LESS DROWSY dronabinol drospirenone-ethinyl estradiol oral tablet mg DROXIA DRY EYE RELIEF DSS DUCODYL DULCOLAX STOOL SOFTENER (DSS) DULERA duloxetine oral capsule, delayed release(dr/ec) 20 mg duloxetine oral capsule, delayed release(dr/ec) 30 mg duloxetine oral capsule, delayed release(dr/ec) 40 mg duloxetine oral capsule, delayed release(dr/ec) 60 mg duramorph (pf) injection solution 0.5 mg/ml duramorph (pf) injection solution 1 mg/ml DUREZOL dutasteride dutasteridetamsulosin E econazole topical (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全 天候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 158

160 ECONTRA EZ ECOTRIN LOW STRENGTH ECZEMA ANTI-ITCH ED A-HIST ORAL TABLET ED A-HIST PSE EDURANT EFFIENT ELAPRASE ELIDEL elinest ELIQUIS ORAL TABLET 2.5 MG ELIQUIS ORAL TABLET 5 MG ELITEK INTRAVENOUS RECON SOLN 1.5 MG elitek intravenous recon soln 7.5 mg ELLA EMCYT EMEND ORAL CAPSULE 125 MG EMEND ORAL CAPSULE 40 MG EMEND ORAL CAPSULE 80 MG EMEND ORAL CAPSULE,DOSE PACK EMEND ORAL SUSPENSION FOR RECONSTITUTION EMPLICITI EMSAM EMTRIVA ORAL CAPSULE EMTRIVA ORAL SOLUTION enalapril maleate enalaprilhydrochlorothiazide ENBREL SUBCUTANEOUS RECON SOLN ENBREL SUBCUTANEOUS SYRINGE 25 MG/0.5ML (0.51) ENBREL SUBCUTANEOUS SYRINGE 50 MG/ML (0.98 ML) ENBREL SURECLICK endocet oral tablet mg, mg, mg ENGERIX-B PEDIATRIC (PF) ENGERIX-B (PF) enoxaparin subcutaneous solution enoxaparin subcutaneous syringe 100 mg/ml, 150 mg/ ml enoxaparin subcutaneous syringe 120 mg/0.8 ml, 80 mg/ 0.8 ml enoxaparin subcutaneous syringe 30 mg/0.3 ml enoxaparin subcutaneous syringe 40 mg/0.4 ml enoxaparin subcutaneous syringe 60 mg/0.6 ml enpresse entacapone entecavir ENTERIC COATED ASPIRIN ENTRE-HIST PSE enulose EPCLUSA epinephrine injection syringe 0.1 mg/ml EPIPEN 2-PAK EPIPEN JR 2-PAK epirubicin intravenous solution 200 mg/100 ml epirubicin intravenous solution 50 mg/25 ml epitol EPIVIR HBV ORAL SOLUTION EPIVIR ORAL SOLUTION eplerenone eprosartan EPZICOM EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 100 MG EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 200 MG EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 300 MG ERAXIS(WATER DILUENT)... 8 ERBITUX ergocalciferol (vitamin d2) oral capsule ergocalciferol (vitamin d2) oral tablet 400 unit ergoloid ERGOMAR ERIVEDGE errin ERWINAZE ery pads ery-tab oral tablet,delayed release (dr/ec) 250 mg, 333 mg ERY-TAB ORAL TABLET,DELAYED RELEASE (DR/EC) 500 MG ERYTHROCIN INTRAVENOUS RECON SOLN 500 MG erythrocin (as stearate) oral tablet 250 mg erythromycin ethylsuccinate oral tablet erythromycin ophthalmic erythromycin oral tablet erythromycin with ethanol (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全 天候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 159

161 erythromycin-benzoyl peroxide ESBRIET escitalopram oxalate oral solution escitalopram oxalate oral tablet 10 mg escitalopram oxalate oral tablet 20 mg escitalopram oxalate oral tablet 5 mg ESTRACE VAGINAL estradiol oral estradiol transdermal patch weekly ESTRING ethambutol ethosuximide etodolac ETOPOPHOS etoposide intravenous EVOMELA EVOTAZ EXELON TRANSDERMAL exemestane EXJADE EXPECTORANT COUGH SYRUP EXPECTORANT ORAL LIQUID EYE DROP TEARS EYE IRRIGATING SOLUTION EYE ITCH RELIEF EYE STREAM EYE WASH EYE WASH STERILE EZFE F FABRAZYME FALLBACK SOLO falmina (28) famciclovir oral tablet 125 mg, 250 mg famciclovir oral tablet 500 mg famotidine intravenous famotidine oral suspension famotidine oral tablet 10 mg famotidine oral tablet 20 mg, 40 mg famotidine (pf) famotidine (pf)-nacl (isoos) FANAPT ORAL TABLET 1 MG FANAPT ORAL TABLET 10 MG FANAPT ORAL TABLET 12 MG FANAPT ORAL TABLET 2 MG FANAPT ORAL TABLET 4 MG FANAPT ORAL TABLET 6 MG FANAPT ORAL TABLET 8 MG FANAPT ORAL TABLETS,DOSE PACK FARESTON FARYDAK ORAL CAPSULE 10 MG FARYDAK ORAL CAPSULE 15 MG, 20 MG FASLODEX FAZACLO ORAL TABLET, DISINTEGRATING 100 MG FAZACLO ORAL TABLET, DISINTEGRATING 12.5 MG FAZACLO ORAL TABLET, DISINTEGRATING 25 MG felbamate felodipine oral er fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg fenofibrate nanocrystallized 48 mg, 145 mg fenofibrate oral tablet 160 mg, 54 mg fenoprofen oral tablet fentanyl citrate fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/ hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr FENTORA FEOSOL ORAL TABLET 325 MG (65 MG IRON) FERATE ORAL TABLET 240 MG (27 MG IRON) FEROSUL ORAL TABLET FERRETTS FERREX FERRIPROX ORAL SOLUTION FERRIPROX ORAL TABLET FERRO-TIME ferrous gluconate oral tablet 240 mg (27 mg iron) ferrous gluconate oral tablet 256 mg (28 mg iron) FERROUS GLUCONATE ORAL TABLET 324 MG (36 MG IRON), 324 MG (37.5 MG IRON), 324 MG (38 MG IRON) ferrous sulfate oral tablet 325 mg (65 mg iron) (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全 天候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 160

162 FERROUS SULFATE ORAL TABLET,DELAYED RELEASE (DR/EC) 324 MG (65 MG IRON) ferrous sulfate oral tablet, delayed release (dr/ec) 325 mg (65 mg iron) FERROUSUL FETZIMA ORAL CAPSULE,EXT REL 24HR DOSE PACK FETZIMA ORAL CAPSULE, EXTENDED RELEASE 24 HR 120 MG, 80 MG FETZIMA ORAL CAPSULE, EXTENDED RELEASE 24 HR 20 MG FETZIMA ORAL CAPSULE, EXTENDED RELEASE 24 HR 40 MG FEVER REDUCER AN PAIN RELIEVER ORAL SUSPENSION FEVERALL RECTAL SUPPOSITORY 650 MG finasteride oral tablet 5 mg FIRAZYR FIRMAGON KIT W DILUENT SYRINGE FLANAX ANTACID FLANAX (NAPROXEN) FLEBOGAMMA DIF flecainide FLEET GLYCERIN (ADULT) FLEET LAXATIVE FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCG/ ACTUATION FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 250 MCG/ ACTUATION, 50 MCG/ ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCG/ ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 220 MCG/ ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 44 MCG/ ACTUATION fluconazole... 8 fluconazole in dextrose(isoo)... 8 fluconazole in nacl (iso-osm) intravenous piggyback 100 mg/50 ml, 400 mg/200 ml... 8 fluconazole in nacl (iso-osm) intravenous piggyback 200 mg/100 ml... 8 flucytosine... 8 fludarabine intravenous recon soln fludarabine intravenous solution fludrocortisone flunisolide nasal spray,nonaerosol 25 mcg (0.025 %) fluocinolone fluocinolone acetonide oil fluocinolone and shower cap fluocinonide topical cream 0.05 % fluocinonide topical gel fluocinonide topical ointment fluocinonide topical solution fluocinonide-e topical cream 0.05 % fluorometholone fluorouracil intravenous fluorouracil topical cream 5 % fluoxetine oral capsule 10 mg fluoxetine oral capsule 20 mg fluoxetine oral capsule 40 mg fluoxetine oral solution fluoxetine oral tablet 10 mg fluoxetine oral tablet 20 mg fluphenazine decanoate fluphenazine hcl flurbiprofen flurbiprofen ophthalmic drops flutamide fluticasone nasal fluticasone topical cream fluticasone topical ointment fluvoxamine oral tablet 100 mg fluvoxamine oral tablet 25 mg fluvoxamine oral tablet 50 mg folic acid oral tablet 1 mg folic acid oral tablet 400 mcg, 800 mcg FOLOTYN (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全 天候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 161

163 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 FORADIL AEROLIZER FORTEO foscarnet fosinopril fosinoprilhydrochlorothiazide fosphenytoin FRAGMIN SUBCUTANEOUS SYRINGE 2,500 ANTI-XA UNIT/ 0.2 ML, 5,000 ANTI-XA UNIT/0.2 ML freamine iii 10 % FREESTYLE INSULINX STRIP FREESTYLE INSULINX TEST STRIPS FREESTYLE LANCETS FREESTYLE LITE STRIPS FREESTYLE TEST FULL SPECTRUM B-VITAMIN C FUNGOID-D furosemide injection solution furosemide oral solution 10 mg/ml, 40 mg/5 ml (8 mg/ ml) furosemide oral tablet FUSILEV FUZEON SUBCUTANEOUS RECON SOLN FYCOMPA ORAL SUSPENSION FYCOMPA ORAL TABLET 10 MG, 12 MG FYCOMPA ORAL TABLET 2 MG FYCOMPA ORAL TABLET 4 MG FYCOMPA ORAL TABLET 6 MG FYCOMPA ORAL TABLET 8 MG G G-TRON gabapentin oral capsule 100 mg gabapentin oral capsule 300 mg gabapentin oral capsule 400 mg gabapentin oral solution 250 mg/5 ml gabapentin oral solution 250 mg/5 ml (5 ml), 300 mg/6 ml (6 ml) gabapentin oral tablet 600 mg gabapentin oral tablet 800 mg GABITRIL ORAL TABLET 12 MG, 16 MG galantamine oral capsule,ext rel. pellets 24 hr galantamine oral solution galantamine oral tablet GAMASTAN S/D GAMMAGARD LIQUID GAMMAGARD S-D (IGA < 1 MCG/ ML) GAMUNEX-C ganciclovir sodium GARDASIL 9 (PF) GARDASIL (PF) GAS RELIEF GAS RELIEF ULTRA STRENGTH GATTEX 30-VIAL GATTEX ONE-VIAL GAUZE PADS 2 X GAVILAX ORAL POWDER gavilyte-c gavilyte-g gavilyte-n GAZYVA gemcitabine intravenous recon soln 1 gram, 200 mg gemcitabine intravenous recon soln 2 gram gemcitabine intravenous solution 1 gram/26.3 ml (38 mg/ml), 200 mg/5.26 ml (38 mg/ml) gemcitabine intravenous solution 2 gram/52.6 ml (38 mg/ml) gemfibrozil oral generlac gengraf oral capsule 100 mg, 25 mg gengraf oral capsule 50 mg gengraf oral solution GENOTROPIN GENOTROPIN MINIQUICK gentak ophthalmic ointment gentamicin injection gentamicin ophthalmic gentamicin sulfate (ped) (pf) gentamicin sulfate (pf) intravenous solution 100 mg/10 ml (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全 天候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 162

164 GENTAMICIN SULFATE (PF) INTRAVENOUS SOLUTION 60 MG/ 6 ML gentamicin sulfate (pf) intravenous solution 80 mg/ 8 ml gentamicin topical GENTLE LAXATIVE GENTLELAX GENVOYA GEODON INTRAMUSCULAR GERI-LANTA GERI-X ANTACID- ANTIGAS GERI-TUSSIN gildagia gildess 1.5/30 (21) GILENYA GILOTRIF GLATOPA GLEEVEC ORAL TABLET 100 MG GLEEVEC ORAL TABLET 400 MG GLEOSTINE glimepiride oral tablet 1 mg glimepiride oral tablet 2 mg glimepiride oral tablet 4 mg glipizide oral tablet 10 mg glipizide oral tablet 5 mg glipizide oral tablet extended release 24hr 10 mg glipizide oral tablet extended release 24hr 2.5 mg glipizide oral tablet extended release 24hr 5 mg glipizide-metformin oral tablet mg glipizide-metformin oral tablet mg, mg GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT (HUMAN) GLUCO BURST GLUCOSE GEL glucose oral tablet,chewable 4 gram GLUTOSE GLUTOSE glycerin (adult) GLYCOLAX ORAL POWDER glycopyrrolate oral GORMEL TEN griseofulvin microsize oral suspension... 8 griseofulvin ultramicrosize... 8 GUAIFENESIN AC guaifenesin oral liquid GUAIFENESIN-DM guanidine H HALAVEN halobetasol propionate HALOG haloperidol haloperidol decanoate haloperidol lactate HARVONI HAVRIX (PF) INTRAMUSCULAR SUSPENSION HAVRIX (PF) INTRAMUSCULAR SYRINGE 1,440 ELISA UNIT/ ML HAVRIX (PF) INTRAMUSCULAR SYRINGE 720 ELISA UNIT/0.5 ML HEADACHE RELIEF (ASA-ACET- CAF) HEALTHYLAX HEARTBURN ANTACID HEARTBURN PREVENTION HEARTBURN RELIEF HEARTBURN RELIEF (FATIDINE) HEARTBURN RELIEF (RANITIDINE) heather HEPARIN FLUSH heparin lock flush intravenous kit 100 unit/ ml heparin lock flush intravenous solution 10 unit/ml, 100 unit/ml heparin lock flush intravenous syringe 10 unit/ml HEPARIN LOCK FLUSH INTRAVENOUS SYRINGE 100 UNIT/ML HEPARIN LOCKFLUSH(PORCINE) (PF) heparin (porcine) in 5 % dex intravenous parenteral solution 12,500 unit/250 ml heparin (porcine) in 5 % dex intravenous parenteral solution 25,000 unit/250 ml (100 unit/ml), 25,000 unit/ 500 ml (50 unit/ml) (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全 天候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 163

165 heparin (porcine) in nacl (pf) intravenous parenteral solution 1,000 unit/500 ml, 2,000 unit/1,000 ml heparin (porcine) injection cartridge heparin (porcine) injection solution heparin, porcine (pf) injection solution heparin, porcine (pf) intravenous solution 100 unit/ml (1 ml) HEPARIN, PORCINE (PF) INTRAVENOUS SYRINGE 1 UNIT/ ML heparin, porcine (pf) intravenous syringe 10 unit/ml, 100 unit/ml HEPARIN(PORCINE) IN 0.45% NACL INTRAVENOUS PARENTERAL SOLUTION 12,500 UNIT/250 ML heparin(porcine) in 0.45% nacl intravenous parenteral solution 25,000 unit/250 ml, 25,000 unit/500 ml HEPATAMINE 8% HERCEPTIN HETLIOZ HEXALEN HI-CAL PLUS VIT D HIBERIX (PF) HIGH POTENCY IRON HUMATROPE INJECTION CARTRIDGE 12 MG (36 UNIT), 24 MG (72 UNIT) HUMIRA PEDIATRIC CROHN'S START SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML HUMIRA PEDIATRIC CROHN'S START SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML (6 PACK) HUMIRA PEN HUMIRA PEN CROHN'S-UC-HS START HUMIRA PEN PSORIASIS- UVEITIS HUMIRA SUBCUTANEOUS SYRINGE KIT 10 MG/0.2 ML, 20 MG/0.4 ML HUMIRA SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML hydralazine hydrochlorothiazide 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 hydrocodone-acetaminophen oral tablet mg, mg, mg hydrocodonechlorpheniramine hydrocodone-homatropine oral syrup mg/5 ml HYDROCODONE-HOMATROPINE ORAL SYRUP MG/5 ML (5 ML) hydrocodone-homatropine oral tablet hydrocodone-ibuprofen oral tablet mg hydrocortisone acetate topical hydrocortisone oral HYDROCORTISONE PLUS hydrocortisone rectal cream 2.5 % hydrocortisone rectal enema hydrocortisone topical cream 0.5 % hydrocortisone topical cream 1 %, 2.5 % hydrocortisone topical lotion 1 % hydrocortisone topical lotion 2.5 % hydrocortisone topical ointment 0.5 % hydrocortisone topical ointment 1 %, 2.5 % hydrocortisone valerate hydrocortisone-acetic acid hydrocortisone-min oil-wht pet HYDROCREAM HYDROMET hydromorphone oral tablet 2 mg, 4 mg hydromorphone oral tablet 8 mg HYDROSKIN TOPICAL LOTION hydroxychloroquine oral hydroxyprogesterone caproate hydroxyurea I I-PRIN (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全 天候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 164

166 ibandronate intravenous ibandronate oral IBRANCE IBUPROFEN IB ORAL TABLET ibuprofen oral capsule ibuprofen oral suspension ibuprofen oral tablet 200 mg ibuprofen oral tablet 400 mg, 600 mg, 800 mg ICLUSIG ORAL TABLET 15 MG ICLUSIG ORAL TABLET 45 MG idarubicin IFEREX ifosfamide intravenous recon soln ifosfamide intravenous solution ILARIS (PF) ILEVRO imatinib oral tablet 100 mg imatinib oral tablet 400 mg IMBRUVICA imipenem-cilastatin imipramine hcl imiquimod IVAX RABIES VACCINE (PF) INCRELEX indapamide INFANRIX (DTAP) (PF) INTRAMUSCULAR SUSPENSION INLYTA ORAL TABLET 1 MG INLYTA ORAL TABLET 5 MG INSTA-GLUCOSE insulin pen needle INSULIN SYRINGE (DISP) U ML, 1 ML, 1/2 ML INTELENCE ORAL TABLET 100 MG INTELENCE ORAL TABLET 200 MG INTELENCE ORAL TABLET 25 MG intralipid intravenous emulsion 20 % INTRON A INJECTION INTUNIV ER INVANZ INJECTION INVEGA ORAL TABLET EXTENDED RELEASE 24HR 1.5 MG INVEGA ORAL TABLET EXTENDED RELEASE 24HR 3 MG INVEGA ORAL TABLET EXTENDED RELEASE 24HR 6 MG INVEGA ORAL TABLET EXTENDED RELEASE 24HR 9 MG INVEGA SUSTENNA INVEGA TRINZA INTRAMUSCULAR SYRINGE 273 MG/0.875 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 410 MG/1.315 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 546 MG/1.75 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 819 MG/2.625 ML INVIRASE ORAL CAPSULE INVIRASE ORAL TABLET INVOKANA ORAL TABLET 100 MG INVOKANA ORAL TABLET 300 MG INZO ANTIFUNGAL IOPHEN C-NR IOPHEN DM-NR IOPHEN-NR IPOL INJECTION SUSPENSION ipratropium bromide inhalation ipratropium bromide nasal ipratropium-albuterol irbesartan IRESSA irinotecan intravenous solution 100 mg/5 ml, 40 mg/ 2 ml irinotecan intravenous solution 500 mg/25 ml IRON HIGH POTENCY IRON ORAL TABLET 325 MG (65 MG IRON) IRON (DRIED) IRON (FERROUS SULFATE) ISENTRESS ORAL POWDER IN PACKET ISENTRESS ORAL TABLET ISENTRESS ORAL TABLET, CHEWABLE 100 MG ISENTRESS ORAL TABLET, CHEWABLE 25 MG isoniazid oral isosorbide dinitrate oral isosorbide mononitrate ISTODAX ITCHY EYE DROPS itraconazole... 8 IXEMPRA IXIARO (PF) (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全 天候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 165

167 J JAKAFI ORAL TABLET 10 MG JAKAFI ORAL TABLET 15 MG JAKAFI ORAL TABLET 20 MG JAKAFI ORAL TABLET 25 MG JAKAFI ORAL TABLET 5 MG JALYN jantoven JANUMET JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 100-1,000 MG JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 50-1,000 MG, MG JANUVIA ORAL TABLET 100 MG JANUVIA ORAL TABLET 25 MG JANUVIA ORAL TABLET 50 MG JARDIANCE jencycla JEVTANA JOCK ITCH JOCK ITCH (CLOTRIMAZOLE) 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 K-PEC ANTIDIARRHEAL (BISM SUB) KADCYLA KALETRA ORAL SOLUTION KALETRA ORAL TABLET MG KALETRA ORAL TABLET MG KALYDECO ORAL TABLET KAO-TIN (BISMUTH SUBSALICYLAT) KAO-TIN (DOCUSATE CALCIUM) KAOPECTATE EX STR (BISMUTH SS) KAOPECTATE (BISMUTH SUBSALICY) kariva (28) kelnor 1/35 (28) KEPIVANCE ketoconazole oral... 8 ketoconazole topical ketorolac ophthalmic KETOTIFEN FUM 0.025% EYE DROPS ketotifen fumarate KEYTRUDA KHEDEZLA ORAL TABLET EXTENDED RELEASE 24HR 100 MG KHEDEZLA ORAL TABLET EXTENDED RELEASE 24HR 50 MG KINERET kionex (with sorbitol) KLOR-CON KLOR-CON klor-con m KLOR-CON M KLOR-CON M KORLYM KPN kurvelo KUVAN ORAL TABLET, SOLUBLE KYNAMRO L labetalol intravenous solution labetalol oral lactated ringers intravenous lactated ringers irrigation lactulose LAMISIL AT TOPICAL CREAM lamivudine oral solution lamivudine oral tablet 100 mg lamivudine oral tablet 150 mg lamivudine oral tablet 300 mg lamivudine-zidovudine lamotrigine oral tablet lamotrigine oral tablet, chewable dispersible LANOXIN ORAL TABLET 125 MCG, 62.5 MCG lansoprazole oral capsule, delayed release(dr/ ec) LANTUS LANTUS SOLOSTAR LARIN 1.5/30 (21) LARIN FE 1/20 (28) latanoprost LATUDA ORAL TABLET 120 MG LATUDA ORAL TABLET 20 MG (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全 天候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 166

168 LATUDA ORAL TABLET 40 MG LATUDA ORAL TABLET 60 MG LATUDA ORAL TABLET 80 MG LAXA CLEAR LAXATIVE PEG 3350 ORAL POWDER LAXATIVE (BISACODYL) ORAL TABLET,DELAYED RELEASE (DR/EC) LAXATIVE (BISACODYL) RECTAL LAZANDA NASAL SPRAY,NON- AEROSOL 100 MCG/SPRAY, 400 MCG/SPRAY LAZANDA NASAL SPRAY,NON- AEROSOL 300 MCG/SPRAY leflunomide LENVIMA ORAL CAPSULE 10 MG/ DAY (10 MG X 1/DAY) LENVIMA ORAL CAPSULE 14 MG/ DAY(10 MG X 1-4 MG X 1), 20 MG/DAY (10 MG X 2) LENVIMA ORAL CAPSULE 18 MG/ DAY (10 MG X 1-4 MG X2) LENVIMA ORAL CAPSULE 24 MG/ DAY(10 MG X 2-4 MG X 1) LENVIMA ORAL CAPSULE 8 MG/ DAY (4 MG X 2), 8 MG/DAY (4 MG X 2) (60 PACK) lessina LETAIRIS letrozole leucovorin calcium injection recon soln 100 mg, 200 mg, 350 mg, 50 mg leucovorin calcium injection recon soln 500 mg leucovorin calcium oral LEUKERAN LEUKINE INJECTION RECON SOLN leuprolide subcutaneous kit levalbuterol hcl inhalation solution for nebulization 0.31 mg/3 ml, 1.25 mg/0.5 ml, 1.25 mg/3 ml levalbuterol hcl inhalation solution for nebulization 0.63 mg/3 ml LEVEMIR LEVEMIR FLEXTOUCH levetiracetam intravenous levetiracetam oral solution 100 mg/ml levetiracetam oral solution 500 mg/5 ml (5 ml) levetiracetam oral tablet levetiracetam oral tablet extended release 24 hr 500 mg levetiracetam oral tablet extended release 24 hr 750 mg levobunolol ophthalmic drops 0.5 % levocarnitine oral tablet levocarnitine (with sugar) levocetirizine oral tablet levofloxacin intravenous levofloxacin oral levoleucovorin calcium intravenous recon soln levonest (28) levonorg-eth estrad triphasic levonorgestrel oral tablet 1.5 mg levonorgestrel-ethinyl estrad oral tablet mgmcg, mg levonorgestrel-ethinyl estrad oral tablets,dose pack,3 month levorphanol tartrate levothyroxine oral levoxyl oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg LEXIVA ORAL SUSPENSION LEXIVA ORAL TABLET LICE BEDDING SPRAY LICE COMPLETE KIT LICE CREAM RINSE LICE KILLING LICE KILLING (PERMETHRIN) LICE PYRINYL SHAMPOO LICE SOLUTION LICE TREATMENT TOPICAL LIQUID 1 % LICE TREATMENT TOPICAL SHAMPOO LICE TREATMENT (PERMETHRIN) lidocaine hcl injection solution 10 mg/ml (1 %), 20 mg/ml (2 %) lidocaine hcl injection solution 5 mg/ml (0.5 %) lidocaine hcl laryngotracheal lidocaine hcl mucous membrane (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全 天候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 167

169 lidocaine hcl urethral lidocaine topical adhesive patch,medicated lidocaine topical ointment lidocaine viscous lidocaine (pf) injection solution 10 mg/ml (1 %), 20 mg/ml (2 %), 40 mg/ml (4 %), 5 mg/ml (0.5 %) lidocaine (pf) injection solution 15 mg/ml (1.5 %) lidocaine (pf) intravenous solution lidocaine (pf) intravenous syringe 100 mg/5 ml (2 %) lidocaine-prilocaine topical cream lindane topical shampoo linezolid oral suspension for reconstitution linezolid oral tablet LINZESS liothyronine oral LIQUID ANTACID LIQUITEARS lisinopril lisinoprilhydrochlorothiazide lithium carbonate lithium citrate oral solution 8 meq/5 ml LOHIST-DM LOKARA LONSURF loperamide oral capsule loperamide oral liquid 1 mg/ 5 ml LORADAMED loratadine oral tablet loratadine oral tablet, disintegrating LORAZEPAM INTENSOL lorazepam oral tablet LORCET HD LORCET PLUS ORAL TABLET MG LORCET (HYDROCODONE) LORTAB LORTAB LORTAB losartan oral tablet 100 mg losartan oral tablet 25 mg, 50 mg losartanhydrochlorothiazide LOTRIMIN AF TOPICAL CREAM LOTRIMIN AF TOPICAL POWDER lovastatin oral tablet 10 mg, 20 mg lovastatin oral tablet 40 mg low-ogestrel (28) loxapine succinate LUBRICANT EYE DROPS LUBRICANT EYE DROPS (GLYC- PG) LUBRICANT EYE (PG-PEG 400) LUBRICANT REDNESS RELIEVER OPHTHALMIC DROPS % LUBRICATING PLUS LUMIGAN OPHTHALMIC DROPS 0.01 % LUNESTA LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 3.75 MG LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 7.5 MG LUPRON DEPOT (3 NTH) INTRAMUSCULAR SYRINGE KIT 22.5 MG lutera (28) LYNPARZA LYRICA ORAL CAPSULE 100 MG LYRICA ORAL CAPSULE 150 MG LYRICA ORAL CAPSULE 200 MG LYRICA ORAL CAPSULE 225 MG, 300 MG LYRICA ORAL CAPSULE 25 MG LYRICA ORAL CAPSULE 50 MG LYRICA ORAL CAPSULE 75 MG LYRICA ORAL SOLUTION LYSODREN lyza M M-CLEAR WC M-M-R II (PF) MAALOX MAXIMUM STRENGTH MACRODANTIN ORAL CAPSULE 25 MG, 50 MG MAG-AL PLUS MAG-AL PLUS EXTRA STRENGTH magnesium citrate oral solution MAGNESIUM OXIDE ORAL CAPSULE 500 MG (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全 天候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 168

170 magnesium sulfate in water intravenous parenteral solution magnesium sulfate in water intravenous piggyback 2 gram/50 ml (4 %), 4 gram/50 ml (8 %) magnesium sulfate in water intravenous piggyback 4 gram/100 ml (4 %) magnesium sulfate injection solution magnesium sulfate injection syringe MAPAP EXTRA STRENGTH maprotiline oral tablet 25 mg maprotiline oral tablet 50 mg maprotiline oral tablet 75 mg marlissa MARPLAN MARQIBO MASANTI DOUBLE STRENGTH MASOPHEN ORAL TABLET 500 MG MATULANE matzim la MAXIMUM REDNESS RELIEF meclizine oral tablet 12.5 mg, 25 mg meclizine oral tablet, chewable meclofenamate oral MEDI-MECLIZINE MEDIPROXEN MEDIWASH MEDIWASH EYE IRRIGANT medroxyprogesterone intramuscular medroxyprogesterone oral mefloquine megestrol oral suspension 400 mg/10 ml (10 ml), 800 mg/ 20 ml (20 ml) megestrol oral suspension 400 mg/10 ml (40 mg/ml) megestrol oral tablet MEKINIST ORAL TABLET 0.5 MG MEKINIST ORAL TABLET 2 MG meloxicam oral suspension meloxicam oral tablet melphalan hcl memantine oral solution memantine oral tablet 10 mg memantine oral tablet 5 mg MENACTRA (PF) INTRAMUSCULAR SOLUTION MENEST MENOMUNE - A/C/Y/W MENOMUNE - A/C/Y/W-135 (PF) MENSTRUAL RELIEF MENVEO A-C-Y-W-135-DIP (PF) MEPHYTON mercaptopurine meropenem MESALAMINE ORAL mesalamine rectal mesalamine with cleansing wipe mesna MESNEX ORAL MESTINON ORAL SYRUP MESTINON TIMESPAN METADATE ER metaproterenol metformin oral tablet 1,000 mg metformin oral tablet 500 mg metformin oral tablet 850 mg metformin oral tablet extended release 24 hr 500 mg metformin oral tablet extended release 24 hr 750 mg metformin oral tablet extended release 24hr 1,000 mg methadone injection methadone intensol methadone oral concentrate methadone oral solution 10 mg/5 ml methadone oral solution 5 mg/5 ml methadone oral tablet 10 mg methadone oral tablet 5 mg methadose oral concentrate methazolamide oral methenamine hippurate methimazole oral tablet 10 mg, 5 mg methotrexate sodium (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全 天候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 169

171 methotrexate sodium (pf) injection recon soln methotrexate sodium (pf) injection solution methoxsalen rapid methyclothiazide methyldopa methyldopahydrochlorothiazide methyldopate methylphenidate oral capsule, er biphasic mg methylphenidate oral capsule, er biphasic mg methylphenidate oral capsule,er biphasic mg methylphenidate oral capsule,er biphasic mg methylphenidate oral tablet methylphenidate oral tablet extended release methylphenidate oral tablet extended release 24hr 18 mg methylprednisolone acetate methylprednisolone oral tablets methylprednisolone sodium succ injection recon soln 125 mg, 40 mg methylprednisolone sodium succ intravenous metipranolol metoclopramide hcl injection solution metoclopramide hcl injection syringe metoclopramide hcl oral solution metoclopramide hcl oral tablet metolazone metoprolol succinate metoprolol tahydrochlorothiaz metoprolol tartrate intravenous solution metoprolol tartrate intravenous syringe metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg metro i.v metronidazole in nacl (isoos) metronidazole oral metronidazole topical cream metronidazole topical gel 0.75 % metronidazole topical lotion metronidazole vaginal mexiletine MI-ACID GAS RELIEF MIACALCIN INJECTION MICATIN MICONAZOLE 3 DAY VAGINAL CREAM MICONAZOLE miconazole nitrate topical cream miconazole nitrate vaginal comb pack,prefill appl, cream miconazole nitrate vaginal cream miconazole nitrate vaginal suppository MICONAZOLE-3 VAGINAL KIT miconazole-3 vaginal suppository MICONAZORB AF MICRO-GUARD MICROGESTIN 1.5/30 (21) MICROGESTIN 1/20 (21) MICROGESTIN FE 1.5/30 (28) MICROGESTIN FE 1/20 (28) midodrine MIGRAINE FORMULA MIGRAINE RELIEF MIGRANAL MILK OF MAGNESIA MILK OF MAGNESIA CONCENTRATED MINERAL OIL EXTRA HEAVY MINERAL OIL HEAVY ORAL MINERAL OIL LAXATIVE mineral oil oral mineral oil rectal minocycline oral capsule minocycline oral tablet minoxidil oral MINTOX MINTOX MAXIMUM STRENGTH MINTOX PLUS MIRALAX ORAL POWDER IN PACKET MIRCETTE (28) mirtazapine oral tablet 15 mg (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全 天候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 170

172 mirtazapine oral tablet 30 mg mirtazapine oral tablet 45 mg mirtazapine oral tablet 7.5 mg mirtazapine oral tablet, disintegrating 15 mg mirtazapine oral tablet, disintegrating 30 mg mirtazapine oral tablet, disintegrating 45 mg misoprostol mitomycin mitoxantrone modafinil oral tablet 100 mg modafinil oral tablet 200 mg DERIBA ISTURE DROPS molindone mometasone topical mono-linyah NOJECT PREFILL (PF) mononessa (28) montelukast morgidox oral capsule 100 mg morgidox oral capsule 50 mg morphine concentrate oral solution morphine intravenous cartridge 2 mg/ml RPHINE INTRAVENOUS CARTRIDGE 8 MG/ML morphine intravenous solution 10 mg/ml, 50 mg/ ml morphine intravenous solution 100 mg/4 ml, 25 mg/ ml, 250 mg/10 ml RPHINE INTRAVENOUS SOLUTION 4 MG/ML, 8 MG/ ML morphine intravenous syringe 2 mg/ml, 4 mg/ml morphine oral capsule, er multiphase 24 hr 30 mg, 60 mg morphine oral capsule, extend.release pellets 100 mg, 20 mg, 30 mg, 50 mg, 60 mg, 80 mg morphine oral solution 10 mg/5 ml morphine oral solution 20 mg/5 ml (4 mg/ml) morphine oral tablet 15 mg morphine oral tablet 30 mg morphine oral tablet extended release 100 mg, 15 mg, 30 mg, 60 mg morphine oral tablet extended release 200 mg morphine (pf) injection solution 0.5 mg/ml morphine (pf) injection solution 1 mg/ml morphine (pf) intravenous patient control.analgesia soln 150 mg/30 ml morphine (pf) intravenous patient control.analgesia soln 30 mg/30 ml TION RELIEF (MECLIZINE) TION SICKNESS RELIEF (MECLIZ) TION SICKNESS (MECLIZINE) VIPREP ZOBIL MULTAQ mupirocin topical ointment MUSTARGEN MY WAY MYCOBUTIN mycophenolate mofetil mycophenolate sodium MYFERON MYOZYME MYRBETRIQ MYTAB GAS MYTAB GAS MAXIMUM STRENGTH myzilra N nabumetone nadolol nadololbendroflumethiazide nafcillin injection recon soln 1 gram, 10 gram nafcillin injection recon soln 2 gram nafcillin intravenous recon soln 2 gram NAGLAZYME nalbuphine injection solution 10 mg/ml nalbuphine injection solution 20 mg/ml naloxone naltrexone oral NAMENDA ORAL SOLUTION NAMENDA ORAL TABLET 10 MG (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全 天候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 171

173 NAMENDA ORAL TABLET 5 MG NAMENDA TITRATION PAK NAMENDA XR ORAL CAP, SPRINKLE,ER 24HR DOSE PACK NAMENDA XR ORAL CAPSULE, SPRINKLE,ER 24HR naproxen naproxen sodium oral capsule naproxen sodium oral tablet 220 mg naproxen sodium oral tablet 275 mg, 550 mg NARCAN NASAL DECONGESTANT (PSEUDOEPH) ORAL LIQUID NASAL DECONGESTANT (PSEUDOEPH) ORAL TABLET NASAL DECONGESTANT (PSEUDOEPH) ORAL TABLET EXTENDED RELEASE NASAL MIST NATACYN nateglinide oral tablet 120 mg nateglinide oral tablet 60 mg NATPARA NATURAL TEARS (PF) NEBUPENT necon 0.5/35 (28) necon 1/35 (28) necon 10/11 (28) necon 7/7/7 (28) needles, insulin disp., safety nefazodone oral tablet 100 mg nefazodone oral tablet 150 mg nefazodone oral tablet 200 mg nefazodone oral tablet 250 mg nefazodone oral tablet 50 mg neo-polycin neo-polycin hc neomycin neomycin-bacitracin-polyhc neomycin-bacitracinpolymyxin neomycin-polymyxin b gu neomycin-polymyxin b- dexameth neomycin-polymyxingramicidin neomycin-polymyxin-hc ophthalmic neomycin-polymyxin-hc otic NEOSPORIN ANTI-ITCH NEOSPORIN PLUS PAINRELIEF (BAC) NEULASTA SUBCUTANEOUS SYRINGE NEUPOGEN NEUPRO NEVANAC nevirapine oral suspension nevirapine oral tablet nevirapine oral tablet extended release 24 hr 100 mg nevirapine oral tablet extended release 24 hr 400 mg NEXAVAR NEXT CHOICE ONE DOSE niacin oral capsule, extended release 250 mg, 500 mg niacin oral tablet 100 mg, 50 mg, 500 mg NIACIN ORAL TABLET 250 MG niacin oral tablet extended release 24 hr 1,000 mg, 750 mg niacin oral tablet extended release 24 hr 500 mg niacin oral tablet extended release 250 mg, 750 mg NIACOR NIASPAN EXTENDED-RELEASE ORAL TABLET EXTENDED RELEASE 24 HR 1,000 MG, 750 MG NIASPAN EXTENDED-RELEASE ORAL TABLET EXTENDED RELEASE 24 HR 500 MG nicardipine oral NICORELIEF NICOTINE TRANSDERMAL nicotine transdermal system transdermal patch 24 hour 14 mg/24 hr, 21 mg/24 hr, 7 mg/24 hr nicotine transdermal system transdermal patch, td daily, sequential mg/24 hr nicotine (polacrilex) NICOTROL NS nifedical xl nifedipine oral tablet extended release nifedipine oral tablet extended release 24hr (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全 天候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 172

174 NIGHTIME SLEEP NIGHTTIME SLEEP AID (DIPHEN) ORAL CAPSULE 50 MG NIGHTTIME SLEEP AID (DIPHEN) ORAL TABLET NILANDRON NINLARO NIPENT nitro-bid nitroglycerin intravenous nitroglycerin sublingual nitroglycerin transdermal patch 24 hour NITROSTAT NOBLE FORMULA HC TOPICAL CREAM NON-ASPIRIN ORAL SUSPENSION NON-DROWSY ALLERGY nora-be NORCO 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) norethindrone acetate norethindrone (contraceptive) norethindrone-e.estradioliron norgestimate-ethinyl estradiol oral tablet 0.18/ 0.215/0.25 mg-35 mcg (28), mg-mcg NORLYROC NORSOL-M IN 5 % DEXTROSE NORSOL-R NORSOL-R IN 5 % DEXTROSE NORSOL-R PH nortrel 0.5/35 (28) nortrel 1/35 (21) nortrel 1/35 (28) nortrel 7/7/7 (28) nortriptyline NORVIR ORAL CAPSULE NORVIR ORAL SOLUTION NORVIR ORAL TABLET NOVOLIN 70/ NOVOLIN N NOVOLIN R NOVOLOG NOVOLOG FLEXPEN NOVOLOG MIX NOVOLOG MIX FLEXPEN NOVOLOG PENFILL NOXAFIL ORAL SUSPENSION... 8 NUEDEXTA NULOJIX NUPLAZID NUVARING nyamyc nystatin oral suspension... 8 nystatin oral tablet... 8 nystatin topical nystatin-triamcinolone nystop O ocella octreotide acetate OCUSOFT IRRIGATING OPHTH SOLN ODEFSEY ODOMZO ODOR CONTROL FOOT- SNEAKER ofloxacin ophthalmic ofloxacin oral tablet 400 mg ofloxacin otic ogestrel (28) olanzapine intramuscular olanzapine oral tablet 10 mg olanzapine oral tablet 15 mg olanzapine oral tablet 2.5 mg olanzapine oral tablet 20 mg olanzapine oral tablet 5 mg olanzapine oral tablet 7.5 mg olanzapine oral tablet, disintegrating 10 mg olanzapine oral tablet, disintegrating 15 mg olanzapine oral tablet, disintegrating 20 mg olanzapine oral tablet, disintegrating 5 mg olanzapine-fluoxetine oral capsule mg, mg, 6-50 mg olanzapine-fluoxetine oral capsule 3-25 mg, 6-25 mg olopatadine ophthalmic OLYSIO omega-3 acid ethyl esters omeprazole oral capsule, delayed release(dr/ ec) OMEPRAZOLE ORAL TABLET, DELAYED RELEASE (DR/ EC) (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全 天候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 173

175 ONCASPAR ondansetron hcl intravenous ondansetron hcl oral solution ondansetron hcl oral tablet 24 mg ondansetron hcl oral tablet 4 mg, 8 mg ondansetron hcl (pf) injection solution ondansetron hcl (pf) injection syringe ondansetron odt ONE DAILY PRENATAL ORAL COMBO PACK MG- MCG-MG ONFI ORAL SUSPENSION ONFI ORAL TABLET 10 MG ONFI ORAL TABLET 20 MG OPCICON ONE-STEP OPDIVO ORAL SALINE LAXATIVE ORAL LIQUID oralone ORAP ORENCIA ORENCIA CLICKJECT ORENCIA (WITH MALTOSE) ORFADIN ORAL CAPSULE 10 MG, 2 MG, 5 MG ORFADIN ORAL CAPSULE 20 MG ORFADIN ORAL SUSPENSION orsythia oxacillin injection recon soln 1 gram, 2 gram oxacillin injection recon soln 10 gram oxacillin intravenous recon soln 1 gram oxacillin intravenous recon soln 2 gram oxaliplatin intravenous recon soln 100 mg oxaliplatin intravenous recon soln 50 mg oxaliplatin intravenous solution oxandrolone oral tablet 10 mg oxandrolone oral tablet 2.5 mg oxaprozin oxcarbazepine oral tablet OXSORALEN OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR 150 MG OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR 300 MG OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR 600 MG oxybutynin chloride oral syrup oxybutynin chloride oral tablet oxybutynin chloride oral tablet extended release 24hr 10 mg, 15 mg oxybutynin chloride oral tablet extended release 24hr 5 mg oxycodone oral capsule oxycodone oral concentrate oxycodone oral tablet 10 mg, 5 mg oxycodone oral tablet 15 mg oxycodone oral tablet 20 mg, 30 mg oxycodone-acetaminophen oral solution oxycodone-acetaminophen oral tablet mg, mg, mg, mg oxycodone-aspirin OYSCO 500/D ORAL TABLET OYSCO D OYSCO OYST-CAL OYSTER SHELL + D OYSTER SHELL CALCIUM OYSTER SHELL CALCIUM OYSTER SHELL CALCIUM-VIT D2 ORAL TABLET 250 (625)-125 MG-UNIT OYSTER SHELL CALCIUM-VIT D OYSTERCAL-D P pacerone oral tablet 100 mg, 200 mg, 400 mg paclitaxel PAIN AND FEVER ORAL TABLET 500 MG PAIN RELIEF EXTRA STRENGTH PAIN RELIEF ORAL TABLET PAIN RELIEF (ACETAMIN-ASP- CAF) PAIN RELIEVER EXTRA STRENGTH PAIN RELIEVER ORAL CAPSULE (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全 天候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 174

176 PAIN RELIEVER ORAL TABLET 500 MG PAIN RELIEVER PLUS PAIN RELIEVER (ACETAM- ASPIRIN) PAIN-OFF paliperidone oral tablet extended release 24hr 1.5 mg paliperidone oral tablet extended release 24hr 3 mg paliperidone oral tablet extended release 24hr 6 mg paliperidone oral tablet extended release 24hr 9 mg pamidronate PAMPRIN MAX PANCREAZE PANRETIN pantoprazole paroex oral rinse paromomycin paroxetine hcl oral tablet 10 mg paroxetine hcl oral tablet 20 mg paroxetine hcl oral tablet 30 mg paroxetine hcl oral tablet 40 mg paroxetine hcl oral tablet extended release 24 hr 12.5 mg paroxetine hcl oral tablet extended release 24 hr 25 mg paroxetine hcl oral tablet extended release 24 hr 37.5 mg PASER PATADAY PATANOL PAXIL ORAL SUSPENSION PAZEO PEDVAX HIB (PF) peg 3350-electrolytes oral recon soln gram peg 3350-electrolytes oral recon soln gram peg-electrolyte soln PEGANONE PEGINTRON PEGINTRON REDIPEN PENICILLIN G POT IN DEXTROSE INTRAVENOUS PIGGYBACK 1 MILLION UNIT/50 ML PENICILLIN G POT IN DEXTROSE INTRAVENOUS PIGGYBACK 2 MILLION UNIT/50 ML, 3 MILLION UNIT/50 ML penicillin g potassium injection recon soln 20 million unit penicillin g potassium injection recon soln 5 million unit penicillin g procaine intramuscular syringe 1.2 million unit/2 ml penicillin g procaine intramuscular syringe 600, 000 unit/ml penicillin g sodium penicillin v potassium PENTACEL ACTHIB COMPONENT (PF) PENTAM PENTASA pentoxifylline PEPCID AC ORAL TABLET 20 MG PEPTIC RELIEF PEPTO-BISL ORAL TABLET, CHEWABLE PEPTO-BISL TO-GO periogard PERJETA permethrin topical cream permethrin topical liquid perphenazine PERSA-GEL PHARBETOL ORAL TABLET 500 MG phenadoz phenelzine phenobarbital oral elixir phenobarbital oral tablet 100 mg phenobarbital oral tablet 15 mg phenobarbital oral tablet 16.2 mg phenobarbital oral tablet 30 mg phenobarbital oral tablet 32.4 mg phenobarbital oral tablet 60 mg phenobarbital oral tablet 64.8 mg phenobarbital oral tablet 97.2 mg phentermine PHENYLEPHRINE HCL/ DIPHENHYDRAMINE HCL phenytoin oral suspension 100 mg/4 ml (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全 天候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 175

177 phenytoin oral suspension 125 mg/5 ml phenytoin oral tablet, chewable phenytoin sodium extended phenytoin sodium intravenous solution philith PHOSPHATE LAXATIVE ORAL LIQUID PHOSPHOLINE IODIDE PICATO pilocarpine hcl oral PIMTREA (28) pindolol PINK BISMUTH MAXIMUM STRENGTH PINK BISMUTH ORAL SUSPENSION PINK BISMUTH ORAL TABLET PINK BISMUTH ORAL TABLET, CHEWABLE pioglitazone oral tablet 15 mg pioglitazone oral tablet 30 mg pioglitazone oral tablet 45 mg pioglitazone-metformin piperacillintazobactam pirmella piroxicam PLASMA-LYTE PLASMA-LYTE-56 IN 5 % DEXTROSE podofilox POLY BACITRACIN POLY-IRON POLY-VITA POLY-VITAMIN polycin polyethylene glycol 3350 oral powder polyethylene glycol 3350 oral powder in packet polymyxin b sulftrimethoprim polysaccharide iron complex polyvinyl alcohol POMALYST ORAL CAPSULE 1 MG POMALYST ORAL CAPSULE 2 MG POMALYST ORAL CAPSULE 3 MG, 4 MG portia PORTRAZZA 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 potassium chloride in 5 % dex intravenous parenteral solution 20 meq/l, 40 meq/ l potassium chloride in 5 % dex intravenous parenteral solution 30 meq/l potassium chloride in lr-d5 intravenous parenteral solution 20 meq/l potassium chloride in lr-d5 intravenous parenteral solution 40 meq/l potassium chloride intravenous piggyback 10 meq/100 ml, 20 meq/100 ml, 20 meq/50 ml, 40 meq/100 ml potassium chloride intravenous piggyback 10 meq/50 ml potassium chloride intravenous piggyback 30 meq/100 ml potassium chloride intravenous solution potassium chloride oral capsule, extended release potassium chloride oral tablet extended release potassium chloride oral tablet,er particles/ crystals potassium chloride-0.45 % nacl potassium chloride-d5-0.2%nacl intravenous parenteral solution 20 meq/ l potassium chloride-d5-0.2%nacl intravenous parenteral solution 40 meq/ l potassium chloride-d5-0.3%nacl intravenous parenteral solution 20 meq/ l potassium chloride-d5-0.9%nacl intravenous (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全 天候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 176

178 parenteral solution 20 meq/ l potassium chloride-d5-0.9%nacl intravenous parenteral solution 40 meq/ l potassium citrate oral tablet extended release 10 meq (1,080 mg), 5 meq (540 mg) POTIGA ORAL TABLET 200 MG, 300 MG, 400 MG POTIGA ORAL TABLET 50 MG POWDERLAX PRADAXA ORAL CAPSULE 110 MG PRADAXA ORAL CAPSULE 150 MG, 75 MG PRALUENT PEN PRALUENT SYRINGE pramipexole oral tablet pravastatin prazosin oral prednisolone acetate prednisolone oral solution 15 mg/5 ml prednisolone sodium phosphate ophthalmic prednisolone sodium phosphate oral solution 15 mg/5 ml (3 mg/ml), 5 mg base/ 5 ml (6.7 mg/5 ml) prednisolone sodium phosphate oral tablet, disintegrating prednisone intensol prednisone oral PREMARIN PREMPHASE PREMPRO PRENATAL FORMULA ORAL TABLET 28 MG IRON- 800 MCG PRENATAL ONE DAILY PRENATAL TABLET PRENATAL VITAMIN ORAL CAPSULE MG prenatal vitamin oral tablet PRENATAL VITAMIN ORAL TABLET, MG, 28 MG IRON- 800 MCG PRENATAL VITAMIN ORAL TABLET 27 MG IRON- 800 MCG prenatal vitamin oral tablet 28 mg iron- 800 mcg prevalite previfem PREZCOBIX PREZISTA ORAL SUSPENSION PREZISTA ORAL TABLET 150 MG PREZISTA ORAL TABLET 600 MG, 800 MG PREZISTA ORAL TABLET 75 MG PRIFTIN PRIMAQUINE primidone PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 100 MG PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 25 MG PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 50 MG PROAIR HFA PROAIR RESPICLICK probenecid procainamide injection solution 100 mg/ml procainamide injection solution 500 mg/ml prochlorperazine edisylate injection solution 10 mg/2 ml (5 mg/ml) prochlorperazine maleate oral tablet 10 mg, 5 mg prochlorperazine maleate rectal PROCRIT procto-pak proctosol hc proctozone-hc PROGLYCEM PROGRAF INTRAVENOUS PROLEUKIN PROLIA PROMACTA ORAL TABLET 12.5 MG, 25 MG, 75 MG PROMACTA ORAL TABLET 50 MG promethazine oral tablet PROMETHAZINE VC- CODEINE promethazine-codeine promethazine-dm promethazine-phenylephcodeine promethegan rectal suppository 12.5 mg PROLAXIN propafenone oral tablet propranolol intravenous propranolol oral propranololhydrochlorothiazid (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全 天候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 177

179 propylthiouracil PROQUAD (PF) PROTONIX INTRAVENOUS PROTOPIC protriptyline PROVIL PSEUDOEPHEDRINE 120 MG ER pseudoephedrine hcl oral liquid pseudoephedrine hcl oral tablet 30 mg pseudoephedrine hcl oral tablet 60 mg pseudoephedrine hcl oral tablet extended release PSEUDOEPHEDRINE HCL/ CHLORPHENIRAMINE MALEATE ORAL TABLET 4-10 MG, 4-60 MG PSEUDOEPHEDRINE HCL/ CHLORPHENIRAMINE MALEATE TABLET PSEUDOEPHEDRINE HCL/ TRIPROLIDINE HCL ORAL TABLET PULZYME PURELAX PURIXAN pyrazinamide pyridostigmine bromide pyridoxine (vitamin b6) oral tablet 100 mg, 25 mg, 50 mg Q Q-DRYL ORAL CAPSULE Q-DRYL ORAL LIQUID Q-PAP EXTRA STRENGTH Q-PAP ORAL TABLET 500 MG Q-TUSSIN QUADRACEL (PF) quetiapine oral tablet 100 mg quetiapine oral tablet 200 mg quetiapine oral tablet 25 mg quetiapine oral tablet 300 mg quetiapine oral tablet 400 mg quetiapine oral tablet 50 mg quinapril quinaprilhydrochlorothiazide quinidine gluconate oral quinidine sulfate oral tablet quinine sulfate QUIT QUIT 4 BUCCAL GUM QVAR INHALATION AEROSOL 40 MCG/ACTUATION QVAR INHALATION AEROSOL 80 MCG/ACTUATION R RABAVERT (PF) raloxifene ramipril RANEXA ranitidine hcl oral syrup ranitidine hcl oral tablet 150 mg, 300 mg ranitidine hcl oral tablet 75 mg RAPAMUNE RAVICTI READY-TO-USE ENEMA (MIN OIL) REBIF REBIDOSE REBIF TITRATION PACK REBIF (WITH ALBUMIN) reclipsen (28) RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 10 MCG/ML RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 5 MCG/0.5 ML RECORT PLUS REDNESS RELIEVER LUBRICANT RELCOF C RELENZA DISKHALER RELISTOR SUBCUTANEOUS SOLUTION REMICADE RENA-VITE RENAGEL RENVELA ORAL POWDER IN PACKET 0.8 GRAM RENVELA ORAL POWDER IN PACKET 2.4 GRAM RENVELA ORAL TABLET repaglinide oral tablet 0.5 mg repaglinide oral tablet 1 mg repaglinide oral tablet 2 mg REPATHA PUSHTRONEX REPATHA SURECLICK REPATHA SYRINGE RESCRIPTOR ORAL TABLET RESCRIPTOR ORAL TABLET, DISPERSIBLE (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全 天候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 178

180 REST SIMPLY NIGHTTIME SLEEP RESTASIS RESTFULLY SLEEP RETROVIR INTRAVENOUS REVIVE PLUS REVLIMID ORAL CAPSULE 10 MG REVLIMID ORAL CAPSULE 15 MG, 2.5 MG, 20 MG, 25 MG REVLIMID ORAL CAPSULE 5 MG REXULTI ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG REXULTI ORAL TABLET 3 MG, 4 MG REYATAZ ORAL CAPSULE 150 MG, 200 MG REYATAZ ORAL CAPSULE 300 MG REYATAZ ORAL POWDER IN PACKET RI-GEL RI-GEL II RI-X RI-TUSSIN ribasphere oral capsule ribasphere oral tablet 200 mg ribavirin oral capsule ribavirin oral tablet 200 mg RID COMPLETE LICE ELIM KIT TOPICAL RIDAURA rifampin RIFATER riluzole rimantadine ringers intravenous ringers irrigation RINGWORM RISACAL-D RISPERDAL CONSTA INTRAMUSCULAR SYRINGE 12.5 MG/2 ML, 25 MG/2 ML, 37.5 MG/ 2 ML RISPERDAL CONSTA INTRAMUSCULAR SYRINGE 50 MG/2 ML risperidone oral solution risperidone oral tablet 0.25 mg risperidone oral tablet 0.5 mg risperidone oral tablet 1 mg risperidone oral tablet 2 mg risperidone oral tablet 3 mg risperidone oral tablet 4 mg risperidone oral tablet, disintegrating 0.25 mg risperidone oral tablet, disintegrating 0.5 mg risperidone oral tablet, disintegrating 1 mg risperidone oral tablet, disintegrating 2 mg risperidone oral tablet, disintegrating 3 mg risperidone oral tablet, disintegrating 4 mg RITUXAN rivastigmine rivastigmine tartrate rizatriptan ROBAFEN ROBAFEN DM COUGH ropinirole oral tablet rosadan topical cream ROTARIX ROTATEQ VACCINE roweepra ROZEREM RYDEX S SABRIL SALICYLIC ACID TOPICAL LIQUID 3 % SANDIMMUNE ORAL SOLUTION SANI-SUPP (ADULT) SANTYL SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 10 MG SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 2.5 MG SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 5 MG SAVELLA ORAL TABLET 100 MG SAVELLA ORAL TABLET 12.5 MG SAVELLA ORAL TABLET 25 MG SAVELLA ORAL TABLET 50 MG SAVELLA ORAL TABLETS,DOSE PACK SCALP RELIEF HYDROCORTISONE TOPICAL LIQUID 3 % SCALP RELIEF HYDROCORTISONE TOPICAL SOLUTION 1 % SCALPICIN ANTI-ITCH SCOT-TUSSIN EXPECTORANT SECURA ANTIFUNGAL (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全 天候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 179

181 SECURA ANTIFUNGAL EXTRA THICK selegiline hcl selenium sulfide topical lotion SELZENTRY SENSIPAR ORAL TABLET 30 MG, 60 MG SENSIPAR ORAL TABLET 90 MG SEREVENT DISKUS SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 150 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 200 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 300 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 400 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 50 MG sertraline oral concentrate sertraline oral tablet 100 mg sertraline oral tablet 25 mg sertraline oral tablet 50 mg SHAROBEL SIGNIFOR SILACE ORAL LIQUID SILACE ORAL SYRUP SILADRYL SA sildenafil oral SILTUSSIN DM DAS SILTUSSIN SA silver sulfadiazine SIMETHICONE ORAL CAPSULE 125 MG, 180 MG simethicone oral capsule 180 mg simethicone oral tablet, chewable SIMETHICONE ORAL TABLET, CHEWABLE 125 MG SIMETHICONE ORAL TABLET, CHEWABLE 125 MG, 80 MG SIMULECT INTRAVENOUS RECON SOLN 10 MG SIMULECT INTRAVENOUS RECON SOLN 20 MG simvastatin SINUS 12 HOUR SINUS AND ALLERGY PE SINUS-ALLERGY (PHENYLEPHRINE) sirolimus SIRTURO SKIN TREATMENT SLEEP AID MAX STR (DIPHENHYDR) SLEEP AID (DIPHENHYDRAMINE) ORAL CAPSULE 50 MG SLEEP AID (DIPHENHYDRAMINE) ORAL TABLET SLEEP AID (DOXYLAMINE) SLEEP TABLET (DIPHENHYDRAMINE) SLEEP-TABS SLOW RELEASE IRON ORAL TABLET EXTENDED RELEASE 160 MG (50 MG IRON), 250 MG (50 MG IRON), 47.5 MG IRON SOTH ANTACID SOTHLAX sodium chloride 0.45 % intravenous parenteral solution sodium chloride 0.45 % intravenous piggyback sodium chloride 0.9 % intravenous sodium chloride 3 % sodium chloride 5 % sodium chloride inhalation solution for nebulization 0.9 %, 3 % sodium chloride intravenous parenteral solution 2.5 meq/ ml sodium chloride intravenous parenteral solution 4 meq/ ml sodium chloride irrigation sodium fluoride oral tablet sodium fluoride oral tablet, chewable 1 mg fluoride (2.2 mg) sodium polystyrene sulfonate oral powder sodium polystyrene sulfonate oral suspension sodium polystyrene sulfonate rectal enema 30 gram/120 ml SODIUM POLYSTYRENE SULFONATE RECTAL ENEMA 50 GRAM/200 ML sodium polystyrene (sorb free) SOF-LAX SOLTAX SOMATULINE DEPOT (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全 天候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 180

182 SOMAVERT SUBCUTANEOUS RECON SOLN 10 MG, 15 MG, 20 MG SOMAVERT SUBCUTANEOUS RECON SOLN 25 MG, 30 MG SOOTHE REGULAR STRENGTH SOOTHE (BISMUTH SUBSALICYLATE) SOOTHING CARE (HYDROCORTISONE) SORIATANE ORAL CAPSULE 10 MG, 17.5 MG, 25 MG sorine oral tablet 120 mg, 160 mg, 80 mg sorine oral tablet 240 mg sotalol af sotalol oral SOVALDI SPIRIVA RESPIMAT SPIRIVA WITH HANDIHALER spironolactonhydrochlorothiaz spironolactone sprintec (28) SPRITAM ORAL TABLET FOR SUSPENSION 1,000 MG, 250 MG, 500 MG SPRITAM ORAL TABLET FOR SUSPENSION 750 MG SPRYCEL sps (with sorbitol) oral sps (with sorbitol) rectal sronyx ssd stavudine oral capsule 15 mg, 20 mg stavudine oral capsule 30 mg, 40 mg stavudine oral recon soln STERILE EYE DROPS OPHTHALMIC DROPS %, % STERILE EYE WASH STERILE SALINE NASAL STIMATE STIVARGA STOMACH RELIEF STOMACH RELIEF MAX STRENGTH STOMACH RELIEF ORIGINAL STOOL SOFTENER ORAL CAPSULE 100 MG, 240 MG, 250 MG STOOL SOFTENER ORAL CAPSULE 50 MG STOOL SOFTENER ORAL LIQUID STOOL SOFTENER ORAL SYRUP STOOL SOFTENER ORAL TABLET STOP LICE STOP SKING AID STRATTERA ORAL CAPSULE 10 MG, 18 MG, 25 MG, 40 MG STRATTERA ORAL CAPSULE 100 MG, 60 MG, 80 MG STRAWBERRY C STREPTOMYCIN INTRAMUSCULAR STRIBILD STROMECTOL SUBSYS sucralfate oral tablet SUDOGEST SUDOGEST 12-HOUR SUDOGEST COLD AND ALLERGY SUDOGEST SINUS AND ALLERGY sulfacetamide sodium ophthalmic drops sulfacetamide sodium (acne) sulfacetamideprednisolone sulfadiazine oral sulfamethoxazoletrimethoprim SULFAMYLON sulfasalazine sulindac oral sumatriptan succinate oral sumatriptan succinate subcutaneous cartridge sumatriptan succinate subcutaneous pen injector 4 mg/0.5 ml, 6 mg/0.5 ml sumatriptan succinate subcutaneous pen injector 6 mg/0.5 ml (autoinjector) sumatriptan succinate subcutaneous solution sumatriptan succinate subcutaneous syringe 6 mg/ 0.5 ml SUPER CALCIUM SUPER PAIN RELIEF SUPHEDRIN SUPHEDRIN 12 HOUR SUPHEDRINE SUPHEDRINE 12 HOUR SUPHEDRINE PE COLD AND ALLERGY (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全 天候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 181

183 SUPHEDRINE PE SINUS ANDALLERGY SUPPOSITORY ADULT SUPREP BOWEL PREP KIT SURFAK SURNTIL SUSTIVA ORAL CAPSULE 200 MG SUSTIVA ORAL CAPSULE 50 MG SUSTIVA ORAL TABLET SUTENT ORAL CAPSULE 12.5 MG SUTENT ORAL CAPSULE 25 MG, 37.5 MG, 50 MG syeda SYLATRON SYMBICORT SYMLINPEN SYMLINPEN SYNAGIS SYNAREL SYNERCID SYNRIBO SYNTHROID SYPRINE T TABLOID tacrolimus oral TAFINLAR TAGRISSO ORAL TABLET 40 MG TAGRISSO ORAL TABLET 80 MG TAKE ACTION TAMIFLU tamoxifen tamsulosin TARCEVA ORAL TABLET 100 MG, 150 MG TARCEVA ORAL TABLET 25 MG TARGRETIN ORAL TARGRETIN TOPICAL TARINA FE 1/20 (28) TASIGNA TAZORAC taztia xt TEARS AGAIN (PVA) TEARS NATURALE FREE (PF) TECENTRIQ TECHNIVIE TEFLARO telmisartan oral tablet 20 mg, 40 mg telmisartan oral tablet 80 mg temazepam oral capsule 15 mg, 22.5 mg, 30 mg terazosin terbinafine hcl oral... 8 terbinafine hcl topical terbutaline oral terbutaline subcutaneous terconazole TESTIM testosterone cypionate testosterone enanthate tetanus,diphtheria tox ped (pf) TETANUS-DIPHTHERIA TOXOIDS- TD tetrabenazine oral tablet 12.5 mg tetrabenazine oral tablet 25 mg tetracycline THALOMID ORAL CAPSULE 100 MG, 50 MG THALOMID ORAL CAPSULE 150 MG, 200 MG THE MAGIC BULLET theophylline oral tablet extended release 12 hr theophylline oral tablet extended release 24 hr THERA-D thermazene thiamine hcl (vitamin b1) oral tablet 100 mg, 250 mg, 50 mg thiamine mononitrate (vit b1) thioridazine thiotepa thiothixene THYGLOBULIN tiagabine TICE BCG TIKOSYN timolol maleate ophthalmic timolol maleate oral TINACTIN TOPICAL AEROSOL POWDER TIVICAY ORAL TABLET 10 MG, 25 MG TIVICAY ORAL TABLET 50 MG tizanidine oral tablet TOBI tobramycin tobramycin sulfate injection recon soln tobramycin sulfate injection solution tobramycin-dexamethasone opthalmic suspension tolcapone (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全 天候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 182

184 tolmetin tolnaftate topical aerosol powder tolnaftate topical cream tolterodine oral capsule, extended release 24hr tolterodine oral tablet topiramate oral capsule, sprinkle topiramate oral tablet 100 mg topiramate oral tablet 200 mg topiramate oral tablet 25 mg topiramate oral tablet 50 mg toposar topotecan intravenous recon soln topotecan intravenous solution TORISEL torsemide oral TOUJEO SOLOSTAR TOVIAZ TPN ELECTROLYTES TRACLEER tramadol oral tablet tramadolacetaminophen trandolapril tranexamic acid intravenous tranexamic acid oral TRANSDERM-SCOP tranylcypromine travasol 10 % TRAVATAN Z TRAVEL SICKNESS (MECLIZINE) travoprost (benzalkonium) trazodone TREANDA INTRAVENOUS RECON SOLN TRECATOR TRELSTAR DEPOT TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION TRELSTAR INTRAMUSCULAR SYRINGE MG/2 ML, 3.75 MG/2 ML TRELSTAR INTRAMUSCULAR SYRINGE 22.5 MG/2 ML TRELSTAR LA tretinoin topical cream tretinoin topical gel 0.01 %, % tretinoin (chemotherapy) TREXALL TRI-BIOZENE tri-estarylla tri-linyah tri-previfem (28) tri-sprintec (28) triamcinolone acetonide dental triamcinolone acetonide injection suspension 10 mg/ ml triamcinolone acetonide injection suspension 40 mg/ ml triamcinolone acetonide topical cream triamcinolone acetonide topical lotion triamcinolone acetonide topical ointment %, 0.1 %, 0.5 % triamterenehydrochlorothiazid oral capsule mg triamterenehydrochlorothiazid oral tablet trianex triderm topical cream trifluoperazine trifluridine trihexyphenidyl TRILEPTAL ORAL SUSPENSION trimethoprim trinessa (28) trintellix oral tablet 10 mg trintellix oral tablet 20 mg trintellix oral tablet 5 mg TRIPLE ANTIBIOTIC PLUS TRIPLE ANTIBIOTIC TOPICAL OINTMENT TRIPLE ANTIBIOTIC TOPICAL OINTMENT IN PACKET TRIPLE ANTIBIOTIC (PRAM) EXTRA TRIPLE ANTIBIOTIC-PAIN RELIEF TRISENOX TRIUMEQ trivora (28) TRIZIVIR TROPHAMINE 10 % TROPHAMINE 6% TRUMENBA (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全 天候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 183

185 TRUVADA ORAL TABLET MG, MG, MG TRUVADA ORAL TABLET MG TUDORZA PRESSAIR INHALATION AEROSOL POWDR BREATH ACTIVATED 400 MCG/ ACTUATION TUDORZA PRESSAIR INHALATION AEROSOL POWDR BREATH ACTIVATED 400 MCG/ ACTUATION (30 ACTUAT) TUMS ULTRA ORAL TABLET, CHEWABLE 400 MG (1,000 MG) TUSNEL DIABETIC TUSSI PRES-B ORAL LIQUID MG/5 ML TUSSIGON TUSSIN CHEST CONGESTION TUSSIN COUGH-CHEST CONGESTION TUSSIN DM COUGH AND CHEST ORAL LIQUID MG/5 ML TUSSIN DM ORAL LIQUID TUSSIN EXPECTORANT TUSSIN HONEY TUSSIN ORAL LIQUID TWINRIX (PF) TYBOST TYGACIL TYKERB TYPHIM VI INTRAMUSCULAR SOLUTION TYPHIM VI INTRAMUSCULAR SYRINGE TYSABRI TYZEKA TYZINE NASAL DROPS 0.05 % U ULTRA FRESH ULTRA SLEEP (DOXYLAMINE SUCC) ULTRA STRENGTH ANTACID ULTRA STRENGTH CALCIUM ANTACID 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 UNITUXIN urea topical cream 10 %, 20 % urea topical lotion 10 % UREACIN URINARY PAIN RELIEF ORAL TABLET 95 MG URINARY TRACT ursodiol UVADEX V VAGIFEM VAGINAL CONTRACEPTIVE FOAM VAGISTAT valacyclovir VALCHLOR valganciclovir oral tablet valproate sodium valproic acid valproic acid (as sodium salt) oral solution 250 mg/5 ml valproic acid (as sodium salt) oral solution 250 mg/5 ml (5 ml), 500 mg/10 ml (10 ml) valsartan oral tablet 160 mg valsartan oral tablet 320 mg valsartan oral tablet 40 mg, 80 mg valsartanhydrochlorothiazide VALU-DRYL ALLERGY ORAL CAPSULE vancomycin in 0.9% sodium cl intravenous piggyback 1 gram/200 ml VANCOMYCIN IN 0.9% SODIUM CL INTRAVENOUS PIGGYBACK 500 MG/100 ML, 750 MG/150 ML vancomycin in dextrose 5 % intravenous piggyback 1 gram/200 ml VANCOMYCIN IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK 500 MG/100 ML, 750 MG/150 ML vancomycin intravenous recon soln 1,000 mg, 10 gram, 500 mg, 750 mg vancomycin intravenous recon soln 5 gram vancomycin oral capsule 125 mg vancomycin oral capsule 250 mg VAQTA (PF) VARIVAX (PF) VARIZIG VECAMYL VECTIBIX VECTICAL VELCADE (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全 天候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 184

186 velivet triphasic regimen (28) VENCLEXTA ORAL TABLET 10 MG VENCLEXTA ORAL TABLET 100 MG VENCLEXTA ORAL TABLET 50 MG VENCLEXTA STARTING PACK venlafaxine oral capsule, extended release 24hr 150 mg venlafaxine oral capsule, extended release 24hr 37.5 mg venlafaxine oral capsule, extended release 24hr 75 mg venlafaxine oral tablet 100 mg venlafaxine oral tablet 25 mg venlafaxine oral tablet 37.5 mg venlafaxine oral tablet 50 mg venlafaxine oral tablet 75 mg venlafaxine oral tablet extended release 24hr 150 mg venlafaxine oral tablet extended release 24hr 37.5 mg venlafaxine oral tablet extended release 24hr 75 mg VENTAVIS VENTOLIN HFA verapamil intravenous solution verapamil oral capsule, 24 hr er pellet ct verapamil oral capsule,ext rel. pellets 24 hr verapamil oral tablet verapamil oral tablet extended release 120 mg (24 hours) verapamil oral tablet extended release 120 mg, 180 mg, 240 mg VERSACLOZ VESICARE vicodin vicodin es vicodin hp VICTOZA 2-PAK VICTOZA 3-PAK VIDEX 2 GRAM PEDIATRIC VIDEX 4 GRAM PEDIATRIC VIEKIRA PAK VIEKIRA XR VIGAX VIIBRYD ORAL TABLET 10 MG VIIBRYD ORAL TABLET 20 MG VIIBRYD ORAL TABLET 40 MG VIMPAT INTRAVENOUS VIMPAT ORAL SOLUTION VIMPAT ORAL TABLET 100 MG VIMPAT ORAL TABLET 150 MG VIMPAT ORAL TABLET 200 MG VIMPAT ORAL TABLET 50 MG vinblastine intravenous solution VINCASAR PFS INTRAVENOUS SOLUTION 1 MG/ML vincasar pfs intravenous solution 2 mg/2 ml vincristine vinorelbine viorele (28) VIRACEPT ORAL TABLET 250 MG VIRACEPT ORAL TABLET 625 MG VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 HR 100 MG VIRAZOLE VIREAD ORAL POWDER VIREAD ORAL TABLET VIRTUSSIN AC VITAMIN A PALMITATE ORAL CAPSULE VITAMIN A PALMITATE ORAL TABLET 10,000 UNIT vitamin a palmitate oral tablet 15,000 unit VITAMIN B VITAMIN B-1 (NONITRATE) VITAMIN B-12 ORAL TABLET 1, 000 MCG, 100 MCG, 250 MCG, 500 MCG VITAMIN B-12 ORAL TABLET EXTENDED RELEASE 1,000 MCG VITAMIN B-12 ORAL TABLET EXTENDED RELEASE 2,000 MCG VITAMIN B-12 SUBLINGUAL TABLET 2,500 MCG VITAMIN B VITAMIN B-6 ORAL TABLET 100 MG, 25 MG, 50 MG (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全 天候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 185

187 VITAMIN C ORAL CAPSULE, EXTENDED RELEASE VITAMIN C ORAL TABLET 1,000 MG, 250 MG, 500 MG VITAMIN C ORAL TABLET, CHEWABLE 250 MG, 500 MG VITAMIN C WITH ROSE HIPS ORAL TABLET VITAMIN D VITAMIN D3 ORAL CAPSULE 1, 000 UNIT, 2,000 UNIT, 400 UNIT VITAMIN D3 ORAL TABLET 1,000 UNIT, 2,000 UNIT, 400 UNIT VITAMIN D3 ORAL TABLET 5,000 UNIT vitamin e oral capsule 1,000 unit, 200 unit, 400 unit vitamin e oral capsule 100 unit VITAMIN E (DL, ACETATE) ORAL CAPSULE 100 UNIT VITEKTA VIVELLE-DOT VOLTAREN TOPICAL GEL 1 % voriconazole intravenous... 9 voriconazole oral suspension for reconstitution... 9 voriconazole oral tablet 200 mg... 9 voriconazole oral tablet 50 mg... 9 VOSPIRE ER VOTRIENT VPRIV VRAYLAR ORAL CAPSULE VRAYLAR ORAL CAPSULE,DOSE PACK VYFEMLA (28) W warfarin water for irrigation, sterile WELCHOL WOMAN'S LAXATIVE ORAL TABLET,DELAYED RELEASE (DR/EC) WOMEN'S GENTLE LAXATIVE (BISAC) WOMEN'S LAXATIVE (BISACODYL) ORAL TABLET, DELAYED RELEASE (DR/ EC) X XALKORI XARELTO ORAL TABLET 10 MG, 20 MG XARELTO ORAL TABLET 15 MG XARELTO ORAL TABLETS,DOSE PACK XENAZINE ORAL TABLET 12.5 MG XENAZINE ORAL TABLET 25 MG XGEVA XIFAXAN ORAL TABLET 550 MG XODOL 10/ XODOL 5/ XODOL 7.5/ XOLAIR XTANDI XYREM Y YERVOY YF-VAX (PF) YONDELIS Z zafirlukast zaleplon oral capsule 10 mg zaleplon oral capsule 5 mg ZALTRAP ZANOSAR zarah ZAVESCA ZEASORB (MICONAZOLE) ZELBORAF ZEMAIRA zenchent (28) zenzedi oral tablet 10 mg zenzedi oral tablet 5 mg ZEPATIER ZETIA ZIAGEN ORAL SOLUTION zidovudine oral capsule zidovudine oral syrup zidovudine oral tablet ziprasidone hcl oral capsule 20 mg ziprasidone hcl oral capsule 40 mg ziprasidone hcl oral capsule 60 mg, 80 mg ZIRGAN zoledronic acid intravenous recon soln 4 mg zoledronic acid intravenous solution 4 mg/5 ml ZOLINZA zolmitriptan ZOMETA INTRAVENOUS SOLUTION 4 MG/100 ML ZOMIG NASAL zonisamide (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全 天候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 186

188 ZORTRESS ZOSTAVAX (PF) ZOSYN IN DEXTROSE (ISO-OSM) INTRAVENOUS PIGGYBACK 2.25 GRAM/50 ML ZOSYN IN DEXTROSE (ISO-OSM) INTRAVENOUS PIGGYBACK GRAM/50 ML, 4.5 GRAM/100 ML zovia 1/35e (28) zovia 1/50e (28) ZYDELIG ZYKADIA ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 210 MG, 405 MG ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 300 MG ZYTIGA ZYVOX INTRAVENOUS PARENTERAL SOLUTION 200 MG/ 100 ML ZYVOX INTRAVENOUS PARENTERAL SOLUTION 600 MG/ 300 ML ZYVOX ORAL SUSPENSION FOR RECONSTITUTION (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全 天候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 187

189 如果您有任何疑問, 請致電 CareMore Cal MediConnect Plan 會員服務部, 電話號碼 (TTY 711), 太平洋時間週一至週五上午 8 點至下午 8 點 如需更多資訊, 請瀏覽網站 duals.caremore.com 給付藥物清單 和 / 或網路內藥房和醫療服務提供者可能於全年內隨時變動 在我們做的改變對您造成影 響之前, 我們會向您寄送通知 福利 和 / 或共付費用可能於每年 1 月 1 日進行變動 您可以隨時查詢 CareMore Cal MediConnect Plan 最新的給付藥物清單, 請上網至網站 duals.caremore.com 或致電 (TTY 711). 條件及限制可能適用 有關更多資訊, 請致電 CareMore Cal MediConnect Plan 會員服務部, 或查閱 CareMore Cal MediConnect Plan 會員手冊 處方藥物的共付費用可能會根據您所取得的 Extra Help( 額外補助 ) 等級而有所不同 請聯絡本計劃以 取得更多詳情 CareMore Cal MediConnect Plan (Medicare-Medicaid Plan) 是一個同時與 Medicare 和 Medi-Cal 訂立合 約的醫療保健計劃, 從而為參保人提供這兩個計劃的福利 CareMore 代表 CareMore 的附屬公司負責執 行合約 CareMore 為 CareMore Health System 的註冊商標 H6629_16_25137_T_001_CT CMS Approved 08/26/2015 處方藥物 ID: 版本.. 22 發佈時間 1/1/2016 CCADMKT