1.877.ICS.2525 行 政 辦 公 室 Independence Care System 257 Park Ave. South 2nd Floor New York, NY 10010 會 員 中 心 400 East Fordham Road 10th fl

承 保 藥 物 清 單 Community Care Plus FIDA-MMP 2015 1.877.ICS.2525 www.icsny.org ICS_15412000_A2TC_G_EFF01012015_ 08042014_174025_Comprehensive_R11 3 14_Approved

1.877.ICS.2525 www.icsny.org 行 政 辦 公 室 Independence Care System 257 Park Ave. South 2nd Floor New York, NY 10010 會 員 中 心 400 East Fordham Road 10th floor Bronx, New York 10458 25 Elm Place 5th Floor Brooklyn, NY 11201

ICS COMMUNITY CARE PLUS FIDA-MMP 计 划 2015 承 保 药 物 清 单 ( 处 方 集 ) 此 文 件 列 明 了 参 与 者 能 够 在 ICS COMMUNITY CARE PLUS FIDA-MMP 计 划 中 获 得 的 药 物 清 单 ICS COMMUNITY CARE PLUS FIDA-MMP 计 划 是 一 项 管 理 中 的 护 理 计 划, 与 Medicare 及 纽 约 州 卫 生 部 (Medicaid) 签 定 合 约, 通 过 全 面 整 合 特 惠 计 划 (FIDA) 示 范 项 目 向 参 与 者 提 供 两 个 计 划 的 福 利 在 一 年 当 中 以 及 每 年 的 1 月 1 日, 有 关 福 利 承 保 药 物 清 单 及 药 房 与 医 疗 保 健 提 供 者 网 络 可 能 会 不 时 变 化 您 可 随 时 访 问 www.icsny.org/care-plus, 在 线 查 看 ICS COMMUNITY CARE PLUS FIDA-MMP 计 划 的 最 新 承 保 药 物 清 单, 或 致 电 ICS COMMUNITY CARE PLUS FIDA- MMP 计 划 参 与 者 服 务 部, 电 话 号 码 为 1.887.ICS.2525 可 能 会 适 用 相 关 限 制 和 规 定 更 多 详 情, 请 致 电 ICS COMMUNITY CARE PLUS FIDA-MMP 计 划 参 与 者 服 务 部 或 阅 读 ICS COMMUNITY CARE PLUS FIDA-MMP 计 划 参 与 者 手 册 承 保 药 物 没 有 共 付 额 您 可 以 其 他 形 式 免 费 获 得 此 资 料 ( 例 如 盲 文 版 或 大 字 版 ) 致 电 1.877.ICS.2525 此 为 免 费 电 话 您 可 免 费 获 得 所 有 这 些 信 息 的 其 他 语 言 版 本 请 在 周 一 至 周 五 上 午 8 点 至 晚 上 8 点 致 电 ICS, 电 话 号 码 为 1.877.ICS.2525, 听 障 专 线 (TTY) 为 1.855.ICS.4TTY 此 为 免 费 电 话 You can get this information for free in other languages. Call 1.877.ICS.2525 and TTY 1.855.ICS.4TTY during the hours of 8 a.m. to 8 p.m., Monday through Friday. The call is free. Вы можете бесплатно получить всю эту информацию на других языках. Звоните в ICS по телефону 1.877.ICS.2525 и телетайпу 1.855.ICS.4TTY с понедельника по пятницу с 8:00 до 20:00. Звонок бесплатный.? 如 有 问 题, 请 在 周 一 至 周 五 上 午 8 点 至 晚 上 8 点 致 电 ICS Community Care Plus FIDA- MMP 计 划, 电 话 号 码 为 1.877.ICS.2525, 听 障 专 线 (TTY) 为 1.855.ICS.4TTY 此 为 免 费 电 话 更 多 详 1

Puede obtener toda esta información en otros idiomas de manera gratuita. Llame a ICS al 1.877.ICS.2525 y a la línea TTY 1.855.ICS.4TTY, entre las 8 a. m. y las 8 p. m., de lunes a viernes. La llamada es gratuita. Ou kapab jwenn tout enfòmasyon sa a gratis nan lòt lang. Rele ICS nan 1.877.ICS.2525 ak TTY 1.855.ICS.4TTY, ant 8 a.m. ak 8 p.m., lendi jiska vandredi. Apèl la gratis. 이 모든 정보는 타 언어로 무료로 제공됩니다. 월요일~금요일, 오전 8 시~오후 8 시 사이에 1.877.ICS.2525 및 TTY(청각 장애인용 전화) 1.855.ICS.4TTY 로 ICS 에 전화해 주십시오. 이 전화는 무료입니다. Le informazioni in questione sono disponibili gratuitamente anche in altre lingue. Chiamare ICS ai numeri 1.877.ICS.2525 e TTY 1.855.ICS.4TTY tra le 8:00 e le 20.00 dal lunedì al venerdì. La chiamata è gratuita. 纽 约 州 成 立 了 名 为 独 立 消 费 者 倡 导 网 络 (ICAN) 的 参 与 者 监 察 专 员 计 划, 就 ICS COMMUNITY CARE PLUS FIDA-MMP 计 划 所 提 供 的 服 务 为 参 与 者 提 供 免 费 协 助, 并 为 您 保 密 您 可 拨 打 免 费 电 话 1.844.614.8800 或 在 线 访 问 www.icannys.org, 联 系 ICAN? 如 有 问 题, 请 在 周 一 至 周 五 上 午 8 点 至 晚 上 8 点 致 电 ICS Community Care Plus FIDA- MMP 计 划, 电 话 号 码 为 1.877.ICS.2525, 听 障 专 线 (TTY) 为 1.855.ICS.4TTY 此 为 免 费 电 话 更 多 详 2

常 见 问 题 (FAQ) 如 您 对 此 承 保 药 物 清 单 有 任 何 疑 问, 可 于 下 文 寻 找 回 答 您 可 通 读 FAQ 全 文 了 解 详 情, 或 查 找 问 题 及 回 答 1. 承 保 药 物 清 单 包 含 哪 些 处 方 药? ( 承 保 药 物 清 单 下 文 简 称 为 药 物 清 单 ) 从 第 15 页 开 始 的 承 保 药 物 清 单 中 的 药 物, 为 ICS COMMUNITY CARE PLUS FIDA- MMP 计 划 的 保 障 范 围 内 药 物 这 些 药 物 在 我 们 的 网 络 内 药 房 均 有 提 供 如 药 房 与 我 们 签 定 协 议, 同 意 与 我 们 合 作 及 向 您 提 供 服 务, 则 该 药 房 即 属 于 我 们 的 网 络 我 们 将 此 类 药 房 称 为 网 络 内 药 房 在 下 列 情 况 中,ICS COMMUNITY CARE PLUS FIDA-MMP 计 划 将 承 保 药 物 清 单 中 的 所 有 药 物 : 您 的 医 生 或 其 他 网 络 处 方 人 表 示 您 需 要 有 关 药 物 进 行 治 疗 或 保 持 健 康, 就 您 的 情 况 而 言, 该 药 物 在 医 疗 上 属 必 需, 及 您 在 ICS COMMUNITY CARE PLUS FIDA-MMP 计 划 网 络 内 药 房 填 写 处 方 对 于 某 些 药 物 的 获 取,ICS COMMUNITY CARE PLUS FIDA-MMP 计 划 可 能 会 设 置 额 外 步 骤 ( 参 见 下 文 问 题 5) 在 某 些 情 况 下, 您 在 获 得 药 物 前 可 能 需 要 采 取 某 些 行 动, 例 如 首 先 尝 试 其 他 药 物 您 亦 可 访 问 我 们 的 网 站 www.icsny.org/care-plus/pharmacy-benefits 查 看 我 们 的 最 新 承 保 药 物 清 单, 或 致 电 参 与 者 服 务 部, 电 话 号 码 为 1.877.ICS.2525 2. 药 物 清 单 会 不 时 变 化 吗? 会 ICS COMMUNITY CARE PLUS FIDA-MMP 计 划 可 能 会 在 这 一 年 里 对 药 物 清 单 的 药 物 进 行 增 减 一 般 而 言, 仅 会 在 以 下 情 况 下 修 改 药 物 清 单 : 出 现 一 种 与 药 物 清 单 中 的 某 一 现 有 药 物 具 有 相 同 效 果 的 新 药, 或 我 们 获 悉 某 种 药 物 不 安 全 我 们 亦 可 能 会 修 改 我 们 的 药 物 规 定 例 如, 我 们 会 :? 如 有 问 题, 请 在 周 一 至 周 五 上 午 8 点 至 晚 上 8 点 致 电 ICS Community Care Plus FIDA- MMP 计 划, 电 话 号 码 为 1.877.ICS.2525, 听 障 专 线 (TTY) 为 1.855.ICS.4TTY 此 为 免 费 电 话 更 多 详 3

决 定 某 一 药 物 是 否 需 要 预 审 批 ( 预 审 批 是 指 在 您 获 得 药 物 前 获 得 ICS COMMUNITY CARE PLUS FIDA-MMP 计 划 或 您 的 跨 领 域 团 队 (IDT) 的 许 可 ) 增 加 或 修 改 您 可 获 得 药 物 的 数 量 ( 称 为 数 量 上 限 ) 增 加 或 修 改 一 种 药 物 的 阶 梯 疗 法 限 制 ( 阶 梯 疗 法 是 指 您 须 首 先 尝 试 一 种 药 物, 然 后 我 们 才 会 承 保 另 一 种 药 物 ) ( 有 关 药 物 规 定 的 更 多 详 情, 请 参 见 第 5 页 ) 如 您 所 使 用 的 药 物 何 时 从 药 物 清 单 中 删 除, 我 们 将 告 诉 您 如 我 们 修 改 某 一 药 物 的 承 保 规 定, 亦 会 通 知 您 下 文 问 题 3 4 和 7 载 有 关 于 药 物 清 单 变 更 时 的 更 多 信 息 您 可 随 时 访 问 www.icsny.org/care-plus/drug-list, 在 线 查 看 ICS COMMUNITY CARE PLUS FIDA-MMP 计 划 的 最 新 药 物 清 单 您 亦 可 致 电 参 与 者 服 务 部, 查 看 最 新 药 物 清 单, 电 话 号 码 为 1.877.ICS.2525 3. 如 出 现 一 种 与 药 物 清 单 中 的 某 一 现 有 药 物 具 有 相 同 效 果 并 且 价 格 更 低 的 药 物, 会 出 现 什 么 情 况? 如 有 一 种 与 药 物 清 单 中 的 某 一 现 有 药 物 具 有 相 同 效 果 并 且 价 格 更 低 的 药 物 : 您 的 药 剂 师 可 能 会 在 您 下 次 按 方 抓 药 时 向 您 提 供 这 种 价 格 更 低 的 药 物 如 您 及 您 的 医 疗 保 健 提 供 者 认 为 这 种 药 物 虽 然 价 格 更 低, 但 不 适 合 您, 您 的 医 疗 保 健 提 供 者 可 指 示 药 剂 师 继 续 向 您 提 供 您 目 前 使 用 的 药 物 ICS COMMUNITY CARE PLUS FIDA-MMP 计 划 可 能 会 作 出 将 贵 价 药 物 从 药 物 清 单 中 删 去 的 决 定 如 我 们 因 出 现 一 种 效 果 相 同 但 价 格 更 低 的 药 物, 而 将 您 正 在 使 用 的 药 物 从 药 物 清 单 中 删 除, 我 们 会 在 将 其 从 药 物 清 单 中 删 除 或 您 要 求 补 充 药 物 前 至 少 提 前 60 天 通 知 您 这 样 您 可 在 药 物 清 单 变 更 前 获 得 60 天 的 药 物 供 应 ICS COMMUNITY CARE PLUS FIDA-MMP 计 划 将 通 过 信 件 向 会 员 通 知 有 关 变 更, 当 中 将 载 有 提 交 投 诉 上 诉 或 例 外 申 报 的 相 关 信 息 ICS COMMUNITY CARE PLUS FIDA-MMP 计 划 亦 将 在 我 们 的 网 站 张 贴 有 关 信 息 ( 网 址 为 www.icsny.org/care-plus), 并 每 年 向 会 员 通 报 我 们 的 最 新 处 方 集 有 关 信 息 有 其 他 格 式 可 供 索 要? 如 有 问 题, 请 在 周 一 至 周 五 上 午 8 点 至 晚 上 8 点 致 电 ICS Community Care Plus FIDA- MMP 计 划, 电 话 号 码 为 1.877.ICS.2525, 听 障 专 线 (TTY) 为 1.855.ICS.4TTY 此 为 免 费 电 话 更 多 详 4

4. 如 我 们 发 现 一 种 药 物 不 安 全, 会 出 现 什 么 情 况? 如 食 品 及 药 物 监 督 管 理 局 (FDA) 声 明 您 正 在 使 用 的 一 种 药 物 不 安 全, 我 们 将 立 即 将 其 从 药 物 清 单 中 剔 除 我 们 将 通 过 信 件 及 电 话 告 诉 您 不 安 全 药 物 已 从 药 物 清 单 中 剔 除, 并 告 诉 您 尽 快 与 处 方 医 师 联 系, 获 得 关 于 取 代 停 用 药 物 的 指 示 您 亦 可 向 您 的 护 理 管 理 人 寻 求 协 助 5. 药 物 承 保 范 围 是 否 有 任 何 限 制 或 限 定? 或 者 是 否 需 要 采 取 某 些 行 动 才 能 获 得 某 些 药 物? 是 的, 某 些 药 物 有 承 保 范 围 规 定, 或 者 对 您 能 够 获 得 的 数 量 有 限 定 在 某 些 情 况 下, 您 须 在 获 得 药 物 前 采 取 一 些 行 动 例 如 : 预 审 批 ( 或 预 授 权 ): 对 于 某 些 药 物, 您 或 您 的 医 生 或 其 他 处 方 人 须 在 您 按 方 抓 药 前 通 过 ICS COMMUNITY CARE PLUS FIDA-MMP 计 划 或 您 的 跨 领 域 团 队 (IDT) 的 审 批 如 您 没 有 获 得 批 准,ICS COMMUNITY CARE PLUS FIDA-MMP 计 划 可 能 不 会 承 保 该 药 物 数 量 上 限 : 有 些 时 候,ICS COMMUNITY CARE PLUS FIDA-MMP 计 划 会 限 定 您 可 以 获 得 的 药 物 数 量 阶 梯 疗 法 : 有 些 时 候,ICS COMMUNITY CARE PLUS FIDA-MMP 计 划 会 要 求 您 采 用 阶 梯 疗 法 这 意 味 着 您 须 按 照 一 定 顺 序 就 您 的 病 情 尝 试 药 物 您 可 能 须 首 先 尝 试 一 种 药 物, 然 后 我 们 才 会 承 保 另 一 种 药 物 如 您 的 医 生 认 为 第 一 种 药 物 对 您 不 起 作 用, 我 们 将 承 保 第 二 种 药 物 您 可 查 看 从 第 15 页 开 始 的 表 格, 了 解 您 的 药 物 是 否 有 其 他 要 求 或 限 定 您 亦 可 访 问 我 们 的 网 站 www.icsny.org/care-plus/pharmacy-benefits, 了 解 更 多 信 息 我 们 已 在 网 站 上 张 贴 有 关 文 件, 解 释 我 们 的 预 授 权 及 阶 梯 疗 法 限 制 您 亦 可 要 求 我 们 向 您 发 送 一 份 副 本 您 还 可 就 有 关 限 定 申 报 例 外 情 形 更 多 例 外 情 形 详 情, 请 参 见 问 题 11 如 您 入 住 疗 养 院 或 其 他 长 期 护 理 设 施, 并 且 需 要 一 种 不 在 药 物 清 单 中 的 药 物, 或 如 您 无 法 轻 松 获 得 您 所 需 的 药 物, 我 们 可 以 提 供 帮 助 无 论 您 是 否 是 ICS COMMUNITY CARE PLUS FIDA-MMP 计 划 的 新 参 与 者, 我 们 都 将 对 您 所 需 药 物 提 供 31 天 紧 急 供 应 承 保 ( 除 非 您 的 处 方 用 药 时 间 更 短 ) 这 将 让 您 有 时 间 与 医 生 或 其 他 处 方 人 协 商 他 们 可 帮 助 您 决 定 药 物 清 单 是 否 有 一 种 您 可 以 使 用 的 类 似 药 物, 还 是 申 报 例 外 情 形 更 多 例 外 情 形 详 情, 请 参 见 问 题 11? 如 有 问 题, 请 在 周 一 至 周 五 上 午 8 点 至 晚 上 8 点 致 电 ICS Community Care Plus FIDA- MMP 计 划, 电 话 号 码 为 1.877.ICS.2525, 听 障 专 线 (TTY) 为 1.855.ICS.4TTY 此 为 免 费 电 话 更 多 详 5

6. 您 如 何 知 道 您 所 需 的 药 物 是 否 有 限 制 或 者 是 否 需 要 采 取 某 些 行 动 才 能 获 得 该 药 物? 从 第 15 页 开 始 的 承 保 药 物 清 单 有 一 列 标 为 用 药 的 必 要 行 动 限 制 或 限 定 7. 如 我 们 修 改 某 些 药 物 的 承 保 规 定, 会 出 现 什 么 情 况? 例 如, 如 我 们 对 某 一 药 物 增 设 预 授 权 ( 审 批 ) 数 量 上 限 及 / 或 阶 梯 疗 法 限 制 如 我 们 对 某 一 药 物 增 设 预 审 批 数 量 上 限 及 / 或 阶 梯 疗 法 限 制, 将 通 知 您 我 们 将 在 增 设 限 制 或 您 下 一 次 申 请 药 物 补 充 前 至 少 提 前 60 天 通 知 您 这 样 您 可 在 药 物 清 单 变 更 前 获 得 60 天 的 药 物 供 应 这 将 让 您 有 时 间 与 医 生 或 其 他 处 方 人 协 商 下 一 步 该 怎 么 办 8. 您 如 何 在 药 物 清 单 上 查 找 药 物? 查 找 药 物 有 两 种 方 法 您 可 按 字 母 顺 序 搜 索 ( 如 您 知 道 药 物 如 何 拼 写 ), 或 您 可 按 病 情 搜 索 按 字 母 顺 序 搜 索, 请 前 往 第 I-1 页 的 索 引 然 后 在 清 单 中 查 找 您 的 药 物 名 称 按 病 情 搜 索, 请 于 第 15 页 找 到 病 情 分 类 药 物 清 单 然 后 找 到 您 的 病 情 例 如, 如 您 有 心 脏 病, 您 应 在 相 应 类 别 中 查 找 您 将 在 该 类 别 中 找 到 治 疗 心 脏 病 的 药 物 9. 如 您 想 要 的 药 物 不 在 药 物 清 单 之 中 怎 么 办? 如 您 没 有 在 药 物 清 单 中 找 到 您 的 药 物, 请 拨 打 1.855.ICS.2525 咨 询 参 与 者 服 务 部 如 您 了 解 到 ICS COMMUNITY CARE PLUS FIDA-MMP 计 划 不 承 保 该 药 物, 您 可 采 取 下 列 行 动 : 向 参 与 者 服 务 部 索 要 与 您 所 希 望 获 得 药 物 类 似 的 药 物 清 单 然 后 将 清 单 拿 给 您 的 医 生 或 其 他 处 方 人 看 他 们 可 开 具 与 您 所 希 望 获 得 药 物 类 似 的 药 物 清 单 中 药 物 或 您 可 向 计 划 或 您 的 跨 领 域 团 队 (IDT) 申 报 例 外 情 形, 对 您 的 药 物 进 行 承 保 更 多 例 外 情 形 详 情, 请 参 见 问 题 11? 如 有 问 题, 请 在 周 一 至 周 五 上 午 8 点 至 晚 上 8 点 致 电 ICS Community Care Plus FIDA- MMP 计 划, 电 话 号 码 为 1.877.ICS.2525, 听 障 专 线 (TTY) 为 1.855.ICS.4TTY 此 为 免 费 电 话 更 多 详 6

10. 如 您 是 ICS 社 区 护 理 增 值 FIDA-MMP 计 划 的 新 参 与 者, 并 且 在 药 物 清 单 没 有 找 到 您 的 药 物, 或 者 在 获 得 药 物 方 面 存 在 困 难, 该 怎 么 办? 我 们 可 为 您 提 供 帮 助 在 您 成 为 ICS Community Care Plus FIDA-MMP 计 划 参 与 者 的 前 90 天, 我 们 可 在 必 要 情 况 下 承 保 不 超 过 90 天 的 临 时 供 药 这 将 让 您 有 时 间 与 医 生 或 其 他 处 方 人 协 商 他 们 可 帮 助 您 决 定 药 物 清 单 是 否 有 一 种 您 可 以 使 用 的 类 似 药 物, 还 是 申 报 例 外 情 形 如 您 满 足 以 下 条 件, 我 们 将 承 保 不 超 过 90 天 的 临 时 供 药 : 您 所 使 用 药 物 不 在 我 们 的 药 物 清 单 之 列, 或 健 康 计 划 规 定 让 您 无 法 获 得 您 的 处 方 人 开 具 的 数 量, 或 药 物 需 要 ICS Community Care Plus FIDA-MMP 计 划 或 您 的 跨 领 域 团 队 (IDT) 的 预 审 批, 或 您 正 在 使 用 的 药 物 属 于 某 一 阶 梯 疗 法 限 制 的 一 部 分 如 您 入 住 疗 养 院 或 其 他 长 期 护 理 设 施, 您 的 按 方 补 药 时 间 可 长 达 98 天 您 可 在 这 98 天 内 进 行 多 次 药 物 补 充 这 将 让 您 的 处 方 人 有 时 间 将 您 的 药 物 变 更 为 药 物 清 单 中 药 物, 或 申 报 例 外 情 形 如 您 现 为 参 与 者, 而 护 理 级 别 从 一 种 治 疗 改 为 另 一 种, 则 您 有 资 格 获 得 不 超 过 90 天 的 非 药 物 清 单 所 列 药 物 的 供 药, 以 便 让 您 的 医 生 或 处 方 人 有 时 间 寻 找 一 种 清 单 中 药 物, 或 者 申 报 例 外 情 形 如 您 符 合 以 下 条 件, 您 可 能 有 资 格 获 得 护 理 级 别 过 渡 供 药 : 离 开 医 院 或 其 他 环 境, 入 住 长 期 护 理 (LTC) 设 施 离 开 LTC 设 施, 返 回 社 区 出 院 回 家 结 束 Medicare A 部 下 承 保 的 专 业 疗 养 院 住 院 ( 包 括 药 房 费 用 ), 回 归 D 部 下 的 承 保 范 围 由 安 养 院 状 态 回 归 标 准 Medicare A 部 及 B 部 福 利 或 从 精 神 病 医 院 出 院, 并 获 得 高 度 个 性 化 的 药 物 治 疗 方 案? 如 有 问 题, 请 在 周 一 至 周 五 上 午 8 点 至 晚 上 8 点 致 电 ICS Community Care Plus FIDA- MMP 计 划, 电 话 号 码 为 1.877.ICS.2525, 听 障 专 线 (TTY) 为 1.855.ICS.4TTY 此 为 免 费 电 话 更 多 详 7

11. 您 能 否 申 报 例 外 情 形, 要 求 对 您 的 药 物 进 行 承 保? 会 您 可 向 ICS Community Care Plus FIDA-MMP 计 划 或 您 的 跨 领 域 团 队 (IDT) 申 报 例 外 情 形, 要 求 对 不 在 药 物 清 单 中 的 药 物 进 行 承 保 您 可 要 求 ICS Community Care Plus FIDA-MMP 计 划 或 您 的 IDT 修 改 您 的 药 物 相 关 规 定 例 如,ICS Community Care Plus FIDA-MMP 计 划 可 限 定 我 们 的 承 保 药 物 数 量 如 您 的 药 物 有 限 定, 您 可 向 我 们 或 您 的 IDT 提 出 申 请, 要 求 修 改 限 定 及 提 高 承 保 数 量 其 他 例 子 : 您 可 向 我 们 或 您 的 IDT 提 出 申 请, 要 求 取 消 阶 梯 疗 法 限 制 或 预 审 批 要 求 12. 申 报 例 外 情 形 需 要 多 长 时 间? 首 先,ICS Community Care Plus FIDA-MMP 计 划 或 您 的 跨 领 域 团 队 (IDT) 须 收 到 来 自 您 的 处 方 人 关 于 支 持 您 的 例 外 情 形 申 报 的 声 明 在 我 们 接 获 声 明 后, 您 将 在 72 小 时 内 获 悉 关 于 您 例 外 情 形 申 报 的 决 定 如 您 或 您 的 处 方 人 认 为 等 待 72 小 时 将 对 您 的 健 康 造 成 损 害, 您 可 申 请 加 快 例 外 情 形 申 报 加 快 申 报 的 决 定 时 间 更 短 如 您 的 处 方 人 支 持 您 的 申 请, 您 将 在 我 们 收 到 您 的 处 方 人 支 持 声 明 后 的 24 小 时 内 获 悉 决 定 13. 您 如 何 申 报 例 外 情 形? 申 报 例 外 情 形, 请 致 电 您 的 护 理 管 理 人 您 的 护 理 管 理 人 将 与 您 及 您 的 医 疗 保 健 提 供 者 一 起 帮 助 您 申 报 例 外 情 形 14. 什 么 是 通 用 名 药 物? 通 用 名 药 物 是 由 与 品 牌 药 相 同 成 分 制 成 的 药 物 它 们 的 价 格 往 往 低 于 品 牌 药, 但 是 药 名 不 出 名 通 用 名 药 物 经 食 品 及 药 物 监 督 管 理 局 (FDA) 审 批 ICS Community Care Plus FIDA-MMP 计 划 中 既 有 品 牌 药, 也 有 通 用 名 药 物? 如 有 问 题, 请 在 周 一 至 周 五 上 午 8 点 至 晚 上 8 点 致 电 ICS Community Care Plus FIDA- MMP 计 划, 电 话 号 码 为 1.877.ICS.2525, 听 障 专 线 (TTY) 为 1.855.ICS.4TTY 此 为 免 费 电 话 更 多 详 8

15. 什 么 是 OTC 药 物? OTC 全 称 为 over-the-counter ( 非 处 方 药 ) ICS Community Care Plus FIDA-MMP 计 划 承 保 部 分 OTC 药 物, 前 提 是 您 的 医 疗 保 健 提 供 者 开 出 有 关 书 面 处 方 您 可 阅 读 ICS Community Care Plus FIDA-MMP 计 划 药 物 清 单, 查 看 哪 些 OTC 药 物 获 得 承 保 16. ICS Community Care Plus FIDA-MMP 计 划 是 否 承 保 OTC 非 药 物 产 品? ICS Community Care Plus FIDA-MMP 计 划 承 保 部 分 OTC 非 药 物 产 品, 例 如 纱 布 绷 带 酒 精 拭 片 / 棉 片 胰 岛 素 注 射 器 与 针 头 等, 前 提 是 您 的 医 疗 保 健 提 供 者 开 出 有 关 处 方 您 可 阅 读 ICS Community Care Plus FIDA-MMP 计 划 药 物 清 单, 查 看 哪 些 OTC 非 药 物 产 品 获 得 承 保 17. 您 的 共 付 额 是 多 少? 药 物 清 单 中 药 物 不 收 取 共 付 额 18. 什 么 是 药 物 层 级? 层 级 是 指 不 同 组 别 的 药 物 计 划 药 物 清 单 中 的 每 种 药 物 均 属 于 4 个 层 级 之 一 您 无 需 就 任 何 层 级 中 的 药 物 支 付 任 何 费 用 1 级 :Medicare 承 保 的 通 用 名 药 物 2 级 :Medicare 承 保 的 品 牌 药 及 特 殊 剂 型 药 物 3 级 :Medicaid 承 保 的 非 D 部 通 用 名 药 物 及 品 牌 药 4 级 :Medicaid 承 保 的 非 处 方 (OTC) 药? 如 有 问 题, 请 在 周 一 至 周 五 上 午 8 点 至 晚 上 8 点 致 电 ICS Community Care Plus FIDA- MMP 计 划, 电 话 号 码 为 1.877.ICS.2525, 听 障 专 线 (TTY) 为 1.855.ICS.4TTY 此 为 免 费 电 话 更 多 详 9

承 保 药 物 清 单 从 下 页 开 始 的 承 保 药 物 清 单 将 为 您 提 供 关 于 ICS Community Care Plus FIDA-MMP 计 划 承 保 药 物 的 信 息 如 您 在 清 单 中 没 有 找 到 您 的 药 物, 请 翻 至 从 第 I-1 页 开 始 的 索 引 图 表 第 一 列 为 药 物 名 称 品 牌 药 采 用 大 写 ( 例 如 AVONEX), 通 用 名 药 物 采 用 斜 体 小 写 ( 例 如 阿 莫 西 林 ) 用 药 的 必 要 行 动 限 制 或 限 定 一 栏 将 告 诉 您 ICS Community Care Plus FIDA-MMP 计 划 是 否 对 您 的 药 物 设 有 任 何 承 保 规 定 缩 略 词 与 符 号 本 文 可 能 出 现 的 缩 略 词 如 下 缩 略 词 说 明 解 释 使 用 管 理 限 制 PA PA BvD PA NSO 预 授 权 限 制 B 部 与 D 部 决 定 预 授 权 限 制 仅 适 用 于 新 会 员 的 预 授 权 限 制 在 按 方 抓 药 前, 您 ( 或 您 的 医 师 ) 须 获 得 ICS Community Care Plus FIDA- MMP 计 划 的 预 授 权 未 经 预 审 批,ICS 社 区 护 理 增 值 FIDA-MMP 计 划 可 能 不 会 承 保 此 药 物 此 药 物 可 能 符 合 Medicare B 部 或 D 部 下 的 支 付 条 件 在 按 方 抓 药 前, 您 ( 或 您 的 医 师 ) 须 向 ICS Community Care Plus FIDA-MMP 计 划 取 得 预 授 权, 以 决 定 该 药 物 在 Medicare D 部 下 是 否 承 保 未 经 预 审 批,FIDA Care Complete 可 能 不 会 承 保 此 药 物 如 您 是 新 会 员, 或 您 之 前 没 有 用 过 此 药, 在 按 方 抓 药 前, 您 ( 或 您 的 医 师 ) 须 获 得 ICS Community Care Plus FIDA-MMP 计 划 的 预 授 权 未 经 预 审 批,FIDA Care Complete 可 能 不 会 承? 如 有 问 题, 请 在 周 一 至 周 五 上 午 8 点 至 晚 上 8 点 致 电 ICS Community Care Plus FIDA- MMP 计 划, 电 话 号 码 为 1.877.ICS.2525, 听 障 专 线 (TTY) 为 1.855.ICS.4TTY 此 为 免 费 电 话 更 多 详 10

缩 略 词 说 明 解 释 保 此 药 物 QL ST 数 量 上 限 限 制 阶 梯 疗 法 限 制 ICS Community Care Plus FIDA-MMP 计 划 对 每 张 处 方 承 保 的 药 物 数 量 或 者 一 段 时 间 范 围 内 承 保 的 药 物 数 量 设 有 限 定 在 ICS Community Care Plus FIDA- MMP 计 划 为 药 物 提 供 承 保 前, 您 须 首 先 尝 试 另 一 种 药 物 来 治 疗 您 的 病 情 如 其 他 药 物 对 您 不 起 作 用, 可 能 仅 会 承 保 此 药 物 * 非 D 部 药 物 LA GC 限 量 药 物 缺 口 承 保 其 他 承 保 缩 略 词 该 药 物 为 Medicaid 承 保 的 非 D 部 药 物 可 能 仅 有 部 分 药 房 提 供 此 处 方 更 多 信 息, 请 查 看 您 的 药 房 通 讯 录, 或 在 周 一 至 周 五 上 午 8 点 至 晚 上 8 点 致 电 ICS Community Care Plus FIDA-MMP 计 划, 电 话 号 码 为 1.877.ICS.2525 此 电 话 免 费 更 多 详 情, 请 访 问 www.icsny.org/care-plus 我 们 在 承 保 缺 口 中 为 此 处 方 药 提 供 承 保 此 项 承 保 的 更 多 信 息 请 参 见 我 们 的 承 保 范 围 说 明 书 注 意 : 药 物 旁 边 的 星 号 (*) 表 示 该 药 物 不 是 D 部 药 物 此 类 药 物 有 着 不 同 的 上 诉 规 定 上 诉 是 申 请 审 核 及 更 改 您 认 为 存 在 错 误 的 承 保 决 定 的 一 种 正 式 途 径 例 如,ICS Community Care Plus FIDA-MMP 计 划 或 您 的 跨 领 域 团 队 (IDT) 可 能 会 决 定 您 想 要 获 得 的 药 物 不 获 得 或 不 再 获 得 Medicare 或 Medicaid 承 保 如 您 或 您 的 医 生 或 其 他 处 方 人 不 同 意 此 决 定, 您 可 以 上 诉 了 解 上 诉 相 关 说 明, 请 致 电 参 与 者 服 务 部 ( 电 话 号 码 为 1.877.ICS.2525) 或 致 电 独 立 消 费 者 倡 导 网 络 (ICAN)( 电 话 号 码 为 1.844.614.8800) 您 亦 可 阅 读 参 与 者 手 册, 了 解 如 何 对 决 定 提 起 上 诉? 如 有 问 题, 请 在 周 一 至 周 五 上 午 8 点 至 晚 上 8 点 致 电 ICS Community Care Plus FIDA- MMP 计 划, 电 话 号 码 为 1.877.ICS.2525, 听 障 专 线 (TTY) 为 1.855.ICS.4TTY 此 为 免 费 电 话 更 多 详 11

Analgesics Analgesics, Miscellaneous acephen * (Acetaminophen) acetaminophen * oral (Acetaminophen) acetaminophen * oral (Tylenol 8 Hour) acetaminophen * rectal suppository 120 mg, 650 mg (Acetaminophen) acetaminophen-codeine oral (Acetaminophen solution with Codeine) acetaminophen-codeine oral tablet (Tylenol-Codeine 300-15 mg, 300-30 mg No.3) acetaminophen-codeine oral tablet (Tylenol-Codeine 300-60 mg No.3) buprenorphine hcl injection butalb-acetaminophen-caffeine oral capsule 50-325-40 mg butalbital-acetaminop-caf-cod butalbital-acetaminophen oral tablet 50-325 mg butalbital-acetaminophen-caff oral tablet 50-325-40 mg butalbital-aspirin-caffeine oral capsule (Buprenorphine HCl) (Esgic) (Fioricet with Codeine) (Tencon) (Esgic) (Fiorinal) QL (2700 per 30 days) QL (360 per 30 days) QL (180 per 30 days) PA-HRM; QL (180 per 30 days) PA-HRM; QL (180 per 30 days) PA-HRM; QL (180 per 30 days) PA-HRM; QL (180 per 30 days) PA-HRM; QL (180 per 30 days) QL (5 per 28 days) butorphanol tartrate nasal (Butorphanol Tartrate) BUTRANS QL (4 per 28 days) children's mapap * (Acetaminophen) children's non-aspirin * oral (Acetaminophen) children's pain & fever relief * oral (Infants' Tylenol) 14

children's pain & fever relief * oral tablet,chewable (Acetaminophen) children's pain reliever * oral (Acetaminophen) children's pain reliever * oral (Acetaminophen) children's silapap * (Tylenol Sore Throat) codeine sulfate oral tablet (Codeine Sulfate) QL (180 per 30 days) codeine-butalbital-asa-caffein oral (Fiorinal with PA-HRM; QL (180 per capsule 30-50-325-40 mg Codeine #3) 30 days) DURAMORPH (PF) fentanyl citrate (Actiq) PA; QL (120 per 30 days) fentanyl transdermal patch 72 hour PA; QL (20 per 30 days) (Duragesic) 100 mcg/hr fentanyl transdermal patch 72 hour PA; QL (10 per 30 days) 12 mcg/hr, 25 mcg/hr, 37.5 mcg/hour, 50 mcg/hr, 62.5 (Duragesic) mcg/hour, 75 mcg/hr, 87.5 mcg/hour feverall * rectal suppository 120 mg, 325 mg, 650 mg (Acetaminophen) hydrocodone-acetaminophen oral QL (2700 per 30 days) (Hycet) solution (includes Vicodin, hydrocodone-acetaminophen oral Vicodin ES and Vicodin tablet 10-300 mg, 5-300 mg, (Norco) HP); QL (390 per 30 7.5-300 mg days) hydrocodone-acetaminophen oral QL (360 per 30 days) tablet 10-325 mg, 2.5-325 mg, (Norco) 5-325 mg, 7.5-325 mg hydrocodone-ibuprofen (Ibudone) QL (150 per 30 days) hydromorphone (pf) injection (Hydromorphone solution 10 mg/ml HCl/PF) 15

hydromorphone (pf) injection solution 4 mg/ml (Dilaudid) hydromorphone injection solution (Hydromorphone HCl) hydromorphone injection syringe 2 (Hydromorphone mg/ml HCl) hydromorphone oral liquid (Dilaudid) QL (1200 per 30 days) hydromorphone oral tablet 2 mg, 4 QL (180 per 30 days) (Dilaudid) mg hydromorphone oral tablet 8 mg (Dilaudid) QL (240 per 30 days) infant acetaminophen * (Acetaminophen) infantaire * (Acetaminophen) infant's pain reliever * (Acetaminophen) jr. acetaminophen * (Acetaminophen) junior mapap * (Acetaminophen) LAZANDA PA; QL (30 per 30 days) levorphanol tartrate (Levorphanol QL (180 per 30 days) Tartrate) mapap (acetaminophen) * oral (Acetaminophen) mapap (acetaminophen) * oral (Acetaminophen) mapap (acetaminophen) * oral (Tylenol Sore liquid 500 mg/15 ml Throat) mapap (acetaminophen) * oral (Infants' Tylenol) mapap (acetaminophen) * oral (Tylenol) mapap (acetaminophen) * oral (Acetaminophen) mapap arthritis pain * (Tylenol 8 Hour) mapap extra strength * (Tylenol) methadone hcl oral tablet,soluble QL (90 per 30 days) (Diskets) 40 mg methadone injection (Methadone HCl) methadone oral (Methadone HCl) QL (1800 per 30 days) methadone oral (Diskets) QL (360 per 30 days) 16

morphine concentrate oral solution (Msir) QL (200 per 30 days) morphine concentrate oral syringe (Morphine Sulfate) morphine injection solution 10 mg/ml, 15 mg/ml, 8 mg/ml (Morphine Sulfate) morphine injection syringe (Morphine Sulfate) morphine intramuscular (Morphine Sulfate) morphine intravenous (Morphine Sulfate) morphine intravenous solution 25 mg/ml, 50 mg/ml (Morphine Sulfate) morphine intravenous (Morphine Sulfate) morphine oral solution 10 mg/5 ml (Msir) QL (700 per 30 days) morphine oral solution 20 mg/5 ml (Msir) QL (300 per 30 days) MORPHINE ORAL TABLET QL (180 per 30 days) morphine oral tablet extended QL (120 per 30 days) (MS Contin) release 100 mg, 30 mg, 60 mg morphine oral tablet extended QL (180 per 30 days) (MS Contin) release 15 mg, 200 mg morphine rectal (Morphine Sulfate) non-aspirin extra strength * oral (Acetaminophen) non-aspirin extra strength * oral (Tylenol Sore Throat) non-aspirin jr strength * (Acetaminophen) nortemp * oral (Acetaminophen) NUCYNTA QL (181 per 30 days) NUCYNTA ER QL (60 per 30 days) (Oxycodone QL (1800 per 30 days) oxycodone hcl-acetaminophen oral HCl/Acetaminophe solution 5-325 mg/5 ml n) oxycodone hcl-acetaminophen oral QL (360 per 30 days) tablet 10-325 mg, 2.5-325 mg, (Xolox) 5-325 mg, 7.5-325 mg 17

oxycodone hcl-acetaminophen oral QL (240 per 30 days) (Xolox) tablet 5-500 mg oxycodone hcl-aspirin (Percodan) QL (360 per 30 days) oxycodone oral (Oxycodone HCl) QL (180 per 30 days) oxycodone oral (Oxycodone HCl) QL (1300 per 30 days) oxycodone oral (Percolone) QL (180 per 30 days) oxycodone-acetaminophen oral QL (360 per 30 days) tablet 10-325 mg, 2.5-325 mg, (Xolox) 5-325 mg, 7.5-325 mg oxycodone-acetaminophen oral QL (180 per 30 days) (Xolox) tablet 10-650 mg oxycodone-acetaminophen oral QL (240 per 30 days) (Xolox) tablet 7.5-500 mg oxycodone-aspirin (Percodan) QL (360 per 30 days) OXYCONTIN ORAL QL (60 per 30 days) TABLET,ORAL ONLY,EXT.REL.12 HR 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 60 MG OXYCONTIN ORAL QL (120 per 30 days) TABLET,ORAL ONLY,EXT.REL.12 HR 80 MG oxymorphone oral tablet (Opana) QL (180 per 30 days) oxymorphone oral tablet extended QL (60 per 30 days) release 12 hr 10 mg, 15 mg, 20 mg, (Opana ER) 5 mg, 7.5 mg oxymorphone oral tablet extended QL (120 per 30 days) (Opana ER) release 12 hr 30 mg, 40 mg pain relief adult * (Tylenol Sore Throat) pain relief * oral capsule (Acetaminophen) pain relief * oral tablet extended release (Tylenol 8 Hour) 18

pain reliever jr strength * (Acetaminophen) pain reliever * oral (Acetaminophen) pharbetol * (Tylenol) q-pap extra strength * (Tylenol) q-pap * oral drops (Acetaminophen) q-pap * oral liquid (Tylenol Sore Throat) q-pap * oral tablet (Tylenol) silapap * (Acetaminophen) tactinal * (Tylenol) tactinal extra strength * (Tylenol) tramadol oral tablet (Ultram) QL (240 per 30 days) tramadol-acetaminophen (Ultracet) QL (240 per 30 days) xylon 10 (Ibudone) QL (150 per 30 days) Nonsteroidal Anti-Inflammatory Agents advil * oral tablet (Motrin Ib) advil * oral tablet,chewable (Ibuprofen) aspirin * oral tablet (Ecotrin) aspirin * oral tablet,chewable (Bayer Chewable Aspirin) aspirin * oral tablet,delayed release (Ecotrin) (dr/ec) 325 mg, 500 mg, 81 mg aspirin * rectal (Aspirin) aspirin, buffered * (Aspirin/Calcium Carbonate/Mag) aspir-low * (Ecotrin) bufferin * oral tablet 325 mg (Aspirin/Calcium Carbonate/Mag) CALDOLOR INTRAVENOUS RECON SOLN CELEBREX QL (60 per 30 days) celecoxib (Celebrex) QL (60 per 30 days) 19

(Children'S children's advil * Motrin) (Choline Sal/Mag choline,magnesium salicylate Salicylate) COMFORT PAC-IBUPROFEN COMFORT PAC-MELOXICAM COMFORT PAC-NAPROXEN diclofenac potassium (Cataflam) diclofenac sodium oral tablet extended release 24 hr (Voltaren-XR) diclofenac sodium oral (Diclofenac tablet,delayed release (dr/ec) Sodium) diclofenac sodium topical gel (Solaraze) diclofenac-misoprostol (Arthrotec 50) diflunisal (Diflunisal) e.c. prin * (Ecotrin) etodolac (Etodolac) fenoprofen oral tablet (Fenoprofen Calcium) FLECTOR PA flurbiprofen (Ansaid) ibuprofen * 100 mg/5 ml susp (Children'S children's (otc) Motrin) ibuprofen jr strength * (Ibuprofen) ibuprofen * oral (Advil) ibuprofen oral suspension 100 mg/5 (Ibuprofen) ml ibuprofen * oral tablet 100 mg, 200 mg (Motrin Ib) ibuprofen oral tablet 400 mg, 600 mg, 800 mg (Ibuprofen) 20

indomethacin oral capsule 25 mg (Indomethacin) PA-HRM; QL (240 per 30 days) indomethacin oral capsule 50 mg (Indomethacin) PA-HRM; QL (120 per 30 days) indomethacin oral capsule, PA-HRM; QL (60 per 30 (Indomethacin) extended release days) indomethacin sodium (Indocin I.V.) PA-HRM infant's ibuprofen * (Infants' Motrin) INFANT'S MOTRIN * 3 $0 ketoprofen oral capsule (Ketoprofen) ketoprofen oral capsule,ext rel. pellets 24 hr 200 mg (Ketoprofen) ketorolac injection cartridge 15 QL (40 per 30 days) (Toradol) mg/ml ketorolac injection cartridge 30 QL (20 per 30 days) (Toradol) mg/ml ketorolac injection solution 15 (Ketorolac QL (40 per 30 days) mg/ml Tromethamine) ketorolac injection solution 30 (Ketorolac QL (20 per 30 days) mg/ml (1 ml) Tromethamine) ketorolac intramuscular solution (Ketorolac QL (20 per 30 days) Tromethamine) ketorolac oral (Ketorolac QL (20 per 30 days) Tromethamine) mefenamic acid (Ponstel) meloxicam (Mobic) nabumetone (Nabumetone) naproxen oral suspension (Naprosyn) naproxen oral tablet (Naprosyn) naproxen oral tablet,delayed release (dr/ec) (Ec-Naprosyn) 21

naproxen sodium oral tablet 275 mg, 550 mg (Anaprox) piroxicam (Feldene) salsalate (Salsalate) st joseph aspirin * (Bayer Chewable Aspirin) st. joseph aspirin * (Ecotrin) sulindac oral (Sulindac) tolmetin (Tolmetin Sodium) tri-buffered aspirin * (Aspirin/Calcium Carbonate/Mag) VOLTAREN TOPICAL wal-profen * oral (Advil) Anesthetics Local Anesthetics glydo (Lidocaine HCl) lidocaine (pf) injection solution (Xylocaine-MPF) lidocaine hcl injection solution (Xylocaine) lidocaine hcl laryngotracheal (Xylocaine) lidocaine hcl mucous membrane gel (Lidocaine HCl) lidocaine hcl mucous membrane jelly in applicator (Lidocaine HCl) lidocaine hcl mucous membrane solution (Xylocaine) lidocaine hcl urethral (Lidocaine HCl) lidocaine topical adhesive patch,medicated (Lidoderm) lidocaine topical ointment (Lidocaine) PA BvD; (PA for ESRD Only) PA BvD; (PA for ESRD Only) PA PA BvD; (PA for ESRD Only) 22

lidocaine-prilocaine topical (EMLA) lidocaine-prilocaine topical kit (Lidocaine/Prilocai ne) LIDODERM PA Anti-Addiction/Substance Abuse Treatment Agents Anti-Addiction/Substance Abuse Treatment Agents acamprosate (Campral) PA BvD; (PA for ESRD Only) PA BvD buprenorphine hcl sublingual (Subutex) PA; QL (90 per 30 days) (Buprenorphine PA; QL (90 per 30 days) buprenorphine-naloxone HCl/Naloxone HCl) bupropion hcl sr 150 mg tablet f/c (Zyban) CHANTIX QL (168 per 84 days) CHANTIX CONTINUING QL (56 per 28 days) MONTH PAK CHANTIX STARTING MONTH QL (53 per 28 days) BOX disulfiram (Antabuse) naloxone (Naloxone HCl) naltrexone hcl (Revia) naltrexone (Revia) NICODERM CQ * QL (168 per 365 days) TRANSDERMAL PATCH 24 HOUR 14 MG/24 HR, 21 MG/24 HR NICODERM CQ * TRANSDERMAL PATCH 24 HOUR 7 MG/24 HR nicorelief * buccal gum (Nicorette) nicorette * buccal gum 2 mg (Nicorette) nicotine (polacrilex) * (Nicorette) 23

nicotine * transdermal patch 24 hour 11 mg/24 hr, 21 mg/24 hr, 22 (Nicoderm Cq) mg/24 hr nicotine * transdermal patch 24 hour 14 mg/24 hr, 7 mg/24 hr (Nicoderm Cq) NICOTROL ZUBSOLV SUBLINGUAL TABLET 1.4-0.36 MG, 5.7-1.4 MG ZUBSOLV SUBLINGUAL TABLET 8.6-2.1 MG Antianxiety Agents Benzodiazepines QL (168 per 365 days) QL (180 per 365 days) PA; QL (90 per 30 days) PA; QL (60 per 30 days) alprazolam oral tablet (Xanax) QL (90 per 30 days) alprazolam oral tablet extended QL (90 per 30 days) (Xanax XR) release 24 hr 0.5 mg alprazolam oral tablet extended QL (60 per 30 days) (Xanax XR) release 24 hr 1 mg, 2 mg, 3 mg alprazolam oral QL (90 per 30 days) (Alprazolam) tablet,disintegrating chlordiazepoxide hcl (Chlordiazepoxide QL (120 per 30 days) HCl) clonazepam oral tablet 0.5 mg, 1 QL (90 per 30 days) (Klonopin) mg clonazepam oral tablet 2 mg (Klonopin) QL (300 per 30 days) clonazepam oral QL (90 per 30 days) tablet,disintegrating 0.125 mg, 0.25 (Clonazepam) mg, 0.5 mg, 1 mg clonazepam oral QL (300 per 30 days) (Clonazepam) tablet,disintegrating 2 mg clorazepate dipotassium oral tablet QL (120 per 30 days) (Tranxene T-Tab) 15 mg 24

clorazepate dipotassium oral tablet QL (60 per 30 days) (Tranxene T-Tab) 3.75 mg, 7.5 mg DIASTAT ACUDIAL RECTAL KIT 12.5-15-17.5-20 MG diazepam injection (Diazepam) QL (10 per 28 days) diazepam intensol (Diazepam) QL (1200 per 30 days) diazepam oral solution (Diazepam) QL (1200 per 30 days) diazepam oral tablet (Valium) QL (120 per 30 days) diazepam rectal (Diastat Acudial) estazolam oral tablet 1 mg (Estazolam) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (60 per 30 days) estazolam oral tablet 2 mg (Estazolam) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (30 per 30 days) 25

flurazepam oral capsule 15 mg (Flurazepam HCl) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (60 per 30 days) flurazepam oral capsule 30 mg (Flurazepam HCl) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (30 per 30 days) lorazepam injection solution (Ativan) QL (2 per 30 days) lorazepam injection syringe (Lorazepam) QL (2 per 30 days) lorazepam oral (Ativan) QL (90 per 30 days) midazolam (pf) injection (Midazolam QL (2 per 30 days) HCl/PF) midazolam (pf) injection syringe 2 (Midazolam QL (2 per 30 days) mg/2 ml (1 mg/ml) HCl/PF) midazolam oral syrup 2 mg/ml (Midazolam HCl) QL (10 per 30 days) ONFI ORAL SUSPENSION PA NSO; QL (480 per 30 ONFI ORAL TABLET 10 MG, 20 MG days) PA NSO; QL (60 per 30 days) 26

temazepam oral capsule 15 mg, 22.5 mg, 30 mg (Restoril) temazepam oral capsule 7.5 mg (Restoril) triazolam oral tablet 0.125 mg (Halcion) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (30 per 30 days) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (120 per 30 days) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (120 per 30 days) 27

triazolam oral tablet 0.25 mg (Halcion) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (60 per 30 days) Antibacterials Aminoglycosides BETHKIS PA BvD gentamicin in nacl (iso-osm) (Gentamicin In intravenous piggyback Nacl, Iso-Osm) gentamicin injection solution (Garamycin) gentamicin sulfate (ped) (pf) (Gentamicin Sulfate/PF) gentamicin sulfate (pf) intravenous (Gentamicin solution Sulfate/PF) neomycin (Neomycin Sulfate) streptomycin intramuscular (Streptomycin Sulfate) TOBI PODHALER INHALATION QL (224 per 28 days) tobramycin in 0.225 % nacl (Tobi) PA BvD (Tobramycin/Sodiu tobramycin in 0.9 % nacl m Chloride) tobramycin sulfate injection (Nebcin) solution Antibacterials, Miscellaneous bacitracin intramuscular (Bacitracin) chloramphenicol sod succinate (Chloramphenicol Sod Succ) 28

clindamycin hcl (Cleocin HCl) clindamycin in 5 % dextrose (Cleocin Phosphate In D5w) clindamycin palmitate hcl (Cleocin Palmitate) clindamycin phosphate injection (Cleocin Phosphate) clindamycin phosphate intravenous (Cleocin solution Phosphate) colistin (colistimethate na) (Coly-Mycin M Parenteral) CUBICIN linezolid (Zyvox) methenamine hippurate (Hiprex) methenamine mandelate oral tablet (Methenamine 1 gram Mandelate) nitrofurantoin macrocrystal oral capsule (Macrodantin) nitrofurantoin monohyd/m-cryst (Macrobid) SYNERCID trimethoprim (Trimethoprim) vancomycin in d5w intravenous (Vancomycin piggyback HCl/D5W) vancomycin intravenous recon soln 1,000 mg, 10 gram, 750 mg (Vancomycin HCl) PA BvD; (PA for ESRD Only) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (120 per 30 days) PA-HRM; QL (120 per 30 days) PA BvD; (PA for ESRD Only) 29

vancomycin intravenous recon soln (Vancomycin 500 mg HCl/D5W) vancomycin oral capsule (Vancocin HCl) XIFAXAN ORAL TABLET 200 MG XIFAXAN ORAL TABLET 550 MG ZYVOX INTRAVENOUS PARENTERAL SOLUTION ZYVOX ORAL Cephalosporins cefaclor oral capsule (Cefaclor) cefaclor oral suspension for reconstitution 125 mg/5 ml, 250 (Cefaclor) mg/5 ml, 375 mg/5 ml cefadroxil oral capsule (Cefadroxil) cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 (Cefadroxil) mg/5 ml cefadroxil oral tablet (Cefadroxil) cefazolin in dextrose (iso-os) intravenous piggyback 1 gram/50 (Cefazolin Sodium) ml cefazolin in dextrose (iso-os) (Cefazolin intravenous piggyback 2 gram/50 Sodium/Dextrose, ml Iso) cefazolin injection recon soln (Ancef) cefazolin injection recon soln 100 gram, 300 g (Cefazolin Sodium) cefazolin intravenous (Cefazolin Sodium) cefdinir (Cefdinir) cefditoren pivoxil (Spectracef) PA; QL (9 per 30 days) ST; QL (60 per 30 days) 30

cefepime (Maxipime) CEFEPIME IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK CEFEPIME IN DEXTROSE,ISO-OSM INTRAVENOUS PIGGYBACK cefotaxime (Claforan) cefoxitin (Mefoxin) cefoxitin in dextrose, iso-osm (Cefoxitin intravenous piggyback 2 gram/50 Sodium/Dextrose, ml Iso) cefpodoxime (Cefpodoxime Proxetil) cefprozil (Cefprozil) ceftazidime injection recon soln 1 gram (Fortaz) ceftazidime injection recon soln 2 gram (Fortaz) ceftazidime intravenous recon soln 1 gram, 2 gram (Ceftazidime) ceftibuten (Cedax) ceftriaxone in dextrose,iso-os (Ceftriaxone Na/Dextrose, Iso) ceftriaxone injection recon soln (Rocephin) ceftriaxone intravenous (Ceftriaxone Na/Dextrose, Iso) cefuroxime axetil oral tablet (Ceftin) cefuroxime sodium injection recon soln 1.5 gram, 750 mg (Zinacef) cefuroxime sodium intravenous (Zinacef) 31

(Cefuroxime cefuroxime-dextrose (iso-osm) Sodium/Dextrose, Iso) cephalexin oral capsule (Keflex) cephalexin oral suspension for reconstitution (Cephalexin) cephalexin oral tablet (Cephalexin) MEFOXIN IN DEXTROSE (ISO-OSM) SUPRAX ORAL TABLET SUPRAX ORAL TABLET,CHEWABLE TEFLARO Macrolides azithromycin (Zithromax) clarithromycin oral suspension for reconstitution (Biaxin) clarithromycin oral tablet (Biaxin) clarithromycin oral tablet extended release 24 hr (Biaxin XL) DIFICID QL (20 per 10 days) ERYTHROCIN erythromycin base oral (Erythromycin tablet,delayed release (dr/ec) 250 Base) mg, 500 mg ERYTHROMYCIN BASE ORAL TABLET,DELAYED RELEASE (DR/EC) 333 MG erythromycin ethylsuccinate oral suspension for reconstitution (Eryped 200) erythromycin ethylsuccinate oral (Erythromycin tablet Ethylsuccinate) 32

erythromycin oral capsule,delayed (Erythromycin release(dr/ec) Base) erythromycin oral tablet (Erythromycin Base) erythromycin stearate oral tablet (Erythromycin 250 mg Stearate) Miscellaneous B-Lactam Antibiotics aztreonam (Azactam) CAYSTON imipenem-cilastatin (Primaxin) INVANZ meropenem (Merrem) Penicillins amoxicillin oral capsule (Amoxicillin) amoxicillin oral suspension for reconstitution (Amoxil) amoxicillin oral tablet (Amoxicillin) amoxicillin oral tablet,chewable 125 mg, 250 mg (Amoxicillin) amoxicillin-pot clavulanate oral suspension for reconstitution (Augmentin) amoxicillin-pot clavulanate oral tablet (Augmentin) amoxicillin-pot clavulanate oral tablet extended release 12 hr (Augmentin XR) amoxicillin-pot clavulanate oral (Amoxicillin/Potas tablet,chewable sium Clav) ampicillin (Ampicillin Trihydrate) ampicillin sodium injection recon soln (Totacillin-N) 33

ampicillin sodium intravenous recon soln (Totacillin-N) ampicillin-sulbactam injection recon soln (Unasyn) ampicillin-sulbactam intravenous recon soln (Unasyn) BICILLIN C-R BICILLIN L-A dicloxacillin (Dicloxacillin Sodium) nafcillin in dextrose iso-osm (Nafcillin In Dextrose,Iso-Osm) nafcillin injection (Unipen) nafcillin intravenous recon soln (Nallpen) (Oxacillin oxacillin in dextrose(iso-osm) Sodium/Dextrose, Iso) oxacillin injection recon soln (Oxacillin Sodium) oxacillin intravenous recon soln (Oxacillin Sodium) (Pen G penicillin g pot in dextrose Pot/Dextrose-Wate r) penicillin g potassium injection (Penicillin G recon soln Potassium) (Penicillin G penicillin g procaine Procaine) (Penicillin V penicillin v potassium Potassium) piperacillin-tazobactam intravenous (Zosyn) recon soln Quinolones ciprofloxacin (Cipro) 34

ciprofloxacin hcl oral (Cipro) ciprofloxacin in 5 % dextrose (Cipro I.V.) ciprofloxacin lactate intravenous solution 400 mg/40 ml (Cipro I.V.) levofloxacin in d5w intravenous piggyback (Levaquin) levofloxacin intravenous (Levofloxacin) levofloxacin oral (Levaquin) moxifloxacin (Avelox) ofloxacin oral (Ofloxacin) Sulfonamides sulfadiazine oral (Sulfadiazine) sulfamethoxazole-trimethoprim (Sulfamethoxazole/ intravenous Trimethoprim) sulfamethoxazole-trimethoprim oral (Sulfamethoxazole/ suspension Trimethoprim) sulfamethoxazole-trimethoprim oral (Bactrim) tablet sulfasalazine (Azulfidine) sulfatrim (Sulfamethoxazole/ Trimethoprim) sulfazine (Azulfidine) sulfazine ec (Azulfidine) Tetracyclines doxycycline hyclate oral capsule 100 mg (Morgidox) doxycycline hyclate 100 mg tab f/c (Doryx) doxycycline hyclate intravenous (Doxycycline Hyclate) doxycycline hyclate oral capsule 100 mg (Adoxa) 35

doxycycline hyclate oral capsule 50 mg doxycycline hyclate oral tablet 100 mg doxycycline hyclate oral tablet 20 mg doxycycline monohydrate oral capsule doxycycline monohydrate oral suspension for reconstitution doxycycline monohydrate oral tablet (Morgidox) (Adoxa) (Doryx) (Adoxa) (Vibramycin) (Adoxa) minocycline oral capsule (Minocin) minocycline oral tablet (Minocycline HCl) tetracycline (Ala-Tet) TYGACIL Anticancer Agents Anticancer Agents ABRAXANE ADCETRIS AFINITOR DISPERZ AFINITOR ORAL TABLET 10 MG AFINITOR ORAL TABLET 2.5 MG, 5 MG, 7.5 MG ALIMTA INTRAVENOUS RECON SOLN anastrozole (Arimidex) ARRANON ARZERRA PA NSO PA NSO; QL (4 per 21 days) PA NSO; QL (112 per 28 days) PA NSO; QL (56 per 28 days) PA NSO; QL (28 per 28 days) 36

AVASTIN PA NSO azacitidine (Vidaza) BELEODAQ PA NSO bicalutamide (Casodex) (Bleomycin PA BvD bleomycin Sulfate) PA NSO; QL (140 per BLINCYTO 365 days) BOSULIF ORAL TABLET 100 PA NSO; QL (120 per 30 MG days) BOSULIF ORAL TABLET 500 PA NSO; QL (30 per 30 MG days) CAPRELSA ORAL TABLET 100 PA NSO; QL (60 per 30 MG CAPRELSA ORAL TABLET 300 MG carboplatin intravenous solution (Carboplatin) cisplatin (Cisplatin) days) PA NSO; QL (30 per 30 days) PA NSO; QL (112 per 28 COMETRIQ days) cyclophosphamide intravenous (Cyclophosphamid PA BvD recon soln e) CYCLOPHOSPHAMIDE ORAL PA BvD; ST CAPSULE (Cyclophosphamid PA BvD; ST cyclophosphamide oral tablet e) CYRAMZA PA NSO cytarabine (Cytarabine) PA BvD cytarabine (pf) injection recon soln (Cytarabine/PF) PA BvD cytarabine (pf) injection solution (Cytarabine/PF) PA BvD dacarbazine intravenous recon soln (Dtic-Dome IV) dactinomycin (Dactinomycin) 37

decitabine (Dacogen) doxorubicin hcl intravenous recon PA BvD (Doxorubicin HCl) soln 10 mg doxorubicin hcl peg-liposomal PA BvD (Doxil) intravenous suspension 2 mg/ml doxorubicin, peg-liposomal (Doxil) PA BvD DROXIA ELIGARD SUBCUTANEOUS QL (1 per 84 days) SYRINGE 22.5 MG ELIGARD SUBCUTANEOUS QL (1 per 112 days) SYRINGE 30 MG ELIGARD SUBCUTANEOUS QL (1 per 168 days) SYRINGE 45 MG ELIGARD SUBCUTANEOUS QL (1 per 28 days) SYRINGE 7.5 MG EMCYT epirubicin intravenous solution 50 mg/25 ml (Ellence) ERBITUX INTRAVENOUS PA NSO SOLUTION ERIVEDGE PA NSO; QL (30 per 30 days) ETOPOPHOS etoposide intravenous (Etoposide) exemestane (Aromasin) FARESTON FASLODEX FIRMAGON KIT W DILUENT SYRINGE floxuridine (FUDR) PA BvD fludarabine (Fludara) 38

fluorouracil intravenous solution 2.5 gram/50 ml, 5 gram/100 ml, 500 (Fluorouracil) mg/10 ml flutamide (Flutamide) GAZYVA gemcitabine intravenous recon soln 1 gram (Gemzar) GILOTRIF GLEEVEC ORAL TABLET 100 MG GLEEVEC ORAL TABLET 400 MG HALAVEN PA BvD PA NSO; QL (40 per 28 days) PA NSO; QL (30 per 30 days) PA NSO; QL (90 per 30 days) PA NSO; QL (60 per 30 days) PA NSO; QL (24 per 28 days) HERCEPTIN PA NSO HEXALEN hydroxyurea (Hydrea) ICLUSIG ORAL TABLET 15 MG PA NSO; QL (60 per 30 days) ICLUSIG ORAL TABLET 45 MG PA NSO; QL (30 per 30 days) ifosfamide intravenous recon soln (Ifex) PA BvD ifosfamide intravenous solution (Ifex) PA BvD ifosfamide-mesna (Ifosfamide/Mesna PA BvD ) IMBRUVICA PA NSO; QL (120 per 30 days) INLYTA ORAL TABLET 1 MG PA NSO; QL (180 per 30 days) 39

INLYTA ORAL TABLET 5 MG PA NSO; QL (60 per 30 days) ISTODAX PA NSO IXEMPRA JAKAFI JEVTANA KADCYLA INTRAVENOUS RECON SOLN KEYTRUDA INTRAVENOUS RECON SOLN KYPROLIS PA NSO; QL (60 per 30 days) PA NSO PA NSO PA NSO; QL (6 per 28 days) letrozole (Femara) LEUKERAN leuprolide (Leuprolide Acetate) lomustine (Gleostine) LUPRON DEPOT QL (1 per 28 days) LUPRON DEPOT (3 MONTH) QL (1 per 84 days) LUPRON DEPOT (4 MONTH) QL (1 per 84 days) LUPRON DEPOT (6 MONTH) QL (1 per 168 days) LUPRON DEPOT-PED (3 QL (1 per 84 days) MONTH) INTRAMUSCULAR SYRINGE KIT LUPRON DEPOT-PED QL (1 per 28 days) INTRAMUSCULAR KIT LYNPARZA PA NSO; QL (480 per 30 days) LYSODREN MARQIBO PA NSO; QL (4 per 28 days) 40

MATULANE MEGACE ES megestrol oral suspension (Megace) megestrol oral tablet (Megestrol Acetate) MEKINIST ORAL TABLET 0.5 PA NSO; QL (90 per 30 MG days) MEKINIST ORAL TABLET 2 MG PA NSO; QL (30 per 30 days) melphalan hcl intravenous (Alkeran) mercaptopurine (Purinethol) methotrexate sodium (pf) injection (Methotrexate PA BvD recon soln Sodium/PF) methotrexate sodium (pf) injection (Methotrexate PA BvD solution Sodium) methotrexate sodium injection (Methotrexate PA BvD Sodium) methotrexate sodium oral (Methotrexate PA BvD; ST Sodium) mitomycin intravenous recon soln (Mitomycin) PA BvD mitoxantrone (Novantrone) MUSTARGEN NEXAVAR PA NSO; QL (120 per 30 days) NILANDRON ONCASPAR PA NSO OPDIVO INTRAVENOUS PA NSO SOLUTION 40 MG/4 ML oxaliplatin intravenous solution 100 (Eloxatin) mg/20 ml paclitaxel (Paclitaxel) PERJETA PA NSO 41

POMALYST PROLEUKIN PURIXAN REVLIMID PA NSO; QL (21 per 28 days) PA NSO; QL (21 per 28 days) RITUXAN PA NSO SOLTAMOX SPRYCEL ORAL TABLET 100 MG, 140 MG, 50 MG, 70 MG, 80 PA NSO; QL (30 per 30 days) MG SPRYCEL ORAL TABLET 20 MG PA NSO; QL (60 per 30 days) STIVARGA PA NSO; QL (84 per 28 days) SUTENT PA NSO; QL (30 per 30 days) SYLVANT PA NSO SYNRIBO PA NSO; QL (28 per 28 days) TABLOID TAFINLAR PA NSO; QL (120 per 30 days) tamoxifen (Tamoxifen Citrate) TARCEVA ORAL TABLET 100 PA NSO; QL (60 per 30 MG, 25 MG days) TARCEVA ORAL TABLET 150 PA NSO; QL (90 per 30 MG days) TARGRETIN ORAL PA NSO; QL (420 per 30 days) 42

TARGRETIN TOPICAL PA NSO; QL (60 per 28 days) TASIGNA PA NSO; QL (112 per 28 days) TEMODAR INTRAVENOUS PA NSO; (vial only) toposar intravenous (Etoposide) topotecan intravenous (Hycamtin) TORISEL PA BvD; QL (4 per 28 days) TREANDA INTRAVENOUS RECON SOLN TREANDA INTRAVENOUS SOLUTION TRELSTAR INTRAMUSCULAR QL (1 per 168 days) SUSPENSION FOR RECONSTITUTION TRELSTAR INTRAMUSCULAR QL (1 per 84 days) SYRINGE 11.25 MG/2 ML TRELSTAR INTRAMUSCULAR QL (1 per 168 days) SYRINGE 22.5 MG/2 ML TRELSTAR INTRAMUSCULAR QL (1 per 28 days) SYRINGE 3.75 MG/2 ML tretinoin (chemotherapy) (Tretinoin) (capsule: 10mg) TREXALL PA BvD; ST TYKERB VALSTAR VECTIBIX INTRAVENOUS PA NSO SOLUTION VELCADE PA NSO vinblastine intravenous (Vinblastine PA BvD Sulfate) 43

(Vincristine vincristine Sulfate) vincristine sulfate intravenous (Vincristine solution 1 mg/ml Sulfate) vinorelbine intravenous solution (Navelbine) VOTRIENT XALKORI XTANDI YERVOY INTRAVENOUS SOLUTION ZALTRAP INTRAVENOUS SOLUTION ZELBORAF ZOLADEX SUBCUTANEOUS IMPLANT 10.8 MG ZOLADEX SUBCUTANEOUS IMPLANT 3.6 MG ZOLINZA ZYDELIG ZYKADIA ZYTIGA Anticholinergic Agents Antimuscarinics/Antispasmodics atropine injection solution 0.4 mg/ml (Atropine Sulfate) PA BvD PA BvD PA NSO; QL (120 per 30 days) PA NSO; QL (60 per 30 days) PA NSO; QL (120 per 30 days) PA NSO PA NSO PA NSO; QL (240 per 30 days) QL (1 per 84 days) QL (1 per 28 days) PA NSO; QL (60 per 30 days) PA NSO; QL (140 per 28 days) PA NSO; QL (120 per 30 days) 44

atropine injection syringe 0.05 mg/ml, 0.1 mg/ml propantheline (Atropine Sulfate) (Propantheline Bromide) Anticonvulsants Anticonvulsants APTIOM ST BANZEL ST carbamazepine oral capsule, er multiphase 12 hr (Carbatrol) carbamazepine oral suspension (Tegretol) carbamazepine oral tablet extended release 12 hr (Tegretol XR) carbamazepine oral tablet,chewable (Carbamazepine) CELONTIN ORAL CAPSULE 300 MG DILANTIN divalproex oral capsule, sprinkle (Depakote Sprinkle) divalproex oral tablet extended release 24 hr (Depakote ER) divalproex oral tablet,delayed release (dr/ec) (Depakote) ethosuximide (Zarontin) felbamate (Felbatol) fosphenytoin (Cerebyx) FYCOMPA ST gabapentin oral capsule (Neurontin) gabapentin oral solution (Neurontin) gabapentin oral tablet 600 mg, 800 mg (Neurontin) 45

GABITRIL ORAL TABLET 12 MG, 16 MG LAMICTAL ORAL TABLET, CHEWABLE DISPERSIBLE 2 MG lamotrigine oral tablet (Lamictal) lamotrigine oral tablet extended release 24hr (Lamictal XR) lamotrigine oral tablet, chewable dispersible (Lamictal) lamotrigine oral tablets,dose pack 25 mg (35) (Lamictal (Blue)) levetiracetam intravenous (Keppra) levetiracetam oral solution (Keppra) levetiracetam oral tablet (Keppra) levetiracetam oral tablet extended release 24 hr (Keppra XR) LUMINAL QL (2 per 30 days) LYRICA ORAL CAPSULE QL (90 per 30 days) LYRICA ORAL SOLUTION QL (900 per 30 days) oxcarbazepine oral suspension (Oxcarbazepine) oxcarbazepine oral tablet (Trileptal) OXTELLAR XR ST PEGANONE phenobarbital oral elixir (Phenobarbital) QL (1500 per 30 days) phenobarbital oral tablet 100 mg, QL (90 per 30 days) 15 mg, 16.2 mg, 32.4 mg, 60 mg, (Phenobarbital) 64.8 mg, 97.2 mg phenobarbital oral tablet 30 mg (Phenobarbital) QL (200 per 30 days) phenobarbital sodium injection (Phenobarbital QL (2 per 30 days) solution Sodium) 46

phenytoin oral suspension 125 mg/5 (Dilantin-125) ml phenytoin oral (Dilantin) phenytoin sodium (Phenytoin Sodium) phenytoin sodium extended (Dilantin) POTIGA ORAL TABLET 200 MG, ST; QL (90 per 30 days) 300 MG, 400 MG POTIGA ORAL TABLET 50 MG ST; QL (270 per 30 days) primidone (Mysoline) QUDEXY XR ST SABRIL tiagabine (Gabitril) topiramate oral capsule, sprinkle (Topamax) topiramate oral capsule,sprinkle,er 24hr (Qudexy XR) topiramate oral tablet (Topamax) TRILEPTAL ORAL SUSPENSION TROKENDI XR ST valproate sodium (Depacon) valproic acid (Depakene) valproic acid (as sodium salt) oral solution 250 mg/5 ml (Depakene) VIMPAT INTRAVENOUS ST; QL (200 per 5 days) VIMPAT ORAL SOLUTION ST; QL (1200 per 30 days) VIMPAT ORAL TABLET ST; QL (60 per 30 days) zonisamide (Zonegran) Antidementia Agents Antidementia Agents donepezil oral tablet (Aricept) QL (30 per 30 days) 47

donepezil oral tablet,disintegrating (Aricept Odt) QL (30 per 30 days) EXELON TRANSDERMAL QL (30 per 30 days) PATCH 24 HOUR 4.6 MG/24 HR, 9.5 MG/24 HR galantamine oral capsule,ext rel. QL (30 per 30 days) (Razadyne ER) pellets 24 hr galantamine oral solution (Razadyne) QL (200 per 30 days) galantamine oral tablet (Razadyne) QL (60 per 30 days) NAMENDA ORAL SOLUTION QL (360 per 30 days) NAMENDA ORAL TABLET QL (60 per 30 days) NAMENDA TITRATION PAK QL (49 per 28 days) NAMENDA XR ORAL QL (28 per 28 days) CAP,SPRINKLE,ER 24HR DOSE PACK NAMENDA XR ORAL QL (30 per 30 days) CAPSULE,SPRINKLE,ER 24HR rivastigmine tartrate (Exelon) QL (60 per 30 days) Antidepressants Antidepressants amitriptyline (Amitriptyline PA NSO-HRM HCl) amoxapine (Amoxapine) BRINTELLIX ST bupropion hcl oral tablet (Wellbutrin) bupropion hcl oral tablet extended release, 150 mg (Wellbutrin SR) bupropion hcl oral tablet extended release 24 hr (Wellbutrin XL) citalopram oral solution (Citalopram Hydrobromide) citalopram oral tablet (Celexa) QL (30 per 30 days) clomipramine (Anafranil) PA NSO-HRM 48

desipramine oral (Norpramin) doxepin oral (Doxepin HCl) PA NSO-HRM duloxetine oral capsule,delayed QL (60 per 30 days) (Cymbalta) release(dr/ec) 20 mg, 60 mg duloxetine oral capsule,delayed QL (30 per 30 days) (Cymbalta) release(dr/ec) 30 mg EMSAM QL (30 per 30 days) escitalopram oxalate (Lexapro) FETZIMA ST fluoxetine oral capsule (Prozac) fluoxetine oral capsule,delayed release(dr/ec) (Prozac Weekly) fluoxetine oral solution (Fluoxetine HCl) fluoxetine oral tablet 10 mg, 20 mg (Fluoxetine HCl) FLUOXETINE ORAL TABLET 60 MG fluvoxamine oral capsule,extended release 24hr (Luvox CR) fluvoxamine oral tablet (Fluvoxamine Maleate) imipramine hcl (Tofranil) PA NSO-HRM imipramine pamoate (Tofranil-Pm) PA NSO-HRM KHEDEZLA ST; QL (30 per 30 days) maprotiline (Maprotiline HCl) MARPLAN mirtazapine (Remeron) nefazodone (Nefazodone HCl) nortriptyline oral capsule (Pamelor) nortriptyline oral solution (Nortriptyline HCl) olanzapine-fluoxetine (Symbyax) paroxetine hcl oral tablet (Paxil) 49

paroxetine hcl oral tablet extended release 24 hr (Paxil CR) PAXIL ORAL SUSPENSION (Perphenazine/Ami PA NSO-HRM perphenazine-amitriptyline triptyline HCl) phenelzine (Nardil) PRISTIQ ORAL TABLET ST; QL (30 per 30 days) EXTENDED RELEASE 24 HR 100 MG, 50 MG protriptyline (Vivactil) sertraline (Zoloft) SILENOR QL (30 per 30 days) SURMONTIL PA NSO-HRM tranylcypromine (Parnate) trazodone (Trazodone HCl) venlafaxine oral capsule,extended release 24hr (Effexor XR) venlafaxine oral tablet (Venlafaxine HCl) venlafaxine oral tablet extended release 24hr 150 mg, 37.5 mg, 75 (Venlafaxine HCl) mg VIIBRYD Antidiabetic Agents Antidiabetic Agents, Miscellaneous acarbose (Precose) QL (90 per 30 days) BYDUREON QL (4 per 28 days) BYETTA SUBCUTANEOUS PEN QL (2.4 per 28 days) INJECTOR 10 MCG/DOSE(250 MCG/ML) 2.4 ML BYETTA SUBCUTANEOUS PEN INJECTOR 5 MCG/DOSE (250 MCG/ML) 1.2 ML QL (1.2 per 28 days) 50

CYCLOSET QL (180 per 30 days) INVOKAMET ORAL TABLET ST; QL (60 per 30 days) 150-1,000 MG, 150-500 MG, 50-1,000 MG INVOKAMET ORAL TABLET ST; QL (120 per 30 days) 50-500 MG INVOKANA ORAL TABLET 100 ST; QL (60 per 30 days) MG INVOKANA ORAL TABLET 300 ST; QL (30 per 30 days) MG JANUMET QL (60 per 30 days) JANUMET XR ORAL TABLET, QL (30 per 30 days) ER MULTIPHASE 24 HR 100-1,000 MG, 50-500 MG JANUMET XR ORAL TABLET, QL (60 per 30 days) ER MULTIPHASE 24 HR 50-1,000 MG JANUVIA QL (30 per 30 days) JARDIANCE ST; QL (30 per 30 days) JENTADUETO QL (60 per 30 days) KORLYM PA; QL (112 per 28 days) metformin oral tablet 1,000 mg (Glucophage) QL (60 per 30 days) metformin oral tablet 500 mg (Glucophage) QL (120 per 30 days) metformin oral tablet 850 mg (Glucophage) QL (90 per 30 days) metformin oral tablet extended QL (120 per 30 days) (Glucophage XR) release 24 hr 500 mg metformin oral tablet extended QL (90 per 30 days) (Glucophage XR) release 24 hr 750 mg metformin oral tablet extended QL (60 per 30 days) (Fortamet) release 24hr nateglinide (Starlix) QL (90 per 30 days) pioglitazone (Actos) QL (30 per 30 days) 51

pioglitazone-glimepiride (Duetact) QL (30 per 30 days) pioglitazone-metformin (Actoplus Met) QL (90 per 30 days) PRANDIMET QL (150 per 30 days) repaglinide (Prandin) QL (240 per 30 days) SYMLINPEN 120 PA; QL (10.8 per 28 days) SYMLINPEN 60 PA; QL (6 per 28 days) TRADJENTA QL (30 per 30 days) TRULICITY QL (4 per 28 days) VICTOZA PA; QL (9 per 28 days) Insulins HUMALOG KWIKPEN QL (30 per 28 days) HUMALOG MIX 50-50 QL (40 per 28 days) HUMALOG MIX 50-50 QL (30 per 28 days) KWIKPEN HUMALOG MIX 75-25 QL (40 per 28 days) HUMALOG MIX 75-25 QL (30 per 28 days) KWIKPEN HUMALOG SUBCUTANEOUS QL (40 per 28 days) HUMULIN 70/30 QL (40 per 28 days) HUMULIN 70/30 KWIKPEN QL (30 per 28 days) HUMULIN 70/30 PEN QL (30 per 28 days) HUMULIN N QL (40 per 28 days) HUMULIN N KWIKPEN QL (30 per 28 days) HUMULIN N PEN QL (30 per 28 days) HUMULIN R QL (40 per 28 days) HUMULIN R U-500 QL (40 per 28 days) "CONCENTRATED" LANTUS QL (40 per 28 days) LANTUS SOLOSTAR QL (30 per 28 days) NOVOLIN 70/30 QL (40 per 28 days) 52

NOVOLIN N QL (40 per 28 days) NOVOLIN R QL (40 per 28 days) NOVOLOG QL (40 per 28 days) NOVOLOG FLEXPEN QL (30 per 28 days) NOVOLOG MIX 70-30 QL (40 per 28 days) NOVOLOG MIX 70-30 FLEXPEN QL (30 per 28 days) Sulfonylureas glimepiride oral tablet 1 mg, 2 mg (Amaryl) QL (30 per 30 days) glimepiride oral tablet 4 mg (Amaryl) QL (60 per 30 days) glipizide oral tablet 10 mg (Glucotrol) QL (120 per 30 days) glipizide oral tablet 5 mg (Glucotrol) QL (60 per 30 days) glipizide oral tablet extended QL (60 per 30 days) (Glucotrol XL) release 24hr 10 mg glipizide oral tablet extended QL (30 per 30 days) (Glucotrol XL) release 24hr 2.5 mg, 5 mg glipizide-metformin oral tablet (Glipizide/Metform QL (60 per 30 days) 2.5-250 mg in HCl) glipizide-metformin oral tablet (Glipizide/Metform QL (120 per 30 days) 2.5-500 mg, 5-500 mg in HCl) glyburide micronized oral tablet 1.5 PA-HRM; QL (400 per (Glynase) mg 30 days) glyburide micronized oral tablet 3 PA-HRM; QL (180 per (Glynase) mg 30 days) glyburide micronized oral tablet 6 PA-HRM; QL (120 per (Glynase) mg 30 days) glyburide oral tablet 1.25 mg (Glyburide) PA-HRM; QL (280 per 30 days) glyburide oral tablet 2.5 mg (Glyburide) PA-HRM; QL (240 per 30 days) glyburide oral tablet 5 mg (Glyburide) PA-HRM; QL (120 per 30 days) 53

glyburide-metformin oral tablet PA-HRM; QL (240 per (Glucovance) 1.25-250 mg 30 days) glyburide-metformin oral tablet PA-HRM; QL (120 per (Glucovance) 2.5-500 mg, 5-500 mg 30 days) tolazamide oral tablet 250 mg (Tolazamide) QL (120 per 30 days) tolazamide oral tablet 500 mg (Tolazamide) QL (60 per 30 days) tolbutamide (Tolbutamide) QL (180 per 30 days) Antifungals Antifungals 3 day vaginal * (Miconazole Nitrate) ABELCET PA BvD af * (Tinactin) aloe vesta * topical ointment 2 % (Miconazole Nitrate) AMBISOME PA BvD amphotericin b (Amphotericin B) PA BvD antifungal (tolnaftate) * topical (Tolnaftate) antifungal (tolnaftate) * topical (Tolnaftate) antifungal * topical solution (Undecylenic Acid) athlete's foot (clotrimazole) * (Lotrimin AF) baza antifungal * (Nuzole) CANCIDAS ciclopirox topical cream (Ciclodan) ciclopirox topical gel (Loprox) ciclopirox topical shampoo (Loprox) ciclopirox topical solution (Penlac) ciclopirox topical suspension (Ciclopirox Olamine) ciclopirox-ure-camph-menth-euc (Ciclodan) clotrimazole * 1% cream (otc) (Lotrimin AF) 54

clotrimazole * 1% solution (otc) (Clotrimazole) clotrimazole 3 day * (Gyne-Lotrimin) clotrimazole mucous membrane (Clotrimazole) clotrimazole topical cream 1 % (Clotrimazole) clotrimazole topical solution 1 % (Lotrimin) clotrimazole * vaginal cream (Gyne-Lotrimin) clotrimazole * vaginal tablet (Clotrimazole) clotrimazole-3 * (Gyne-Lotrimin) clotrimazole-betamethasone topical cream (Lotrisone) clotrimazole-betamethasone topical (Clotrimazole/Beta lotion methasone Dip) critic-aid clear af * (Miconazole Nitrate) dermafungal * (Miconazole Nitrate) desenex * topical cream (Lotrimin AF) econazole topical (Econazole Nitrate) elon dual defense * (Undecylenic Acid) fluconazole (Diflucan) fluconazole in dextrose(iso-o) (Fluconazole In intravenous piggyback Nacl,Iso-Osm) fluconazole in nacl (iso-osm) (Fluconazole In intravenous piggyback Nacl,Iso-Osm) flucytosine (Ancobon) fungi cure * (Clotrimazole) FUNGI-NAIL * TOPICAL fungoid-d * (Tinactin) griseofulvin microsize oral tablet (Grifulvin V) inzo antifungal * (Nuzole) itraconazole (Sporanox) ketoconazole oral (Ketoconazole) 55

ketoconazole topical cream (Ketoconazole) ketoconazole topical shampoo (Nizoral) LAMISIL (AEROSOL) * lamisil af * (Tolnaftate) LAMISIL AT * TOPICAL LOTRIMIN ULTRA * micatin * (Nuzole) miconazole 7 * vaginal suppository (Miconazole Nitrate) miconazole nitrate * topical cream (Nuzole) miconazole nitrate * vaginal (Miconazole Nitrate) miconazole nitrate * vaginal (Miconazole Nitrate) miconazole nitrate * vaginal kit 200 (Monistat 1) mg- 2 % (9 gram) miconazole nitrate vaginal suppository 200 mg (Monistat 3) MONISTAT 3 * VAGINAL COMB PACK,PREFILL APPL & CREAM MONISTAT 3 * VAGINAL KIT monistat 7 * vaginal (Miconazole Nitrate) myco nail a * (Undecylenic Acid) NOXAFIL ORAL nystatin (Nystatin) NYSTATIN (BULK) POWDER 1 BILLION UNIT nystatin oral (Nystatin) nystatin oral (Nystatin) nystatin topical (Nystatin) 56

nystatin-triamcinolone (Nystatin/Triamcin ) podactin * (Tolnaftate) terbinafine hcl oral (Lamisil) terbinafine hcl * topical (Desenex) tolnaftate * topical (Tinactin) tolnaftate * topical (Tolnaftate) triple paste af * (Miconazole Nitrate) voriconazole intravenous (Vfend IV) voriconazole oral (Vfend) Antihistamines Antihistamines alavert d-12 allergy-sinus * (Claritin-D 12 Hour) aller-chlor * oral syrup (Chlorpheniramine Maleate) aller-chlor * oral tablet (Chlor-Trimeton) allerclear d-12hr * (Claritin-D 12 Hour) allerclear d-24hr * (Claritin-D 24 Hour) allergy (chlorpheniramine) * (Chlor-Trimeton) allergy relief (cetirizine) * oral (Zyrtec) allergy relief (loratadine) * oral (Claritin) allerhist-1 * (Tavist-1) aller-tec d * (Zyrtec-D) ambi 60pse-4cpm * (Pseudoephed/Chlo rpheniramine) aprodine * (Pseudoephedrine/ Triprolidine) banophen allergy * (Zzzquil) 57

banophen * oral capsule 25 mg (Benadryl) banophen * oral (Diphenhydramine HCl) benadryl allergy * oral tablet (Diphenhydramine HCl) cetirizine * oral solution (Cetirizine HCl) cetirizine * oral tablet (Zyrtec) cetirizine * oral tablet,chewable (Zyrtec) cetirizine-pseudoephedrine * (Zyrtec-D) child triaminic cold & allergy * (Dimetapp) child wal-tap cold-allergy * (Dimetapp) children's aller-tec * (Cetirizine HCl) children's cetirizine * oral tablet,chewable 5 mg (Zyrtec) CHILDREN'S CLARITIN * ORAL children's wal-dryl allergy * oral (Zzzquil) children's wal-zyr * oral (Zyrtec) CHILDREN'S ZYRTEC ALLERGY * CLARITIN * CLARITIN LIQUI-GEL * CLARITIN REDITABS * CLARITIN-D 12 HOUR * CLARITIN-D 24 HOUR * clemastine oral syrup (Clemastine Fumarate) clemastine * oral tablet 1.34 mg (Tavist-1) clemastine oral tablet 2.68 mg (Clemastine Fumarate) cold & cough * oral liquid (Phenylephrine/Dip henhydramine) PA-HRM PA-HRM 58

compoz * (Diphenhydramine HCl) cyproheptadine (Cyproheptadine HCl) dailyhist-1 * (Tavist-1) dayhist allergy * (Tavist-1) dimaphen (pe) * (Dimetapp) (Phenylephrine/Dip dimetapp cold-congestion * henhydramine) diphenhist * oral capsule (Benadryl) diphenhist * oral (Zzzquil) diphenhist * oral tablet 25 mg (Diphenhydramine HCl) diphenhydramine hcl injection (Diphenhydramine solution 50 mg/ml HCl) diphenhydramine hcl injection (Diphenhydramine syringe HCl) diphenhydramine hcl * oral capsule (Benadryl) diphenhydramine hcl * oral tablet (Diphenhydramine 50 mg HCl) ed chlorped jr * (Chlorpheniramine Maleate) levocetirizine (Xyzal) loradamed * (Claritin) loratadine * oral (Claritin) loratadine * oral (Claritin) loratadine-d * oral tablet extended (Claritin-D 12 release 12 hr Hour) loratadine-d * oral tablet extended (Claritin-D 24 release 24 hr Hour) phenylephrine-chlorpheniramine * (Phenylephrine/Chl oral tablet 4-10 mg orpheniramine) PA-HRM 59

promethazine oral syrup (Promethazine HCl) q-dryl * oral liquid (Zzzquil) q-tapp * (Pseudoephedrine/ Brompheniramin) siladryl sa * (Zzzquil) simply sleep * (Diphenhydramine HCl) (Pseudoephed/Chlo sinus & allergy (pseudoephed) * rpheniramine) sleep aid (diphenhydramine) * oral (Zzzquil) sleep-tabs * (Diphenhydramine HCl) sudogest cold & allergy * (Pseudoephed/Chlo rpheniramine) (Phenylephrine/Dip triaminic cold & cough nt (pe) * henhydramine) (Doxylamine ultra sleep (doxylamine succ) * Succinate) unisom sleepgels * (Benadryl) (Pseudoephedrine/ wal-act d cold & allergy * Triprolidine) wal-dryl allergy * oral (Benadryl) wal-dryl allergy * oral (Diphenhydramine HCl) wal-finate * (Chlor-Trimeton) wal-finate-d * (Pseudoephed/Chlo rpheniramine) wal-itin * (Claritin) wal-itin d * (Claritin-D 24 Hour) PA-HRM 60

wal-itin d 12 hour * (Claritin-D 12 Hour) wal-phed * oral tablet 4-60 mg (Pseudoephed/Chlo rpheniramine) (Phenylephrine/Chl wal-phed pe sinus & allergy * orpheniramine) wal-sleep z * oral capsule (Benadryl) wal-sleep z * oral liquid (Zzzquil) wal-sleep z * oral (Unisom tablet,disintegrating Sleepmelts) wal-som * oral capsule (Benadryl) wal-tap * (Dimetapp) wal-zyr (cetirizine) * oral (Cetirizine HCl) wal-zyr (cetirizine) * oral (Zyrtec) wal-zyr d * (Zyrtec-D) z-sleep * (Zzzquil) ZYRTEC * ORAL CAPSULE ZYRTEC * ORAL TABLET ZYRTEC * ORAL TABLET,DISINTEGRATING Anti-Infectives (Skin And Mucous Membrane) Anti-Infectives (Skin And Mucous Membrane) ABREVA * AVC VAGINAL clindamycin phosphate vaginal (Cleocin) metronidazole vaginal (Metrogel-Vaginal) terconazole vaginal cream (Terazol 7) terconazole vaginal suppository (Terconazole) Antimigraine Agents Antimigraine Agents dihydroergotamine injection (D.H.E.45) QL (30 per 28 days) 61

dihydroergotamine nasal (Migranal) QL (4 per 28 days) ERGOMAR QL (40 per 28 days) naratriptan (Amerge) QL (18 per 28 days) rizatriptan oral tablet (Maxalt) QL (18 per 28 days) rizatriptan oral QL (18 per 28 days) (Maxalt Mlt) tablet,disintegrating sumatriptan (Imitrex) QL (12 per 28 days) sumatriptan succinate oral (Imitrex) QL (18 per 28 days) sumatriptan succinate subcutaneous QL (4 per 28 days) (Imitrex) cartridge 6 mg/0.5 ml sumatriptan succinate subcutaneous (Imitrex) QL (4 per 28 days) sumatriptan succinate subcutaneous (Imitrex) QL (4 per 28 days) zolmitriptan oral tablet (Zomig) QL (12 per 28 days) zolmitriptan oral tablet,disintegrating (Zomig Zmt) Antimycobacterials Antimycobacterials CAPASTAT dapsone (Dapsone) ethambutol (Myambutol) isoniazid oral (Isoniazid) PASER PRIFTIN pyrazinamide (Pyrazinamide) rifabutin (Mycobutin) rifampin (Rifadin) rifampin (Rifadin) RIFATER SIRTURO TRECATOR QL (12 per 28 days) PA; QL (188 per 168 days) 62

Antinausea Agents Antinausea Agents ambizine * (Meclizine HCl) dimenhydrinate injection solution (Dimenhydrinate) dramamine * oral tablet (Dimenhydrinate) driminate * (Dimenhydrinate) dronabinol (Marinol) EMEND INTRAVENOUS RECON SOLN EMEND ORAL CAPSULE 125 MG, 40 MG EMEND ORAL CAPSULE 80 MG EMEND ORAL CAPSULE,DOSE PACK granisetron (pf) intravenous (Granisetron solution HCl/PF) granisetron hcl intravenous solution 1 mg/ml (1 ml) (Kytril) granisetron hcl oral (Granisetron HCl) PA BvD meclizine * 12.5 mg tablet (otc) (Meclizine HCl) meclizine * 25 mg tablet (otc) (Meclizine HCl) meclizine oral tablet 12.5 mg, 25 mg (Antivert) motion sickness * (Dimenhydrinate) ondansetron (Zofran Odt) PA BvD ondansetron hcl (pf) injection (Ondansetron HCl/PF) ondansetron hcl oral (Zofran) PA BvD prochlorperazine edisylate injection (Compazine) solution prochlorperazine maleate (Compazine) QL (2 per 28 days) PA BvD; QL (1 per 1 day) PA BvD; QL (2 per 1 day) PA BvD; QL (3 per 1 day) 63

prochlorperazine maleate oral (Compazine) promethazine hcl (Phenergan) PA-HRM promethazine oral tablet (Promethazine PA-HRM HCl) promethazine rectal (Phenergan) PA-HRM TRANSDERM-SCOP QL (10 per 30 days) travel sickness (meclizine) * (Bonine) wal-dram * (Dimenhydrinate) Antiparasite Agents Antiparasite Agents ALBENZA ALINIA atovaquone (Mepron) atovaquone-proguanil (Malarone) BILTRICIDE chloroquine phosphate oral (Aralen Phosphate) COARTEM DARAPRIM hydroxychloroquine oral (Plaquenil) ivermectin oral (Stromectol) mefloquine (Mefloquine HCl) (Metronidazole/So metronidazole in nacl (iso-os) dium Chloride) metronidazole oral (Flagyl) NEBUPENT PA BvD paromomycin (Paromomycin Sulfate) PENTAM PRIMAQUINE QL (90 per 30 days) quinine sulfate (Qualaquin) PA; QL (42 per 7 days) STROMECTOL 64

Antiparkinsonian Agents Antiparkinsonian Agents amantadine hcl oral (Amantadine HCl) APOKYN QL (60 per 30 days) AZILECT benztropine oral (Benztropine PA-HRM Mesylate) bromocriptine (Parlodel) cabergoline (Cabergoline) carbidopa (Lodosyn) carbidopa-levodopa oral tablet (Sinemet CR) carbidopa-levodopa oral tablet extended release (Sinemet CR) carbidopa-levodopa-entacapone (Stalevo 50) entacapone (Comtan) NEUPRO ST; QL (30 per 30 days) pramipexole oral tablet (Mirapex) ropinirole oral tablet (Requip) ropinirole oral tablet extended release 24 hr (Requip XL) selegiline hcl oral capsule (Eldepryl) selegiline hcl oral tablet (Selegiline HCl) trihexyphenidyl (Trihexyphenidyl PA-HRM HCl) Antipsychotic Agents Antipsychotic Agents ABILIFY DISCMELT ORAL TABLET,DISINTEGRATING 10 MG QL (90 per 30 days) 65

ABILIFY DISCMELT ORAL QL (60 per 30 days) TABLET,DISINTEGRATING 15 MG ABILIFY INTRAMUSCULAR QL (161.2 per 28 days) ABILIFY MAINTENA QL (1 per 28 days) ABILIFY ORAL SOLUTION QL (900 per 30 days) ABILIFY ORAL TABLET 10 MG, QL (30 per 30 days) 15 MG, 20 MG, 30 MG, 5 MG ABILIFY ORAL TABLET 2 MG QL (60 per 30 days) chlorpromazine (Chlorpromazine HCl) clozapine oral tablet 100 mg (Clozaril) QL (270 per 30 days) clozapine oral tablet 200 mg (Clozaril) QL (135 per 30 days) clozapine oral tablet 25 mg, 50 mg (Clozaril) QL (90 per 30 days) clozapine oral tablet,disintegrating (Fazaclo) ST; QL (90 per 30 days) FANAPT ORAL TABLET ST; QL (60 per 30 days) FANAPT ORAL TABLETS,DOSE ST; QL (8 per 28 days) PACK FAZACLO ORAL ST; QL (180 per 30 days) TABLET,DISINTEGRATING 150 MG FAZACLO ORAL ST; QL (120 per 30 days) TABLET,DISINTEGRATING 200 MG fluphenazine decanoate (Fluphenazine Decanoate) fluphenazine hcl (Fluphenazine HCl) GEODON INTRAMUSCULAR QL (6 per 28 days) haloperidol (Haloperidol) haloperidol decanoate (Haloperidol intramuscular solution 100 mg/ml Decanoate) 66

haloperidol decanoate (Haldol Decanoate intramuscular solution 50 mg/ml 50) haloperidol lactate (Haloperidol Lactate) INVEGA ORAL TABLET ST; QL (30 per 30 days) EXTENDED RELEASE 24HR 1.5 MG, 3 MG, 9 MG INVEGA ORAL TABLET ST; QL (60 per 30 days) EXTENDED RELEASE 24HR 6 MG INVEGA SUSTENNA QL (0.75 per 28 days) INTRAMUSCULAR SYRINGE 117 MG/0.75 ML INVEGA SUSTENNA QL (1 per 28 days) INTRAMUSCULAR SYRINGE 156 MG/ML INVEGA SUSTENNA QL (1.5 per 28 days) INTRAMUSCULAR SYRINGE 234 MG/1.5 ML INVEGA SUSTENNA QL (0.25 per 28 days) INTRAMUSCULAR SYRINGE 39 MG/0.25 ML INVEGA SUSTENNA QL (0.5 per 28 days) INTRAMUSCULAR SYRINGE 78 MG/0.5 ML LATUDA ORAL TABLET 120 ST; QL (30 per 30 days) MG, 20 MG, 40 MG, 60 MG LATUDA ORAL TABLET 80 MG ST; QL (60 per 30 days) loxapine succinate (Loxitane) olanzapine intramuscular (Zyprexa) QL (30 per 30 days) olanzapine oral tablet (Zyprexa) QL (30 per 30 days) 67

olanzapine oral QL (30 per 30 days) tablet,disintegrating 10 mg, 15 mg, (Zyprexa Zydis) 5 mg olanzapine oral QL (31 per 30 days) (Zyprexa Zydis) tablet,disintegrating 20 mg ORAP perphenazine (Perphenazine) quetiapine (Seroquel) QL (90 per 30 days) RISPERDAL CONSTA QL (4 per 28 days) risperidone oral (Risperdal) QL (480 per 30 days) risperidone oral (Risperdal) QL (60 per 30 days) risperidone oral QL (60 per 30 days) tablet,disintegrating 0.25 mg, 0.5 (Risperdal M-Tab) mg, 1 mg, 2 mg risperidone oral QL (120 per 30 days) (Risperdal M-Tab) tablet,disintegrating 3 mg, 4 mg SAPHRIS (BLACK CHERRY) ST; QL (60 per 30 days) SEROQUEL XR ORAL TABLET ST; QL (60 per 30 days) EXTENDED RELEASE 24 HR 150 MG, 300 MG, 400 MG, 50 MG SEROQUEL XR ORAL TABLET ST; QL (30 per 30 days) EXTENDED RELEASE 24 HR 200 MG thioridazine (Thioridazine HCl) PA NSO-HRM thiothixene (Navane) trifluoperazine (Trifluoperazine HCl) VERSACLOZ ST; QL (540 per 30 days) ziprasidone hcl (Geodon) QL (60 per 30 days) 68

ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION Name of Drug Antivirals (Systemic) Antiretrovirals abacavir (Ziagen) abacavir-lamivudine-zidovudine (Trizivir) APTIVUS ATRIPLA COMPLERA CRIXIVAN ORAL CAPSULE 200 MG, 400 MG didanosine (Videx EC) EDURANT EMTRIVA EPIVIR HBV ORAL SOLUTION EPIVIR ORAL SOLUTION EPZICOM FUZEON SUBCUTANEOUS INTELENCE INVIRASE ISENTRESS KALETRA lamivudine (Epivir) lamivudine-zidovudine (Combivir) LEXIVA nevirapine oral suspension (Viramune) nevirapine oral tablet (Viramune) nevirapine oral tablet extended release 24 hr (Viramune XR) QL (2 per 28 days) 69

NORVIR PREZISTA RESCRIPTOR RETROVIR INTRAVENOUS REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG REYATAZ ORAL POWDER IN PACKET SELZENTRY stavudine (Zerit) STRIBILD SUSTIVA TIVICAY TRIUMEQ TRUVADA VIDEX 2 GRAM PEDIATRIC VIDEX 4 GRAM PEDIATRIC VIRACEPT ORAL TABLET VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 HR 100 MG VIREAD VITEKTA ZIAGEN ORAL SOLUTION zidovudine oral capsule (Retrovir) zidovudine oral syrup (Retrovir) zidovudine oral tablet (Zidovudine) Antivirals, Miscellaneous foscarnet (Foscavir) PA BvD RELENZA DISKHALER rimantadine (Flumadine) 70

SYNAGIS TAMIFLU ORAL CAPSULE 30 QL (84 per 180 days) MG TAMIFLU ORAL CAPSULE 45 QL (48 per 180 days) MG TAMIFLU ORAL CAPSULE 75 QL (42 per 180 days) MG TAMIFLU ORAL SUSPENSION QL (540 per 180 days) FOR RECONSTITUTION Hcv Antivirals HARVONI PA; QL (30 per 30 days) OLYSIO PA; QL (28 per 28 days) SOVALDI PA; QL (28 per 28 days) VIEKIRA PAK PA; QL (112 per 28 days) Interferons INTRON A INJECTION PA NSO PEGASYS PA PEGASYS PROCLICK PA SUBCUTANEOUS PEN INJECTOR PEGINTRON PA PEGINTRON REDIPEN PA SYLATRON PA NSO; QL (4 per 28 days) SYLATRON 4-PACK SUBCUTANEOUS KIT 200 MCG, PA NSO; QL (4 per 28 days) 300 MCG Nucleosides And Nucleotides acyclovir oral capsule (Zovirax) acyclovir oral suspension 200 mg/5 ml (Zovirax) acyclovir oral tablet (Zovirax) 71

acyclovir sodium intravenous recon (Acyclovir PA BvD soln Sodium) acyclovir sodium intravenous (Acyclovir PA BvD solution Sodium) adefovir (Hepsera) BARACLUDE ORAL TABLET entecavir (Baraclude) famciclovir (Famvir) ganciclovir sodium (Cytovene) PA BvD ribavirin oral capsule 200 mg (Rebetol) ribavirin oral tablet 200 mg, 400 mg, 600 mg (Copegus) TYZEKA valacyclovir (Valtrex) VALCYTE ORAL TABLET valganciclovir (Valcyte) VIRAZOLE PA BvD Blood Products/Modifiers/Volume Expanders Anticoagulants CEPROTIN (BLUE BAR) ELIQUIS enoxaparin subcutaneous solution (Lovenox) QL (36 per 30 days) enoxaparin subcutaneous syringe QL (36 per 30 days) (Lovenox) 100 mg/ml enoxaparin subcutaneous syringe QL (27.2 per 30 days) (Lovenox) 120 mg/0.8 ml, 80 mg/0.8 ml enoxaparin subcutaneous syringe QL (34 per 30 days) (Lovenox) 150 mg/ml enoxaparin subcutaneous syringe QL (18 per 30 days) (Lovenox) 30 mg/0.3 ml enoxaparin subcutaneous syringe QL (13.6 per 30 days) (Lovenox) 40 mg/0.4 ml 72

enoxaparin subcutaneous syringe 60 mg/0.6 ml (Lovenox) fondaparinux subcutaneous syringe 10 mg/0.8 ml (Arixtra) fondaparinux subcutaneous syringe 2.5 mg/0.5 ml (Arixtra) fondaparinux subcutaneous syringe 5 mg/0.4 ml (Arixtra) fondaparinux subcutaneous syringe 7.5 mg/0.6 ml (Arixtra) heparin (porcine) in 5 % dex intravenous parenteral solution (Heparin Sodium 12,500 unit/250 ml, 20,000 unit/500 in 5% Dextrose) ml (40 unit/ml) heparin (porcine) in 5 % dex intravenous parenteral solution (Heparin Sod,Pork 25,000 unit/250 ml(100 unit/ml), In 0.45% NaCl) 25,000 unit/500 ml (50 unit/ml) heparin (porcine) in nacl (pf) (Heparin intravenous parenteral solution Sodium,Porcine/Ns 1,000 unit/500 ml /PF) heparin (porcine) injection (Heparin Sodium,Porcine) heparin, porcine (pf) injection (Monoject Prefill Advanced) heparin, porcine (pf) intravenous (Monoject Prefill syringe 100 unit/ml Advanced) heparin-0.45% nacl 25,000 (Heparin Sod,Pork units/250 ml (100 units/ml) bag In 0.45% NaCl) latex-free, outer heparin-0.45% nacl 25,000 units/500 ml (50 units/ml) bag latex-free, outer (Heparin Sod,Pork In 0.45% NaCl) QL (20.4 per 30 days) QL (24 per 30 days) QL (15 per 30 days) QL (12 per 30 days) QL (18 per 30 days) PA BvD; (PA for ESRD Only) PA BvD; (PA for ESRD Only) 73

heparin-d5w 25,000 units/250 ml (Heparin Sodium (100 units/ml) bag excel container in 5% Dextrose) heparin-d5w 25,000 units/500 ml (Heparin Sodium (50 units/ml) bag excel container in 5% Dextrose) IPRIVASK PA; QL (24 per 28 days) jantoven (Coumadin) PRADAXA QL (60 per 30 days) warfarin (Coumadin) XARELTO Blood Formation Modifiers EPOGEN INJECTION SOLUTION PA; QL (12 per 28 days) 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML GRANIX LEUKINE INJECTION RECON SOLN MIRCERA PA; QL (0.6 per 28 days) MOZOBIL NEULASTA SUBCUTANEOUS SYRINGE NEUMEGA NEUPOGEN PROCRIT INJECTION PA; QL (12 per 28 days) SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML PROCRIT INJECTION PA; QL (6 per 28 days) SOLUTION 40,000 UNIT/ML PROMACTA PA; QL (30 per 30 days) 74

Hematologic Agents, Miscellaneous aminocaproic acid oral (Amicar) anagrelide (Agrylin) protamine (Protamine Sulfate) PA BvD; (PA for ESRD Only) tranexamic acid intravenous (Tranexamic Acid) tranexamic acid oral (Lysteda) QL (30 per 30 days) Platelet-Aggregation Inhibitors AGGRENOX QL (60 per 30 days) BRILINTA cilostazol (Pletal) clopidogrel (Plavix) EFFIENT QL (30 per 30 days) pentoxifylline (Pentoxifylline) Volume Expanders ALBUKED-25 ALBUKED-5 ALBUMIN, HUMAN 25 % ALBUMIN, HUMAN 5 % ALBUMINAR 25 % ALBUMINAR 5 % ALBURX (HUMAN) 5 % ALBUTEIN 25 % ALBUTEIN 5 % BUMINATE 25 % BUMINATE 5 % FLEXBUMIN 25 % FLEXBUMIN 5 % KEDBUMIN PLASBUMIN 25 % PLASBUMIN 5 % 75

Caloric Agents Caloric Agents AMINO ACIDS 15 % PA BvD AMINOSYN 10 % PA BvD AMINOSYN 3.5 % PA BvD AMINOSYN 7 % PA BvD AMINOSYN 7 % WITH PA BvD ELECTROLYTES AMINOSYN 8.5 % PA BvD AMINOSYN 8.5 PA BvD %-ELECTROLYTES AMINOSYN II 10 % PA BvD AMINOSYN II 15 % PA BvD AMINOSYN II 7 % PA BvD AMINOSYN II 8.5 % PA BvD AMINOSYN II 8.5 PA BvD %-ELECTROLYTES AMINOSYN M 3.5 % PA BvD AMINOSYN-HBC 7% PA BvD AMINOSYN-PF 10 % PA BvD AMINOSYN-PF 7 % PA BvD (SULFITE-FREE) AMINOSYN-RF 5.2 % PA BvD CLINIMIX 5%/D15W SULFITE PA BvD FREE CLINIMIX 5%/D25W PA BvD SULFITE-FREE CLINIMIX 2.75%/D5W SULFIT PA BvD FREE CLINIMIX 4.25%/D10W SULF PA BvD FREE 76

CLINIMIX 4.25%/D5W SULFIT PA BvD FREE CLINIMIX 4.25%-D20W PA BvD SULF-FREE CLINIMIX 4.25%-D25W PA BvD SULF-FREE CLINIMIX PA BvD 5%-D20W(SULFITE-FREE) CLINIMIX E 2.75%/D10W SUL PA BvD FREE CLINIMIX E 2.75%/D5W SULF PA BvD FREE CLINIMIX E 4.25%/D10W SUL PA BvD FREE CLINIMIX E 4.25%/D25W SUL PA BvD FREE CLINIMIX E 4.25%/D5W SULF PA BvD FREE CLINIMIX E 5%/D15W SULFIT PA BvD FREE CLINIMIX E 5%/D20W SULFIT PA BvD FREE CLINIMIX E 5%/D25W SULFIT PA BvD FREE CLINISOL SF 15 % PA BvD cysteine (l-cysteine) intravenous PA BvD (Cysteine HCl) solution (Dextrose 10 % d10 % & 0.45 % sodium chloride and 0.45 % NaCl) (Dextrose 2.5 % d2.5 %-0.45 % sodium chloride and 0.45 % NaCl) (Dextrose 5 % and d5 % and 0.9 % sodium chloride 0.9 % NaCl) 77

d5 %-0.45 % sodium chloride (Dextrose 5 %-0.45 % NaCl) dex4 glucose * oral tablet,chewable (Dextrose) dextrose 10 % and 0.2 % nacl (Dextrose 10 % and 0.2 % NaCl) dextrose 10 % in water (d10w) (Dextrose 10 % in PA BvD intravenous Water) dextrose 2.5 % in water(d2.5w) (Dextrose 2.5 % in PA BvD Water) dextrose 20 % in water (d20w) (Dextrose 20 % in PA BvD Water) dextrose 25 % in water (d25w) (Dextrose 25 % in PA BvD Water) dextrose 40 % in water (d40w) (Dextrose 40 % in PA BvD Water) dextrose 5 % in ringers (Dextrose 5% In Ringers) dextrose 5 % in water (d5w) (Dextrose 5 % in intravenous Water) (Dextrose dextrose 5 %-lactated ringers 5%-Lactated Ringers) dextrose 5%-0.2 % sod chloride (Dextrose 5 %-0.2 % NaCl) dextrose 5%-0.3 % sod.chloride (Dextrose 5 % and 0.3 % NaCl) dextrose 50 % in water (d50w) (Dextrose 50 % in PA BvD Water) dextrose 70 % in water (d70w) (Dextrose 70 % in PA BvD Water) dextrose with sodium chloride (Dextrose 5 %-0.2 % NaCl) FREAMINE HBC 6.9 % PA BvD 78

FREAMINE III 10 % PA BvD gluco burst * (Dextrose) glucose gel * (Dextrose) glucose * oral tablet,chewable (Dextrose) glutose 15 * (Dextrose) HEPATAMINE 8% PA BvD HEPATASOL 8 % PA BvD insta-glucose * (Dextrose/Dextrin/ Maltose) INTRALIPID INTRAVENOUS PA BvD EMULSION 20 %, 30 % KABIVEN PA BvD LIPOSYN II PA BvD LIPOSYN III PA BvD NEPHRAMINE 5.4 % PA BvD NUTRILIPID PA BvD PERIKABIVEN PA BvD potassium chloride in lr-d5 (Potassium intravenous parenteral solution Chloride In Lr-D5) PREMASOL 10 % PA BvD PREMASOL 6 % PA BvD PROCALAMINE 3% PA BvD PROSOL 20 % PA BvD TRAVASOL 10 % PA BvD TROPHAMINE 10 % PA BvD TROPHAMINE 6% PA BvD Cardiovascular Agents Alpha-Adrenergic Agents clonidine hcl oral tablet (Catapres) 79

(Clonidine clonidine hcl-chlorthalidone HCl/Chlorthalidon e) clonidine transdermal patch weekly QL (4 per 28 days) (Catapres-Tts 1) 0.1 mg/24 hr, 0.2 mg/24 hr clonidine transdermal patch weekly QL (8 per 28 days) (Catapres-Tts 1) 0.3 mg/24 hr doxazosin (Cardura) guanfacine oral tablet (Tenex) PA-HRM midodrine (Midodrine HCl) nasal decongestant (pe) * oral tablet 10 mg (Medi-Phenyl) NORTHERA PA; QL (180 per 30 days) phenylephrine hcl injection (Vazculep) prazosin oral (Minipress) sudogest pe * (Medi-Phenyl) wal-phed pe * (Medi-Phenyl) Angiotensin Ii Receptor Antagonists BENICAR ST BENICAR HCT ST candesartan (Atacand) candesartan-hydrochlorothiazid (Atacand HCT) DIOVAN ST irbesartan (Avapro) irbesartan-hydrochlorothiazide (Avalide) losartan (Cozaar) losartan-hydrochlorothiazide (Hyzaar) telmisartan (Micardis) telmisartan-hydrochlorothiazid (Micardis HCT) TRIBENZOR ST valsartan (Diovan) 80

valsartan-hydrochlorothiazide (Diovan HCT) Angiotensin-Converting Enzyme Inhibitors benazepril (Lotensin) benazepril-hydrochlorothiazide (Lotensin HCT) captopril (Captopril) (Captopril/Hydroch captopril-hydrochlorothiazide lorothiazide) enalapril maleate (Vasotec) enalaprilat intravenous injectable (Enalaprilat Dihydrate) enalapril-hydrochlorothiazide (Vaseretic) fosinopril (Fosinopril Sodium) (Fosinopril/Hydroc fosinopril-hydrochlorothiazide hlorothiazide) lisinopril (Zestril) lisinopril-hydrochlorothiazide (Zestoretic) moexipril (Univasc) moexipril-hydrochlorothiazide (Uniretic) perindopril erbumine (Aceon) quinapril (Accupril) quinapril-hydrochlorothiazide (Accuretic) ramipril (Altace) trandolapril (Mavik) Antiarrhythmic Agents amiodarone hcl oral tablet 100 mg, 200 mg, 400 mg (Cordarone) amiodarone oral (Cordarone) disopyramide phosphate oral capsule (Norpace) flecainide (Flecainide Acetate) 81

lidocaine (pf) intravenous syringe (Lidocaine 50 mg/5 ml (1 %) HCl/PF) lidocaine in 5 % dextrose (pf) (Lidocaine intravenous parenteral solution 8 HCl/D5w/PF) mg/ml (0.8 %) mexiletine (Mexiletine HCl) MULTAQ procainamide injection (Procainamide HCl) propafenone oral capsule,extended release 12 hr (Rythmol SR) propafenone oral tablet (Rythmol) quinidine gluconate oral (Quinidine Gluconate) quinidine sulfate (Quinidine Sulfate) TIKOSYN Beta-Adrenergic Blocking Agents acebutolol oral (Sectral) atenolol (Tenormin) atenolol-chlorthalidone (Tenoretic 50) betaxolol oral (Kerlone) bisoprolol fumarate (Zebeta) bisoprolol-hydrochlorothiazide (Ziac) BYSTOLIC carvedilol (Coreg) esmolol intravenous (Esmolol HCl) PA BvD labetalol intravenous solution (Trandate) labetalol oral (Trandate) metoprolol succinate (Toprol XL) metoprolol ta-hydrochlorothiaz (Lopressor HCT) metoprolol tartrate intravenous (Metoprolol Tartrate) 82

metoprolol tartrate oral (Lopressor) nadolol (Corgard) pindolol (Pindolol) propranolol intravenous (Propranolol HCl) propranolol oral capsule,extended release 24 hr (Inderal LA) propranolol oral solution (Propranolol HCl) propranolol oral tablet (Propranolol HCl) (Propranolol/Hydro propranolol-hydrochlorothiazid chlorothiazid) sotalol hcl oral tablet 120 mg, 160 (Betapace) mg, 240 mg, 80 mg sotalol oral (Betapace) timolol maleate oral (Timolol Maleate) Calcium-Channel Blocking Agents cartia xt (Cardizem CD) diltiazem hcl intravenous (Cardizem CD) diltiazem hcl oral capsule, extended (Cardizem CD) release 180 mg, 360 mg, 420 mg diltiazem hcl oral (Cardizem CD) diltiazem hcl oral capsule,extended release 24hr 120 mg, 180 mg, 240 (Cardizem CD) mg, 300 mg diltiazem hcl oral (Cardizem CD) diltiazem hcl oral (Cardizem LA) dilt-xr (Cardizem CD) matzim la (Cardizem CD) taztia xt (Cardizem CD) verapamil intravenous syringe (Verapamil HCl) verapamil oral capsule, 24 hr er pellet ct (Verelan Pm) 83

verapamil oral capsule,ext rel. pellets 24 hr (Verelan) verapamil oral tablet (Calan) verapamil oral tablet extended release (Calan SR) Cardiovascular Agents, Miscellaneous ADRENALIN 1 MG/ML VIAL SUV adrenalin injection solution 1 mg/ml (1:1,000) (1ml) (Epinephrine) DEMSER digitek oral tablet 125 mcg (Lanoxin) digitek oral tablet 250 mcg (Lanoxin) PA-HRM; (High Risk Med for Ages 65 and Older and Dose is Greater Than 125mcg Per Day); QL (30 per 30 days) PA-HRM; QL (30 per 30 days) digoxin injection (Digoxin) PA-HRM DIGOXIN ORAL SOLUTION PA-HRM; QL (300 per 30 days) digoxin oral tablet (Lanoxin) PA-HRM; (High Risk Med for Ages 65 and Older and Dose is Greater Than 125mcg Per Day); QL (30 per 30 days) dobutamine in d5w intravenous (Dobutamine PA BvD parenteral solution HCl/D5W) dobutamine intravenous solution (Dobutamine HCl) PA BvD dopamine in 5 % dextrose (Dopamine PA BvD intravenous solution HCl/D5W) 84

dopamine intravenous solution (Dopamine HCl) PA BvD ephedrine sulfate injection solution (Ephedrine Sulfate) epinephrine 1 mg/ml ampul latex-free (Epinephrine) epinephrine injection auto-injector (Adrenaclick) epinephrine injection syringe 0.1 mg/ml (1:10,000) (Epinephrine) EPIPEN 2-PAK EPIPEN JR 2-PAK ethamolin (Ethanolamine Oleate) FIRAZYR hydralazine (Hydralazine HCl) LANOXIN ORAL TABLET 187.5 MCG, 62.5 MCG milrinone (Milrinone Lactate) PA BvD milrinone in 5 % dextrose PA BvD (Milrinone intravenous piggyback 40 mg/200 Lactate/D5W) ml (200 mcg/ml) (Levophed PA BvD norepinephrine bitartrate Bitartrate) papaverine injection solution (Papaverine HCl) PA papaverine oral (Papaverine HCl) PA RANEXA Dihydropyridines amlodipine (Norvasc) amlodipine-benazepril (Lotrel) AZOR ST PA-HRM; (High Risk Med for Ages 65 and Older and Dose is Greater Than 125mcg Per Day); QL (30 per 30 days) 85

CLEVIPREX INTRAVENOUS EMULSION EXFORGE ST EXFORGE HCT ST felodipine (Felodipine) isradipine (Isradipine) nicardipine oral (Nicardipine HCl) nifedipine oral tablet extended release 24hr 30 mg (Adalat CC) nifedipine oral tablet extended release 24hr 60 mg, 90 mg (Procardia XL) nifedipine oral tablet extended release 30 mg, 60 mg (Adalat CC) Diuretics amiloride oral (Midamor) (Amiloride/Hydroc amiloride-hydrochlorothiazide hlorothiazide) bumetanide (Bumetanide) chlorothiazide (Chlorothiazide) chlorothiazide sodium (Sodium Diuril) chlorthalidone oral tablet 25 mg, 50 (Chlorthalidone) mg DYRENIUM furosemide injection (Furosemide) furosemide oral solution (Furosemide) furosemide oral tablet (Lasix) hydrochlorothiazide oral capsule (Microzide) (Hydrochlorothiazi hydrochlorothiazide oral tablet de) indapamide (Indapamide) methyclothiazide (Methyclothiazide) metolazone (Zaroxolyn) 86

torsemide oral (Demadex) triamterene-hydrochlorothiazid oral (Dyazide) capsule triamterene-hydrochlorothiazid oral (Maxzide) tablet Dyslipidemics amlodipine-atorvastatin (Caduet) atorvastatin (Lipitor) cholestyramine (with sugar) oral (Questran) cholestyramine-aspartame oral (Cholestyramine/A powder 4 gram spartame) cholestyramine-aspartame oral powder in packet 4 gram (Questran) colestipol (Colestid) CRESTOR endur-acin * oral tablet extended release 500 mg (Slo-Niacin) fenofibrate micronized (Antara) fenofibrate nanocrystallized (Tricor) fenofibrate oral tablet (Lofibra) fenofibric acid (Fibricor) fenofibric acid (choline) (Trilipix) gemfibrozil oral (Lopid) lipogen * (Inositol/Choline/V it B Comp) lovastatin (Mevacor) niacin * oral capsule, extended release 500 mg (Niacin) niacin * oral tablet 100 mg, 50 mg, 500 mg (Slo-Niacin) niacin oral tablet extended release 24 hr (Niaspan) 87

niacin * oral tablet extended release 500 mg (Slo-Niacin) omega-3 acid ethyl esters oral capsule 1 gram (Lovaza) pravastatin (Pravachol) simvastatin (Zocor) QL (30 per 30 days) VASCEPA WELCHOL ZETIA Renin-Angiotensin-Aldosterone System Inhibitors eplerenone (Inspra) spironolactone (Aldactone) spironolacton-hydrochlorothiaz (Aldactazide) Vasodilators isosorbide dinitrate oral (Isochron) isosorbide dinitrate sublingual (Isosorbide Dinitrate) isosorbide mononitrate oral tablet (Isosorbide Mononitrate) isosorbide mononitrate oral tablet extended release 24 hr (Imdur) minitran transdermal patch 24 hour QL (30 per 30 days) (Nitro-Dur) 0.1 mg/hr, 0.2 mg/hr, 0.6 mg/hr minitran transdermal patch 24 hour QL (60 per 30 days) (Nitro-Dur) 0.4 mg/hr minoxidil oral (Minoxidil) NITRO-BID nitroglycerin in 5 % dextrose (Nitroglycerin/D5 intravenous solution W) nitroglycerin intravenous (Nitroglycerin) 88

nitroglycerin transdermal patch 24 hour 0.1 mg/hr, 0.2 mg/hr, 0.6 mg/hr nitroglycerin transdermal patch 24 hour 0.4 mg/hr (Nitro-Dur) (Nitro-Dur) QL (30 per 30 days) QL (60 per 30 days) NITROSTAT PROGLYCEM Central Nervous System Agents Central Nervous System Agents amphetamine salt combo (Adderall) QL (60 per 30 days) AMPYRA PA; QL (60 per 30 days) caffeine citrated intravenous (Cafcit) caffeine citrated oral (Cafcit) caffeine-sodium benzoate (Caffeine/Sodium Benzoate) clonidine hcl oral tablet extended release 12 hr (Kapvay) dexmethylphenidate oral tablet (Focalin) QL (60 per 30 days) dextroamphetamine oral capsule, QL (120 per 30 days) (Dexedrine) extended release dextroamphetamine oral tablet (Dexedrine) QL (180 per 30 days) dextroamphetamine-amphetamine QL (30 per 30 days) oral capsule,extended release 24hr (Adderall XR) 10 mg, 15 mg, 5 mg dextroamphetamine-amphetamine QL (60 per 30 days) oral capsule,extended release 24hr (Adderall XR) 20 mg, 25 mg, 30 mg flumazenil (Romazicon) guanfacine oral tablet extended release 24 hr (Intuniv) INTUNIV ER QL (30 per 30 days) lithium carbonate oral capsule (Eskalith) 89

lithium carbonate oral tablet (Lithobid) lithium carbonate oral tablet extended release (Lithobid) lithium citrate oral solution (Lithium Citrate) methylphenidate oral capsule, er QL (30 per 30 days) biphasic 30-70 10 mg, 20 mg, 50 (Metadate Cd) mg, 60 mg methylphenidate oral capsule, er QL (60 per 30 days) (Metadate Cd) biphasic 30-70 30 mg methylphenidate oral capsule,er QL (30 per 30 days) (Metadate Cd) biphasic 50-50 20 mg methylphenidate oral capsule,er QL (60 per 30 days) (Metadate Cd) biphasic 50-50 30 mg methylphenidate oral capsule,er QL (30 per 30 days) (Ritalin LA) biphasic 50-50 40 mg methylphenidate oral solution (Methylin) QL (900 per 30 days) methylphenidate oral tablet (Ritalin) QL (90 per 30 days) methylphenidate oral tablet QL (90 per 30 days) (Ritalin-SR) extended release methylphenidate oral tablet QL (30 per 30 days) extended release 24hr 18 mg, 27 (Concerta) mg, 54 mg methylphenidate oral tablet QL (60 per 30 days) (Concerta) extended release 24hr 36 mg NUEDEXTA QL (60 per 30 days) QUILLIVANT XR riluzole (Rilutek) SAVELLA QL (60 per 30 days) STRATTERA XENAZINE PA; QL (112 per 28 days) 90

Contraceptives Contraceptives ashlyna (Seasonique) QL (91 per 84 days) deblitane (Nor-Q-D) desog-e.estradiol/e.estradiol (Mircette) desogestrel-ethinyl estradiol oral tablet 0.1/.125/.15-25 mg-mcg, (Desogen) 0.15-0.03 mg drospirenone-ethinyl estradiol (Yaz) ELLA ethinyl estradiol/drospirenone (Yaz) (Ethynodiol ethynodiol d-ethinyl estradiol D-Ethinyl Estradiol) gildess 24 fe (Loestrin Fe) l norgest&e estradiol-e estrad (Seasonique) QL (91 per 84 days) levonorgestrel 1.5 mg tablet (rx) (Plan B One-Step) QL (6 per 365 days) levonorgestrel oral tablet 0.75 mg (Plan B One-Step) levonorgestrel * oral tablet 1.5 mg (Plan B One-Step) QL (6 per 365 days) levonorgestrel-ethin estradiol oral (Levonorgestrel-Et tablet 0.1-20 mg-mcg, 0.15-0.03 hin Estradiol) mg, 50-30 (6)/75-40 (5)/125-30(10) levonorgestrel-ethin estradiol oral QL (91 per 84 days) (Levonorgestrel-Et tablets,dose pack,3 month 0.15-30 hin Estradiol) mg-mcg levonorgestrel-ethinyl estrad oral (Levonorgestrel-Et tablet hin Estradiol) levonorgestrel-ethinyl estrad oral (Levonorgestrel-Et QL (91 per 84 days) tablets,dose pack,3 month hin Estradiol) l-norgest-eth estr/ethin estra (Seasonique) QL (91 per 84 days) next choice one dose 1.5 mg tb (rx) QL (6 per 365 days) (Plan B One-Step) 1.5 mg 91

norelgestromin/ethin.estradiol (Ortho Evra) QL (3 per 28 days) noreth-ethinyl estradiol/iron (Femcon Fe) norethindrone (Nor-Q-D) norethindrone (contraceptive) (Nor-Q-D) norethindrone ac-eth estradiol (Loestrin) norethindrone ac-eth estradiol oral tablet 1.5-30 mg-mcg (Loestrin) norethindrone-e.estradiol-iron oral tablet 1 mg-20 mcg (21)/75 mg (7), 1 mg-20 mcg (24)/75 mg (4), (Loestrin Fe) 1-20(5)/1-30(7) /1mg-35mcg (9), 1.5 mg-30 mcg (21)/75 mg (7) norethindrone-ethinyl estrad oral tablet 0.4-35 mg-mcg, 0.5-35 mg-mcg, 0.5-35/1-35 mg-mcg/mg-mcg, 0.5/0.75/1 mg- 35 (Modicon) mcg, 0.5/1/0.5-35 mg-mcg, 1-35 mg-mcg norethindrone-mestranol (Norinyl 1+50) norgestimate-ethinyl estradiol (Ortho-Cyclen) norgestrel-ethinyl estradiol (Norgestrel-Ethinyl Estradiol) NUVARING ST; QL (1 per 28 days) opcicon one-step * (Plan B One-Step) QL (6 per 365 days) PLAN B ONE-STEP * 3 $0 QL (6 per 365 days) tarina fe (Loestrin Fe) Cough And Cold Products Cough And Cold Products 30pse-150gfn-15dm * (Trispec Pse) adt robitussin peak cld dm max * (G-Zyncof) adult nasal decongestant * (Pseudoephedrine HCl) 92

adult robitussin lingering cld * (Dextromethorphan Hbr) adult robitussin peak cold dm * (G-Zyncof) (Robitussin adult wal-tussin * Mucus-Chest Congest) adult wal-tussin dm max * (G-Zyncof) alka-seltzer plus mucus-conges * (Guaifenesin/Dextr omethorphan) alka-seltzer plus sinus-cough * (D-Methorphan/Pe/ Acetaminophen) (Dm/Phenyleph/Ch ambi 10peh-4cpm-20dm * lorpheniramine) ambi 20dm-4cpm * (Coricidin Hbp) ambi 40pse-400gfn-20dm * (Guaifenesin/Dm/P seudoephedrine) (D-Methorphan ambi 60pse-4cpm-20dm * Hb/P-Ephed HCl/Cp) benzonatate * (Tessalon Perle) 3 $0 (D-Methorphan bio-dtuss dmx * Hb/P-Epd HCl/Bpm) bionel * (Guaifenesin/Dm/P seudoephedrine) bionel pediatric * (Trispec Pse) biospec dmx * (G-Zyncof) (D-Methorphan bromphenex dm * Hb/P-Epd HCl/Bpm) (D-Methorphan brompheniramine-pseudoeph-dm * Hb/P-Epd oral liquid HCl/Bpm) 93

(D-Methorphan brompheniramine-pseudoeph-dm * Hb/P-Epd oral syrup HCl/Bpm) (Brompheniram/Ph brompheniram-phenylephrine-dm * 3 $0 enylephrine/dm) broncotron-s * (G-Zyncof) cardec dm (phenyleph-chlorphn) * (Accuhist Pdx) cheratussin ac * (M-Clear Wc) cheratussin dac * (Tusnel C) chest congestion relief + dm * (Allfen Dm) (Guaifenesin/Pseud chest congestion relief d * oephedrne HCl) chest congestion relief pe * (Maxiphen) (D-Methorphan child cough & sore throat * Hb/Acetaminophen ) (Robitussin child mucinex chest congestion * Mucus-Chest Congest) child mucus relief cough * (G-Zyncof) child plus cough & runny nose * child triaminic cough-congest * child wal-tussin cough relief * children's chest congestion * children's dimetapp cold &flu * (Dextromethorphn/ Acetaminoph/Cp) (Guaifenesin/Dextr omethorphan) (Dextromethorphan Hbr) (Robitussin Mucus-Chest Congest) (Dm Hb/Pe/Acetaminop hen/chlorph) 94

children's flu relief * (Childrens Tylenol Plus Cold) children's mucinex cough * (G-Zyncof) children's silfedrine * (Pseudoephedrine HCl) children's sudafed * (Pseudoephedrine HCl) children's sudafed pe cough * (Dextromethorphan /Phenylephrine) chlophedianol-guaifenesin * (Vanacof G) chlorpheniramine-phenyleph-dm * codituss dm * cold multi-symptom * cold multi-symptom day/night * (Dm/Phenyleph/Ch lorpheniramine) (Pyrilamine/Pe/De xtromethorphan) (Comtrex Cold and Cough) (Dm Hb/Pe/Acetaminop hen/chlorph) (Dm/Pe/Acetamino cold multi-symptom nighttime * phen/doxylamine) (Dm cold relief m/s day/night * Hb/Pe/Acetaminop hen/chlorph) cold-flu relief * oral liquid (D-Methorphan/Ac 12.5-30-1,000 mg/30 ml etamin/doxylamn) cold-flu relief, day/night * (Vicks Dayquil-Nyquil) (Guaifenesin/Pseud congestac * oephedrne HCl) (Guaifenesin/Dextr coricidin hbp * oral capsule omethorphan) cough & cold * oral (Coricidin Hbp) 95

cough & runny nose * oral liquid (Dimetapp 1-5 mg/5 ml Long-Acting) coughtab * (Allfen) (Guaifenesin/Dextr creo-terpin (dm-guaifenesin) * omethorphan) DALLERGY DM * daytime cold & cough * (Triaminic) daytime cold-flu * (D-Methorphan/Pe/ Acetaminophen) day-time cough * (Dextromethorphan Hbr) daytime mucus relief dm * (G-Zyncof) daytime-nighttime * (Vicks Dayquil-Nyquil) (Dm/Pe/Acetamino daytime-nighttime cold-flu * phen/doxylamine) (Dextromethorphan daytime-nighttime cough * Hb/Doxylamine) decongestant cough * (Trispec Pse) delsym cough+chest congest dm * (G-Zyncof) despec-dm (pseudoeph-dm-guaif) * (Guaifenesin/Dm/P oral tablet 30-10-200 mg seudoephedrine) (D-Chlorphenira/Ps dexchlorphen-pse-chlophedianol * e/chlophedian) dextromethorphan polistirex * (Delsym) (Robitussin diabetic siltussin das-na * Mucus-Chest Congest) diabetic tussin dm * (G-Zyncof) (Robitussin diabetic tussin ex * oral Mucus-Chest Congest) 96

dimaphen dm * Name of Drug d-methorphan hb-p-epd hcl-bpm * oral syrup 2-30-10 mg/5 ml dm-phenyleph-chlorpheniramine * oral drops 1-2-3 mg/ml (Brompheniram/Ph enylephrine/dm) (D-Methorphan Hb/P-Epd HCl/Bpm) (Dm/Phenyleph/Ch lorpheniramine) 3 $0 dm-phenyleph-chlorpheniramine * (Dm/Phenyleph/Ch oral liquid 2-5-15 mg/5 ml, 4-10-15 lorpheniramine) mg/5 ml double-tussin dm * (G-Zyncof) ed bron gp * (Despec) entre-cough * (Trispec Pse) exefen dmx * (Guaifenesin/Dm/P seudoephedrine) expectorant max strength * (Dextromethorphan /Pseudoephed) (Robitussin expectorant * oral Mucus-Chest Congest) (Dm/Pe/Acetamino flu formula daytime-nighttime * ph/diphenhydram) (Dm flu severe cold-congestion * Hb/Pseudoephed/A cetamin/cp) flu-severe cold-cough * oral (D-Methorphan/Pe/ powder in packet 10-20-650 mg Acetaminophen) guaiatussin ac * (M-Clear Wc) guaifenesin dac * (Tusnel C) guaifenesin * oral tablet 200 mg (Allfen) guaifenesin * oral tablet extended release 12hr (Mucinex) 97

(Dm head congestion day-night * Hb/Pe/Acetaminop hen/chlorph) (Hydrocodone hydrocodone bit-homatrop me-br * Bit/Homatrop oral syrup 5-1.5 mg/5 ml Me-Br) 3 $0 hydrocodone-chlorpheniramine * (Tussionex) 3 $0 (Hydrocodone hydrocodone-homatropine * oral Bit/Homatrop syrup 5-1.5 mg/5 ml Me-Br) 3 $0 hydrocodone-homatropine * oral tablet (Tussigon) 3 $0 (Dm/Pseudoephed/ infants' non-aspirin cold * Acetaminophen) intense cough reliever * oral liquid (G-Zyncof) (Child Triaminic-D kidkare cough/cold * Mt-Sym Cold) liquibid d-r * (Maxiphen) lohist peb dm * (Ala-Hist Dm) lortuss ex * oral syrup (Tusnel C) mar-cof bp * (Bromphenira/Pseu doephed/codein) 3 $0 mar-cof cg * (M-Clear Wc) 3 $0 maximum strength flu * (Coricidin Hbp) (D-Methorphan medi-brom * Hb/P-Epd HCl/Bpm) (D-Methorphan mesehist dm * Hb/P-Ephed HCl/Cp) mucinex fast-max dm max * (G-Zyncof) mucus dm * (Mucinex Dm) 98

mucus dm max * (Mucinex Dm) mucus relief * oral tablet 400 mg (Allfen) (Dm multi-symptom cold night time * Hb/Pe/Acetaminop hen/chlorph) (Dm multi-symptom cold-cough * Hb/Pseudoephed/A cetamin/cp) nasal & sinus decongestant * (Sudafed 12-Hour) nasohist dm * (Accuhist Pdx) neo-tuss * (G-Zyncof) NEXAFED * night time cold-flu * oral night time cold-flu relief * oral liquid night time * oral capsule nighttime cold-flu * nighttime cough * nite time cold-flu * oral nite time-d cold-flu relief * nohist-dm * non-aspirin cold * (Dm/P-Ephed/Acet aminoph/doxylam) (Dm/P-Ephed/Acet aminoph/doxylam) (Dm/P-Ephed/Acet aminoph/doxylam) (D-Methorphan/Ac etamin/doxylamn) (Dextromethorphan Hb/Doxylamine) (D-Methorphan/Ac etamin/doxylamn) (Dm/P-Ephed/Acet aminoph/doxylam) (Dm/Phenyleph/Ch lorpheniramine) (Dm Hb/Pseudoephed/A cetamin/cp) 99

non-aspirin flu * oral tablet (Dm/Pseudoephed/ 30-15-500 mg Acetaminophen) pecgen dmx * (G-Zyncof) pedia relief * pedia relief infant * pediacare multi-symptom cold * phenylhistine dh * (Child Triaminic-D Mt-Sym Cold) (Dextromethorphan /Pseudoephed) (Dextromethorphan /Phenylephrine) (P-Ephed HCl/Cod/Chlorphe nir) poly-tussin * (Chlorcyclizine/Co deine) POLY-TUSSIN DM * promethazine-codeine * (Promethazine HCl/Codeine) 3 $0 promethazine-dm * (D-Methorphan Hb/Prometh HCl) 3 $0 (Promethazine/Phe promethazine-phenyleph-codeine * 3 $0 nyleph/codeine) (Pseudoephedrine pseudoephedrine hcl * oral HCl) pseudoephedrine hcl * oral (Sudafed 12-Hour) (D-Methorphan q-tapp dm * Hb/P-Epd HCl/Bpm) (Robitussin q-tussin * Mucus-Chest Congest) q-tussin dm * (Guaifenesin/Dextr omethorphan) refenesen * (Allfen) 100

refenesen pe * (Maxiphen) relcof c * (M-Clear Wc) 3 $0 REZIRA * 3 $0 (Robitussin robafen * Mucus-Chest Congest) robafen cough * (Dextromethorphan Hbr) robafen dm * (Guaifenesin/Dextr omethorphan) robitussin cough & cold cf * (Giltuss) (Guaifenesin/Dextr robitussin cough-chest-cong dm * omethorphan) robitussin dm max * (G-Zyncof) robitussin long-acting * (Dimetapp Long-Acting) robitussin pediatric * (Dextromethorphan Hbr) rydex * (Bromphenira/Pseu doephed/codein) safe tussin dm * (G-Zyncof) scot-tussin dm * (Dimetapp Long-Acting) (Robitussin scot-tussin expectorant * Mucus-Chest Congest) siltussin dm das * (G-Zyncof) (Robitussin siltussin sa * Mucus-Chest Congest) sudogest * (Sudafed 12-Hour) 101

suphedrin * oral suphedrine pe day-night * Name of Drug suphedrine severe cold max str * theraflu nighttime severe cold * oral tablet 2-5-15-325 mg theraflu severe cold-cough * triacting m-sym cold/cough * triaminic cold & cough (pe) * triaminic cough-nasal congesti * triaminic cough-sore throat * oral liquid 160-5 mg/5 ml (Pseudoephedrine HCl) (Diphenhydram/Pe/ Dm/Acetamin/Gg) (Dm/Pseudoephed/ Acetaminophen) (Dm Hb/Pe/Acetaminop hen/chlorph) (Dm Hb/Pseudoephed/A cetamin/cp) (Child Triaminic-D Mt-Sym Cold) (Dextromethorphan /Phenylephrine) (Robitussin Pediatric) (Triaminic) tri-dex pe * (Dm/Phenyleph/Ch lorpheniramine) trigofen dm * (Accuhist Pdx) trymine cg * (M-Clear Wc) tusnel diabetic * (G-Zyncof) TUSNEL PEDIATRIC * ORAL LIQUID tussin cf cough-cold * (Giltuss) tussin cf * oral (Guaifenesin/Dm/P seudoephedrine) tussin cold-congestion * (Guaifenesin/Dm/P seudoephedrine) 102

tussin cough (dm only) * oral (Dextromethorphan Hbr) tussin dm cough & chest * oral liquid 10-200 mg/5 ml (G-Zyncof) tussin dm * oral syrup 15-100 mg/5 (Guaifenesin/Dextr ml omethorphan) tussin maximum strength cough * (Dextromethorphan Hbr) tussin pe * oral liquid (Despec) (D-Methorphan valu-tapp dm * Hb/P-Epd HCl/Bpm) vicks dayquil cough * (Dextromethorphan Hbr) vicks nature fusion cough * (Dextromethorphan Hbr) virdec dm * (Accuhist Pdx) wal-phed * oral tablet 30 mg (Sudafed 12-Hour) (Diphenhydram/Pe/ wal-phed pe day-night * Dm/Acetamin/Gg) wal-tussin cough & cold cf * (Giltuss) wal-tussin cough * oral capsule (Dextromethorphan Hbr) wal-tussin cough * oral liquid (Scot-Tussin) wal-tussin dm * (Guaifenesin/Dextr omethorphan) zephrex-d * (Sudafed 12-Hour) ZONATUSS * 3 $0 zyncof * (G-Zyncof) Dental And Oral Agents Dental And Oral Agents cevimeline (Evoxac) 103

chlorhexidine gluconate mucous membrane (Peridex) PHOS-FLUR * DENTAL SOLUTION pilocarpine hcl oral (Salagen) PREVIDENT 5000 SENSITIVE * 3 $0 triamcinolone acetonide dental (Triamcinolone paste 0.1 % Acetonide) Dermatological Agents Dermatological Agents, Other 8-MOP acitretin (Soriatane) acne medication * topical gel 10 % (Benzoyl Peroxide) acne medication * topical lotion (Benzoyl Peroxide) acne-clear * (Benzoyl Peroxide) acyclovir topical (Zovirax) QL (30 per 30 days) ALCOHOL PADS ALCOHOL PREP PADS ALCOH-WIPE aluminum chloride (Drysol) amlactin * topical lotion (Lac-Hydrin Five) ammonium lactate * 12% cream (Ammonium fragrance free (otc) Lactate) ammonium lactate * 12% lotion (otc) (Lac-Hydrin Five) ammonium lactate topical cream 12 (Lac-Hydrin) % ammonium lactate topical lotion 12 % (Lac-Hydrin) ANACAINE benzoyl peroxide * 10% gel aqueous (otc) (Benzoyl Peroxide) 104

benzoyl peroxide * topical gel 10 % (Benzac Ac) 3 $0 benzoyl peroxide * topical gel 5 % (Benzoyl Peroxide) benzoyl peroxide * topical (Benzoyl Peroxide) BETADINE SPRAY * calcipotriene (Calcipotriene) calcipotriene topical cream (Dovonex) calcipotriene topical solution (Calcipotriene) calcitriol topical (Vectical) CASTELLANI PAINT MODIFIED * CONDYLOX TOPICAL GEL FLUOROPLEX fluorouracil topical cream (Carac) fluorouracil topical solution (Fluorouracil) geri-hydrolac * topical (Lac-Hydrin Five) imiquimod (Aldara) PA NSO; QL (24 per 30 days) isotretinoin oral capsule 10 mg, 20 mg, 30 mg, 40 mg (Isotretinoin) LACTINOL HX * lobana bath * (Mineral Oil) mafenide acetate (Mafenide Acetate) methoxsalen rapid (Oxsoralen-Ultra) PANRETIN persa-gel * (Benzoyl Peroxide) PICATO TOPICAL GEL 0.015 % QL (3 per 56 days) PICATO TOPICAL GEL 0.05 % QL (2 per 56 days) podofilox (Condylox) podophyllum resin (Podophyllum Resin) 105

potassium hydroxide (Potassium Hydroxide) SANTYL silver nitrate applicators (Silver Nitrate Applicator) skin treatment * (Lac-Hydrin Five) VALCHLOR zinc oxide * topical ointment (Boudreauxs) ZOVIRAX TOPICAL CREAM QL (15 per 30 days) Dermatological Antibacterials bacitracin * topical (Bacitracin) bacitraycin plus * topical ointment 500 unit/gram (Bacitracin) clindamycin phosphate topical gel (Cleocin T) clindamycin phosphate topical lotion (Cleocin T) clindamycin phosphate topical solution (Cleocin T) clindamycin phosphate topical swab (Cleocin T) erythromycin base-ethanol (Erythromycin Base/Ethanol) erythromycin with ethanol topical gel (Emgel) erythromycin with ethanol topical (Erythromycin solution Base/Ethanol) erythromycin with ethanol topical (Erythromycin swab Base/Ethanol) gentamicin topical (Gentamicin Sulfate) metronidazole topical cream 0.75 % (Metrocream) metronidazole topical (Nydamax) metronidazole topical (Metrolotion) 106

mupirocin (Centany) mupirocin calcium (Bactroban) neomycin-polymyxin b gu (Neosporin G.U. Irrigant) selenium sulfide topical shampoo (Selenium Sulfide) selenium sulfide topical suspension 2.5 % (Selenium Sulfide) silver nitrate topical (Silver Nitrate) silver sulfadiazine topical cream 1 % (Silvadene) sulfacetamide sodium (acne) (Klaron) Dermatological Anti-Inflammatory Agents alclometasone (Aclovate) aquanil hc * (Cortizone-10) beta-hc * (Cortizone-10) betamethasone dipropionate topical (Diprosone) cream betamethasone dipropionate topical (Betamethasone lotion Dipropionate) betamethasone dipropionate topical (Betamethasone ointment Dipropionate) betamethasone valerate topical (Betamethasone cream Valerate) betamethasone valerate topical foam (Luxiq) betamethasone valerate topical (Betamethasone lotion Valerate) betamethasone valerate topical (Betamethasone ointment Valerate) betamethasone, augmented topical cream (Diprolene AF) 107

betamethasone, augmented topical (Betamethasone gel Dipropionate) betamethasone, augmented topical lotion (Diprolene) betamethasone, augmented topical ointment (Diprolene) clobetasol propionate topical (Clobetasol solution 0.05 % Propionate) clobetasol topical cream (Temovate) clobetasol topical foam (Olux) clobetasol topical gel (Temovate) clobetasol topical lotion (Clobex) clobetasol topical ointment (Temovate) clobetasol topical shampoo (Clobex) clobetasol topical solution (Clobetasol Propionate) clobetasol-emollient topical (Temovate) clocortolone pivalate (Cloderm) CORDRAN TOPICAL OINTMENT cortizone-10 * topical cream (Hydrocortisone) CORTIZONE-10 * TOPICAL LOTION cortizone-10 * topical ointment (Hydrocortisone) dermarest eczema (hydrocort) * (Cortizone-10) desonide topical cream (Desowen) desonide topical ointment (Tridesilon) desoximetasone (Topicort) ELIDEL fluocinonide topical cream 0.05 % (Vanos) fluocinonide topical gel (Fluocinonide) PA; (PA for Ages < 2); AGE (Min 2 Years) 108

fluocinonide topical ointment (Fluocinonide) fluocinonide topical solution (Fluocinonide) fluocinonide-emollient base (Vanos) fluticasone topical cream (Cutivate) fluticasone topical ointment (Fluticasone Propionate) halobetasol propionate (Ultravate) hydro skin * topical (Cortizone-10) hydrocortisone * 1% cream maximum strength (otc) (Hydrocortisone) hydrocortisone * 1% lotion (otc) (Cortizone-10) 3 $0 hydrocortisone * 1% ointment carton (otc) (Hydrocortisone) hydrocortisone acet-aloe vera topical gel (Nuzon) hydrocortisone acetate * topical (Hydrocortisone cream 1 % Acetate) hydrocortisone acetate-urea (Hydrocortisone Acetate/Urea) hydrocortisone butyrate (Locoid) hydrocortisone butyr-emollient (Locoid) hydrocortisone rectal cream 1 % (Anusol-HC) hydrocortisone rectal cream 2.5 % (Hydrocortisone) hydrocortisone rectal enema (Cortenema) hydrocortisone * topical cream 0.5 % (Hydrocortisone) hydrocortisone topical cream 1 %, 2.5 % (Anusol-HC) hydrocortisone * topical lotion 1 % (Rederm) 3 $0 hydrocortisone topical lotion 2 % (Rederm) hydrocortisone * topical ointment 0.5 % (Hydrocortisone) 109

hydrocortisone topical ointment 1 %, 2.5 % (Hydrocortisone) hydrocortisone valerate topical (Hydrocortisone cream Valerate) hydrocortisone valerate topical ointment (Westcort) mometasone (Elocon) neosporin anti-itch * (Hydrocortisone) prednicarbate (Dermatop) preparation h hydrocortisone * (Hydrocortisone) PROTOPIC TOPICAL OINTMENT 0.03 % PROTOPIC TOPICAL OINTMENT 0.1 % recort plus * (Hydrocortisone) tacrolimus topical (Protopic) triamcinolone acetonide topical (Triamcinolone cream Acetonide) triamcinolone acetonide topical lotion (Kenalog) triamcinolone acetonide topical ointment 0.025 %, 0.05 %, 0.1 %, (Triderm) 0.5 % triderm topical cream (Triamcinolone Acetonide) Dermatological Retinoids adapalene topical cream (Differin) adapalene topical gel 0.1 % (Differin) TAZORAC TOPICAL CREAM tretinoin microspheres (Tretinoin Microspheres) PA; (0.03%; PA for Ages < 2); AGE (Min 2 Years) PA; (0.1%; PA for Ages < 15); AGE (Min 15 Years) PA 110

tretinoin topical (Retin-A) PA Scabicides And Pediculicides lice cream rinse * (Nix) (Piperonyl lice killing * Butoxide/Pyrethrin s) lice treatment * topical liquid 1 % (Nix) malathion (Ovide) permethrin topical cream (Elimite) permethrin * topical liquid (Nix) Devices Devices ASSURE ID INSULIN SAFETY SYRINGE BD INSULIN PEN NEEDLE UF SHORT BD INSULIN SYRINGE ULTRA-FINE SYRINGE 0.3 ML 31 X 5/16", 1 ML 31 X 5/16", 1/2 ML 31 X 5/16" INSULIN PEN NEEDLE NEEDLE INSULIN SYRINGE NEEDLELESS INSULIN SYRINGE SYRINGE INSULIN SYRINGE-NEEDLE U-100 SYRINGE SURE COMFORT INS. SYR. U-100 Disinfectants (For Non-Dermatologic Use) Disinfectants (For Non-Dermatologic Use) iodine * (Iodine) 111

Enzyme Replacement/Modifiers Enzyme Replacement/Modifiers ADAGEN ALDURAZYME CEREZYME INTRAVENOUS RECON SOLN 400 UNIT CIMZIA PA CIMZIA POWDER FOR PA RECONST CREON ELAPRASE ELITEK INTRAVENOUS RECON SOLN FABRAZYME INTRAVENOUS RECON SOLN KRYSTEXXA KUVAN LINZESS QL (30 per 30 days) lipase-protease-amylase (Zenpep) LOTRONEX LUMIZYME MYOZYME NAGLAZYME ORFADIN PULMOZYME PA BvD VIMIZIM PA VPRIV ZAVESCA QL (90 per 30 days) ZENPEP 112

Eye, Ear, Nose, Throat Agents Eye, Ear, Nose, Throat Agents, Miscellaneous AKTEN (PF) alaway * (Zaditor) altacaine (Tetcaine) altamist * (Little Remedies) apraclonidine (Iopidine) artificial tears (petro/min) * (Genteal Pm) (Dextran artificial tears (pf) * ophthalmic 70/Hypromellose/P dropperette 0.1-0.3 % F) artificial tears * ophthalmic drops 0.1-0.3 % (Tears Naturale) artificial tears * ophthalmic drops (Polyvinyl 0.5-0.6 % Alcohol/Povidone) artificial tears * ophthalmic (Petrolat,Wht/Min ointment Oil/Sod Chl) (Glycerin/Propylen artificial tears(glycerin-peg) * e Glycol) (Genteal Mild To artificial tears(hypromellose) * Moderate) atropine ophthalmic drops (Isopto Atropine) atropine ophthalmic ointment (Atropine Sulfate) ayr saline * nasal aerosol,spray (Little Remedies) ayr saline * nasal drops (Sodium Chloride) azelastine nasal (Astelin) QL (30 per 25 days) azelastine ophthalmic (Optivar) (Dextran bion tears (pf) * 70/Hypromellose/P F) carteolol (Carteolol HCl) 113

cromolyn ophthalmic (Cromolyn Sodium) CYCLOGYL OPHTHALMIC DROPS 0.5 % cyclopentolate (Cyclogyl) CYSTARAN deep sea nasal * (Little Remedies) dristan long lasting * (Oxymetazoline HCl) epinastine (Elestat) eq gentle * (Genteal Mild To Moderate) GENTEAL MILD TO MODERATE * GENTEAL GEL * GENTEAL MILD * GENTEAL SEVERE * homatropine hbr (Isopto Homatropine) ipratropium bromide nasal spray,non-aerosol 0.03 % (Atrovent) ipratropium bromide nasal spray,non-aerosol 0.06 % (Atrovent) isopto tears * (Genteal Mild To Moderate) ketotifen fumarate * (Zaditor) LACRISERT liquitears * (Polyvinyl Alcohol) lubricant dry eye relief * (Carboxymethylcel lulose Sodium) QL (30 per 28 days) QL (15 per 10 days) 114

lubricant eye (polyv alcohol) * (Polyvinyl Alcohol) lubricant eye (propyl glycol) * (Systane Balance) lubricant eye drops * ophthalmic (Carboxymethylcel dropperette lulose Sodium) lubricant eye drops * ophthalmic drops (Refresh Tears) lubricating drops * (Refresh Optive) lubrifresh pm * (Genteal Pm) muro 128 * (Sodium Chloride) naphazoline (Naphazoline HCl) nasal decongestant (oxymetazl) * (Afrin) natural balance * (Genteal Mild To Moderate) (Dextran natural tears (pf) * 70/Hypromellose/P F) nature's tears * (Genteal Mild To Moderate) neo-synephrine 12 h spr (oxym) * (Oxymetazoline HCl) nighttime relief eye * (Petrolat,Wht/Min Oil/Sod Chl) ocean nasal * (Little Remedies) olopatadine (Patanase) QL (30.5 per 30 days) PATADAY ST PATANOL ST phenylephrine hcl ophthalmic (Mydfrin) proparacaine (Proparacaine HCl) proparacaine hcl ophthalmic drops 0.5 % (Proparacaine HCl) 115

(Proparacaine/Fluo proparacaine-fluorescein sod rescein Sod) (Genteal Mild To pure & gentle eye * Moderate) REFRESH CLASSIC (PF) * REFRESH LACRI-LUBE * REFRESH LIQUIGEL * REFRESH OPTIVE * retaine cmc * (Carboxymethylcel lulose Sodium) saline mist * (Little Remedies) sea soft nasal mist * (Little Remedies) sochlor * ophthalmic (Sodium Chloride) sodium chloride * ophthalmic (Sodium Chloride) STERILE LUBRICANT * tears again * ophthalmic drops (Polyvinyl Alcohol) tears again * ophthalmic ointment (Lanolin/Min Oil/Petrolat, Wht) TEARS NATURALE II * tetracaine hcl (Tetcaine) ultra fresh pm * (Lanolin/Min Oil/Petrolat, Wht) vicks qlearquil(oxymetazoline) * (Oxymetazoline HCl) vicks sinex 12-hour * (Afrin) wal-zyr (ketotifen) * (Zaditor) zyrtec itchy eye drops (keto) * (Zaditor) Eye, Ear, Nose, Throat Anti-Infectives Agents acetic acid otic (Vosol) bacitracin ophthalmic (Bacitracin) 116

(Bacitracin/Polymy bacitracin-polymyxin b ophthalmic xin B Sulfate) CIPRODEX ciprofloxacin hcl ophthalmic (Ciloxan) ciprofloxacin hcl otic (Cetraxal) COLY-MYCIN S erythromycin ophthalmic (Ilotycin) gatifloxacin (Zymaxid) gentamicin ophthalmic (Garamycin) gentamicin sulfate ophthalmic ointment 0.3 % (3 mg/gram) (Garamycin) levofloxacin ophthalmic (Quixin) MOXEZA NATACYN (Neomy neomy sulf-bacitrac zn-poly-hc Sulf/Bacitrac Zn/Poly/HC) (Neomy neomycin-bacitracin-poly-hc Sulf/Bacitrac Zn/Poly/HC) (Neomy neomycin-bacitracin-polymyxin Sulf/Bacitra/Polym yxin B) neomycin-polymyxin b-dexameth (Maxitrol) neomycin-polymyxin-gramicidin (Neosporin) neomycin-polymyxin-hc (Oticin HC) ofloxacin ophthalmic (Ocuflox) ofloxacin otic (Ocuflox) polymyxin b sulf-trimethoprim (Polytrim) REFRESH OPTIVE ADVANCED * 117

sulfacetamide sodium Name of Drug sulfacetamide sodium ophthalmic drops 10 % (Sulfacetamide Sodium) (Sulfacetamide Sodium) (Sulfacetamide/Pre sulfacetamide-prednisolone dnisolone Sp) TOBRADEX ST tobramycin (Tobrex) trifluridine (Viroptic) VIGAMOX ZYLET Eye, Ear, Nose, Throat Anti-Inflammatory Agents ALREX bromfenac (Bromfenac Sodium) dexamethasone sodium phosphate ophthalmic (Dexasol) diclofenac sodium ophthalmic (Diclofenac Sodium) DUREZOL fluorometholone (FML) flurbiprofen sodium (Ocufen) fluticasone nasal (Flonase) QL (16 per 30 days) ILEVRO ketorolac ophthalmic (Acular) LOTEMAX NASONEX QL (34 per 28 days) NEVANAC prednisolone acetate (Omnipred) prednisolone sodium phosphate ophthalmic (Prednisol) PROLENSA 118

RESTASIS QL (60 per 30 days) Gastrointestinal Agents Antiflatulents anti-gas maximum strength * (Gas-X) bicarsim forte * (Simethicone) gas free extra strength * (Gas-X) gas relief 80 * (Gas-X) gas relief extra strength * oral (Gas-X) gas relief * oral (Gas-X) gas-x ultra-strength * (Gas-X) mi-acid gas relief * (Gas-X) mylanta gas * (Gas-X) mytab gas * (Gas-X) mytab gas maximum strength * (Gas-X) simethicone * oral capsule 180 mg (Gas-X) simethicone * oral (Infants' Mylicon) Antiulcer Agents And Acid Suppressants acid reducer (famotidine) * (Pepcid Ac) acid reducer (ranitidine) * oral tablet 150 mg (Zantac) acid relief (cimetidine) * (Tagamet Hb) amoxicil-clarithromy-lansopraz (Prevpac) CARAFATE ORAL SUSPENSION cimetidine hcl oral (Cimetidine HCl) cimetidine oral tablet 200 mg, 300 mg, 400 mg, 800 mg (Tagamet) cvs cimetidine * 200 mg tablet (otc) (Tagamet Hb) esomeprazole sodium (Nexium I.V.) famotidine (pf) (Famotidine/PF) famotidine (pf)-nacl (iso-os) (Famotidine In Nacl,Iso-Osm/PF) (Rx Product Only) 119

famotidine oral tablet 20 mg, 40 mg (Pepcid) (Rx Product Only) lansoprazole * dr 15 mg capsule 2x14 day course (otc) (Prevacid 24hr) lansoprazole oral capsule,delayed (Rx Product Only) (Prevacid) release(dr/ec) 15 mg, 30 mg misoprostol (Cytotec) omeprazole magnesium * (Omeprazole Magnesium) omeprazole oral capsule,delayed release(dr/ec) (Prilosec) omeprazole * oral tablet,delayed release (dr/ec) (Omeprazole) omeprazole-sodium bicarbonate (Rx Product Only) (Zegerid) 3 $0 oral capsule 20-1.1 mg-gram pantoprazole intravenous (Pantoprazole Sodium) pantoprazole oral (Protonix) PRILOSEC OTC * pub famotidine * 20 mg tablet max strength (otc) (Pepcid Ac) ra omepraz-bicarb 20-1,100 cap 3x14 day course (otc) (Zegerid Otc) ranitidine hcl injection solution 25 (Rx Product Only) (Zantac) mg/ml ranitidine hcl oral syrup (Ranitidine HCl) (Rx Product Only) ranitidine hcl oral tablet 150 mg, (Rx Product Only) (Zantac) 300 mg ranitidine hcl * oral tablet 75 mg (Zantac) sucralfate oral suspension (Sucralfate) sucralfate oral tablet (Carafate) wal-zan 75 * (Zantac) zantac 75 * (Zantac) 120

Gastrointestinal Agents, Other acid gone antacid * (Gaviscon) almacone * oral suspension (Mylanta) almacone-2 * (Mylanta) aluminum hydroxide gel * oral suspension 320 mg/5 ml (Alternagel) AMITIZA QL (60 per 30 days) (Calcium antacid anti-gas * oral Carbonate/Simethi cone) antacid * oral tablet,chewable 200 mg calcium (500 mg) (Tums) antacid plus anti-gas * oral suspension (Mylanta) anti-diarrheal * (Pepto-Bismol) anti-diarrheal (loperamide) * oral capsule (Loperamide HCl) anti-diarrheal (loperamide) * oral (Imodium A-D) bismatrol * oral suspension 262 mg/15 ml (Pepto-Bismol) bismatrol * oral tablet,chewable (Pepto-Bismol) BUPHENYL ORAL TABLET calci-chew * (Tums) calcium antacid * oral tablet,chewable (Tums) calcium carbonate * oral tablet,chewable 500 mg calcium (Tums) (1,250 mg) CALCIUM CARBONATE-VITAMIN D3 * ORAL TABLET,CHEWABLE 500-100 MG-UNIT 121

cal-gest antacid * (Tums) children's pepto * (Tums) children's soothe * (Tums) comfort gel extra strength * (Mylanta) cromolyn oral (Gastrocrom) diamode * (Imodium A-D) dicyclomine oral capsule (Bentyl) dicyclomine oral solution (Dicyclomine HCl) dicyclomine oral tablet (Bentyl) diphenoxylate-atropine oral liquid (Diphenoxylate HCl/Atropine) diphenoxylate-atropine oral tablet (Lomotil) flanax antacid * (Mylanta) foaming antacid * (Gaviscon) gelusil antacid & anti-gas * oral suspension (Mylanta) gelusil antacid & anti-gas * oral tablet,chewable (Almacone) glycopyrrolate (Robinul) glycopyrrolate (Robinul) imodium a-d * oral liquid (Loperamide HCl) IMODIUM A-D * ORAL TABLET kaopectate (bismuth subsalicy) * (Pepto-Bismol) lactulose (Lactulose) loperamide oral (Loperamide HCl) loperamide * oral (Loperamide HCl) maalox advanced * oral suspension (Mylanta) MAGNEBIND 300 * magnesium oxide * oral capsule 500 mg (Uromag) 122

magnesium oxide * oral tablet 250 mg, 400 mg, 500 mg (Magox 400) masanti double strength * (Mylanta) methscopolamine oral (Pamine) metoclopramide hcl injection (Reglan) metoclopramide hcl oral (Metoclopramide HCl) metoclopramide hcl oral (Reglan) mi-acid * oral suspension (Mylanta) (Calcium mi-acid * oral tablet,chewable Carb/Magnesium Hydrox) mintox * (Mylanta) mintox maximum strength * (Mylanta) mintox plus * (Almacone) NUTRESTORE pep-t-med * (Pepto-Bismol) phillips * (Magox 400) RELISTOR SUBCUTANEOUS PA; QL (28 per 28 days) RELISTOR SUBCUTANEOUS PA; QL (28 per 28 days) ri-gel * (Mylanta) ri-gel ii * (Mylanta) ri-mox * (Mylanta) sodium bicarbonate * oral tablet (Sodium 650 mg Bicarbonate) soothe (bismuth subsalicylate) * (Bismuth oral Subsalicylate) soothe regular strength * (Pepto-Bismol) stomach relief * oral (Bismuth Subsalicylate) ultra strength antacid * (Tums) ursodiol oral capsule (Actigall) 123

ursodiol oral tablet (Urso) Laxatives alophen * (Dulcolax) bisac-evac * (Dulcolax) bisacodyl * oral (Dulcolax) bisacodyl * rectal (Dulcolax) biscolax * (Dulcolax) clearlax * oral (Miralax) colace * oral capsule 100 mg (Sof-Lax) doc-q-lace * oral (Sof-Lax) docu * (Docusate Sodium) docusate calcium * (Surfak) docusate sodium * oral (Docusate Sodium) docusol * (Docusate Sodium) dok * oral capsule (Sof-Lax) dok * oral tablet (Docusate Sodium) dulcolax stool softener (dss) * (Sof-Lax) enema disposable * (Enema) enema * rectal enema * 19-7 gram/118 ml (Enema) enemeez * rectal enema 283 mg/5 ml (Docusate Sodium) enemeez * rectal enema 283-20 mg/5 ml (Docusol Plus) equalactin * (Calcium Polycarbophil) fiber (calcium polycarbophil) * (Fibercon) fiber laxative * oral tablet (Citrucel) fiber smooth * (Psyllium Seed) fiber therapy (psyllium/sugar) * (Psyllium Seed (With Sugar)) 124

fiber therapy * oral powder 2 gram/19 gram (Citrucel) fiber-lax * (Fibercon) FLEET BISACODYL * gentlelax * (Miralax) glycolax * oral powder (Miralax) 3 $0 healthylax * (Miralax) hydrocil instant * (Psyllium Seed) konsyl (sugar) * oral (Metamucil) konsyl fiber * (Fibercon) konsyl sugar-free * oral powder in packet (Psyllium Husk) laxative peg 3350 * (Miralax) milk of magnesia * (Milk Of Magnesia) mineral oil laxative * (Mineral Oil) MOVIPREP natural fiber laxative therapy * (Psyllium Seed (With Sugar)) oral saline laxative * oral (Na Phos,M-B/Na Phos,Di-Ba) peg 3350-electrolytes (Golytely) PEG 3350-GRX peg 3350-na sulf,bicarb,cl-kcl (Golytely) peg3350 * (Miralax) peg-electrolyte soln (Nulytely with Flavor Packs) peri-colace * (Sennosides/Docus ate Sodium) phillips liqui-gels * (Sof-Lax) phosphate laxative * oral (Na Phos,M-B/Na Phos,Di-Ba) 125

polyethylene glycol 3350 oral (Polyethylene powder Glycol 3350) polyethylene glycol 3350 * oral powder in packet (Miralax) promolaxin * (Docusate Sodium) purelax * (Miralax) reguloid * oral powder (Psyllium Seed (With Sugar)) senexon * oral syrup (Sennosides) senexon * oral tablet (Senokot) senna lax * (Senokot) senna * oral capsule (Sennosides) senna * oral syrup 8.8 mg/5 ml (Sennosides) senna * oral tablet (Senokot) senna with docusate sodium * (Sennosides/Docus ate Sodium) senokot-s * (Sennosides/Docus ate Sodium) silace * oral liquid (Docusate Sodium) silace * oral syrup (Colace) smoothlax * oral (Miralax) sodium chloride-nahco3-kcl-peg (Nulytely with oral recon soln 420 gram Flavor Packs) the magic bullet * (Dulcolax) Phosphate Binders calcium acetate oral capsule (Phoslo) calcium acetate oral tablet (Calcium Acetate) (Calcium calcium carbonate-mag carb-fa Carbonate/Mag Carb/Fa) calphron * (Calcium Acetate) PHOSLYRA 126

RENAGEL RENVELA (Sodium sodium polystyrene sulfonate oral Polystyrene powder Sulfonate) (Sodium sodium polystyrene sulfonate oral Polystyrene suspension 15 gram/60 ml Sulfonate) (Sodium sodium polystyrene sulfonate rectal Polystyrene enema 30 gram/120 ml Sulfonate) Genitourinary Agents Antispasmodics, Urinary oxybutynin chloride oral tablet (Oxybutynin Chloride) oxybutynin chloride oral tablet extended release 24hr (Ditropan XL) tolterodine oral capsule,extended release 24hr (Detrol LA) tolterodine oral tablet (Detrol) TOVIAZ trospium oral capsule,extended release 24hr (Sanctura XR) trospium oral tablet (Sanctura) Genitourinary Agents, Miscellaneous alfuzosin (Uroxatral) tamsulosin (Flomax) terazosin (Terazosin HCl) Heavy Metal Antagonists Heavy Metal Antagonists deferoxamine injection recon soln (Desferal) PA BvD DEPEN TITRATABS 127

EXJADE FERRIPROX sodium thiosulfate intravenous (Sodium solution 1 gram/10 ml (100 mg/ml), Thiosulfate) 12.5 gram/50 ml (250 mg/ml) SYPRINE Hormonal Agents, Stimulant/Replacement/Modifying Androgens ANDRODERM PA; QL (30 per 30 days) ANDROGEL TRANSDERMAL PA; QL (300 per 30 days) GEL IN METERED-DOSE PUMP 1.25 GRAM/ ACTUATION (1 %) ANDROGEL TRANSDERMAL PA; QL (150 per 30 days) GEL IN METERED-DOSE PUMP 20.25 MG/1.25 GRAM (1.62 %) ANDROGEL TRANSDERMAL GEL IN PACKET 1 % (25 MG/2.5GRAM), 1 % (50 MG/5 GRAM) PA; QL (300 per 30 days) ANDROGEL TRANSDERMAL PA; QL (150 per 30 days) GEL IN PACKET 1.62 % (20.25 MG/1.25 GRAM), 1.62 % (40.5 MG/2.5 GRAM) danazol oral (Danazol) fluoxymesterone (Fluoxymesterone) oxandrolone (Oxandrin) (Depo-Testosteron PA testosterone cypionate e) testosterone enanthate (Delatestryl) PA; QL (5 per 28 days) testosterone transdermal gel in PA; QL (150 per 30 days) (Androgel) packet 1 % (25 mg/2.5gram) 128

Estrogens And Antiestrogens COMBIPATCH PA-HRM; QL (8 per 28 days) DUAVEE PA-HRM ESTRACE VAGINAL estradiol oral (Estrace) PA-HRM estradiol transdermal patch semiweekly (Vivelle-Dot) estradiol transdermal patch weekly (Climara) estradiol valerate (Delestrogen) estradiol/norethindrone acet (Activella) PA-HRM estradiol-norethindrone acet (Activella) PA-HRM ESTRASORB PA-HRM; QL (8 per 28 days) PA-HRM; QL (4 per 28 days) PA-HRM; QL (97.44 per 28 days) estropipate (Ogen) PA-HRM FEMRING QL (1 per 84 days) MENEST PA-HRM norethindrone ac-eth estradiol oral PA-HRM (Femhrt) tablet 1-5 mg-mcg PREMARIN INJECTION PREMARIN ORAL PA-HRM PREMARIN VAGINAL PREMPHASE PA-HRM PREMPRO PA-HRM raloxifene (Evista) VAGIFEM QL (18 per 28 days) VIVELLE-DOT PA-HRM; QL (8 per 28 days) Glucocorticoids/Mineralocorticoids betamethasone acet,sod phos (Celestone) PA BvD cortisone (Cortisone Acetate) PA BvD 129

dexamethasone oral (Dexamethasone) PA BvD dexamethasone oral (Dexamethasone) PA BvD dexamethasone sodium phosphate (Dexamethasone PA BvD injection Sod Phosphate) fludrocortisone (Fludrocortisone Acetate) hydrocortisone oral (Cortef) PA BvD hydrocortisone sod succinate (Hydrocortisone PA BvD Sod Succinate) methylprednisolone (Medrol) PA BvD methylprednisolone acetate (Depo-Medrol) PA BvD methylprednisolone sodium succ PA BvD (A-Methapred) injection recon soln 125 mg, 40 mg methylprednisolone sodium succ PA BvD (A-Methapred) intravenous prednisolone sodium phosphate PA BvD (Orapred) oral solution prednisone (Prednisone) PA BvD SOLU-CORTEF (PF) INJECTION PA BvD RECON SOLN 100 MG/2 ML triamcinolone acetonide injection (Triamcinolone Acetonide) Pituitary desmopressin injection (DDAVP) desmopressin nasal (Desmopressin QL (15 per 30 days) Acetate) desmopressin nasal (Desmopressin QL (15 per 30 days) Acetate) desmopressin oral (DDAVP) GENOTROPIN PA GENOTROPIN MINIQUICK PA HUMATROPE PA 130

INCRELEX NORDITROPIN FLEXPRO PA SUBCUTANEOUS PEN INJECTOR 10 MG/1.5 ML (6.7 MG/ML), 15 MG/1.5 ML (10 MG/ML), 5 MG/1.5 ML (3.3 MG/ML) NORDITROPIN NORDIFLEX PA NUTROPIN AQ NUSPIN PA NUTROPIN AQ PA SUBCUTANEOUS NUTROPIN SUBCUTANEOUS PA RECON SOLN 10 MG octreotide acetate injection solution 1,000 mcg/ml, 100 mcg/ml, 200 (Sandostatin) mcg/ml, 500 mcg/ml octreotide acetate injection solution (Octreotide 50 mcg/ml Acetate) octreotide acetate injection syringe (Octreotide Acetate) OMNITROPE PA PREGNYL SAIZEN PA SAIZEN CLICK.EASY PA SANDOSTATIN LAR DEPOT SEROSTIM SUBCUTANEOUS PA RECON SOLN 4 MG, 5 MG, 6 MG SOMATULINE DEPOT QL (1 per 28 days) SOMAVERT SUPPRELIN LA QL (1 per 360 days) TEV-TROPIN PA vasopressin (Pitressin) 131

Progestins DEPO-PROVERA INTRAMUSCULAR SOLUTION medroxyprogesterone intramuscular suspension (Depo-Provera) medroxyprogesterone (Medroxyprogester intramuscular syringe one Acetate) medroxyprogesterone oral (Provera) norethindrone acetate (Aygestin) progesterone (Progesterone) progesterone micronized (Prometrium) Thyroid And Antithyroid Agents levothyroxine intravenous (Levothyroxine Sodium) levothyroxine oral (Levoxyl) liothyronine oral (Cytomel) methimazole oral tablet 10 mg, 5 (Tapazole) mg QL (10 per 28 days) QL (1 per 84 days) QL (1 per 84 days) propylthiouracil (Propylthiouracil) Immunological Agents Immunological Agents ARCALYST ASTAGRAF XL PA BvD AUBAGIO PA; QL (28 per 28 days) azathioprine (Imuran) PA BvD azathioprine sodium (Azathioprine PA BvD Sodium) CARIMUNE NF PA BvD NANOFILTERED INTRAVENOUS RECON SOLN CELLCEPT INTRAVENOUS PA BvD 132

CELLCEPT ORAL SUSPENSION PA BvD FOR RECONSTITUTION cyclosporine intravenous (Sandimmune) PA BvD cyclosporine modified (Neoral) PA BvD cyclosporine oral capsule (Sandimmune) PA BvD cyclosporine, modified (Neoral) PA BvD ENBREL PA ENBREL SURECLICK PA FLEBOGAMMA DIF PA BvD GAMASTAN S/D PA BvD GAMMAGARD LIQUID PA BvD GAMMAPLEX PA BvD GAMUNEX-C INJECTION PA BvD SOLUTION HUMIRA PA HUMIRA CROHN'S DIS START PA PCK HUMIRA PEN PA HYPERRAB S/D (PF) HYQVIA PA BvD ILARIS (PF) PA IMOGAM RABIES-HT (PF) KINERET PA; QL (18.76 per 28 days) leflunomide (Arava) mycophenolate mofetil (Cellcept) PA BvD mycophenolate sodium (Myfortic) PA BvD NULOJIX PA BvD OCTAGAM PA BvD ORENCIA PA; QL (4 per 28 days) ORENCIA (WITH MALTOSE) PA 133

PRIVIGEN PA BvD PROGRAF INTRAVENOUS PA BvD RAPAMUNE ORAL SOLUTION PA BvD RAPAMUNE ORAL TABLET 1 PA BvD MG, 2 MG RIDAURA sirolimus (Rapamune) PA BvD tacrolimus oral (Hecoria) PA BvD TYSABRI PA; QL (15 per 28 days) ZORTRESS PA BvD; QL (120 per 30 days) Vaccines ACTHIB (PF) ADACEL(TDAP ADOLESN/ADULT)(PF) BCG VACCINE, LIVE (PF) PA BvD BOOSTRIX TDAP CERVARIX VACCINE (PF) COMVAX (PF) DAPTACEL (DTAP PEDIATRIC) (PF) ENGERIX-B (PF) PA BvD ENGERIX-B PEDIATRIC (PF) PA BvD GARDASIL (PF) GARDASIL 9 (PF) HAVRIX (PF) INTRAMUSCULAR SUSPENSION HAVRIX (PF) INTRAMUSCULAR SYRINGE IMOVAX RABIES VACCINE (PF) PA BvD 134

INFANRIX (DTAP) (PF) INTRAMUSCULAR IPOL IXIARO (PF) KINRIX (PF) MENACTRA (PF) INTRAMUSCULAR SOLUTION MENHIBRIX (PF) MENOMUNE - A/C/Y/W-135 (PF) MENVEO A-C-Y-W-135-DIP (PF) M-M-R II (PF) PEDIARIX (PF) PEDVAX HIB (PF) PENTACEL (PF) PENTACEL ACTHIB COMPONENT (PF) PENTACEL DTAP-IPV COMPNT (PF) PROQUAD (PF) RABAVERT (PF) PA BvD RECOMBIVAX HB (PF) PA BvD ROTARIX ROTATEQ VACCINE TENIVAC (PF) INTRAMUSCULAR TETANUS TOXOID,ADSORBED PA BvD (PF) TETANUS,DIPHTHERIA TOX PED(PF) INTRAMUSCULAR SUSPENSION 5-25 LF UNIT/0.5 ML 135

TETANUS-DIPHTHERIA TOXOIDS-TD Name of Drug TICE BCG PA BvD TRUMENBA TWINRIX (PF) TYPHIM VI INTRAMUSCULAR VAQTA (PF) VARIVAX (PF) YF-VAX (PF) ZOSTAVAX (PF) QL (1 per 365 days) Inflammatory Bowel Disease Agents Inflammatory Bowel Disease Agents APRISO ASACOL HD balsalazide (Colazal) budesonide oral (Entocort EC) DELZICOL DIPENTUM ST Irrigating Solutions Irrigating Solutions acetic acid irrigation (Acetic Acid) GLYCINE IRRIGATION LACTATED RINGERS IRRIGATION ringers irrigation (Tis-U-Sol) sodium chloride irrigation (Sodium Chloride Irrig Solution) sorbitol irrigation (Sorbitol Solution) sorbitol-mannitol (Mannitol/Sorbitol Solution) 136

water for irrigation, sterile Name of Drug Metabolic Bone Disease Agents (Water For Irrigation,Sterile) Metabolic Bone Disease Agents alendronate oral solution (Alendronate QL (300 per 28 days) Sodium) alendronate oral tablet 10 mg, 40 mg, 5 mg (Fosamax) alendronate oral tablet 35 mg, 70 QL (4 per 28 days) (Fosamax) mg calcitonin (salmon) (Miacalcin) QL (3.7 per 28 days) calcitriol intravenous solution 1 PA BvD; (PA for ESRD (Calcitriol) mcg/ml Only) calcitriol oral (Rocaltrol) PA BvD; (PA for ESRD Only) doxercalciferol intravenous (Doxercalciferol) PA BvD; (PA for ESRD Only) doxercalciferol oral (Hectorol) PA BvD; (PA for ESRD Only) etidronate disodium (Etidronate Disodium) FORTEO PA; QL (2.4 per 28 days) FORTICAL QL (3.7 per 28 days) ibandronate intravenous solution PA BvD; (PA for ESRD (Ibandronate Only); QL (3 per 84 Sodium) days) ibandronate oral (Boniva) QL (1 per 28 days) MIACALCIN INJECTION PA BvD; (PA for ESRD Only) paricalcitol oral (Zemplar) PA BvD; (PA for ESRD Only) PROLIA QL (1 per 180 days) 137

risedronate (Actonel) QL (1 per 28 days) XGEVA PA; QL (1.7 per 28 days) ZEMPLAR INTRAVENOUS PA BvD; (PA for ESRD Only) zoledronic acid intravenous (Zometa) (Zoledronic zoledronic acid-mannitol-water Acid/Mannitol and intravenous piggyback Water) zoledronic acid-mannitol-water QL (100 per 300 days) (Reclast) intravenous solution ZOMETA INTRAVENOUS SOLUTION 4 MG/100 ML Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents ACTEMRA INTRAVENOUS PA; QL (40 per 30 days) SOLUTION ACTEMRA SUBCUTANEOUS PA; QL (3.6 per 28 days) ACTIMMUNE allopurinol (Zyloprim) amifostine crystalline (Ethyol) anticoag citrate phos dextrose (Citrate Phosphate Dextros Soln) AVODART AVONEX (WITH ALBUMIN) ST AVONEX INTRAMUSCULAR ST AVONEX INTRAMUSCULAR ST BENLYSTA INTRAVENOUS PA RECON SOLN BETASERON SUBCUTANEOUS ST bethanechol chloride (Urecholine) BOTOX INJECTION RECON PA; QL (4 per 90 days) SOLN 100 UNIT 138

BOTOX INJECTION RECON PA; QL (1 per 90 days) SOLN 200 UNIT buspirone (Vanspar) CERDELGA PA colchicine oral tablet (Colcrys) (Colchicine/Proben colchicine-probenecid ecid) COLCRYS COPAXONE SUBCUTANEOUS SYRINGE CURITY GAUZE TOPICAL BANDAGE 2 X 2 " CYSTADANE douche vinegar & water extra * (Acetic Acid) droperidol injection solution (Droperidol) ELMIRON ergoloid (Ergoloid Mesylates) EXTAVIA SUBCUTANEOUS ST extra cleansing douche * (Acetic Acid) feminine care douche * (Acetic Acid) finasteride oral tablet 5 mg (Proscar) fomepizole (Fomepizole) FUSILEV GILENYA PA; QL (28 per 28 days) GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT (HUMAN) guanidine (Guanidine HCl) hydroxyzine hcl intramuscular (Hydroxyzine HCl) PA-HRM hydroxyzine hcl oral syrup 10 mg/5 PA-HRM (Hydroxyzine HCl) ml 139

hydroxyzine hcl oral tablet (Hydroxyzine HCl) PA-HRM hydroxyzine pamoate (Vistaril) PA-HRM JALYN QL (30 per 30 days) LEMTRADA PA; QL (9.6 per 365 days) leucovorin calcium injection recon (Leucovorin soln 100 mg, 200 mg, 350 mg Calcium) leucovorin calcium oral (Leucovorin Calcium) levocarnitine (with sugar) (Levocarnitine (With Sugar)) levocarnitine oral (Carnitor) PA BvD; (PA for ESRD Only) PA BvD; (PA for ESRD Only) mesna (Mesnex) MESNEX ORAL MESTINON ORAL SYRUP MESTINON TIMESPAN mineral oil * (Mineral Oil) mineral oil light * (Mineral Oil) morrhuate sodium (Sodium Morrhuate) OTEZLA PA; QL (60 per 30 days) OTEZLA STARTER ORAL PA; QL (60 per 30 days) TABLETS,DOSE PACK 10 MG (4)-20 MG (4)-30 MG(19) PLEGRIDY SUBCUTANEOUS ST PEN INJECTOR PLEGRIDY SUBCUTANEOUS ST SYRINGE 125 MCG/0.5 ML probenecid (Probenecid) PROCYSBI pyridostigmine bromide (Mestinon) 140

REBIF (WITH ALBUMIN) REBIF REBIDOSE REBIF TITRATION PACK REMICADE PA SENSIPAR SIMPONI ARIA PA; QL (12 per 28 days) SIMPONI SUBCUTANEOUS PEN PA; QL (3 per 28 days) INJECTOR 100 MG/ML SIMPONI SUBCUTANEOUS PEN PA; QL (0.5 per 28 days) INJECTOR 50 MG/0.5 ML SIMPONI SUBCUTANEOUS PA; QL (3 per 28 days) SYRINGE 100 MG/ML SIMPONI SUBCUTANEOUS PA; QL (0.5 per 28 days) SYRINGE 50 MG/0.5 ML SOLIRIS STELARA SUBCUTANEOUS PA SYRINGE STERILE PADS TOPICAL BANDAGE 2 X 2 " summer's eve disposable douche * (Acetic Acid) vaginal solution summers eve extra cleansing * (Acetic Acid) SUSPENDOL-S * SYNAREL TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 120 MG TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 120 MG (14)- 240 MG (46), 240 MG PA; QL (14 per 30 days) PA; QL (60 per 30 days) 141

THALOMID PA NSO; QL (60 per 30 days) TYBOST QL (30 per 30 days) ULORIC ST; QL (30 per 30 days) XELJANZ PA; QL (60 per 30 days) Ophthalmic Agents Antiglaucoma Agents acetazolamide oral capsule, extended release (Diamox Sequels) acetazolamide oral tablet (Acetazolamide) acetazolamide sodium (Acetazolamide Sodium) ALPHAGAN P OPHTHALMIC DROPS 0.1 % AZOPT betaxolol ophthalmic (Betaxolol HCl) brimonidine (Alphagan P) (drops: 0.15%, 0.20%) COMBIGAN dorzolamide (Trusopt) dorzolamide-timolol (Cosopt) latanoprost (Xalatan) levobunolol (Betagan) LUMIGAN OPHTHALMIC QL (2.5 per 25 days) DROPS 0.01 % methazolamide oral (Neptazane) metipranolol (Metipranolol) PHOSPHOLINE IODIDE pilocarpine hcl ophthalmic drops 1 %, 2 %, 4 % (Isopto Carpine) SIMBRINZA timolol maleate ophthalmic drops (Timolol Maleate) 142

timolol maleate ophthalmic gel (Timoptic-Xe) forming solution TRAVATAN Z QL (2.5 per 25 days) (Travoprost QL (2.5 per 25 days) travoprost (benzalkonium) (Benzalkonium)) Replacement Preparations Replacement Preparations (Ca/D3/Mag ca-d3-mag ox-zinc-cop-mang-bor * Ox/Zinc/Cop/Mang oral tablet,chewable /Bor) calcionate * (Calcium Glubionate) calcitrate * (Calcium Citrate) calcitrate-vitamin d * (Citracal-Vitamin D) calcium 500 + d (d3) * (Os-Cal 500+D3) calcium 500 + d * oral tablet 500 mg(1,250mg) -400 unit (Os-Cal 500+D3) calcium 500 with d * (Os-Cal 500+D3) calcium 600 * (Caltrate 600) (Calcium calcium 600 + d(3) * oral capsule Carbonate/Vitamin D3) calcium 600 + d(3) * oral tablet (Os-Cal 500+D3) (Calcium calcium 600 with vitamin d3 * oral Carbonate/Vitamin D3) calcium carbonate * oral (Calcium Carbonate) calcium carbonate * oral tablet 260 (Caltrate 600) mg calcium (648 mg) 143

(Calcium calcium carbonate-vitamin d2 * Carbonate/Vitamin D2) calcium carbonate-vitamin d3 * (Calcium oral capsule 600 mg(1,500mg) -100 Carbonate/Vitamin unit, 600 mg(1,500mg) -400 unit, D3) 600 mg(1,500mg) -500 unit calcium carbonate-vitamin d3 * oral tablet (Os-Cal 500+D3) calcium carbonate-vitamin d3 * oral tablet,chewable 500 (Os-Cal 500+D) mg(1,250mg) -400 unit calcium chloride intravenous (Calcium Chloride) calcium citrate-vitamin d3 * oral (Citracal-Vitamin tablet 315-250 mg-unit D) calcium gluconate intravenous (Calcium Gluconate) calcium gluconate * oral tablet 45 (Calcium mg (500 mg) Gluconate) calcium lactate * oral tablet 84 mg (648 mg), 85 mg (650 mg) (Calcium Lactate) calcium+d * oral tablet (Os-Cal 500+D3) caltrate 600 + d * (Os-Cal 500+D) CALTRATE-600 + D VIT D3 (800) * citracal + d maximum * (Citracal-Vitamin D) (Citric citric acid-sodium citrate Acid/Sodium Citrate) citrus calcium * oral tablet (Citracal-Vitamin D) coral calcium * oral tablet (Caltrate 600) PA BvD; (PA for ESRD Only) 144

electrolyte-48 in d5w (Electrolyte-48 Solution/D5W) enfalyte * (Pedialyte) hi-cal plus vit d * (Os-Cal 500+D3) HYPERLYTE CR IONOSOL-B IN D5W IONOSOL-MB IN D5W ISOLYTE M IN 5 % DEXTROSE ISOLYTE-H IN 5 % DEXTROSE ISOLYTE-P IN 5 % DEXTROSE ISOLYTE-S KELP (IODINE) * KLOR-CON KLOR-CON 10 KLOR-CON 8 klor-con m15 (Potassium Chloride) klor-con m20 (Potassium Chloride) KLOR-CON/EF (Calcium liquid calcium with vitamin d * Carbonate/Vitamin D3) mag 64 * (Magnesium Chloride) mag-delay * (Magnesium Chloride) mag-g * (Magonate) (Magnesium magnesium (oxide/aa chelate) * Oxide/Mag Aa Chelate) 145

magnesium chloride injection (Magnesium Chloride) magnesium gluconate * oral tablet (Magonate) magnesium * oral tablet 250 mg (Magnesium) magnesium sulfate in d5w (Magnesium intravenous piggyback 1 gram/100 Sulfate/D5W) ml magnesium sulfate in water (Magnesium intravenous parenteral solution 20 Sulfate in Water) gram/500 ml (4 %) magnesium sulfate in water (Magnesium intravenous piggyback 4 gram/50 Sulfate in Water) ml (8 %) magnesium sulfate injection (Magnesium Sulfate) natural calcium * (Caltrate 600) NORMOSOL-M IN 5 % DEXTROSE NORMOSOL-R NORMOSOL-R PH 7.4 NUTRILYTE NUTRILYTE II oralyte * (Pedialyte) oysco 500/d * oral tablet (Os-Cal 500+D3) oysco d * (Os-Cal 500+D3) oysco-500 * (Caltrate 600) oyster shell calcium 500 * (Caltrate 600) oyster shell calcium-vit d3 * (Os-Cal 500+D3) oystercal-d * (Os-Cal 500+D3) pediatric electrolyte * oral solution (Pedialyte) pediatric freezer pops * (Pedialyte) PHOS-NAK * 146

phosphorus #1 (K-Phos Neutral) PLASMA-LYTE 148 PLASMA-LYTE A PLASMA-LYTE-56 IN 5 % DEXTROSE potassium acetate intravenous (Potassium Acetate) potassium bicarb and chloride (Pot Chloride/Pot Bicarb/Cit Ac) potassium bicarb-citric acid (Klor-Con-Ef) potassium bicarbonate-cit ac oral tablet, effervescent 25 meq (Klor-Con-Ef) (Potassium potassium chlorid-d5-0.45%nacl Chloride/D5-0.45n acl) potassium chloride in 0.9%nacl (Potassium intravenous parenteral solution 20 Chloride In meq/l, 40 meq/l 0.9%NaCl) potassium chloride in 5 % dex (Potassium intravenous parenteral solution 20 Chloride In D5w) meq/l, 30 meq/l, 40 meq/l potassium chloride intravenous (Potassium Chloride) potassium chloride oral capsule, extended release (Micro-K) potassium chloride oral liquid (Kaochlor) potassium chloride oral packet (Klor-Con) potassium chloride oral tablet extended release (Klor-Con 10) potassium chloride oral tablet,er particles/crystals 10 meq (Klor-Con 10) 147

potassium chloride oral tablet,er (Potassium particles/crystals 20 meq Chloride) (Potassium potassium chloride-0.45 % nacl Chloride-0.45% NaCl) (Potassium potassium chloride-d5-0.2%nacl Chloride/D5-0.2% NaCl) potassium chloride-d5-0.3%nacl (Potassium intravenous parenteral solution 20 Chloride/D5-0.3% meq/l NaCl) (Potassium potassium chloride-d5-0.9%nacl Chloride/D5-0.9% NaCl) potassium citrate-citric acid oral (Potassium packet Citrate/Citric Acid) potassium citrate-citric acid oral (Potassium solution 1,100-334 mg/5 ml Citrate/Citric Acid) (Potassium potassium phosphate dibasic Phos,M-Basic-D-B asic) ringers intravenous (Ringers Solution) sodium acetate intravenous (Sodium Acetate) sodium bicarbonate intravenous (Sodium Bicarbonate) (Sodium Chloride sodium chloride 0.45 % intravenous 0.45 %) sodium chloride 0.9 % injection (0.9 % Sodium solution Chloride) sodium chloride 0.9 % intravenous (0.9 % Sodium Chloride) sodium chloride 3 % (Sodium Chloride 3 %) 148

sodium chloride 5 % (Sodium Chloride 5 %) sodium chloride intravenous (Sodium Chloride) (Citric sodium citrate-citric acid Acid/Sodium Citrate) sodium lactate intravenous (Sodium Lactate) (Sodium sodium phosphate Phos,M-Basic-D-B asic) sod-pot-k cit-sod cit-cit acid (Sod/Pot/K Cit/Sod Cit/Cit Acid) TPN ELECTROLYTES TPN ELECTROLYTES II Respiratory Tract Agents Anti-Inflammatories, Inhaled Corticosteroids ADVAIR DISKUS QL (60 per 30 days) ADVAIR HFA QL (12 per 28 days) BREO ELLIPTA QL (60 per 30 days) DULERA QL (13 per 28 days) FLOVENT DISKUS QL (60 per 30 days) INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 50 MCG/ACTUATION FLOVENT DISKUS QL (120 per 30 days) INHALATION BLISTER WITH DEVICE 250 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCG/ACTUATION QL (12 per 28 days) 149

FLOVENT HFA INHALATION QL (24 per 28 days) HFA AEROSOL INHALER 220 MCG/ACTUATION FLOVENT HFA INHALATION QL (21.2 per 28 days) HFA AEROSOL INHALER 44 MCG/ACTUATION QVAR QL (17.4 per 25 days) Antileukotrienes montelukast (Singulair) zafirlukast (Accolate) Bronchodilators albuterol sulfate inhalation solution PA BvD (Albuterol Sulfate) for nebulization albuterol sulfate oral syrup (Albuterol Sulfate) albuterol sulfate oral tablet (Albuterol Sulfate) albuterol sulfate oral tablet extended release 12 hr (Vospire ER) ANORO ELLIPTA QL (60 per 30 days) ATROVENT HFA QL (25.8 per 28 days) COMBIVENT RESPIMAT QL (8 per 30 days) metaproterenol oral (Metaproterenol Sulfate) PROAIR HFA QL (17 per 25 days) SEREVENT DISKUS QL (60 per 30 days) SPIRIVA RESPIMAT QL (4 per 30 days) SPIRIVA WITH HANDIHALER QL (30 per 30 days) terbutaline oral (Terbutaline Sulfate) terbutaline subcutaneous (Terbutaline Sulfate) 150

theophylline anhydrous oral tablet (Theophylline extended release 12 hr 100 mg, 200 Anhydrous) mg, 300 mg theophylline in dextrose 5 % (Theophylline/D5 intravenous parenteral solution W) theophylline oral (Theophylline Anhydrous) theophylline oral (Theophylline Anhydrous) theophylline oral (Theophylline Anhydrous) TUDORZA PRESSAIR QL (1 per 28 days) Respiratory Tract Agents, Other acetylcysteine (Acetadote) PA BvD acetylcysteine solution (Acetadote) PA BvD ARALAST NP cromolyn inhalation (Cromolyn PA BvD Sodium) cromolyn * nasal (Nasalcrom) DALIRESP QL (30 per 30 days) ESBRIET PA; QL (270 per 30 days) KALYDECO PA; QL (60 per 30 days) OFEV PA; QL (60 per 30 days) sodium chloride * inhalation solution for nebulization 0.9 % (Pulmosal) 3 $0 XOLAIR PA; QL (6 per 28 days) ZEMAIRA Skeletal Muscle Relaxants Skeletal Muscle Relaxants baclofen (Baclofen) carisoprodol (Soma) PA-HRM; QL (120 per 30 days) 151

chlorzoxazone (Parafon Forte DSC) COMFORT PAC-CYCLOBENZAPRINE COMFORT PAC-TIZANIDINE cyclobenzaprine oral tablet 10 mg, 5 mg (Fexmid) PA-HRM PA-HRM PA-HRM dantrolene (Dantrium) dantrolene sodium (Dantrium) metaxalone oral tablet 800 mg (Skelaxin) PA-HRM methocarbamol oral (Robaxin) PA-HRM tizanidine (Zanaflex) Sleep Disorder Agents Sleep Disorder Agents NUVIGIL PA ROZEREM XYREM zaleplon (Sonata) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (60 per 30 days) 152

zolpidem oral tablet (Ambien) zolpidem oral tablet,ext release multiphase Sympatholytic Adrenergic Blocking Agents Alpha-Adrenergic Blocking Agents phentolamine injection (Ambien CR) (Phentolamine Mesylate) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (30 per 30 days) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (30 per 30 days) Vasodilating Agents Vasodilating Agents ADCIRCA PA; QL (60 per 30 days) ADEMPAS PA; QL (90 per 30 days) epoprostenol (glycine) (Flolan) PA BvD LETAIRIS PA; QL (30 per 30 days) OPSUMIT PA; QL (30 per 30 days) ORENITRAM PA REMODULIN PA BvD REVATIO INTRAVENOUS PA; QL (37.5 per 1 day) PA 153

sildenafil (Revatio) PA; QL (90 per 30 days) TRACLEER PA; QL (60 per 30 days) TYVASO PA BvD TYVASO REFILL KIT PA BvD TYVASO STARTER KIT PA BvD VENTAVIS PA BvD Vitamins And Minerals Vitamins And Minerals (Multivitamin/Iron/ a thru z advanced formula * Folic Acid) (Multivitamin a thru z high potency * oral tablet W-Minerals/Lutein ) a thru z select 50+ formula * (Biocel) (Multivitamin a thru z select * oral tablet W-Minerals/Lutein ) a thru z select * oral tablet 300-600-300 mcg, 500-300-250 (Biocel) mcg (Multivits a thru z select women's * W-Fe,Other Min/Lut) abc plus * (Biocel) adult one daily gummies * (One-A-Day Vitacraves) adults 50+ daily formula * (Biocel) adults' daily formula * airshield * oral tablet, effervescent 5,000-1000-30 unit-mg-unit (Multivitamin/Iron/ Folic Acid) (Vit A,C, and E/Dietary Supp No.12) 154

animal chews * (Multivitamin) animal shape vitamins * (Multivitamin) animal shapes plus iron * (Multivitamins with Iron) antioxidant * (Beta-Carotene(A) W-C and E/Min) (Beta-Carotene(A) antioxidant formula * W-C and E/Min) (Multivitamin with antioxidant vitamins * oral tablet Minerals) antioxidant vitamins * oral tablet (Ocuvite with 1,000 unit-200 mg-60 unit-2 mg Lutein) apatate forte * (Multivitamin with Minerals) ascorbic acid * oral tablet extended (Ascorbic Acid) release 1,500 mg ascorbic acid * oral (Ascorbic Acid) b complete * (Vitamin B Complex) b complex 1 * (Vitamin B Complex) (Vitamin B b complex-vitamin b12 * Complex) b complex-vitamin c-folic acid * (Dialyvite 800) (Vitamin B b-100 complex * oral tablet Complex) b-12 dots * (B-12) b50 balanced * b-50 complex * oral tablet (Vitamin B Complex) (Vitamin B Complex) 155

bal b-100 * (Vitamin B Complex) bal b-50 * (Vitamin B Complex) balance b-100 * (Vitamin B Complex) balance b-50 * (Vitamin B Complex) (Vitamin B balanced b-100 * oral Complex) (Vit B Complex balanced b-100 * oral tablet 100 100 Cmb mg #3/Herbs) balanced b-150 * (Vitamin B Complex) balanced b-50 * oral tablet (Vitamin B Complex) (Vitamin B b-complex * oral tablet Complex) b-complex with vitamin c * oral (B Complex with capsule Vitamin C) b-complex with vitamin c * oral tablet (Vita-Bee with C) bee-zee * (Multivitamin with Minerals) biosupp * (Multivitamin with Minerals) biotin * oral tablet 300 mcg (Biotin) biovol * (Multivitamin with Minerals) c complex * (Ascorbic Acid) calcidol * (Drisdol) 156

(Multivits centamin * W-Min/Ferrous Gluc) central vite with lutein * (Biocel) central-vite for seniors * (Multivitamin W/Iron, Minerals) central-vite * oral tablet 18-400 (Multivitamin/Iron/ mg-mcg Folic Acid) (Multivitamin central-vite select * oral tablet W-Minerals/Lutein ) central-vite senior * (Biocel) (Multivits centram-care * W-Min/Ferrous Gluc) centravites 50 plus * (Multivitamin W/Iron, Minerals) centrum complete * (Multivitamin/Iron/ Folic Acid) (Multivits centrum * oral liquid W-Min/Ferrous Gluc) centrum silver * oral tablet (Biocel) (Multivitamin/Iron/ centrum ultra women's * Folic Acid) century adults 50+ * (Biocel) (Multivits century advanced formula * W-Fe,Other Min/Lut) (Multivitamin century mature * oral tablet W-Minerals/Lutein ) 157

century mature * oral tablet 0.4-300-250 mg-mcg-mcg, (Biocel) 500-300-250 mcg century * oral tablet 18-400 (Multivitamin/Iron/ mg-mcg Folic Acid) century ultimate women's * oral (Multivitamin/Iron/ tablet 18-400 mg-mcg Folic Acid) (Multivits cerovite * W-Min/Ferrous Gluc) (Multivitamin/Iron/ cerovite advanced formula * Folic Acid) (Multivitamin cerovite jr * W/Iron, Minerals) (Multivitamin cerovite senior * W-Minerals/Lutein ) certavite senior-antioxidant * (Biocel) (Multivits certavite-antioxid (iron gluc) * oral W-Min/Ferrous liquid 9 mg iron/15 ml Gluc) (Multivitamin/Iron/ certavite-antioxidant * Folic Acid) chewable multi vitamin * (Multivitamin) chewable-vite * (Multivitamin) (Multivitamins chewable-vite with iron * with Iron) (Pedi Mv child complete multivitamin * No.58/Ferrous Fumarate) child vitamin with minerals * (Multivitamin W/Iron, Minerals) children's chewable * (Multivitamin) 158

children's chewable complete * oral (Multivitamin) tablet,chewable children's chewable vitamin * (Multivitamin) children's chewable w/minerals * (Multivitamin W/Iron, Minerals) (Pedi Mv children's complete vitamin * No.67/Ferrous Fumarate) children's multivit w/extra c * (Multivitamin) (Multivitamins children's vitamin with iron * with Iron) childs chew vite * (Multivitamin) (Multivitamins child's chewable vitamins/iron * with Iron) (Multivitamins child's vitamin with iron * with Iron) child's vitamin with vitamin c * (Multivitamin) childs/iron * (Multivitamins with Iron) compete * (Multivitamin W/Iron, Minerals) complete 50+ * (Biocel) complete multi 50+ * (Biocel) complete multivitamin * oral tablet (Multivits,Th W-Fe,Other Min) complete multivitamin * oral tablet 0.4-300-250 mg-mcg-mcg (Biocel) complete multivitamin-mineral * (Multivitamin/Iron/ oral tablet Folic Acid) complete senior * oral tablet (Multivitamin W/Iron, Minerals) 159

complete senior * oral tablet 0.4-300-250 mg-mcg-mcg (Biocel) cyanocobalamin (vitamin b-12) * (Cyanocobalamin injection (Vitamin B-12)) 3 $0 cyanocobalamin (vitamin b-12) * (Cyanocobalamin oral drops 1,000 mcg/ml (Vitamin B-12)) cyanocobalamin (vitamin b-12) * oral tablet 1,000 mcg, 100 mcg, 250 (B-12) mcg, 500 mcg daily gummies * (One-A-Day Vitacraves) daily multiple * oral tablet (Multivitamin) daily multiple * oral tablet 18-400 (Multivitamin/Iron/ mg-mcg Folic Acid) daily multi-vitamin * (Multivitamin) (Multivitamin/Iron/ daily multivitamin with iron * Folic Acid) (Multivitamin with daily multivitamin-minerals * Minerals) daily multi-vitamins/iron * (Multivitamins with Iron) (Multivitamin/Iron/ daily teen multi-vitamin * Folic Acid) daily value * (Multivitamin) daily vitamin * (Multivitamin) daily vitamin formula * (Multivitamin) daily vitamin formula + iron * daily vitamin formula-minerals * daily vitamin with iron * (Multivitamin/Iron/ Folic Acid) (Multivitamin with Minerals) (Multivitamins with Iron) 160

(Multivitamins daily vites/iron * with Iron) daily-vite * (Multivitamin) dino-life * (Multivitamin) dino-life with extra c * (Multivitamin) dino-life with iron-zinc * (Multivitamin W/Iron, Minerals) ECEE PLUS * eldertonic * (Multivitamin with Minerals) ellis tonic * (Multivitamin with Minerals) ergocalciferol (vitamin d2) * oral capsule (Drisdol) 3 $0 ergocalciferol (vitamin d2) * oral drops (Drisdol) essentia * (Multivitamin/Iron/ Folic Acid) (Multivits essential balance with lutein * W-Fe,Other Min/Lut) essential daily * (Tab A Vite) essential one daily * (Multivitamin) (Fe fe fumarate-doss-fa-bcomp and c * Fumarate/Doss/Fa/ 3 $0 Bcomp and C) fe fumarate-vit c-b12-if-fa * oral (Fe Fumarate/Vit capsule 110-0.5 mg C/B12-If/Fa) 3 $0 ferate * oral tablet (Fergon) ferotrinsic * (Fe Fumarate/Vit C/B12-If/Fa) 3 $0 ferretts * oral tablet (Ferrous Fumarate) 161

ferrex 150 * (Pic 200) ferrex 150 plus * (Iron Aspgly and Ps Cmplx/C/Sucac) ferrocite * (Ferrous Fumarate) ferrous fumarate * oral tablet 324 mg (106 mg iron) (Ferrous Fumarate) ferrous gluconate * oral tablet (Fergon) ferrous sulfate * oral (Fer-In-Sol) ferrous sulfate * oral (Ferrous Sulfate) ferrous sulfate * oral (Ferrous Sulfate) ferrous sulfate * oral tablet 325 mg (65 mg iron) (Ferrous Sulfate) ferrous sulfate * oral tablet,delayed release (dr/ec) 324 mg (65 mg iron) (Ferrous Sulfate) flintstones complete (iron) * oral (Multivitamin tablet,chewable W/Iron, Minerals) flintstones multivitamin * oral tablet,chewable (Multivitamin) (Pedi Mv flintstones with iron * No.79/Ferrous Fumarate) flintstones/extra c * oral tablet,chewable (Multivitamin) folic acid * 1 mg tablet (rx) (Folic Acid) 3 $0 FOLIC ACID * ORAL CAPSULE folic acid * oral tablet 1 mg, 400 mcg, 800 mcg (Folic Acid) fosfree * (Calcium/Multivita mins W-Iron) fruity chews * (Multivitamin) geravim * (Pediavit) geriaton * (Pediavit) 162

(Vit A,C, and germ defense * E/Dietary Supp No.12) gummi bear multivitamin * (Multivitamin) gummy swirls * (Multivitamin) hair vitamins * (Multivitamins with Iron) hair,skin & nails * oral tablet (Multivitamin with Minerals) hair,skin & nails * oral tablet 1 mg (Mv,Ca,Min/Iron iron-66.7 mcg-1,000 mcg Gluc/Fa/Biotin) healthy eyes * (Ocuvite with Lutein) hemocyte * (Ferrous Fumarate) (Vitamin B hi-b complex * Complex) (Multivitamin high potency multivit-multimin * W-Minerals/Lutein ) honey bears * (Multivitamin) honey bears with iron-zinc * (Multivitamin W/Iron, Minerals) icaps plus * (Multivitamin with Minerals) iferex 150 * (Pic 200) iron high potency * (Fergon) i-vite * (Ocuvite with Lutein) kid's vitamins + extra c * (Multivitamin) kids vitamins + iron * (Ped Multivit #17/Iron Fumarate) 163

kid's vitamins + iron * kid's vitamins * oral tablet,chewable Name of Drug (Multivitamins with Iron) (Multivitamin) life-pack women's * (Multivitamin W/Iron, Minerals) LIQUI-E * little animals * (Multivitamin) (Multivitamins little animals/iron * with Iron) lysiplex plus * oral liquid (Pediavit) (Beta-Carotene(A) macuvite * oral tablet W-C and E/Min) macuvite * oral tablet 5,000-60-30 (A/C/E/Zinc/Sod unit-mg-unit Selenite/Copper) maximum daily multivitamin * (Tab A Vite) mega multiple/chelated mineral * (Multivitamin with Minerals) mega multivitamin with mineral * (Multivitamin with oral tablet Minerals) men's multi-vitamin * (Multivitamin) men's one daily * oral tablet (Multivitamin with Minerals) MEPHYTON * 3 $0 (Multivitamin milltrium senior * W-Minerals/Lutein ) multi complete with iron * (Multivitamin/Iron/ Folic Acid) multi-day with iron * (Multivitamin/Iron/ Folic Acid) multi-delyn * (Multivitamin) 164

(Multivitamin/Ferr multi-delyn with iron * ous Gluconate) (Multivitamin multilex * W/Iron, Minerals) multilex-t&m * (Multivits,Th W-Fe,Other Min) multiple vitamin-minerals * (Multivitamin with Minerals) multiple vitamins * (Multivitamin) multiple vitamins with iron * multivital platinum * oral tablet multivital platinum * oral tablet 500-300-250 mcg (Multivitamins with Iron) (Multivitamin W-Minerals/Lutein ) (Biocel) (Multivitamins,The multi-vitamin hp/minerals * r W-Minerals) multivitamin * oral tablet (Multivitamin) multivitamin with iron * multivitamin with minerals * oral liquid multivitamin with minerals * oral tablet multivitamins with min no.7-fa * oral capsule 1 mg multi-vite * multi-vite 50 & over * (Multivitamins with Iron) (Multivits W-Min/Ferrous Gluc) (Multivitamin with Minerals) (Multivitamins with Min No.7/Fa) (Multivitamin/Iron/ Folic Acid) (Multivitamin W-Minerals/Lutein ) 3 $0 165

my favorite multiple * (Multivitamin) my-vitalife * (Multivitamin with Minerals) NASCOBAL * 3 $0 (Vitamin B natural b-100 * Complex) (Vit B Complex natural b-100 complex * 100 Cmb #2/Herbs) nephro-vite * (Dialyvite 800) niacinamide * oral tablet 500 mg (Niacinamide) niacinamide * oral tablet extended release (Niacinamide) nu-iron * (Pic 200) ocutabs * (Beta-Carotene(A) W-C and E/Min) once daily * (Multivitamin) oncovite * (Multivitamins,The rapeutic) one daily 50 plus * (Multivitamin with Minerals) one daily complete * oral tablet (Multivitamin with Minerals) one daily energy * oral tablet (Multivitamin with Minerals) one daily essential * oral tablet (Multivitamin) one daily maximum (with ca) * (Tab A Vite) one daily men's 50+ * oral tablet (Multivitamin with Minerals) (Multivitamins one daily multi-vit w-mineral * with Iron) one daily multivitamin * oral tablet (Multivitamin) 166

one daily multivitamin * oral tablet 400 mcg (Quintabs) (Multivitamin/Iron/ one daily multivitamin-iron * Folic Acid) one daily * oral tablet (Multivitamin) (Multivitamins one daily plus iron * oral tablet with Iron) one daily plus iron * oral tablet (Multivitamin/Iron/ 18-400 mg-mcg Folic Acid) one daily plus minerals * (Multivitamin with Minerals) (Multivitamins one daily with iron * with Iron) one-a-day essential * (Multivitamin) one-a-day maximum formula * (Multivitamin with Minerals) one-a-day teen advantage * oral (Multivitamin/Iron/ tablet 18-400 mg-mcg Folic Acid) one-a-day teen advantage * oral (Multivits,Ca,Mine tablet 9 mg iron-400 mcg rals/iron/fa) (Beta-Carotene(A) opti-vitamins * oral tablet W-C and E/Min) opti-vitamins * oral tablet 1,000 (Ocuvite with unit-200 mg-60 unit-2 mg Lutein) pedi m.vit no.17 with fluoride oral (Pedi Mvi No.82 drops 0.25 mg/ml with Fluoride) pediatric multivitamin * (Multivitamin) pharmacist favorite multi-vit * (Multivitamin) phytonadione * oral tablet 100 mcg (Phytonadione) poly-iron * (Pic 200) poly-vita * (Pediatric Multivit Comb No.20) 167

poly-vita (iron) * (Ped Multivit #46/Iron Sulfate) poly-vitamin * (Pediatric Multivit Comb No.20) poly-vitamin with iron * oral drops (Ped Multivit 1,500 unit-400 unit-10 mg/ml #46/Iron Sulfate) polyvitamin/iron * (Multivitamin W/Iron, Minerals) poly-vitamins * (Multivitamin) prenatal formula * oral tablet 28-0.8 mg (Classic Prenatal) prenatal * oral tablet 28-0.8 mg (Classic Prenatal) (Prenatal prenatal vit#96-ferrous fum-fa * Vit#96/Ferrous Fum/Fa) prenatal vitamin with minerals * (Classic Prenatal) prenatal vitamins with iron (Pnv with Ca,No.72/Iron/Fa) prenatal vitamins with iron (Pnv119/Iron Fumarate/Fa/Dss) prenatal vit-iron fumarate-fa * (Classic Prenatal) prosight * oral tablet 5,000-60-30 (A/C/E/Zinc/Sod unit-mg-unit Selenate/Copper) pyridoxine * injection (Pyridoxine HCl) 3 $0 ra central-vite select * tab p/f (Multivitamin W/Iron, Minerals) scooby-doo one a day * (Multivitamin W/Iron, Minerals) (Multivitamin/Iron/ sentry * oral tablet 18-400 mg-mcg Folic Acid) sentry senior * (Biocel) 168

(Pedi Mvi No.82 sodium fluoride oral tablet with Fluoride) sodium fluoride * oral tablet,chewable 0.25 mg fluorid (Sodium Fluoride) 3 $0 (0.55 mg) spectravite adult 50+ * oral tablet (Biocel) spectravite advanced formula * oral (Multivitamin/Iron/ tablet Folic Acid) spectravite * oral liquid (Pediavit) spectravite * oral tablet,chewable spectravite senior * oral tablet spectravite senior w-lycopene * spectravite ultra women * stress 500 plus zinc * stress b with zinc * stress b-biotin * stress formula * stress formula plus iron * stress formula with iron * stress formula with zinc * (Multivitamins with Iron) (Multivitamin W/Iron, Minerals) (Multivitamin W-Minerals/Lutein ) (Multivitamin/Iron/ Folic Acid) (Multivits,Stress Formula/Zinc) (Multivits,Stress Formula/Zinc) (Vitamin B Complex) (Multivits,Stress Formula) (Iron/Multivits,Stre ss Formula) (Vit B Comp/C/Fa/Iron/Vi t E) (Multivits,Stress Formula/Zinc) 169

stuart prenatal * (Classic Prenatal) (Mv-Min/Iron sunvite * Fum/Fa/Lyco/Lutn/ K) super b complex-vitamin c * (Vita-Bee with C) super b/c * (B Complex with Vitamin C) super b-50 complex * (Vitamin B Complex) (Vitamin B super b-50 complex plus * Complex) (Multivitamin super multiple * oral tablet W/Iron, Minerals) super multivitamin * (Multivitamin) super quints b-50 * (Vitamin B Complex) super thera vite m * (Multivitamins,The r W-Minerals) superior 35 * (Multivitamin W/Iron, Minerals) superplex-t * (Vita-Bee with C) support * (Multivitamin with Minerals) support-500 * (B Complex with Vitamin C) 3 $0 tab-a-vite * (Multivitamin) tab-a-vite/iron * tab-a-vite-minerals * thera m plus (ferrous fumarat) * (Multivitamins with Iron) (Multivitamin with Minerals) (Multivits,Ca,Mine rals/iron/fa) 170

(Multivitamins,The thera vitamin * rapeutic) (Multivit,Ther theradex m * Iron,Ca,Fa and Min) (Multivits,Th thera-m * oral tablet W-Fe,Other Min) (Multivit,Ther thera-m * oral tablet 27-0.4 mg Iron,Ca,Fa and Min) thera-m * oral tablet 9 mg iron-400 (Multivits,Ca,Mine mcg rals/iron/fa) (Multivitamin with theramill forte * oral capsule Minerals) therapeutic liquid * (Multivitamins,The rapeutic) therapeutic m + beta-carotene * (Tab A Vite) therapeutic vitamins/minerals * therapeutic-m * oral tablet 9 mg iron-400 mcg therapeutic-m vitamin/minerals * oral tablet 27-0.4 mg thera-tabs * theratrum complete 50 plus * theratrum complete 50 plus/lut * therems * (Multivitamins with Min No.7/Fa) (Multivits,Ca,Mine rals/iron/fa) (Multivit,Ther Iron,Ca,Fa and Min) (Multivitamins,The rapeutic) (Multivitamin W/Iron, Minerals) (Multivitamin W-Minerals/Lutein ) (Multivitamins,The rapeutic) 3 $0 171

therems-h * (Multivits,Th W-Fe,Other Min) therems-m * (Multivits,Th W-Fe,Other Min) thiamine hcl * injection (Thiamine HCl) 3 $0 thiamine hcl * oral tablet 500 mg (Thiamine HCl) total b/c * (Vita-Bee with C) totalday multiple * (Multivitamin with Minerals) (Vit A tri-vi-sol * Palmitate/Vit C/Vit D3) (Pedi Multivits tri-vita * A,C, and D3 No.21) (Pedi Multivits tri-vitamin * A,C, and D3 No.21) ultra b-100 complex * oral tablet unicomplex-m * vision * vision formula * vision formula (with lutein) * vision plus lutein * vit b cmplx 3-fa-vit c-biotin * oral tablet 1-60-300 mg-mg-mcg (Vitamin B Complex) (Multivitamin W/Iron, Minerals) (Beta-Carotene(A) W-C and E/Min) (Beta-Carotene(A) W-C and E/Min) (Ocuvite with Lutein) (Multivitamin W-Minerals/Lutein ) (Vit B Cmplx 3/Fa/Vit C/Biotin) 3 $0 172

(Vit B Cmplx vit b cmplx no3-fa-c-biot-zinc * No3/Fa/C/Biot/Zin 3 $0 c) vitabee/c * (Vita-Bee with C) vitalets * oral tablet,chewable vitamin a * oral capsule 10,000 unit, 25,000 unit (Multivitamins with Iron) (Vitamin A) (Vitamin B vitamin b complex * Complex) (B Complex with vitamin b complex with c * Vitamin C) vitamin b-1 * oral tablet (Thiamine HCl) vitamin b-100 complex * (Vitamin B Complex) (Cyanocobalamin/ vitamin b12-folic acid * oral Folic Acid) vitamin b-6 * oral tablet 100 mg, 25 (Pyridoxine HCl) mg, 250 mg, 50 mg vitamin c * oral capsule, extended release (Ascorbic Acid) vitamin c * oral syrup (Ascorbic Acid) vitamin c * oral tablet 1,000 mg, 250 mg, 500 mg (Ascorbic Acid) vitamin c * oral tablet extended release (Ascorbic Acid) vitamin c * oral tablet,chewable 250 mg, 500 mg (Ascorbic Acid) vitamins & minerals * vitamins b complex * oral capsule (Multivitamins,The r W-Minerals) (Vitamin B Complex) 173

(Vitamin B vitamins b complex * oral tablet Complex) (Vit B vitamins b complex * oral tablet Comp/C/Fa/Iron/Vi 500 mg-400 mcg- 18 mg iron t E) vitamins for hair * oral tablet (Multivitamin) (Multivitamin vitrum senior * oral tablet W-Minerals/Lutein ) vitrum senior * oral tablet 500-300-250 mcg (Biocel) women's daily multivitamin * (Tab A Vite) yelets * (Multivitamin/Iron/ Folic Acid) zoo chews * (Multivitamin) 174

手 册 第 11 页 及 第 12 页 亦 载 有 此 表 所 列 符 号 及 缩 略 词 的 含 义 175 ICS 社 区 护 理 增 值 计 划 2015 FIDA-MMP 处 方 集 生 效 日 期 :2015 年 5 月 1 日 处 方 集 ID:15412.000; 版 本 :9

索 引 3 day vaginal... 54 30pse-150gfn-15dm... 92 8-MOP... 104 a thru z advanced formula... 154 a thru z high potency... 154 a thru z select... 154 a thru z select 50+ formula... 154 a thru z select women's... 154 abacavir... 69 abacavir-lamivudine-zidovudine... 69 abc plus... 154 ABELCET... 54 ABILIFY... 66 ABILIFY DISCMELT... 65, 66 ABILIFY MAINTENA... 66 ABRAXANE... 36 ABREVA... 61 acamprosate... 23 acarbose... 50 acebutolol... 82 acephen... 14 acetaminophen... 14 acetaminophen-codeine... 14 acetazolamide... 142 acetazolamide sodium... 142 acetic acid... 116, 136 acetylcysteine... 151 acid gone antacid... 121 acid reducer (famotidine)... 119 acid reducer (ranitidine)... 119 acid relief (cimetidine)... 119 acitretin... 104 acne medication... 104 acne-clear... 104 ACTEMRA... 138 ACTHIB (PF)... 134 ACTIMMUNE... 138 acyclovir... 71, 104 acyclovir sodium... 72 ADACEL(TDAP ADOLESN/ADULT)(PF)... 134 ADAGEN... 112 adapalene... 110 ADCETRIS... 36 ADCIRCA... 153 adefovir... 72 ADEMPAS... 153 ADRENALIN... 84 adrenalin... 84 adt robitussin peak cld dm max... 92 adult nasal decongestant... 92 adult one daily gummies... 154 adult robitussin lingering cld... 93 adult robitussin peak cold dm... 93 adult wal-tussin... 93 adult wal-tussin dm max... 93 adults 50+ daily formula... 154 adults' daily formula... 154 ADVAIR DISKUS... 149 ADVAIR HFA... 149 advil... 19 af... 54 AFINITOR... 36 AFINITOR DISPERZ... 36 AGGRENOX... 75 airshield... 154 AKTEN (PF)... 113 alavert d-12 allergy-sinus... 57 alaway... 113 ALBENZA... 64 ALBUKED-25... 75 ALBUKED-5... 75 ALBUMIN, HUMAN 25 %... 75 ALBUMIN, HUMAN 5 %... 75 ALBUMINAR 25 %... 75 ALBUMINAR 5 %... 75 ALBURX (HUMAN) 5 %... 75 ALBUTEIN 25 %... 75 ALBUTEIN 5 %... 75 albuterol sulfate... 150 alclometasone... 107 ALCOHOL PADS... 104 ALCOHOL PREP PADS... 104 ALCOH-WIPE... 104 ALDURAZYME... 112 alendronate... 137 alfuzosin... 127 ALIMTA... 36 ALINIA... 64 alka-seltzer plus mucus-conges... 93 alka-seltzer plus sinus-cough... 93 aller-chlor... 57 allerclear d-12hr... 57 allerclear d-24hr... 57 allergy (chlorpheniramine)... 57 allergy relief (cetirizine)... 57 allergy relief (loratadine)... 57 allerhist-1... 57 aller-tec d... 57 allopurinol... 138 almacone... 121 almacone-2... 121 aloe vesta... 54 alophen... 124 ALPHAGAN P... 142 alprazolam... 24 ALREX... 118 altacaine... 113 altamist... 113 aluminum chloride... 104 aluminum hydroxide gel... 121 amantadine hcl... 65 ambi 10peh-4cpm-20dm... 93 ambi 20dm-4cpm... 93 ambi 40pse-400gfn-20dm... 93 ambi 60pse-4cpm... 57 ambi 60pse-4cpm-20dm... 93 AMBISOME... 54 ambizine... 63 amifostine crystalline... 138 amiloride... 86 amiloride-hydrochlorothiazide... 86 AMINO ACIDS 15 %... 76 ICS 社 区 护 理 增 值 计 划 2015 FIDA-MMP 处 方 集 处 方 集 ID:15412.000; 版 本 :9 I-1 生 效 日 期 :2015 年 5 月 1 日

aminocaproic acid... 75 AMINOSYN 10 %... 76 AMINOSYN 3.5 %... 76 AMINOSYN 7 %... 76 AMINOSYN 7 % WITH ELECTROLYTES... 76 AMINOSYN 8.5 %... 76 AMINOSYN 8.5 %-ELECTROLYTES... 76 AMINOSYN II 10 %... 76 AMINOSYN II 15 %... 76 AMINOSYN II 7 %... 76 AMINOSYN II 8.5 %... 76 AMINOSYN II 8.5 %-ELECTROLYTES... 76 AMINOSYN M 3.5 %... 76 AMINOSYN-HBC 7%... 76 AMINOSYN-PF 10 %... 76 AMINOSYN-PF 7 % (SULFITE-FREE)... 76 AMINOSYN-RF 5.2 %... 76 amiodarone... 81 amiodarone hcl... 81 AMITIZA... 121 amitriptyline... 48 amlactin... 104 amlodipine... 85 amlodipine-atorvastatin... 87 amlodipine-benazepril... 85 ammonium lactate... 104 amoxapine... 48 amoxicil-clarithromy-lansopraz... 119 amoxicillin... 33 amoxicillin-pot clavulanate... 33 amphetamine salt combo... 89 amphotericin b... 54 ampicillin... 33 ampicillin sodium... 33, 34 ampicillin-sulbactam... 34 AMPYRA... 89 ANACAINE... 104 anagrelide... 75 anastrozole... 36 ANDRODERM... 128 ANDROGEL... 128 animal chews... 155 animal shape vitamins... 155 animal shapes plus iron... 155 ANORO ELLIPTA... 150 antacid... 121 antacid anti-gas... 121 antacid plus anti-gas... 121 anticoag citrate phos dextrose... 138 anti-diarrheal... 121 anti-diarrheal (loperamide)... 121 antifungal... 54 antifungal (tolnaftate)... 54 anti-gas maximum strength... 119 antioxidant... 155 antioxidant formula... 155 antioxidant vitamins... 155 apatate forte... 155 APOKYN... 65 apraclonidine... 113 APRISO... 136 aprodine... 57 APTIOM... 45 APTIVUS... 69 aquanil hc... 107 ARALAST NP... 151 ARCALYST... 132 ARRANON... 36 artificial tears... 113 artificial tears (petro/min)... 113 artificial tears (pf)... 113 artificial tears(glycerin-peg)... 113 artificial tears(hypromellose)... 113 ARZERRA... 36 ASACOL HD... 136 ascorbic acid... 155 ashlyna... 91 aspirin... 19 aspirin, buffered... 19 aspir-low... 19 ASSURE ID INSULIN SAFETY... 111 ASTAGRAF XL... 132 atenolol... 82 atenolol-chlorthalidone... 82 athlete's foot (clotrimazole)... 54 atorvastatin... 87 atovaquone... 64 atovaquone-proguanil... 64 ATRIPLA... 69 atropine... 44, 45, 113 ATROVENT HFA... 150 AUBAGIO... 132 AVASTIN... 37 AVC VAGINAL... 61 AVODART... 138 AVONEX... 138 AVONEX (WITH ALBUMIN)... 138 ayr saline... 113 azacitidine... 37 azathioprine... 132 azathioprine sodium... 132 azelastine... 113 AZILECT... 65 azithromycin... 32 AZOPT... 142 AZOR... 85 aztreonam... 33 b complete... 155 b complex 1... 155 b complex-vitamin b12... 155 b complex-vitamin c-folic acid... 155 b-100 complex... 155 b-12 dots... 155 b50 balanced... 155 b-50 complex... 155 bacitracin... 28, 106, 116 bacitracin-polymyxin b... 117 bacitraycin plus... 106 baclofen... 151 bal b-100... 156 bal b-50... 156 balance b-100... 156 balance b-50... 156 balanced b-100... 156 balanced b-150... 156 balanced b-50... 156 ICS 社 区 护 理 增 值 计 划 2015 FIDA-MMP 处 方 集 处 方 集 ID:15412.000; 版 本 :9 I-2 生 效 日 期 :2015 年 5 月 1 日

balsalazide... 136 banophen... 58 banophen allergy... 57 BANZEL... 45 BARACLUDE... 72 baza antifungal... 54 BCG VACCINE, LIVE (PF)... 134 b-complex... 156 b-complex with vitamin c... 156 BD INSULIN PEN NEEDLE UF SHORT... 111 BD INSULIN SYRINGE ULTRA-FINE... 111 bee-zee... 156 BELEODAQ... 37 benadryl allergy... 58 benazepril... 81 benazepril-hydrochlorothiazide... 81 BENICAR... 80 BENICAR HCT... 80 BENLYSTA... 138 benzonatate... 93 benzoyl peroxide... 104, 105 benztropine... 65 BETADINE SPRAY... 105 beta-hc... 107 betamethasone acet,sod phos... 129 betamethasone dipropionate... 107 betamethasone valerate... 107 betamethasone, augmented... 107, 108 BETASERON... 138 betaxolol... 82, 142 bethanechol chloride... 138 BETHKIS... 28 bicalutamide... 37 bicarsim forte... 119 BICILLIN C-R... 34 BICILLIN L-A... 34 BILTRICIDE... 64 bio-dtuss dmx... 93 bion tears (pf)... 113 bionel... 93 bionel pediatric... 93 biospec dmx... 93 biosupp... 156 biotin... 156 biovol... 156 bisac-evac... 124 bisacodyl... 124 biscolax... 124 bismatrol... 121 bisoprolol fumarate... 82 bisoprolol-hydrochlorothiazide... 82 bleomycin... 37 BLINCYTO... 37 BOOSTRIX TDAP... 134 BOSULIF... 37 BOTOX... 138, 139 BREO ELLIPTA... 149 BRILINTA... 75 brimonidine... 142 BRINTELLIX... 48 bromfenac... 118 bromocriptine... 65 bromphenex dm... 93 brompheniramine-pseudoeph-dm... 93, 94 brompheniram-phenylephrine-dm... 94 broncotron-s... 94 budesonide... 136 bufferin... 19 bumetanide... 86 BUMINATE 25 %... 75 BUMINATE 5 %... 75 BUPHENYL... 121 buprenorphine hcl... 14, 23 buprenorphine-naloxone... 23 bupropion hcl... 23, 48 buspirone... 139 butalb-acetaminophen-caffeine... 14 butalbital-acetaminop-caf-cod... 14 butalbital-acetaminophen... 14 butalbital-acetaminophen-caff... 14 butalbital-aspirin-caffeine... 14 butorphanol tartrate... 14 BUTRANS... 14 BYDUREON... 50 BYETTA... 50 BYSTOLIC... 82 c complex... 156 cabergoline... 65 ca-d3-mag ox-zinc-cop-mang-bor... 143 caffeine citrated... 89 caffeine-sodium benzoate... 89 calci-chew... 121 calcidol... 156 calcionate... 143 calcipotriene... 105 calcitonin (salmon)... 137 calcitrate... 143 calcitrate-vitamin d... 143 calcitriol... 105, 137 calcium 500 + d... 143 calcium 500 + d (d3)... 143 calcium 500 with d... 143 calcium 600... 143 calcium 600 + d(3)... 143 calcium 600 with vitamin d3... 143 calcium acetate... 126 calcium antacid... 121 calcium carbonate... 121, 143 calcium carbonate-mag carb-fa... 126 calcium carbonate-vitamin d2... 144 CALCIUM CARBONATE-VITAMIN D3... 121 calcium carbonate-vitamin d3... 144 calcium chloride... 144 calcium citrate-vitamin d3... 144 calcium gluconate... 144 calcium lactate... 144 calcium+d... 144 CALDOLOR... 19 cal-gest antacid... 122 calphron... 126 caltrate 600 + d... 144 ICS 社 区 护 理 增 值 计 划 2015 FIDA-MMP 处 方 集 处 方 集 ID:15412.000; 版 本 :9 I-3 生 效 日 期 :2015 年 5 月 1 日

CALTRATE-600 + D VIT D3 (800)... 144 CANCIDAS... 54 candesartan... 80 candesartan-hydrochlorothiazid... 80 CAPASTAT... 62 CAPRELSA... 37 captopril... 81 captopril-hydrochlorothiazide... 81 CARAFATE... 119 carbamazepine... 45 carbidopa... 65 carbidopa-levodopa... 65 carbidopa-levodopa-entacapone... 65 carboplatin... 37 cardec dm (phenyleph-chlorphn)... 94 CARIMUNE NF NANOFILTERED... 132 carisoprodol... 151 carteolol... 113 cartia xt... 83 carvedilol... 82 CASTELLANI PAINT MODIFIED... 105 CAYSTON... 33 cefaclor... 30 cefadroxil... 30 cefazolin... 30 cefazolin in dextrose (iso-os)... 30 cefdinir... 30 cefditoren pivoxil... 30 cefepime... 31 CEFEPIME IN DEXTROSE 5 %... 31 CEFEPIME IN DEXTROSE,ISO-OSM... 31 cefotaxime... 31 cefoxitin... 31 cefoxitin in dextrose, iso-osm... 31 cefpodoxime... 31 cefprozil... 31 ceftazidime... 31 ceftibuten... 31 ceftriaxone... 31 ceftriaxone in dextrose,iso-os... 31 cefuroxime axetil... 31 cefuroxime sodium... 31 cefuroxime-dextrose (iso-osm)... 32 CELEBREX... 19 celecoxib... 19 CELLCEPT... 133 CELLCEPT INTRAVENOUS... 132 CELONTIN... 45 centamin... 157 central vite with lutein... 157 central-vite... 157 central-vite for seniors... 157 central-vite select... 157, 168 central-vite senior... 157 centram-care... 157 centravites 50 plus... 157 centrum... 157 centrum complete... 157 centrum silver... 157 centrum ultra women's... 157 century... 158 century adults 50+... 157 century advanced formula... 157 century mature... 157, 158 century ultimate women's... 158 cephalexin... 32 CEPROTIN (BLUE BAR)... 72 CERDELGA... 139 CEREZYME... 112 cerovite... 158 cerovite advanced formula... 158 cerovite jr... 158 cerovite senior... 158 certavite senior-antioxidant... 158 certavite-antioxid (iron gluc)... 158 certavite-antioxidant... 158 CERVARIX VACCINE (PF)... 134 cetirizine... 58 cetirizine-pseudoephedrine... 58 cevimeline... 103 CHANTIX... 23 CHANTIX CONTINUING MONTH PAK... 23 CHANTIX STARTING MONTH BOX... 23 cheratussin ac... 94 cheratussin dac... 94 chest congestion relief + dm... 94 chest congestion relief d... 94 chest congestion relief pe... 94 chewable multi vitamin... 158 chewable-vite... 158 chewable-vite with iron... 158 child complete multivitamin... 158 child cough & sore throat... 94 child mucinex chest congestion... 94 child mucus relief cough... 94 child plus cough & runny nose... 94 child triaminic cold & allergy... 58 child triaminic cough-congest... 94 child vitamin with minerals... 158 child wal-tap cold-allergy... 58 child wal-tussin cough relief... 94 children's advil... 20 children's aller-tec... 58 children's cetirizine... 58 children's chest congestion... 94 children's chewable... 158 children's chewable complete... 159 children's chewable vitamin... 159 children's chewable w/minerals... 159 CHILDREN'S CLARITIN... 58 children's complete vitamin... 159 children's dimetapp cold &flu... 94 children's flu relief... 95 children's mapap... 14 children's mucinex cough... 95 children's multivit w/extra c... 159 children's non-aspirin... 14 children's pain & fever relief... 14, 15 children's pain reliever... 15 children's pepto... 122 children's silapap... 15 children's silfedrine... 95 ICS 社 区 护 理 增 值 计 划 2015 FIDA-MMP 处 方 集 处 方 集 ID:15412.000; 版 本 :9 I-4 生 效 日 期 :2015 年 5 月 1 日

children's soothe... 122 children's sudafed... 95 children's sudafed pe cough... 95 children's vitamin with iron... 159 children's wal-dryl allergy... 58 children's wal-zyr... 58 CHILDREN'S ZYRTEC ALLERGY... 58 childs chew vite... 159 child's chewable vitamins/iron... 159 child's vitamin with iron... 159 child's vitamin with vitamin c... 159 childs/iron... 159 chlophedianol-guaifenesin... 95 chloramphenicol sod succinate... 28 chlordiazepoxide hcl... 24 chlorhexidine gluconate... 104 chloroquine phosphate... 64 chlorothiazide... 86 chlorothiazide sodium... 86 chlorpheniramine-phenyleph-dm... 95 chlorpromazine... 66 chlorthalidone... 86 chlorzoxazone... 152 cholestyramine (with sugar)... 87 cholestyramine-aspartame... 87 choline,magnesium salicylate... 20 ciclopirox... 54 ciclopirox-ure-camph-menth-euc... 54 cilostazol... 75 cimetidine... 119 cimetidine hcl... 119 CIMZIA... 112 CIMZIA POWDER FOR RECONST... 112 CIPRODEX... 117 ciprofloxacin... 34 ciprofloxacin hcl... 35, 117 ciprofloxacin in 5 % dextrose... 35 ciprofloxacin lactate... 35 cisplatin... 37 citalopram... 48 citracal + d maximum... 144 citric acid-sodium citrate... 144 citrus calcium... 144 clarithromycin... 32 CLARITIN... 58 CLARITIN LIQUI-GEL... 58 CLARITIN REDITABS... 58 CLARITIN-D 12 HOUR... 58 CLARITIN-D 24 HOUR... 58 clearlax... 124 clemastine... 58 CLEVIPREX... 86 clindamycin hcl... 29 clindamycin in 5 % dextrose... 29 clindamycin palmitate hcl... 29 clindamycin phosphate... 29, 61, 106 CLINIMIX 5%/D15W SULFITE FREE... 76 CLINIMIX 5%/D25W SULFITE-FREE... 76 CLINIMIX 2.75%/D5W SULFIT FREE... 76 CLINIMIX 4.25%/D10W SULF FREE... 76 CLINIMIX 4.25%/D5W SULFIT FREE... 77 CLINIMIX 4.25%-D20W SULF-FREE... 77 CLINIMIX 4.25%-D25W SULF-FREE... 77 CLINIMIX 5%-D20W(SULFITE-FREE)... 77 CLINIMIX E 2.75%/D10W SUL FREE... 77 CLINIMIX E 2.75%/D5W SULF FREE... 77 CLINIMIX E 4.25%/D10W SUL FREE... 77 CLINIMIX E 4.25%/D25W SUL FREE... 77 CLINIMIX E 4.25%/D5W SULF FREE... 77 CLINIMIX E 5%/D15W SULFIT FREE... 77 CLINIMIX E 5%/D20W SULFIT FREE... 77 CLINIMIX E 5%/D25W SULFIT FREE... 77 CLINISOL SF 15 %... 77 clobetasol... 108 clobetasol propionate... 108 clobetasol-emollient... 108 clocortolone pivalate... 108 clomipramine... 48 clonazepam... 24 clonidine... 80 clonidine hcl... 79, 89 clonidine hcl-chlorthalidone... 80 clopidogrel... 75 clorazepate dipotassium... 24, 25 clotrimazole... 54, 55 clotrimazole 3 day... 55 clotrimazole-3... 55 clotrimazole-betamethasone... 55 clozapine... 66 COARTEM... 64 codeine sulfate... 15 codeine-butalbital-asa-caffein... 15 codituss dm... 95 colace... 124 colchicine... 139 colchicine-probenecid... 139 COLCRYS... 139 cold & cough... 58 cold multi-symptom... 95 cold multi-symptom day/night... 95 cold multi-symptom nighttime... 95 cold relief m/s day/night... 95 cold-flu relief... 95 cold-flu relief, day/night... 95 colestipol... 87 colistin (colistimethate na)... 29 COLY-MYCIN S... 117 COMBIGAN... 142 COMBIPATCH... 129 COMBIVENT RESPIMAT... 150 COMETRIQ... 37 comfort gel extra strength... 122 ICS 社 区 护 理 增 值 计 划 2015 FIDA-MMP 处 方 集 处 方 集 ID:15412.000; 版 本 :9 I-5 生 效 日 期 :2015 年 5 月 1 日

COMFORT PAC-CYCLOBENZAPRINE... 152 COMFORT PAC-IBUPROFEN... 20 COMFORT PAC-MELOXICAM... 20 COMFORT PAC-NAPROXEN... 20 COMFORT PAC-TIZANIDINE... 152 compete... 159 COMPLERA... 69 complete 50+... 159 complete multi 50+... 159 complete multivitamin... 159 complete multivitamin-mineral... 159 complete senior... 159, 160 compoz... 59 COMVAX (PF)... 134 CONDYLOX... 105 congestac... 95 COPAXONE... 139 coral calcium... 144 CORDRAN... 108 coricidin hbp... 95 cortisone... 129 cortizone-10... 108 CORTIZONE-10... 108 cough & cold... 95 cough & runny nose... 96 coughtab... 96 CREON... 112 creo-terpin (dm-guaifenesin)... 96 CRESTOR... 87 critic-aid clear af... 55 CRIXIVAN... 69 cromolyn... 114, 122, 151 CUBICIN... 29 CURITY GAUZE... 139 cyanocobalamin (vitamin b-12)... 160 cyclobenzaprine... 152 CYCLOGYL... 114 cyclopentolate... 114 cyclophosphamide... 37 CYCLOPHOSPHAMIDE... 37 CYCLOSET... 51 cyclosporine... 133 cyclosporine modified... 133 cyclosporine, modified... 133 cyproheptadine... 59 CYRAMZA... 37 CYSTADANE... 139 CYSTARAN... 114 cysteine (l-cysteine)... 77 cytarabine... 37 cytarabine (pf)... 37 d10 % & 0.45 % sodium chloride... 77 d2.5 %-0.45 % sodium chloride... 77 d5 % and 0.9 % sodium chloride... 77 d5 %-0.45 % sodium chloride... 78 dacarbazine... 37 dactinomycin... 37 daily gummies... 160 daily multiple... 160 daily multi-vitamin... 160 daily multivitamin with iron... 160 daily multivitamin-minerals... 160 daily multi-vitamins/iron... 160 daily teen multi-vitamin... 160 daily value... 160 daily vitamin... 160 daily vitamin formula... 160 daily vitamin formula + iron... 160 daily vitamin formula-minerals... 160 daily vitamin with iron... 160 daily vites/iron... 161 dailyhist-1... 59 daily-vite... 161 DALIRESP... 151 DALLERGY DM... 96 danazol... 128 dantrolene... 152 dantrolene sodium... 152 dapsone... 62 DAPTACEL (DTAP PEDIATRIC) (PF)... 134 DARAPRIM... 64 dayhist allergy... 59 daytime cold & cough... 96 daytime cold-flu... 96 day-time cough... 96 daytime mucus relief dm... 96 daytime-nighttime... 96 daytime-nighttime cold-flu... 96 daytime-nighttime cough... 96 deblitane... 91 decitabine... 38 decongestant cough... 96 deep sea nasal... 114 deferoxamine... 127 delsym cough+chest congest dm... 96 DELZICOL... 136 DEMSER... 84 DEPEN TITRATABS... 127 DEPO-PROVERA... 132 dermafungal... 55 dermarest eczema (hydrocort)... 108 desenex... 55 desipramine... 49 desmopressin... 130 desog-e.estradiol/e.estradiol... 91 desogestrel-ethinyl estradiol... 91 desonide... 108 desoximetasone... 108 despec-dm (pseudoeph-dm-guaif)... 96 dex4 glucose... 78 dexamethasone... 130 dexamethasone sodium phosphate... 118, 130 dexchlorphen-pse-chlophedianol... 96 dexmethylphenidate... 89 dextroamphetamine... 89 dextroamphetamine-amphetamine... 89 dextromethorphan polistirex... 96 ICS 社 区 护 理 增 值 计 划 2015 FIDA-MMP 处 方 集 处 方 集 ID:15412.000; 版 本 :9 I-6 生 效 日 期 :2015 年 5 月 1 日

dextrose 10 % and 0.2 % nacl... 78 dextrose 10 % in water (d10w)... 78 dextrose 2.5 % in water(d2.5w)... 78 dextrose 20 % in water (d20w)... 78 dextrose 25 % in water (d25w)... 78 dextrose 40 % in water (d40w)... 78 dextrose 5 % in ringers... 78 dextrose 5 % in water (d5w)... 78 dextrose 5 %-lactated ringers... 78 dextrose 5%-0.2 % sod chloride... 78 dextrose 5%-0.3 % sod.chloride... 78 dextrose 50 % in water (d50w)... 78 dextrose 70 % in water (d70w)... 78 dextrose with sodium chloride... 78 diabetic siltussin das-na... 96 diabetic tussin dm... 96 diabetic tussin ex... 96 diamode... 122 DIASTAT ACUDIAL... 25 diazepam... 25 diazepam intensol... 25 diclofenac potassium... 20 diclofenac sodium... 20, 118 diclofenac-misoprostol... 20 dicloxacillin... 34 dicyclomine... 122 didanosine... 69 DIFICID... 32 diflunisal... 20 digitek... 84 digoxin... 84 DIGOXIN... 84 dihydroergotamine... 61, 62 DILANTIN... 45 diltiazem hcl... 83 dilt-xr... 83 dimaphen (pe)... 59 dimaphen dm... 97 dimenhydrinate... 63 dimetapp cold-congestion... 59 dino-life... 161 dino-life with extra c... 161 dino-life with iron-zinc... 161 DIOVAN... 80 DIPENTUM... 136 diphenhist... 59 diphenhydramine hcl... 59 diphenoxylate-atropine... 122 disopyramide phosphate... 81 disulfiram... 23 divalproex... 45 d-methorphan hb-p-epd hcl-bpm... 97 dm-phenyleph-chlorpheniramine... 97 dobutamine... 84 dobutamine in d5w... 84 doc-q-lace... 124 docu... 124 docusate calcium... 124 docusate sodium... 124 docusol... 124 dok... 124 donepezil... 47, 48 dopamine... 85 dopamine in 5 % dextrose... 84 dorzolamide... 142 dorzolamide-timolol... 142 double-tussin dm... 97 douche vinegar & water extra... 139 doxazosin... 80 doxepin... 49 doxercalciferol... 137 doxorubicin hcl... 38 doxorubicin hcl peg-liposomal... 38 doxorubicin, peg-liposomal... 38 doxycycline hyclate... 35, 36 doxycycline monohydrate... 36 dramamine... 63 driminate... 63 dristan long lasting... 114 dronabinol... 63 droperidol... 139 drospirenone-ethinyl estradiol... 91 DROXIA... 38 DUAVEE... 129 dulcolax stool softener (dss)... 124 DULERA... 149 duloxetine... 49 DURAMORPH (PF)... 15 DUREZOL... 118 DYRENIUM... 86 e.c. prin... 20 ECEE PLUS... 161 econazole... 55 ed bron gp... 97 ed chlorped jr... 59 EDURANT... 69 EFFIENT... 75 ELAPRASE... 112 eldertonic... 161 electrolyte-48 in d5w... 145 ELIDEL... 108 ELIGARD... 38 ELIQUIS... 72 ELITEK... 112 ELLA... 91 ellis tonic... 161 ELMIRON... 139 elon dual defense... 55 EMCYT... 38 EMEND... 63 EMSAM... 49 EMTRIVA... 69 enalapril maleate... 81 enalaprilat... 81 enalapril-hydrochlorothiazide... 81 ENBREL... 133 ENBREL SURECLICK... 133 endur-acin... 87 enema... 124 enema disposable... 124 enemeez... 124 enfalyte... 145 ENGERIX-B (PF)... 134 ENGERIX-B PEDIATRIC (PF)... 134 enoxaparin... 72, 73 entacapone... 65 entecavir... 72 entre-cough... 97 ICS 社 区 护 理 增 值 计 划 2015 FIDA-MMP 处 方 集 处 方 集 ID:15412.000; 版 本 :9 I-7 生 效 日 期 :2015 年 5 月 1 日

ephedrine sulfate... 85 epinastine... 114 epinephrine... 85 EPIPEN 2-PAK... 85 EPIPEN JR 2-PAK... 85 epirubicin... 38 EPIVIR... 69 EPIVIR HBV... 69 eplerenone... 88 EPOGEN... 74 epoprostenol (glycine)... 153 EPZICOM... 69 eq gentle... 114 equalactin... 124 ERBITUX... 38 ergocalciferol (vitamin d2)... 161 ergoloid... 139 ERGOMAR... 62 ERIVEDGE... 38 ERYTHROCIN... 32 erythromycin... 33, 117 erythromycin base... 32 ERYTHROMYCIN BASE... 32 erythromycin base-ethanol... 106 erythromycin ethylsuccinate... 32 erythromycin stearate... 33 erythromycin with ethanol... 106 ESBRIET... 151 escitalopram oxalate... 49 esmolol... 82 esomeprazole sodium... 119 essentia... 161 essential balance with lutein... 161 essential daily... 161 essential one daily... 161 estazolam... 25 ESTRACE... 129 estradiol... 129 estradiol valerate... 129 estradiol/norethindrone acet... 129 estradiol-norethindrone acet... 129 ESTRASORB... 129 estropipate... 129 ethambutol... 62 ethamolin... 85 ethinyl estradiol/drospirenone... 91 ethosuximide... 45 ethynodiol d-ethinyl estradiol... 91 etidronate disodium... 137 etodolac... 20 ETOPOPHOS... 38 etoposide... 38 exefen dmx... 97 EXELON... 48 exemestane... 38 EXFORGE... 86 EXFORGE HCT... 86 EXJADE... 128 expectorant... 97 expectorant max strength... 97 EXTAVIA... 139 extra cleansing douche... 139 FABRAZYME... 112 famciclovir... 72 famotidine... 120 famotidine (pf)... 119 famotidine (pf)-nacl (iso-os)... 119 FANAPT... 66 FARESTON... 38 FASLODEX... 38 FAZACLO... 66 fe fumarate-doss-fa-bcomp and c... 161 fe fumarate-vit c-b12-if-fa... 161 felbamate... 45 felodipine... 86 feminine care douche... 139 FEMRING... 129 fenofibrate... 87 fenofibrate micronized... 87 fenofibrate nanocrystallized... 87 fenofibric acid... 87 fenofibric acid (choline)... 87 fenoprofen... 20 fentanyl... 15 fentanyl citrate... 15 ferate... 161 ferotrinsic... 161 ferretts... 161 ferrex 150... 162 ferrex 150 plus... 162 FERRIPROX... 128 ferrocite... 162 ferrous fumarate... 162 ferrous gluconate... 162 ferrous sulfate... 162 FETZIMA... 49 feverall... 15 fiber (calcium polycarbophil)... 124 fiber laxative... 124 fiber smooth... 124 fiber therapy... 125 fiber therapy (psyllium/sugar)... 124 fiber-lax... 125 finasteride... 139 FIRAZYR... 85 FIRMAGON KIT W DILUENT SYRINGE... 38 flanax antacid... 122 FLEBOGAMMA DIF... 133 flecainide... 81 FLECTOR... 20 FLEET BISACODYL... 125 FLEXBUMIN 25 %... 75 FLEXBUMIN 5 %... 75 flintstones complete (iron)... 162 flintstones multivitamin... 162 flintstones with iron... 162 flintstones/extra c... 162 FLOVENT DISKUS... 149 FLOVENT HFA... 149, 150 floxuridine... 38 flu formula daytime-nighttime... 97 flu severe cold-congestion... 97 fluconazole... 55 fluconazole in dextrose(iso-o)... 55 fluconazole in nacl (iso-osm)... 55 flucytosine... 55 fludarabine... 38 fludrocortisone... 130 flumazenil... 89 fluocinonide... 108, 109 fluocinonide-emollient base... 109 fluorometholone... 118 ICS 社 区 护 理 增 值 计 划 2015 FIDA-MMP 处 方 集 处 方 集 ID:15412.000; 版 本 :9 I-8 生 效 日 期 :2015 年 5 月 1 日

FLUOROPLEX... 105 fluorouracil... 39, 105 fluoxetine... 49 FLUOXETINE... 49 fluoxymesterone... 128 fluphenazine decanoate... 66 fluphenazine hcl... 66 flurazepam... 26 flurbiprofen... 20 flurbiprofen sodium... 118 flu-severe cold-cough... 97 flutamide... 39 fluticasone... 109, 118 fluvoxamine... 49 foaming antacid... 122 folic acid... 162 FOLIC ACID... 162 fomepizole... 139 fondaparinux... 73 FORTEO... 137 FORTICAL... 137 foscarnet... 70 fosfree... 162 fosinopril... 81 fosinopril-hydrochlorothiazide... 81 fosphenytoin... 45 FREAMINE HBC 6.9 %... 78 FREAMINE III 10 %... 79 fruity chews... 162 fungi cure... 55 FUNGI-NAIL... 55 fungoid-d... 55 furosemide... 86 FUSILEV... 139 FUZEON... 69 FYCOMPA... 45 gabapentin... 45 GABITRIL... 46 galantamine... 48 GAMASTAN S/D... 133 GAMMAGARD LIQUID... 133 GAMMAPLEX... 133 GAMUNEX-C... 133 ganciclovir sodium... 72 GARDASIL (PF)... 134 GARDASIL 9 (PF)... 134 gas free extra strength... 119 gas relief... 119 gas relief 80... 119 gas relief extra strength... 119 gas-x ultra-strength... 119 gatifloxacin... 117 GAZYVA... 39 gelusil antacid & anti-gas... 122 gemcitabine... 39 gemfibrozil... 87 GENOTROPIN... 130 GENOTROPIN MINIQUICK... 130 gentamicin... 28, 106, 117 gentamicin in nacl (iso-osm)... 28 gentamicin sulfate... 117 gentamicin sulfate (ped) (pf)... 28 gentamicin sulfate (pf)... 28 GENTEAL MILD TO MODERATE... 114 GENTEAL GEL... 114 GENTEAL MILD... 114 GENTEAL SEVERE... 114 gentlelax... 125 GEODON... 66 geravim... 162 geriaton... 162 geri-hydrolac... 105 germ defense... 163 gildess 24 fe... 91 GILENYA... 139 GILOTRIF... 39 GLEEVEC... 39 glimepiride... 53 glipizide... 53 glipizide-metformin... 53 GLUCAGEN HYPOKIT... 139 GLUCAGON EMERGENCY KIT (HUMAN)... 139 gluco burst... 79 glucose... 79 glucose gel... 79 glutose 15... 79 glyburide... 53 glyburide micronized... 53 glyburide-metformin... 54 GLYCINE... 136 glycolax... 125 glycopyrrolate... 122 glydo... 22 granisetron (pf)... 63 granisetron hcl... 63 GRANIX... 74 griseofulvin microsize... 55 guaiatussin ac... 97 guaifenesin... 97 guaifenesin dac... 97 guanfacine... 80, 89 guanidine... 139 gummi bear multivitamin... 163 gummy swirls... 163 hair vitamins... 163 hair,skin & nails... 163 HALAVEN... 39 halobetasol propionate... 109 haloperidol... 66 haloperidol decanoate... 66, 67 haloperidol lactate... 67 HARVONI... 71 HAVRIX (PF)... 134 head congestion day-night... 98 healthy eyes... 163 healthylax... 125 hemocyte... 163 heparin (porcine)... 73 heparin (porcine) in 5 % dex... 73, 74 heparin (porcine) in nacl (pf)... 73 heparin(porcine) in 0.45% nacl... 73 heparin, porcine (pf)... 73 HEPATAMINE 8%... 79 HEPATASOL 8 %... 79 HERCEPTIN... 39 HEXALEN... 39 hi-b complex... 163 hi-cal plus vit d... 145 high potency multivit-multimin... 163 ICS 社 区 护 理 增 值 计 划 2015 FIDA-MMP 处 方 集 处 方 集 ID:15412.000; 版 本 :9 I-9 生 效 日 期 :2015 年 5 月 1 日

homatropine hbr... 114 honey bears... 163 honey bears with iron-zinc... 163 HUMALOG... 52 HUMALOG KWIKPEN... 52 HUMALOG MIX 50-50... 52 HUMALOG MIX 50-50 KWIKPEN... 52 HUMALOG MIX 75-25... 52 HUMALOG MIX 75-25 KWIKPEN... 52 HUMATROPE... 130 HUMIRA... 133 HUMIRA CROHN'S DIS START PCK... 133 HUMIRA PEN... 133 HUMULIN 70/30... 52 HUMULIN 70/30 KWIKPEN... 52 HUMULIN 70/30 PEN... 52 HUMULIN N... 52 HUMULIN N KWIKPEN... 52 HUMULIN N PEN... 52 HUMULIN R... 52 HUMULIN R U-500 "CONCENTRATED"... 52 hydralazine... 85 hydro skin... 109 hydrochlorothiazide... 86 hydrocil instant... 125 hydrocodone bit-homatrop me-br... 98 hydrocodone-acetaminophen... 15 hydrocodone-chlorpheniramine... 98 hydrocodone-homatropine... 98 hydrocodone-ibuprofen... 15 hydrocortisone... 109, 110, 130 hydrocortisone acet-aloe vera... 109 hydrocortisone acetate... 109 hydrocortisone acetate-urea... 109 hydrocortisone butyrate... 109 hydrocortisone butyr-emollient... 109 hydrocortisone sod succinate... 130 hydrocortisone valerate... 110 hydromorphone... 16 hydromorphone (pf)... 15, 16 hydroxychloroquine... 64 hydroxyurea... 39 hydroxyzine hcl... 139, 140 hydroxyzine pamoate... 140 HYPERLYTE CR... 145 HYPERRAB S/D (PF)... 133 HYQVIA... 133 ibandronate... 137 ibuprofen... 20 ibuprofen jr strength... 20 icaps plus... 163 ICLUSIG... 39 iferex 150... 163 ifosfamide... 39 ifosfamide-mesna... 39 ILARIS (PF)... 133 ILEVRO... 118 IMBRUVICA... 39 imipenem-cilastatin... 33 imipramine hcl... 49 imipramine pamoate... 49 imiquimod... 105 imodium a-d... 122 IMODIUM A-D... 122 IMOGAM RABIES-HT (PF)... 133 IMOVAX RABIES VACCINE (PF)... 134 INCRELEX... 131 indapamide... 86 indomethacin... 21 indomethacin sodium... 21 INFANRIX (DTAP) (PF)... 135 infant acetaminophen... 16 infantaire... 16 infant's ibuprofen... 21 INFANT'S MOTRIN... 21 infants' non-aspirin cold... 98 infant's pain reliever... 16 INLYTA... 39, 40 insta-glucose... 79 INSULIN PEN NEEDLE... 111 INSULIN SYRINGE... 111 INSULIN SYRINGE NEEDLELESS... 111 INSULIN SYRINGE-NEEDLE U-100... 111 INTELENCE... 69 intense cough reliever... 98 INTRALIPID... 79 INTRON A... 71 INTUNIV ER... 89 INVANZ... 33 INVEGA... 67 INVEGA SUSTENNA... 67 INVIRASE... 69 INVOKAMET... 51 INVOKANA... 51 inzo antifungal... 55 iodine... 111 IONOSOL-B IN D5W... 145 IONOSOL-MB IN D5W... 145 IPOL... 135 ipratropium bromide... 114 IPRIVASK... 74 irbesartan... 80 irbesartan-hydrochlorothiazide... 80 iron high potency... 163 ISENTRESS... 69 ISOLYTE M IN 5 % DEXTROSE... 145 ISOLYTE-H IN 5 % DEXTROSE... 145 ISOLYTE-P IN 5 % DEXTROSE... 145 ISOLYTE-S... 145 isoniazid... 62 isopto tears... 114 isosorbide dinitrate... 88 isosorbide mononitrate... 88 isotretinoin... 105 isradipine... 86 ISTODAX... 40 itraconazole... 55 ivermectin... 64 i-vite... 163 IXEMPRA... 40 ICS 社 区 护 理 增 值 计 划 2015 FIDA-MMP 处 方 集 处 方 集 ID:15412.000; 版 本 :9 I-10 生 效 日 期 :2015 年 5 月 1 日

IXIARO (PF)... 135 JAKAFI... 40 JALYN... 140 jantoven... 74 JANUMET... 51 JANUMET XR... 51 JANUVIA... 51 JARDIANCE... 51 JENTADUETO... 51 JEVTANA... 40 jr. acetaminophen... 16 junior mapap... 16 KABIVEN... 79 KADCYLA... 40 KALETRA... 69 KALYDECO... 151 kaopectate (bismuth subsalicy)... 122 KEDBUMIN... 75 KELP (IODINE)... 145 ketoconazole... 55, 56 ketoprofen... 21 ketorolac... 21, 118 ketotifen fumarate... 114 KEYTRUDA... 40 KHEDEZLA... 49 kidkare cough/cold... 98 kid's vitamins... 164 kid's vitamins + extra c... 163 kids vitamins + iron... 163 kid's vitamins + iron... 164 KINERET... 133 KINRIX (PF)... 135 KLOR-CON... 145 KLOR-CON 10... 145 KLOR-CON 8... 145 klor-con m15... 145 klor-con m20... 145 KLOR-CON/EF... 145 konsyl (sugar)... 125 konsyl fiber... 125 konsyl sugar-free... 125 KORLYM... 51 KRYSTEXXA... 112 KUVAN... 112 KYPROLIS... 40 l norgest&e estradiol-e estrad... 91 labetalol... 82 LACRISERT... 114 LACTATED RINGERS... 136 LACTINOL HX... 105 lactulose... 122 LAMICTAL... 46 LAMISIL (AEROSOL)... 56 lamisil af... 56 LAMISIL AT... 56 lamivudine... 69 lamivudine-zidovudine... 69 lamotrigine... 46 LANOXIN... 85 lansoprazole... 120 LANTUS... 52 LANTUS SOLOSTAR... 52 latanoprost... 142 LATUDA... 67 laxative peg 3350... 125 LAZANDA... 16 leflunomide... 133 LEMTRADA... 140 LETAIRIS... 153 letrozole... 40 leucovorin calcium... 140 LEUKERAN... 40 LEUKINE... 74 leuprolide... 40 levetiracetam... 46 levobunolol... 142 levocarnitine... 140 levocarnitine (with sugar)... 140 levocetirizine... 59 levofloxacin... 35, 117 levofloxacin in d5w... 35 levonorgestrel... 91 levonorgestrel-ethin estradiol... 91 levonorgestrel-ethinyl estrad... 91 levorphanol tartrate... 16 levothyroxine... 132 LEXIVA... 69 lice cream rinse... 111 lice killing... 111 lice treatment... 111 lidocaine... 22 lidocaine (pf)... 22, 82 lidocaine hcl... 22 lidocaine in 5 % dextrose (pf)... 82 lidocaine-prilocaine... 23 LIDODERM... 23 life-pack women's... 164 linezolid... 29 LINZESS... 112 liothyronine... 132 lipase-protease-amylase... 112 lipogen... 87 LIPOSYN II... 79 LIPOSYN III... 79 liquibid d-r... 98 liquid calcium with vitamin d... 145 LIQUI-E... 164 liquitears... 114 lisinopril... 81 lisinopril-hydrochlorothiazide... 81 lithium carbonate... 89, 90 lithium citrate... 90 little animals... 164 little animals/iron... 164 l-norgest-eth estr/ethin estra... 91 lobana bath... 105 lohist peb dm... 98 lomustine... 40 loperamide... 122 loradamed... 59 loratadine... 59 loratadine-d... 59 lorazepam... 26 lortuss ex... 98 losartan... 80 losartan-hydrochlorothiazide... 80 LOTEMAX... 118 LOTRIMIN ULTRA... 56 LOTRONEX... 112 lovastatin... 87 loxapine succinate... 67 lubricant dry eye relief... 114 lubricant eye (polyv alcohol)... 115 lubricant eye (propyl glycol)... 115 ICS 社 区 护 理 增 值 计 划 2015 FIDA-MMP 处 方 集 处 方 集 ID:15412.000; 版 本 :9 I-11 生 效 日 期 :2015 年 5 月 1 日

lubricant eye drops... 115 lubricating drops... 115 lubrifresh pm... 115 LUMIGAN... 142 LUMINAL... 46 LUMIZYME... 112 LUPRON DEPOT... 40 LUPRON DEPOT (3 MONTH)... 40 LUPRON DEPOT (4 MONTH)... 40 LUPRON DEPOT (6 MONTH)... 40 LUPRON DEPOT-PED... 40 LUPRON DEPOT-PED (3 MONTH)... 40 LYNPARZA... 40 LYRICA... 46 lysiplex plus... 164 LYSODREN... 40 maalox advanced... 122 macuvite... 164 mafenide acetate... 105 mag 64... 145 mag-delay... 145 mag-g... 145 MAGNEBIND 300... 122 magnesium... 146 magnesium (oxide/aa chelate)... 145 magnesium chloride... 146 magnesium gluconate... 146 magnesium oxide... 122, 123 magnesium sulfate... 146 magnesium sulfate in d5w... 146 magnesium sulfate in water... 146 malathion... 111 mapap (acetaminophen)... 16 mapap arthritis pain... 16 mapap extra strength... 16 maprotiline... 49 mar-cof bp... 98 mar-cof cg... 98 MARPLAN... 49 MARQIBO... 40 masanti double strength... 123 MATULANE... 41 matzim la... 83 maximum daily multivitamin... 164 maximum strength flu... 98 meclizine... 63 medi-brom... 98 medroxyprogesterone... 132 mefenamic acid... 21 mefloquine... 64 MEFOXIN IN DEXTROSE (ISO-OSM)... 32 mega multiple/chelated mineral... 164 mega multivitamin with mineral... 164 MEGACE ES... 41 megestrol... 41 MEKINIST... 41 meloxicam... 21 melphalan hcl intravenous... 41 MENACTRA (PF)... 135 MENEST... 129 MENHIBRIX (PF)... 135 MENOMUNE - A/C/Y/W-135 (PF)... 135 men's multi-vitamin... 164 men's one daily... 164 MENVEO A-C-Y-W-135-DIP (PF)... 135 MEPHYTON... 164 mercaptopurine... 41 meropenem... 33 mesehist dm... 98 mesna... 140 MESNEX... 140 MESTINON... 140 MESTINON TIMESPAN... 140 metaproterenol... 150 metaxalone... 152 metformin... 51 methadone... 16 methadone hcl... 16 methazolamide... 142 methenamine hippurate... 29 methenamine mandelate... 29 methimazole... 132 methocarbamol... 152 methotrexate sodium... 41 methotrexate sodium (pf)... 41 methoxsalen rapid... 105 methscopolamine... 123 methyclothiazide... 86 methylphenidate... 90 methylprednisolone... 130 methylprednisolone acetate... 130 methylprednisolone sodium succ... 130 metipranolol... 142 metoclopramide hcl... 123 metolazone... 86 metoprolol succinate... 82 metoprolol ta-hydrochlorothiaz... 82 metoprolol tartrate... 82, 83 metronidazole... 61, 64, 106 metronidazole in nacl (iso-os)... 64 mexiletine... 82 MIACALCIN... 137 mi-acid... 123 mi-acid gas relief... 119 micatin... 56 miconazole 7... 56 miconazole nitrate... 56 midazolam... 26 midazolam (pf)... 26 midodrine... 80 milk of magnesia... 125 milltrium senior... 164 milrinone... 85 milrinone in 5 % dextrose... 85 mineral oil... 140 mineral oil laxative... 125 mineral oil light... 140 minitran... 88 minocycline... 36 minoxidil... 88 mintox... 123 mintox maximum strength... 123 mintox plus... 123 ICS 社 区 护 理 增 值 计 划 2015 FIDA-MMP 处 方 集 处 方 集 ID:15412.000; 版 本 :9 I-12 生 效 日 期 :2015 年 5 月 1 日

MIRCERA... 74 mirtazapine... 49 misoprostol... 120 mitomycin... 41 mitoxantrone... 41 M-M-R II (PF)... 135 moexipril... 81 moexipril-hydrochlorothiazide... 81 mometasone... 110 MONISTAT 3... 56 monistat 7... 56 montelukast... 150 morphine... 17 MORPHINE... 17 morphine concentrate... 17 morrhuate sodium... 140 motion sickness... 63 MOVIPREP... 125 MOXEZA... 117 moxifloxacin... 35 MOZOBIL... 74 mucinex fast-max dm max... 98 mucus dm... 98 mucus dm max... 99 mucus relief... 99 MULTAQ... 82 multi complete with iron... 164 multi-day with iron... 164 multi-delyn... 164 multi-delyn with iron... 165 multilex... 165 multilex-t&m... 165 multiple vitamin-minerals... 165 multiple vitamins... 165 multiple vitamins with iron... 165 multi-symptom cold night time... 99 multi-symptom cold-cough... 99 multivital platinum... 165 multivitamin... 165 multi-vitamin hp/minerals... 165 multivitamin with iron... 165 multivitamin with minerals... 165 multivitamins with min no.7-fa... 165 multi-vite... 165 multi-vite 50 & over... 165 mupirocin... 107 mupirocin calcium... 107 muro 128... 115 MUSTARGEN... 41 my favorite multiple... 166 myco nail a... 56 mycophenolate mofetil... 133 mycophenolate sodium... 133 mylanta gas... 119 MYOZYME... 112 mytab gas... 119 mytab gas maximum strength... 119 my-vitalife... 166 nabumetone... 21 nadolol... 83 nafcillin... 34 nafcillin in dextrose iso-osm... 34 NAGLAZYME... 112 naloxone... 23 naltrexone... 23 naltrexone hcl... 23 NAMENDA... 48 NAMENDA TITRATION PAK... 48 NAMENDA XR... 48 naphazoline... 115 naproxen... 21 naproxen sodium... 22 naratriptan... 62 nasal & sinus decongestant... 99 nasal decongestant (oxymetazl)... 115 nasal decongestant (pe)... 80 NASCOBAL... 166 nasohist dm... 99 NASONEX... 118 NATACYN... 117 nateglinide... 51 natural b-100... 166 natural b-100 complex... 166 natural balance... 115 natural calcium... 146 natural fiber laxative therapy... 125 natural tears (pf)... 115 nature's tears... 115 NEBUPENT... 64 nefazodone... 49 neomy sulf-bacitrac zn-poly-hc... 117 neomycin... 28 neomycin-bacitracin-poly-hc... 117 neomycin-bacitracin-polymyxin... 117 neomycin-polymyxin b gu... 107 neomycin-polymyxin b-dexameth... 117 neomycin-polymyxin-gramicidin... 117 neomycin-polymyxin-hc... 117 neosporin anti-itch... 110 neo-synephrine 12 h spr (oxym)... 115 neo-tuss... 99 NEPHRAMINE 5.4 %... 79 nephro-vite... 166 NEULASTA... 74 NEUMEGA... 74 NEUPOGEN... 74 NEUPRO... 65 NEVANAC... 118 nevirapine... 69 NEXAFED... 99 NEXAVAR... 41 niacin... 87, 88 niacinamide... 166 nicardipine... 86 NICODERM CQ... 23 nicorelief... 23 nicorette... 23 nicotine... 24 nicotine (polacrilex)... 23 NICOTROL... 24 nifedipine... 86 night time... 99 night time cold-flu... 99 night time cold-flu relief... 99 nighttime cold-flu... 99 nighttime cough... 99 nighttime relief eye... 115 ICS 社 区 护 理 增 值 计 划 2015 FIDA-MMP 处 方 集 处 方 集 ID:15412.000; 版 本 :9 I-13 生 效 日 期 :2015 年 5 月 1 日

NILANDRON... 41 nite time cold-flu... 99 nite time-d cold-flu relief... 99 NITRO-BID... 88 nitrofurantoin macrocrystal... 29 nitrofurantoin monohyd/m-cryst... 29 nitroglycerin... 88, 89 nitroglycerin in 5 % dextrose... 88 NITROSTAT... 89 nohist-dm... 99 non-aspirin cold... 99 non-aspirin extra strength... 17 non-aspirin flu... 100 non-aspirin jr strength... 17 NORDITROPIN FLEXPRO... 131 NORDITROPIN NORDIFLEX... 131 norelgestromin/ethin.estradiol... 92 norepinephrine bitartrate... 85 noreth-ethinyl estradiol/iron... 92 norethindrone... 92 norethindrone (contraceptive)... 92 norethindrone acetate... 132 norethindrone ac-eth estradiol... 92, 129 norethindrone-e.estradiol-iron... 92 norethindrone-ethinyl estrad... 92 norethindrone-mestranol... 92 norgestimate-ethinyl estradiol... 92 norgestrel-ethinyl estradiol... 92 NORMOSOL-M IN 5 % DEXTROSE... 146 NORMOSOL-R... 146 NORMOSOL-R PH 7.4... 146 nortemp... 17 NORTHERA... 80 nortriptyline... 49 NORVIR... 70 NOVOLIN 70/30... 52 NOVOLIN N... 53 NOVOLIN R... 53 NOVOLOG... 53 NOVOLOG FLEXPEN... 53 NOVOLOG MIX 70-30... 53 NOVOLOG MIX 70-30 FLEXPEN... 53 NOXAFIL... 56 NUCYNTA... 17 NUCYNTA ER... 17 NUEDEXTA... 90 nu-iron... 166 NULOJIX... 133 NUTRESTORE... 123 NUTRILIPID... 79 NUTRILYTE... 146 NUTRILYTE II... 146 NUTROPIN... 131 NUTROPIN AQ... 131 NUTROPIN AQ NUSPIN... 131 NUVARING... 92 NUVIGIL... 152 nystatin... 56 NYSTATIN (BULK)... 56 nystatin-triamcinolone... 57 ocean nasal... 115 OCTAGAM... 133 octreotide acetate... 131 ocutabs... 166 OFEV... 151 ofloxacin... 35, 117 olanzapine... 67, 68 olanzapine-fluoxetine... 49 olopatadine... 115 OLYSIO... 71 omega-3 acid ethyl esters... 88 omeprazole... 120 omeprazole magnesium... 120 omeprazole-sodium bicarbonate... 120 OMNITROPE... 131 ONCASPAR... 41 once daily... 166 oncovite... 166 ondansetron... 63 ondansetron hcl... 63 ondansetron hcl (pf)... 63 one daily... 167 one daily 50 plus... 166 one daily complete... 166 one daily energy... 166 one daily essential... 166 one daily maximum (with ca)... 166 one daily men's 50+... 166 one daily multi-vit w-mineral... 166 one daily multivitamin... 166, 167 one daily multivitamin-iron... 167 one daily plus iron... 167 one daily plus minerals... 167 one daily with iron... 167 one-a-day essential... 167 one-a-day maximum formula... 167 one-a-day teen advantage... 167 ONFI... 26 opcicon one-step... 92 OPDIVO... 41 OPSUMIT... 153 opti-vitamins... 167 oral saline laxative... 125 oralyte... 146 ORAP... 68 ORENCIA... 133 ORENCIA (WITH MALTOSE)... 133 ORENITRAM... 153 ORFADIN... 112 OTEZLA... 140 OTEZLA STARTER... 140 oxacillin... 34 oxacillin in dextrose(iso-osm)... 34 oxaliplatin... 41 oxandrolone... 128 oxcarbazepine... 46 OXTELLAR XR... 46 oxybutynin chloride... 127 oxycodone... 18 oxycodone hcl-acetaminophen... 17, 18 oxycodone hcl-aspirin... 18 oxycodone-acetaminophen... 18 oxycodone-aspirin... 18 OXYCONTIN... 18 oxymorphone... 18 oysco 500/d... 146 oysco d... 146 ICS 社 区 护 理 增 值 计 划 2015 FIDA-MMP 处 方 集 处 方 集 ID:15412.000; 版 本 :9 I-14 生 效 日 期 :2015 年 5 月 1 日

oysco-500... 146 oyster shell calcium 500... 146 oyster shell calcium-vit d3... 146 oystercal-d... 146 paclitaxel... 41 pain relief... 18 pain relief adult... 18 pain reliever... 19 pain reliever jr strength... 19 PANRETIN... 105 pantoprazole... 120 papaverine... 85 paricalcitol... 137 paromomycin... 64 paroxetine hcl... 49, 50 PASER... 62 PATADAY... 115 PATANOL... 115 PAXIL... 50 pecgen dmx... 100 pedi m.vit no.17 with fluoride... 167 pedia relief... 100 pedia relief infant... 100 pediacare multi-symptom cold... 100 PEDIARIX (PF)... 135 pediatric electrolyte... 146 pediatric freezer pops... 146 pediatric multivitamin... 167 PEDVAX HIB (PF)... 135 peg 3350-electrolytes... 125 PEG 3350-GRX... 125 peg 3350-na sulf,bicarb,cl-kcl... 125 peg3350... 125 PEGANONE... 46 PEGASYS... 71 PEGASYS PROCLICK... 71 peg-electrolyte soln... 125 PEGINTRON... 71 PEGINTRON REDIPEN... 71 penicillin g pot in dextrose... 34 penicillin g potassium... 34 penicillin g procaine... 34 penicillin v potassium... 34 PENTACEL (PF)... 135 PENTACEL ACTHIB COMPONENT (PF)... 135 PENTACEL DTAP-IPV COMPNT (PF)... 135 PENTAM... 64 pentoxifylline... 75 pep-t-med... 123 peri-colace... 125 PERIKABIVEN... 79 perindopril erbumine... 81 PERJETA... 41 permethrin... 111 perphenazine... 68 perphenazine-amitriptyline... 50 persa-gel... 105 pharbetol... 19 pharmacist favorite multi-vit... 167 phenelzine... 50 phenobarbital... 46 phenobarbital sodium... 46 phentolamine... 153 phenylephrine hcl... 80, 115 phenylephrine-chlorpheniramine... 59 phenylhistine dh... 100 phenytoin... 47 phenytoin sodium... 47 phenytoin sodium extended... 47 phillips... 123 phillips liqui-gels... 125 PHOS-FLUR... 104 PHOSLYRA... 126 PHOS-NAK... 146 phosphate laxative... 125 PHOSPHOLINE IODIDE... 142 phosphorus #1... 147 phytonadione... 167 PICATO... 105 pilocarpine hcl... 104, 142 pindolol... 83 pioglitazone... 51 pioglitazone-glimepiride... 52 pioglitazone-metformin... 52 piperacillin-tazobactam... 34 piroxicam... 22 PLAN B ONE-STEP... 92 PLASBUMIN 25 %... 75 PLASBUMIN 5 %... 75 PLASMA-LYTE 148... 147 PLASMA-LYTE A... 147 PLASMA-LYTE-56 IN 5 % DEXTROSE... 147 PLEGRIDY... 140 podactin... 57 podofilox... 105 podophyllum resin... 105 polyethylene glycol 3350... 126 poly-iron... 167 polymyxin b sulf-trimethoprim... 117 poly-tussin... 100 POLY-TUSSIN DM... 100 poly-vita... 167 poly-vita (iron)... 168 poly-vitamin... 168 poly-vitamin with iron... 168 polyvitamin/iron... 168 poly-vitamins... 168 POMALYST... 42 potassium acetate... 147 potassium bicarb and chloride... 147 potassium bicarb-citric acid... 147 potassium bicarbonate-cit ac... 147 potassium chlorid-d5-0.45%nacl... 147 potassium chloride... 147, 148 potassium chloride in 0.9%nacl... 147 potassium chloride in 5 % dex... 147 potassium chloride in lr-d5... 79 potassium chloride-0.45 % nacl... 148 potassium chloride-d5-0.2%nacl... 148 potassium chloride-d5-0.3%nacl... 148 ICS 社 区 护 理 增 值 计 划 2015 FIDA-MMP 处 方 集 处 方 集 ID:15412.000; 版 本 :9 I-15 生 效 日 期 :2015 年 5 月 1 日

potassium chloride-d5-0.9%nacl... 148 potassium citrate-citric acid... 148 potassium hydroxide... 106 potassium phosphate dibasic... 148 POTIGA... 47 PRADAXA... 74 pramipexole... 65 PRANDIMET... 52 pravastatin... 88 prazosin... 80 prednicarbate... 110 prednisolone acetate... 118 prednisolone sodium phosphate... 118, 130 prednisone... 130 PREGNYL... 131 PREMARIN... 129 PREMASOL 10 %... 79 PREMASOL 6 %... 79 PREMPHASE... 129 PREMPRO... 129 prenatal... 168 prenatal formula... 168 prenatal vit#96-ferrous fum-fa... 168 prenatal vitamin with minerals... 168 prenatal vitamins... 168 prenatal vit-iron fumarate-fa... 168 preparation h hydrocortisone... 110 PREVIDENT 5000 SENSITIVE... 104 PREZISTA... 70 PRIFTIN... 62 PRILOSEC OTC... 120 PRIMAQUINE... 64 primidone... 47 PRISTIQ... 50 PRIVIGEN... 134 PROAIR HFA... 150 probenecid... 140 procainamide... 82 PROCALAMINE 3%... 79 prochlorperazine edisylate... 63 prochlorperazine maleate... 63, 64 PROCRIT... 74 PROCYSBI... 140 progesterone... 132 progesterone micronized... 132 PROGLYCEM... 89 PROGRAF... 134 PROLENSA... 118 PROLEUKIN... 42 PROLIA... 137 PROMACTA... 74 promethazine... 60, 64 promethazine hcl... 64 promethazine-codeine... 100 promethazine-dm... 100 promethazine-phenyleph-codeine... 100 promolaxin... 126 propafenone... 82 propantheline... 45 proparacaine... 115 proparacaine hcl... 115 proparacaine-fluorescein sod... 116 propranolol... 83 propranolol-hydrochlorothiazid... 83 propylthiouracil... 132 PROQUAD (PF)... 135 prosight... 168 PROSOL 20 %... 79 protamine... 75 PROTOPIC... 110 protriptyline... 50 pseudoephedrine hcl... 100 PULMOZYME... 112 pure & gentle eye... 116 purelax... 126 PURIXAN... 42 pyrazinamide... 62 pyridostigmine bromide... 140 pyridoxine... 168 q-dryl... 60 q-pap... 19 q-pap extra strength... 19 q-tapp... 60 q-tapp dm... 100 q-tussin... 100 q-tussin dm... 100 QUDEXY XR... 47 quetiapine... 68 QUILLIVANT XR... 90 quinapril... 81 quinapril-hydrochlorothiazide... 81 quinidine gluconate... 82 quinidine sulfate... 82 quinine sulfate... 64 QVAR... 150 RABAVERT (PF)... 135 raloxifene... 129 ramipril... 81 RANEXA... 85 ranitidine hcl... 120 RAPAMUNE... 134 REBIF (WITH ALBUMIN)... 141 REBIF REBIDOSE... 141 REBIF TITRATION PACK... 141 RECOMBIVAX HB (PF)... 135 recort plus... 110 refenesen... 100 refenesen pe... 101 REFRESH CLASSIC (PF)... 116 REFRESH LACRI-LUBE... 116 REFRESH LIQUIGEL... 116 REFRESH OPTIVE... 116 REFRESH OPTIVE ADVANCED... 117 reguloid... 126 relcof c... 101 RELENZA DISKHALER... 70 RELISTOR... 123 REMICADE... 141 REMODULIN... 153 RENAGEL... 127 RENVELA... 127 repaglinide... 52 RESCRIPTOR... 70 RESTASIS... 119 retaine cmc... 116 RETROVIR... 70 REVATIO... 153 ICS 社 区 护 理 增 值 计 划 2015 FIDA-MMP 处 方 集 处 方 集 ID:15412.000; 版 本 :9 I-16 生 效 日 期 :2015 年 5 月 1 日

REVLIMID... 42 REYATAZ... 70 REZIRA... 101 ribavirin... 72 RIDAURA... 134 rifabutin... 62 rifampin... 62 RIFATER... 62 ri-gel... 123 ri-gel ii... 123 riluzole... 90 rimantadine... 70 ri-mox... 123 ringers... 136, 148 risedronate... 138 RISPERDAL CONSTA... 68 risperidone... 68 RITUXAN... 42 rivastigmine tartrate... 48 rizatriptan... 62 robafen... 101 robafen cough... 101 robafen dm... 101 robitussin cough & cold cf... 101 robitussin cough-chest-cong dm... 101 robitussin dm max... 101 robitussin long-acting... 101 robitussin pediatric... 101 ropinirole... 65 ROTARIX... 135 ROTATEQ VACCINE... 135 ROZEREM... 152 rydex... 101 SABRIL... 47 safe tussin dm... 101 SAIZEN... 131 SAIZEN CLICK.EASY... 131 saline mist... 116 salsalate... 22 SANDOSTATIN LAR DEPOT... 131 SANTYL... 106 SAPHRIS (BLACK CHERRY)... 68 SAVELLA... 90 scooby-doo one a day... 168 scot-tussin dm... 101 scot-tussin expectorant... 101 sea soft nasal mist... 116 selegiline hcl... 65 selenium sulfide... 107 SELZENTRY... 70 senexon... 126 senna... 126 senna lax... 126 senna with docusate sodium... 126 senokot-s... 126 SENSIPAR... 141 sentry... 168 sentry senior... 168 SEREVENT DISKUS... 150 SEROQUEL XR... 68 SEROSTIM... 131 sertraline... 50 silace... 126 siladryl sa... 60 silapap... 19 sildenafil... 154 SILENOR... 50 siltussin dm das... 101 siltussin sa... 101 silver nitrate... 107 silver nitrate applicators... 106 silver sulfadiazine... 107 SIMBRINZA... 142 simethicone... 119 simply sleep... 60 SIMPONI... 141 SIMPONI ARIA... 141 simvastatin... 88 sinus & allergy (pseudoephed)... 60 sirolimus... 134 SIRTURO... 62 skin treatment... 106 sleep aid (diphenhydramine)... 60 sleep-tabs... 60 smoothlax... 126 sochlor... 116 sodium acetate... 148 sodium bicarbonate... 123, 148 sodium chloride... 116, 136, 149, 151 sodium chloride 0.45 %... 148 sodium chloride 0.9 %... 148 sodium chloride 3 %... 148 sodium chloride 5 %... 149 sodium chloride-nahco3-kcl-peg... 126 sodium citrate-citric acid... 149 sodium fluoride... 169 sodium lactate... 149 sodium phosphate... 149 sodium polystyrene sulfonate... 127 sodium thiosulfate... 128 sod-pot-k cit-sod cit-cit acid... 149 SOLIRIS... 141 SOLTAMOX... 42 SOLU-CORTEF (PF)... 130 SOMATULINE DEPOT... 131 SOMAVERT... 131 soothe (bismuth subsalicylate)... 123 soothe regular strength... 123 sorbitol... 136 sorbitol-mannitol... 136 sotalol... 83 sotalol hcl... 83 SOVALDI... 71 spectravite... 169 spectravite adult 50+... 169 spectravite advanced formula... 169 spectravite senior... 169 spectravite senior w-lycopene... 169 spectravite ultra women... 169 SPIRIVA RESPIMAT... 150 SPIRIVA WITH HANDIHALER... 150 spironolactone... 88 spironolacton-hydrochlorothiaz... 88 SPRYCEL... 42 st joseph aspirin... 22 st. joseph aspirin... 22 stavudine... 70 ICS 社 区 护 理 增 值 计 划 2015 FIDA-MMP 处 方 集 处 方 集 ID:15412.000; 版 本 :9 I-17 生 效 日 期 :2015 年 5 月 1 日

STELARA... 141 STERILE LUBRICANT... 116 STERILE PADS... 141 STIVARGA... 42 stomach relief... 123 STRATTERA... 90 streptomycin... 28 stress 500 plus zinc... 169 stress b with zinc... 169 stress b-biotin... 169 stress formula... 169 stress formula plus iron... 169 stress formula with iron... 169 stress formula with zinc... 169 STRIBILD... 70 STROMECTOL... 64 stuart prenatal... 170 sucralfate... 120 sudogest... 101 sudogest cold & allergy... 60 sudogest pe... 80 sulfacetamide sodium... 118 sulfacetamide sodium (acne)... 107 sulfacetamide-prednisolone... 118 sulfadiazine... 35 sulfamethoxazole-trimethoprim... 35 sulfasalazine... 35 sulfatrim... 35 sulfazine... 35 sulfazine ec... 35 sulindac... 22 sumatriptan... 62 sumatriptan succinate... 62 summer's eve disposable douche... 141 summers eve extra cleansing... 141 sunvite... 170 super b complex-vitamin c... 170 super b/c... 170 super b-50 complex... 170 super b-50 complex plus... 170 super multiple... 170 super multivitamin... 170 super quints b-50... 170 super thera vite m... 170 superior 35... 170 superplex-t... 170 suphedrin... 102 suphedrine pe day-night... 102 suphedrine severe cold max str... 102 support... 170 support-500... 170 SUPPRELIN LA... 131 SUPRAX... 32 SURE COMFORT INS. SYR. U-100... 111 SURMONTIL... 50 SUSPENDOL-S... 141 SUSTIVA... 70 SUTENT... 42 SYLATRON... 71 SYLATRON 4-PACK... 71 SYLVANT... 42 SYMLINPEN 120... 52 SYMLINPEN 60... 52 SYNAGIS... 71 SYNAREL... 141 SYNERCID... 29 SYNRIBO... 42 SYPRINE... 128 tab-a-vite... 170 tab-a-vite/iron... 170 tab-a-vite-minerals... 170 TABLOID... 42 tacrolimus... 110, 134 tactinal... 19 tactinal extra strength... 19 TAFINLAR... 42 TAMIFLU... 71 tamoxifen... 42 tamsulosin... 127 TARCEVA... 42 TARGRETIN... 42, 43 tarina fe... 92 TASIGNA... 43 TAZORAC... 110 taztia xt... 83 tears again... 116 TEARS NATURALE II... 116 TECFIDERA... 141 TEFLARO... 32 telmisartan... 80 telmisartan-hydrochlorothiazid... 80 temazepam... 27 TEMODAR... 43 TENIVAC (PF)... 135 terazosin... 127 terbinafine hcl... 57 terbutaline... 150 terconazole... 61 testosterone... 128 testosterone cypionate... 128 testosterone enanthate... 128 TETANUS TOXOID,ADSORBED (PF)... 135 TETANUS,DIPHTHERIA TOX PED(PF)... 135 TETANUS-DIPHTHERIA TOXOIDS-TD... 136 tetracaine hcl... 116 tetracycline... 36 TEV-TROPIN... 131 THALOMID... 142 the magic bullet... 126 theophylline... 151 theophylline anhydrous... 151 theophylline in dextrose 5 %... 151 thera m plus (ferrous fumarat)... 170 thera vitamin... 171 theradex m... 171 theraflu nighttime severe cold... 102 theraflu severe cold-cough... 102 thera-m... 171 theramill forte... 171 therapeutic liquid... 171 therapeutic m + beta-carotene... 171 therapeutic vitamins/minerals... 171 therapeutic-m... 171 therapeutic-m vitamin/minerals... 171 ICS 社 区 护 理 增 值 计 划 2015 FIDA-MMP 处 方 集 处 方 集 ID:15412.000; 版 本 :9 I-18 生 效 日 期 :2015 年 5 月 1 日

thera-tabs... 171 theratrum complete 50 plus... 171 theratrum complete 50 plus/lut... 171 therems... 171 therems-h... 172 therems-m... 172 thiamine hcl... 172 thioridazine... 68 thiothixene... 68 tiagabine... 47 TICE BCG... 136 TIKOSYN... 82 timolol maleate... 83, 142, 143 TIVICAY... 70 tizanidine... 152 TOBI PODHALER... 28 TOBRADEX ST... 118 tobramycin... 118 tobramycin in 0.225 % nacl... 28 tobramycin in 0.9 % nacl... 28 tobramycin sulfate... 28 tolazamide... 54 tolbutamide... 54 tolmetin... 22 tolnaftate... 57 tolterodine... 127 topiramate... 47 toposar intravenous... 43 topotecan... 43 TORISEL... 43 torsemide... 87 total b/c... 172 totalday multiple... 172 TOVIAZ... 127 TPN ELECTROLYTES... 149 TPN ELECTROLYTES II... 149 TRACLEER... 154 TRADJENTA... 52 tramadol... 19 tramadol-acetaminophen... 19 trandolapril... 81 tranexamic acid... 75 TRANSDERM-SCOP... 64 tranylcypromine... 50 TRAVASOL 10 %... 79 TRAVATAN Z... 143 travel sickness (meclizine)... 64 travoprost (benzalkonium)... 143 trazodone... 50 TREANDA... 43 TRECATOR... 62 TRELSTAR... 43 tretinoin... 111 tretinoin (chemotherapy)... 43 tretinoin microspheres... 110 TREXALL... 43 triacting m-sym cold/cough... 102 triamcinolone acetonide... 104, 110, 130 triaminic cold & cough (pe)... 102 triaminic cold & cough nt (pe)... 60 triaminic cough-nasal congesti... 102 triaminic cough-sore throat... 102 triamterene-hydrochlorothiazid... 87 triazolam... 27, 28 TRIBENZOR... 80 tri-buffered aspirin... 22 triderm... 110 tri-dex pe... 102 trifluoperazine... 68 trifluridine... 118 trigofen dm... 102 trihexyphenidyl... 65 TRILEPTAL... 47 trimethoprim... 29 triple paste af... 57 TRIUMEQ... 70 tri-vi-sol... 172 tri-vita... 172 tri-vitamin... 172 TROKENDI XR... 47 TROPHAMINE 10 %... 79 TROPHAMINE 6%... 79 trospium... 127 TRULICITY... 52 TRUMENBA... 136 TRUVADA... 70 trymine cg... 102 TUDORZA PRESSAIR... 151 tusnel diabetic... 102 TUSNEL PEDIATRIC... 102 tussin cf... 102 tussin cf cough-cold... 102 tussin cold-congestion... 102 tussin cough (dm only)... 103 tussin dm... 103 tussin dm cough & chest... 103 tussin maximum strength cough... 103 tussin pe... 103 TWINRIX (PF)... 136 TYBOST... 142 TYGACIL... 36 TYKERB... 43 TYPHIM VI... 136 TYSABRI... 134 TYVASO... 154 TYVASO REFILL KIT... 154 TYVASO STARTER KIT... 154 TYZEKA... 72 ULORIC... 142 ultra b-100 complex... 172 ultra fresh pm... 116 ultra sleep (doxylamine succ)... 60 ultra strength antacid... 123 unicomplex-m... 172 unisom sleepgels... 60 ursodiol... 123, 124 VAGIFEM... 129 valacyclovir... 72 VALCHLOR... 106 VALCYTE... 72 valganciclovir... 72 valproate sodium... 47 valproic acid... 47 valproic acid (as sodium salt)... 47 valsartan... 80 valsartan-hydrochlorothiazide... 81 VALSTAR... 43 valu-tapp dm... 103 vancomycin... 29, 30 vancomycin in d5w... 29 ICS 社 区 护 理 增 值 计 划 2015 FIDA-MMP 处 方 集 处 方 集 ID:15412.000; 版 本 :9 I-19 生 效 日 期 :2015 年 5 月 1 日

VAQTA (PF)... 136 VARIVAX (PF)... 136 VASCEPA... 88 vasopressin... 131 VECTIBIX... 43 VELCADE... 43 venlafaxine... 50 VENTAVIS... 154 verapamil... 83, 84 VERSACLOZ... 68 vicks dayquil cough... 103 vicks nature fusion cough... 103 vicks qlearquil(oxymetazoline)... 116 vicks sinex 12-hour... 116 VICTOZA... 52 VIDEX 2 GRAM PEDIATRIC... 70 VIDEX 4 GRAM PEDIATRIC... 70 VIEKIRA PAK... 71 VIGAMOX... 118 VIIBRYD... 50 VIMIZIM... 112 VIMPAT... 47 vinblastine... 43 vincristine... 44 vincristine sulfate... 44 vinorelbine... 44 VIRACEPT... 70 VIRAMUNE XR... 70 VIRAZOLE... 72 virdec dm... 103 VIREAD... 70 vision... 172 vision formula... 172 vision formula (with lutein)... 172 vision plus lutein... 172 vit b cmplx 3-fa-vit c-biotin... 172 vit b cmplx no3-fa-c-biot-zinc... 173 vitabee/c... 173 vitalets... 173 vitamin a... 173 vitamin b complex... 173 vitamin b complex with c... 173 vitamin b-1... 173 vitamin b-100 complex... 173 vitamin b12-folic acid... 173 vitamin b-6... 173 vitamin c... 173 vitamins & minerals... 173 vitamins b complex... 173, 174 vitamins for hair... 174 VITEKTA... 70 vitrum senior... 174 VIVELLE-DOT... 129 VOLTAREN... 22 voriconazole... 57 VOTRIENT... 44 VPRIV... 112 wal-act d cold & allergy... 60 wal-dram... 64 wal-dryl allergy... 60 wal-finate... 60 wal-finate-d... 60 wal-itin... 60 wal-itin d... 60 wal-itin d 12 hour... 61 wal-phed... 61, 103 wal-phed pe... 80 wal-phed pe day-night... 103 wal-phed pe sinus & allergy... 61 wal-profen... 22 wal-sleep z... 61 wal-som... 61 wal-tap... 61 wal-tussin cough... 103 wal-tussin cough & cold cf... 103 wal-tussin dm... 103 wal-zan 75... 120 wal-zyr (cetirizine)... 61 wal-zyr (ketotifen)... 116 wal-zyr d... 61 warfarin... 74 water for irrigation, sterile... 137 WELCHOL... 88 women's daily multivitamin... 174 XALKORI... 44 XARELTO... 74 XELJANZ... 142 XENAZINE... 90 XGEVA... 138 XIFAXAN... 30 XOLAIR... 151 XTANDI... 44 xylon 10... 19 XYREM... 152 yelets... 174 YERVOY... 44 YF-VAX (PF)... 136 zafirlukast... 150 zaleplon... 152 ZALTRAP... 44 zantac 75... 120 ZAVESCA... 112 ZELBORAF... 44 ZEMAIRA... 151 ZEMPLAR... 138 ZENPEP... 112 zephrex-d... 103 ZETIA... 88 ZIAGEN... 70 zidovudine... 70 zinc oxide... 106 ziprasidone hcl... 68 ZOLADEX... 44 zoledronic acid... 138 zoledronic acid-mannitol-water... 138 ZOLINZA... 44 zolmitriptan... 62 zolpidem... 153 ZOMETA... 138 ZONATUSS... 103 zonisamide... 47 zoo chews... 174 ZORTRESS... 134 ZOSTAVAX (PF)... 136 ZOVIRAX... 106 z-sleep... 61 ZUBSOLV... 24 ZYDELIG... 44 ZYKADIA... 44 ZYLET... 118 zyncof... 103 ICS 社 区 护 理 增 值 计 划 2015 FIDA-MMP 处 方 集 处 方 集 ID:15412.000; 版 本 :9 I-20 生 效 日 期 :2015 年 5 月 1 日

ZYPREXA RELPREVV... 69 ZYRTEC... 61 zyrtec itchy eye drops (keto)... 116 ZYTIGA... 44 ZYVOX... 30 ICS 社 区 护 理 增 值 计 划 2015 FIDA-MMP 处 方 集 处 方 集 ID:15412.000; 版 本 :9 I-1 生 效 日 期 :2015 年 5 月 1 日

此 处 方 集 更 新 时 间 为 2015 年 5 月 1 日 如 有 问 题, 请 在 周 一 至 周 五 上 午 8 点 至 晚 上 8 点 致 电 ICS Community Care Plus FIDA-MMP 计 划, 电 话 号 码 为 1.877.ICS.2525 此 为 免 费 电 话 更 多 详