List of Covered Drugs

H9115_MEM0028v4c Approved 12/24/2014 MetroPlus FIDA 計畫 2015 年承保藥物清單 ( 處方集 ) 此為參與者可以從 MetroPlus FIDA 計畫取得的藥物清單 MetroPlus FIDA 計畫 (Medicare-Medicaid 計畫 ) 是同時與 Medicare 及紐約州衛生署 (New York State Department of Health) (Medicaid) 簽約合作的管理醫療計畫, 旨在透過 全整合式雙利 (Fully Integrated Duals Advantage, FIDA) 示範活動為參與者提供這兩項計畫的福利 福利 承保藥物清單, 以及藥房與提供者網路可能在全年內隨時有變更, 或在每年的 1 月 1 日做出變更 您可以隨時上網查閱 MetroPlus FIDA 計畫的最新給付藥物清單, 網址 : www.metroplusmedicare.org, 或致電 MetroPlus FIDA 計畫參與者服務部, 電話 : 1-844-288-FIDA (3432),TTY:711. 可能會有特定限制 詳情請洽詢 MetroPlus FIDA 計畫參與者服務 (MetroPlus FIDA Plan Participant Services), 或參閱 MetroPlus FIDA 計畫參與者手冊 給付的藥物沒有共付額 我們也能免費以其他格式 ( 如點字或大字體 ) 為您提供此項資訊 請致電 1-844-288-FIDA (3432),TTY:711 此電話號碼為免付費專線 You can get this information for free in other languages. Call 1-844-288-FIDA (3432) and TTY: 711 during Monday-Saturday 8 am-8 pm. After 8pm, Sundays & Holidays: 24/7 Medical Answering Service at number listed above. The call is free. Puede obtener esta información en otros idiomas sin ningún costo. Llame al Plan MetroPlus FIDA al 1-844-288-FIDA (3432), usuarios de TTY: 711, de lunes a sábado, de 8:00 a. m. a 8:00 p. m.; domingos y días festivos: Servicio de Recepción de Llamadas para Médicos, las 24 horas del día, los 7 días de la semana al número arriba mencionados. La llamada es gratuita. Ou kapab jwenn enfòmasyon sa yo pou gratis nan lòt lang yo. Rele MetroPlus FIDA Plan nan nimewo 1-844-288-FIDA (3432), TTY: 711, Lendi - Samdi, 8 am - 8 pm. Apre 8 pm, jou dimanch ak Jou Ferye: Sèvis 24/7 Repondè Medikal Otomatik nan nimewo ki endike anwo a. Koutfil la gratis. È possibile ottenere queste informazioni in altre lingue senza alcun costo. Potete contattare i responsabili del programma MetroPlus Fida al numero 1-844-288-FIDA (3432), TTY: 711, dalle ore 8 alle 20 dal lunedì al sabato e dopo le 20 la domenica e nei giorni festivi. È possibile? 如果您有任何疑問, 請致電 MetroPlus FIDA 計畫, 電話 :1-844-288-FIDA (3432),TTY:711, 服務時間為週一至週六上午 8 點至晚上 8 點 晚上 8 點後 週日及假日 : 請撥打上列的 24 小時全年無休醫療諮詢服務專線 此為免付費專線 詳情請造訪 www.metroplusmedicare.org i

telefonare per una consulenza medica ai numeri indicati, 24 ore su 24, 7 giorni su 7. La chiamata è gratuita. 您可免費取得此資訊的其他語言版本 請於週一至週六上午 8 點至晚上 8 點洽 MetroPlus FIDA Plan, 電話是 1-844-288-FIDA (3432),TTY 專線 :711 晚上 8 點後 週日及假日 : 請撥打上方所列的 24 小時醫療諮詢服務專線 此電話號碼為免付費專線 Вы можете получить эту информацию бесплатно на других языках.звоните в MetroPlus FIDA Plan по номеру 1-844-288-FIDA (3432), для пользователей с нарушениями слуха: 711, с понедельника по субботу, с 8:00 до 20:00. После 20:00, по воскресеньям и праздничным дням: круглосуточная медицинская справочная служба, номера указаны выше.звонок бесплатный. 이정보는다른언어로도무료로제공됩니다.MetroPlus FIDA Plan 에전화번호 1-844-288-FIDA (3432), TTY: 711 로월요일 - 토요일, 오전 8 시부터오후 8 시사이에연락하시기바랍니다. 오후 8 시이후와일요일및공휴일에는상기표시된번호로전화하시면 24 시간의료 ARS 가제공됩니다. 통화는무료입니다. আপ ন বন ম লয অনয নয ভ ষ য় এই তথয প ত প রন ম স FIDA য ন-এ স মব র-শ নব র, সক ল 8 ট র ত 8 ট র ম ধয 1-844-288-FIDA (3432), TTY: 711 ন র ফ ন করন র ত 8 ট র প র, র বব র ও ছ টর দনগ ল ত: উপ র ত লক ভ ন র 24/7 ম ডকয ল আনস র স ভর স-এ কল ট বন ম লয آپ دیگر زبانوں میں یہ معلومات مفت حاصل کر سکتے ہیں سوموار سے سنیچر صبح 8 بجے سے شام 8 بجے تک MetroPlus FIDAکو (3432) 1-844-288-FIDA پر کال کریں 711 پر ڻی ڻی واي ی کریں شام 8 بجے کے بعد اتوار اور چھڻی کے دنوں میں:اوپر مذکور نمبر پر ہفتہ کے ساتوں دن 24/7 گھنڻے طبی جواب دہندگی خدمت کال مفت ہے 紐約州有設立名為 獨立消費者倡權網路 (Independent Consumer Advocacy Network, ICAN) 的參與者監督員方案, 針對 MetroPlus FIDA 計畫所供應的任何服務, 為參與者提供免費的保密協助 您可使用免費電話與 ICAN 聯繫, 電話號碼是 : 1 844 614 8800, 或上網至 www.icannys.org? 如果您有任何疑問, 請致電 MetroPlus FIDA 計畫, 電話 :1-844-288-FIDA (3432),TTY:711, 服務時間為週一至週六上午 8 點至晚上 8 點 晚上 8 點後 週日及假日 : 請撥打上列的 24 小時全年無休醫療諮詢服務專線 此為免付費專線 詳情請造訪 www.metroplusmedicare.org ii

常見問題集 (FAQ) 此處提供承保藥物清單相關問題的答案 您可以閱讀所有的常見問題以深入瞭解, 或尋找特定問題的答案 1. 承保藥物清單有哪些處方藥? ( 我們將承保藥物清單簡稱為 藥物清單 ) 承保藥物清單上的藥物從第 1 頁開始的是 MetroPlus FIDA 計畫承保的藥物 這些藥物可從我們醫療網路內的藥局取得 與我們簽約及合作並提供服務給您的藥局, 即屬於我們的醫療網路 我們稱這些藥局為 醫療網路藥局 在以下情況, MetroPlus FIDA 記畫將給付藥物清單上的所有藥物 : 您的醫生或其他醫療網路處方者說您需要這些藥物用來復原或維持健康, 對於您的病情具有醫療必要性的藥物, 以及 您在 MetroPlus FIDA 計畫的醫療網路藥局內領藥 MetroPlus FIDA 計畫可能需要額外的步驟才能取得特定藥物 ( 請參閱以下問題 #5) 在有些情況下, 您可能需要先進行其他動作, 才能取得藥物, 例如先嘗試其他的藥物 您也可以上網查閱我們給付的最新藥物清單, 網址 :www.metroplusmedicare.org, 或致電參與者服務部, 電話 :1-844-288-FIDA (3432),TTY: 711. 2. 藥物清單會有變更嗎? 會 MetroPlus FIDA 計畫可能在年間新增或移除藥物清單上的藥物 一般而言, 藥物清單會在以下情況變更 : 新藥上市且功效和藥物清單上的藥物一樣好, 或 我們獲悉該藥物並不安全 我們也可能變更關於藥物的規則 例如, 我們可能 : 決定要求或不要求特定藥物的事先核准 ( 事先核准是在取得藥物之前, 先取得 MetroPlus FIDA 計畫或您的跨科別團隊 (Interdisciplinary Team, IDT) 的許可 ) 新增或變更您可以取得的藥物量 ( 稱為 數量限制 )? 如果您有任何疑問, 請致電 MetroPlus FIDA 計畫, 電話 :1-844-288-FIDA (3432),TTY:711, 服務時間為週一至週六上午 8 點至晚上 8 點 晚上 8 點後 週日及假日 : 請撥打上列的 24 小時全年無休醫療諮詢服務專線 此為免付費專線 詳情請造訪 www.metroplusmedicare.org iii

新增或變更特定藥物的階段式療法限制 ( 階段式療法意指您必須先嘗試一種藥物之後, 我們才會給付另一種藥物 ) ( 關於這些藥物規則的詳細資訊, 請參閱第 v 頁 ) 若您目前服用的藥物從藥物清單中移除, 我們將會通知您 若我們改變給付特定藥物的規則, 也會通知您 以下的問題 3 4 與 7 提供關於藥物清單變更之後處理方式的更詳細資訊 您可以隨時上網查閱 MetroPlus FIDA 計畫的最新藥物清單, 網址 : www.metroplusmedicare.org 也可以致電 MetroPlus FIDA 計畫參與者服務部, 電話 :1-844-288-FIDA (3432),TTY: 711. 3. 較便宜的藥物上市且功效和目前藥物清單上的藥物一樣好, 會有什麼情況? 如果較便宜的藥物上市且功效和目前藥物清單上的藥物一樣好 : 您的藥劑師可能會在您下次領藥時給您較便宜的藥物 如果您與您的提供者判定較便宜的藥物並不適合您, 您的提供者可以通知藥劑師繼續給您目前服用的藥物 MetroPlus FIDA 計畫可能決定移除藥物清單上較昂貴的藥物 如果因為較便宜的藥物上市且功效一樣好, 所以我們移除了您目前服用的藥物, 我們會在從藥物清單上移除的至少 60 天前通知您, 或在您要求續領的時候 然後您可以在藥物清單變更之前, 取得該藥物的 60 天藥量 您將會透過郵件取得任何變更的書面通知 4. 如果我們發現特定藥物並不安全, 會有什麼情況? 如果食品藥物管理局 (Food and Drug Administration, FDA) 說您目前服用的藥物並不安全, 我們會立即將其從藥物清單中移除 我們也將透過信函與電話通知您, 不安全的藥物已從藥物清單中移除 您可以致電 MetroPlus FIDA 計畫參與者服務部詢問關於我們藥物清單的相關變更問題? 如果您有任何疑問, 請致電 MetroPlus FIDA 計畫, 電話 :1-844-288-FIDA (3432),TTY:711, 服務時間為週一至週六上午 8 點至晚上 8 點 晚上 8 點後 週日及假日 : 請撥打上列的 24 小時全年無休醫療諮詢服務專線 此為免付費專線 詳情請造訪 www.metroplusmedicare.org iv

5. 藥物承保範圍是否有任何約束或限制? 或者取得特定藥物是否需要採取任何必要的行動? 是的, 特定藥物有承保範圍規定或是限制您取得的藥量 在有些情況下, 您必須採取特定行動才能取得藥物 例如 : 事先核准 ( 或事先授權 ): 針對某些藥物, 在領取處方藥之前, 您或您的醫生必須取得 MetroPlus FIDA 計畫或跨科別團隊 (Interdisciplinary Team, IDT) 的核准 如果您未取得核准,MetroPlus FIDA Plan 可能不給付該藥物 數量限制 : 有時候 MetroPlus FIDA 計畫會限制您可以取得的藥量 階段式療法 : 有時候 MetroPlus FIDA 計畫會要求您進行階段式療法 這表示您將必須針對您的醫療情況依照特定的順序嘗試不同的藥物 您可能也必須先嘗試一種藥物, 之後我們才會給付另一種藥物 如果您的醫生認為第一種藥物不適合您, 我們將會給付第二種 您可以查閱從第 1 頁開始的表格, 瞭解您的藥物是否有任何額外的要求或限制 您也可以造訪我們的網站, 以取得更多資訊, 網址 :www.metroplusmedicare.org 我們已經在網路上公佈說明事先授權與階段式療法限制的文件 您也可以向我們索取相關文件 您可以要求這些限制的 例外處理 請參閱問題 11 關於例外處理的詳細資訊 如果您住在護理機構或其他長期的照護機構, 所需的藥物未列入藥物清單, 或您無法輕易取得您所需的藥物, 我們可以提供協助 我們將給付您所需藥物的 31 天緊急藥量 ( 除非您的處方籤要球較少的天數 ), 不管您是否為 MetroPlus FIDA 計畫的新參與者 這將讓您有時間可以和您的醫生或其他處方醫生討論 他或她將協助您判定藥物清單上是否有類似的替代藥物, 或是要求例外處理 請參閱問題 11 關於例外處理的詳細資訊 6. 您要如何得知您需要的藥物有限制, 或是取得藥物需採取的必要行動? 第 1 頁的承保藥物清單有一欄標示為 對於使用的必要行動 約束或限制? 如果您有任何疑問, 請致電 MetroPlus FIDA 計畫, 電話 :1-844-288-FIDA (3432),TTY:711, 服務時間為週一至週六上午 8 點至晚上 8 點 晚上 8 點後 週日及假日 : 請撥打上列的 24 小時全年無休醫療諮詢服務專線 此為免付費專線 詳情請造訪 www.metroplusmedicare.org v

7. 如果我們變更關於如何給付特定藥物的規則, 會有什麼情況? 例如, 如果我們對特定藥物新增事先授權 ( 核准 ) 數量限制和 / 或階段式療法限制 如果我們對特定藥物新增事先核准 數量限制和 / 或階段式療法限制, 我們將會通知您 我們將於新 增限制的至少 60 天前, 或是在您下次續領的時候通知您 然後您可以在藥物清單變更之前, 取得 該藥物的 60 天藥量 這將讓您有時間可以和您的醫生或其他處方醫生討論下一步要怎麼做 8. 如何在藥物清單找到特定藥物? 找到特定藥物有二種方式 : 您可以按字母順序搜尋 ( 如果您知道該藥物的拼法 ), 或 您可以依醫療情況搜尋 若要按字母順序搜尋, 請前往第 78 頁的 按字母順序排列清單, 然後在清單中找尋您的藥物名稱 若要依醫療情況搜尋, 請在第 1 頁搜尋標示 依醫療情況的藥物清單 然後搜尋您的醫療情況 例如, 如果您有心臟病, 就應查詢該類別 那是您會找到治療心臟病藥物的地方 9. 如果您要服用的藥物不在藥物清單上, 該怎麼辦? 如果您在藥物清單上找不到您的藥物, 請致電參與者服務部, 電話 :1-844-288-FIDA (3432),TTY:711 並提出詢問 如果您獲悉 MetroPlus FIDA 計畫將不給付該藥物, 您可以採取以下其中一項行動 : 詢問參與者服務部關於您所要服用的類似藥物清單 然後向您的醫生或其他處方醫生出示清單 他或她可以開立藥物清單上類似您要服用的藥物處方 或 您可以要求計畫或您的跨科別團隊 (Interdisciplinary Team, IDT) 進行例外處理以給付您的藥物 請參閱問題 11 關於例外處理的詳細資訊 10. 如果您是 MetroPlus FIDA 計畫的新參與者, 而且在藥物清單上找不到您的藥物或是在取得藥物方面有問題, 要怎麼辦?? 如果您有任何疑問, 請致電 MetroPlus FIDA 計畫, 電話 :1-844-288-FIDA (3432),TTY:711, 服務時間為週一至週六上午 8 點至晚上 8 點 晚上 8 點後 週日及假日 : 請撥打上列的 24 小時全年無休醫療諮詢服務專線 此為免付費專線 詳情請造訪 www.metroplusmedicare.org vi

我們可協助您 在您剛加入 MetroPlus FIDA 計畫後的前 90 天, 我們必須依情況所需, 給付長達 90 天的臨時藥量 這將讓您有時間可以和您的醫生或其他處方醫生討論 他或她將協助您判定藥物清單上是否有類似的替代藥物, 或是要求例外處理 我們將於以下情況給付長達 90 天的臨時藥量 : 您服用的藥未列入我們的藥物清單, 或 健康計畫規則無法讓您取得處方開立者的醫囑藥量, 或 藥物需要 MetroPlus FIDA 計畫或您的跨科別團隊 (Interdisciplinary Team, IDT) 的事先核准, 或 您服用的藥物受到階段式療法的限制 如果您住在護理機構或其他長期照護機構, 您可以續領長達 91 天的處方藥 您可以在 91 天期間內多次續領藥物 這讓您的處方開立者有時間將您的藥物轉換成藥物清單上的藥物, 或是要求例外處理 在您登記加入 MetroPlus FIDA 計畫後的前 90 天內, 我們的過渡政策提供至少一次臨時的 30 天續領處方藥量 如果您的處方藥少於 30 天, 在 30 天藥量可以分多次領藥 如果您申請 Medicaid 承保的非 Part D 藥物領藥, 也可以有九十 (90) 天藥量 如果您目前居住在長期照護機構,MetroPlus FIDA 計畫提供最多達 98 天處方藥, 從您登記加入計畫後的前 90 天開始 在前 90 天過後, 我們會提供最多 31 天的非 Part D 處方集藥物緊急藥量, 但如有例外狀況或事先授權決定時可以延期 如果您將要住入或離開長期照護機構, 將不會採用修改提前續領的方式來限制您適當與必要的使用您的福利, 因此您在住入或離開照護機構時將可以使用續領福利 11. 您可以要求例外情況以給付您的藥物嗎? 可以 您可以要求 MetroPlus FIDA 計畫或您的跨科別團隊 (Interdisciplinary Team, IDT) 進行例外處理以給付不在藥物清單上的藥物 您也可以要求 MetroPlus FIDA 計畫或您的 IDT 變更關於您所服用藥物的規則 例如,MetroPlus FIDA 計畫可能限制我們給付的藥物數量 如果您的藥物有限制, 您可以要求我們或您的 IDT 變更限制並給付更多 其他範例 : 您可以要求我們或您的 IDT 解除階段式療法限制或事先核准要求? 如果您有任何疑問, 請致電 MetroPlus FIDA 計畫, 電話 :1-844-288-FIDA (3432),TTY:711, 服務時間為週一至週六上午 8 點至晚上 8 點 晚上 8 點後 週日及假日 : 請撥打上列的 24 小時全年無休醫療諮詢服務專線 此為免付費專線 詳情請造訪 www.metroplusmedicare.org vii

12. 取得例外處理需要多久時間? 首先,MetroPlus FIDA 計畫或您的跨科別團隊 (Interdisciplinary Team, IDT) 必須收到您的處方開立者支持您要求例外處理的聲明 在我們收到聲明之後, 您將於 72 小時內收到我們關於例外處理申請的裁決 如果您或您的處方開立者認為 72 小時的等候裁決時間可能會傷害您的健康, 您可以要求加速的例外處理 這是較快速的裁決 如果您的處方開立者支持您的要求, 我們將於收到處方醫生的支持聲明之後 24 小時內做出裁決 13. 您要如何提出例外申請? 若要申請例外處理, 請致電您的照護經理 您的照護經理將與您與提供者合作協助您提出例外處理申請 14. 何謂學名藥? 學名藥與專利藥的成分相同 它們通常比專利藥便宜, 且通常沒有眾所周知的名稱 學名藥經過食品藥物管理局 (Food and Drug Administration, FDA) 的核准 MetroPlus FIDA 計畫給付專利藥與學名藥 15. 何謂 OTC 藥? OTC 代表 成藥 若由您的提供者開立為處方籤,MetroPlus FIDA 計畫可給付部份 OTC 藥物 您可以閱讀 MetroPlus FIDA 計畫藥物清單, 瞭解哪些 OTC 藥物是有給付的 16. MetroPlus FIDA 計畫是否給 OTC 非藥物產品? 若由您的提供者開立為處方籤,MetroPlus FIDA 計畫可給付部份 OTC 非藥物產品 非藥物 OTC 產品包括酒精棉花球與紗布墊等項目 您可以閱讀 MetroPlus FIDA 計畫藥物清單, 瞭解哪些 OTC 非藥物產品是有給付的? 如果您有任何疑問, 請致電 MetroPlus FIDA 計畫, 電話 :1-844-288-FIDA (3432),TTY:711, 服務時間為週一至週六上午 8 點至晚上 8 點 晚上 8 點後 週日及假日 : 請撥打上列的 24 小時全年無休醫療諮詢服務專線 此為免付費專線 詳情請造訪 www.metroplusmedicare.org viii

17. 您的共付額是多少? 對於藥物清單上的藥物, 您無需支付共付額 18. 何謂藥物級別? MetroPlus FIDA 計畫有三種藥物級別 級別是指藥物的不同分組 計畫藥物清單中的每種藥物都屬於三個級別其中之一 這三個級別的藥物都不需要您支付任何費用 級別 1 是指學名藥 級別 2 是指專利藥 級別 3 藥物是成藥與非 Medicare 給付的處方藥? 如果您有任何疑問, 請致電 MetroPlus FIDA 計畫, 電話 :1-844-288-FIDA (3432),TTY:711, 服務時間為週一至週六上午 8 點至晚上 8 點 晚上 8 點後 週日及假日 : 請撥打上列的 24 小時全年無休醫療諮詢服務專線 此為免付費專線 詳情請造訪 www.metroplusmedicare.org ix

承保藥物清單 下頁開始的承保藥物清單提供您關於 MetroPlus FIDA 記畫所給付的藥物資訊 如果您在清單裡找不到您的藥物, 請返回第 78 頁開始的 索引 表格的第一欄條列藥物的名稱 專利藥是大寫 ( 例如 COLCRYS) 而學名藥則是以小寫斜體條列 ( 例如 penicillin) 在關於使用的必要行動 約束或限制欄的資訊告訴您 MetroPlus FIDA 計畫對您的藥物給付是否有任何規則 注意 : 藥物名稱旁邊的 * 意指該藥物並非 Part D 藥物 這些藥物有不同的上訴規則 上訴是要求審查與變更您認為有誤之給付裁決的正式途徑 例如,MetroPlus FIDA 計畫或您的跨科別團隊 (Interdisciplinary Team, IDT) 可能裁決 Medicare 或 Medicaid 不給付或不再給付您所需的藥物 如果您的醫生或其他處方醫生不同意該裁決, 您可以提出上訴 若需要關於提出上訴的指示, 請致電參與者服務部, 電話號碼 :1-844-288-FIDA (3432), TTY:711 或獨立消費者倡權網路 (Independent Consumer Advocacy Network, ICAN), 電話 :1 844 614 8800 您也可以閱讀參與者手冊以瞭解如何針對裁決提出上訴? 如果您有任何疑問, 請致電 MetroPlus FIDA 計畫, 電話 :1-844-288-FIDA (3432),TTY:711, 服務時間為週一至週六上午 8 點至晚上 8 點 晚上 8 點後 週日及假日 : 請撥打上列的 24 小時全年無休醫療諮詢服務專線 此為免付費專線 詳情請造訪 www.metroplusmedicare.org x

止痛藥 - 藥物 治療疼痛與發炎 痛風 - 治療痛風的藥物 allopurinol tab 1 $0 colchicine w/ probenecid 1 $0 COLCRYS 2 $0 QL (120 tabs / 30 days) probenecid 1 $0 ULORIC 2 $0 ST 雜項 acetaminophen CHEW; ELIX; LIQD; SOLN; 3 $0 NM; * SUSP; TABS; TBCR; TBDP ACETAMINOPHEN SUPP 3 $0 NM; * ACETAMINOPHEN 8 HOUR 3 $0 NM; * ADULT ASPIRIN LOW STRENGT 3 $0 NM; * APAP 500 3 $0 NM; * ASCRIPTIN 3 $0 NM; * aspirin CHEW 3 $0 NM; * ASPIRIN SUPP 60mg, 120mg, 200mg 3 $0 NM; * aspirin SUPP 300mg, 600mg 3 $0 NM; * aspirin TABS 3 $0 NM; * aspirin TBEC 325mg, 500mg, 650mg 3 $0 NM; * ASPIRIN TBEC 650mg 3 $0 NM; * aspirin buffered (cal carb-mag carb-mag 3 $0 NM; * oxide) aspirin effervescent 3 $0 NM; * BUFFERIN EXTRA STRENGTH 3 $0 NM; * BUFFERIN LOW DOSE 3 $0 NM; * CHILDRENS MOTRIN CHEW 3 $0 NM; * ELIXSURE FEVER/PAIN 3 $0 NM; * FEBROL 3 $0 NM; * FEVERALL INFANTS 3 $0 NM; * ibuprofen CAPS 3 $0 NM; * ibuprofen CHEW 3 $0 NM; * ibuprofen SUSP 50mg/1.25ml, 3 $0 NM; * 100mg/5ml IBUPROFEN TABS 100mg 3 $0 NM; * ibuprofen TABS 200mg 3 $0 NM; * magnesium salicylate tetrahydrate 3 $0 NM; * NAPROXEN SODIUM CAPS 3 $0 NM; * naproxen sodium TABS 220mg 3 $0 NM; * PA - 事先授權 QL - 數量限制 ST - 階段式療法 NM - 不提供郵購 1 B/D - 根據 Medicare B 或 D 給付 LA - 有限的使用 * - 非 Part D 藥物, 或是 Medicaid 給付的 OTC 品項

NON-ASPIRIN EXTRA STRENGT TBDP 3 $0 NM; * ST JOSEPH ADULT ANALGESIC 3 $0 NM; * STANBACK ASPIRIN FREE 3 $0 NM; * TRIAMINIC FEVER REDUCER P 3 $0 NM; * 非類固醇抗發炎藥物 - 治療疼痛與發炎 CELEBREX CAP 50MG 2 $0 QL (60 caps / 30 days) CELEBREX CAP 100MG 2 $0 QL (60 caps / 30 days) CELEBREX CAP 200MG 2 $0 QL (60 caps / 30 days) CELEBREX CAP 400MG 2 $0 QL (60 caps / 30 days) diclofenac potassium 1 $0 diclofenac sodium TB24; TBEC 1 $0 diflunisal 1 $0 etodolac 1 $0 etodolac er 1 $0 flurbiprofen TABS 1 $0 ibuprofen SUSP 100mg/5ml 1 $0 ibuprofen TABS 400mg, 600mg 1 $0 ibuprofen tab 800 mg 1 $0 ketoprofen CAPS 1 $0 MELOXICAM SUSP 1 $0 meloxicam TABS 1 $0 nabumetone TABS 1 $0 naproxen SUSP; TABS; TBEC 1 $0 naproxen sodium TABS 275mg, 550mg 1 $0 piroxicam CAPS 1 $0 sulindac TABS 1 $0 類鴉片止痛劑 - 治療疼痛的藥物 acetaminophen w/ codeine SOLN 1 $0 QL (5000 ml / 30 days) acetaminophen w/ codeine TABS 1 $0 QL (400 tabs / 30 days) butorphanol tartrate SOLN 1mg/ml, 1 $0 2mg/ml hydroco/apap tab 5-325mg 1 $0 QL (360 tabs / 30 days) hydroco/apap tab 7.5-325 1 $0 QL (360 tabs / 30 days) hydroco/apap tab 10-325mg 1 $0 QL (360 tabs / 30 days) hydrocodone-acetaminophen 7.5-325 1 $0 QL (5400 ml / 30 days) mg/15ml hydrocodone-ibuprofen tab 7.5-200 mg 1 $0 QL (150 tabs / 30 days) tramadol hcl TABS 1 $0 QL (240 tabs / 30 days) tramadol-acetaminophen 1 $0 QL (240 tabs / 30 days) 類鴉片止痛劑,CII- 治療疼痛的藥物 2 如果您有任何疑問, 請致電 MetroPlus FIDA Plan, 電話 :1-844-288-FIDA (3432), TTY:711, 服務時間為週一至週六上午 8 時至晚上 8 時 晚上 8 時後 週日及假日 : 請撥打上列的 24 小時全年無休醫療諮詢服務專線 此電話號碼為免付費專線 如需詳細資訊, 請造訪 www.metroplusmedicare.org

DURAMORPH 1 $0 B/D endocet 1 $0 QL (360 tabs / 30 days) fentanyl 12mcg/hr, 25mcg/hr 1 $0 QL (10 patches / 30 days) fentanyl 50mcg/hr, 75mcg/hr, 100mcg/hr 1 $0 QL (10 patches / 30 days), PA fentanyl citrate LPOP 2 $0 QL (120 lozenges / 30 days), PA hydromorphon inj 10mg/ml 1 $0 B/D hydromorphone hcl LIQD 1 $0 hydromorphone hcl TABS 1 $0 QL (270 tabs / 30 days) LAZANDA SPR 100MCG 2 $0 QL (30 bottles / 30 days), PA LAZANDA SPR 400MCG 2 $0 QL (30 bottles / 30 days), PA methadone hcl CONC 1 $0 QL (120 ml / 30 days) methadone hcl SOLN 5mg/5ml, 1 $0 QL (600 ml / 30 days) methadone hcl TABS 1 $0 QL (240 tabs / 30 days) morphine ext-rel tab 15mg, 30mg, 60mg, 1 $0 QL (90 tabs / 30 days) 100mg morphine ext-rel tab 200mg 1 $0 QL (60 tabs / 30 days) MORPHINE SUL INJ 1mg/ml, 4mg/ml, 1 $0 B/D 10mg/ml, 15mg/ml morphine sul inj.5mg/ml, 1mg/ml 1 $0 B/D morphine sulfate CP24 10mg, 20mg, 1 $0 QL (60 caps / 30 days) 30mg, 50mg, 60mg morphine sulfate CP24 80mg 2 $0 QL (60 caps / 30 days) MORPHINE SULFATE SOLN 2mg/ml, 1 $0 B/D 8mg/ml MORPHINE SULFATE TABS 1 $0 QL (180 tabs / 30 days) morphine sulfate beads 1 $0 QL (60 caps / 30 days) morphine sulfate cap 100mg er 2 $0 QL (60 caps / 30 days) MORPHINE SULFATE ORAL SOL 1 $0 oxycodone hcl CAPS 1 $0 QL (180 tabs / 30 days) OXYCODONE HCL CONC 1 $0 oxycodone hcl SOLN 1 $0 oxycodone hcl TABS 1 $0 QL (180 tabs / 30 days) oxycodone hcl tab 5 mg 1 $0 QL (180 tabs / 30 days) oxycodone w/ acetaminophen 2.5-325mg 1 $0 QL (360 tabs / 30 days) oxycodone w/ acetaminophen 5-325mg 1 $0 QL (360 tabs / 30 days) oxycodone w/ acetaminophen 7.5-325mg 1 $0 QL (360 tabs / 30 days) oxycodone w/ acetaminophen 10-325mg 1 $0 QL (360 tabs / 30 days) roxicet soln 2 $0 QL (1800 ml / 30 days soln) roxicet tab 5-325mg 1 $0 QL (360 tabs / 30 days) 麻醉劑 - 用於麻醉的藥物 PA - 事先授權 QL - 數量限制 ST - 階段式療法 NM - 不提供郵購 3 B/D - 根據 Medicare B 或 D 給付 LA - 有限的使用 * - 非 Part D 藥物, 或是 Medicaid 給付的 OTC 品項

局部麻醉劑 lidocaine hcl (local anesth.) 1 $0 B/D lidocaine inj 0.5% 1 $0 B/D lidocaine inj 1% 1 $0 B/D lidocaine inj 1.5% 1 $0 B/D lidocaine inj 2% 1 $0 B/D 抗感染藥 - 用於治療感染的藥物 抗菌藥 - 雜項 amikacin sulfate SOLN 1 $0 gentamicin in saline 1 $0 gentamicin sulfate SOLN 1 $0 neomycin sulfate TABS 1 $0 paromomycin sulfate CAPS 1 $0 streptomycin sulfate SOLR 1 $0 sulfadiazine TABS 2 $0 tobramycin NEBU 2 $0 B/D, NM tobramycin sulfate SOLN; SOLR 1 $0 tobramycin sulfate in saline 2 $0 抗感染藥 - 雜項 ALBENZA 2 $0 ALINIA 2 $0 atovaquone SUSP 2 $0 AZACTAM 2 $0 AZACTAM/DEX INJ 1GM 2 $0 AZACTAM/DEX INJ 2GM 2 $0 aztreonam 1 $0 BILTRICIDE 2 $0 CAYSTON 2 $0 NM, LA, PA clindamycin cap 75mg 1 $0 clindamycin cap 300mg 1 $0 clindamycin hcl cap 150 mg 1 $0 clindamycin phosphate inj 1 $0 clindamycin sol 75mg/5ml 1 $0 colistimethate sodium SOLR 1 $0 CUBICIN 2 $0 B/D dapsone TABS 1 $0 DARAPRIM 2 $0 e.s.p. 1 $0 ees/sulfisox sus 200-600 1 $0 imipenem-cilastatin 1 $0 4 如果您有任何疑問, 請致電 MetroPlus FIDA Plan, 電話 :1-844-288-FIDA (3432), TTY:711, 服務時間為週一至週六上午 8 時至晚上 8 時 晚上 8 時後 週日及假日 : 請撥打上列的 24 小時全年無休醫療諮詢服務專線 此電話號碼為免付費專線 如需詳細資訊, 請造訪 www.metroplusmedicare.org

INVANZ 2 $0 meropenem 1 $0 methenamine hippurate 1 $0 metronidazole TABS 1 $0 metronidazole in nacl 1 $0 NEBUPENT 2 $0 B/D nitrofurantoin macrocrystal 2 $0 PA; 90 day limit if >64 yr nitrofurantoin monohyd macro 2 $0 PA; 90 day limit if >64 yr PENTAM 300 2 $0 sulfamethoxazole-trimethoprim 1 $0 sulfamethoxazole-trimethoprim inj 1 $0 SYNERCID 2 $0 trimethoprim TABS 1 $0 TYGACIL 2 $0 vancomycin hcl CAPS 2 $0 vancomycin hcl SOLR 1 $0 B/D ZYVOX 2 $0 抗真菌藥 - 治療真菌感染的藥物 ABELCET 2 $0 B/D AMBISOME 2 $0 B/D amphotericin b SOLR 1 $0 B/D CANCIDAS 2 $0 ERAXIS 2 $0 fluconazole SUSR; TABS 1 $0 fluconazole in dextrose 1 $0 fluconazole in nacl 1 $0 flucytosine CAPS 2 $0 griseofulvin microsize 1 $0 griseofulvin ultramicrosize 1 $0 itraconazole CAPS 1 $0 PA ketoconazole TABS 1 $0 PA MYCAMINE 2 $0 NOXAFIL SUSP; TBEC 2 $0 nystatin TABS 1 $0 terbinafine hcl TABS 1 $0 QL (90 tabs / 365 days) voriconazole SOLR 1 $0 voriconazole SUSR; TABS 2 $0 抗瘧疾藥 - 治療瘧疾的藥物 atovaquone-proguanil hcl 1 $0 chloroquine phosphate TABS 1 $0 PA - 事先授權 QL - 數量限制 ST - 階段式療法 NM - 不提供郵購 5 B/D - 根據 Medicare B 或 D 給付 LA - 有限的使用 * - 非 Part D 藥物, 或是 Medicaid 給付的 OTC 品項

COARTEM 2 $0 mefloquine hcl 1 $0 PRIMAQUINE PHOSPHATE 2 $0 quinine sulfate CAPS 1 $0 PA 抗反轉錄病毒藥劑 - 用於抑制 HIV/AIDS 感染的藥物 abacavir sulfate 1 $0 APTIVUS 2 $0 CRIXIVAN 2 $0 didanosine 1 $0 EDURANT 2 $0 EMTRIVA 2 $0 EPIVIR SOLN 2 $0 FUZEON 2 $0 NM INTELENCE 2 $0 INVIRASE 2 $0 ISENTRESS CHEW; TABS 2 $0 ISENTRESS PACK 1 $0 lamivudine 150mg, 300mg 1 $0 LEXIVA 2 $0 NEVIRAPINE SUSP 1 $0 nevirapine TABS; TB24 1 $0 NORVIR 2 $0 PREZISTA 2 $0 RESCRIPTOR 2 $0 RETROVIR IV INFUSION 2 $0 REYATAZ 2 $0 SELZENTRY 2 $0 stavudine 1 $0 SUSTIVA 2 $0 TIVICAY 2 $0 VIDEX PEDIATRIC 2 $0 VIRACEPT 2 $0 VIRAMUNE XR 100mg 2 $0 VIREAD 2 $0 ZIAGEN SOLN 2 $0 zidovudine 1 $0 抗反轉錄病毒綜合藥劑 - 用於抑制 HIV/AIDS 感染的藥物 abacavir sulfate-lamivudine-zidovudine 2 $0 6 如果您有任何疑問, 請致電 MetroPlus FIDA Plan, 電話 :1-844-288-FIDA (3432), TTY:711, 服務時間為週一至週六上午 8 時至晚上 8 時 晚上 8 時後 週日及假日 : 請撥打上列的 24 小時全年無休醫療諮詢服務專線 此電話號碼為免付費專線 如需詳細資訊, 請造訪 www.metroplusmedicare.org

ATRIPLA 2 $0 COMPLERA 2 $0 EPZICOM 2 $0 KALETRA SOL 2 $0 KALETRA TAB 100-25MG 2 $0 KALETRA TAB 200-50MG 2 $0 lamivudine-zidovudine 2 $0 STRIBILD 2 $0 TRUVADA 2 $0 QL (30 tabs / 30 days) 抗結核藥劑 - 治療肺結核的藥物 CAPASTAT SULFATE 2 $0 ethambutol hcl TABS 1 $0 isoniazid TABS 1 $0 isoniazid inj 100 mg/ml 1 $0 isoniazid syp 50mg/5ml 1 $0 paser d/r 2 $0 PRIFTIN 2 $0 pyrazinamide 1 $0 rifabutin 1 $0 rifampin CAPS; SOLR 1 $0 RIFATER 2 $0 SIRTURO 2 $0 LA, PA TRECATOR 2 $0 抗病毒藥 - 治療病毒感染的藥物 acyclovir CAPS; SUSP; TABS 1 $0 acyclovir sodium SOLN 1 $0 B/D acyclovir sodium SOLR 1000mg 1 $0 B/D adefovir dipivoxil 2 $0 BARACLUDE 2 $0 EPIVIR HBV SOLN 2 $0 famciclovir TABS 1 $0 foscarnet sodium 1 $0 ganciclovir inj 500mg 1 $0 B/D lamivudine 100mg 1 $0 moderiba 800 dose pack 2 $0 NM, PA moderiba pak 600/day 2 $0 NM, PA moderiba pak 1000/day 2 $0 NM, PA moderiba pak 1200/day 2 $0 NM, PA moderiba tab 200mg 1 $0 NM, PA OLYSIO 2 $0 NM, PA PA - 事先授權 QL - 數量限制 ST - 階段式療法 NM - 不提供郵購 7 B/D - 根據 Medicare B 或 D 給付 LA - 有限的使用 * - 非 Part D 藥物, 或是 Medicaid 給付的 OTC 品項

REBETOL SOLN 2 $0 NM, PA RELENZA DISKHALER 2 $0 ribapak mis 600/day 2 $0 NM, PA ribasphere CAPS 1 $0 NM, PA ribasphere TABS 200mg, 400mg 1 $0 NM, PA ribasphere TABS 600mg 2 $0 NM, PA ribasphere ribapak 800 2 $0 NM, PA ribasphere ribapak 1000 2 $0 NM, PA ribasphere ribapak 1200 2 $0 NM, PA ribavirin 200mg 1 $0 NM, PA rimantadine hydrochloride 1 $0 SOVALDI 2 $0 NM, PA TAMIFLU 2 $0 TYZEKA 2 $0 valacyclovir hcl TABS 1 $0 VALCYTE 2 $0 VICTRELIS 2 $0 NM, PA 頭芽胞菌素 - 治療感染的藥物 cefaclor 1 $0 cefaclor monohydrate er 2 $0 cefadroxil 1 $0 cefazolin in d5w 2 $0 cefazolin inj 1 $0 cefazolin sodium 1gm, 20gm 1 $0 cefdinir 1 $0 cefepime hcl 1 $0 cefotaxime sodium 1 $0 cefoxitin sodium 1 $0 cefpodoxime proxetil 1 $0 cefprozil 1 $0 ceftazidime 1gm, 2gm, 6gm 1 $0 CEFTAZIDIME/DEXTROSE 2 $0 ceftriaxone sodium SOLR 1 $0 cefuroxime axetil TABS 1 $0 cefuroxime sodium 1.5gm, 7.5gm, 750mg 1 $0 cephalexin CAPS 250mg, 500mg 1 $0 cephalexin SUSR 1 $0 SUPRAX CAPS 2 $0 suprax CHEW 2 $0 suprax SUSR 100mg/5ml, 200mg/5ml 2 $0 8 如果您有任何疑問, 請致電 MetroPlus FIDA Plan, 電話 :1-844-288-FIDA (3432), TTY:711, 服務時間為週一至週六上午 8 時至晚上 8 時 晚上 8 時後 週日及假日 : 請撥打上列的 24 小時全年無休醫療諮詢服務專線 此電話號碼為免付費專線 如需詳細資訊, 請造訪 www.metroplusmedicare.org

SUPRAX SUSR 500mg/5ml 2 $0 suprax TABS 2 $0 tazicef SOLR 1 $0 tazicef vial 1 $0 TEFLARO 2 $0 頭芽胞菌素 - 治療感染的藥物 AZITHROMYCIN PACK 1 $0 azithromycin SOLR 500mg 1 $0 azithromycin SUSR 1 $0 azithromycin TABS 1 $0 clarithromycin TABS 1 $0 clarithromycin er 1 $0 clarithromycin for susp 1 $0 DIFICID 2 $0 e.e.s. 1 $0 e.e.s. 400 1 $0 E.E.S. GRANULES 2 $0 ery-tab 2 $0 ERYPED 200 2 $0 ERYPED 400 2 $0 erythrocin lactobionate 500mg 2 $0 erythrocin stearate 1 $0 erythromycin base 1 $0 erythromycin cap 250mg ec 1 $0 ZMAX 2 $0 氟喹諾酮 - 治療感染的藥物 ciprofloxacin SUSR 1 $0 ciprofloxacin er 1 $0 ciprofloxacin hcl tab 1 $0 ciprofloxacin in d5w 1 $0 ciprofloxacin inj 1 $0 levofloxacin TABS 1 $0 levofloxacin in d5w 1 $0 levofloxacin inj 25mg/ml 1 $0 levofloxacin oral soln 25 mg/ml 1 $0 青黴素 - 治療感染的藥物 amoxicillin 1 $0 amoxicillin & pot clavulanate 1 $0 ampicillin & sulbactam sodium 1 $0 ampicillin cap 250 mg 1 $0 PA - 事先授權 QL - 數量限制 ST - 階段式療法 NM - 不提供郵購 9 B/D - 根據 Medicare B 或 D 給付 LA - 有限的使用 * - 非 Part D 藥物, 或是 Medicaid 給付的 OTC 品項

ampicillin cap 500 mg 1 $0 ampicillin for susp 125 mg/5ml 1 $0 ampicillin for susp 250 mg/5ml 1 $0 ampicillin inj 1 $0 ampicillin sodium 1 $0 BICILLIN L-A 2 $0 dicloxacillin sodium 1 $0 nafcillin sodium 1gm 1 $0 nafcillin sodium 2gm, 10gm 2 $0 oxacillin sodium 1gm, 2gm 1 $0 oxacillin sodium 10gm 2 $0 PENICILLIN G POT IN DEXTROSE 2 $0 penicillin g potassium 1 $0 penicillin g procaine 2 $0 penicillin g sodium 1 $0 penicillin v potassium 1 $0 penicilln gk inj 5mu 1 $0 piperacillin sodium-tazobactam sodium 1 $0 TIMENTIN 2 $0 TIMENTIN INJ 3.1GM 2 $0 鹽酸四環素 - 治療感染的藥物 doxycycline (monohydrate) CAPS 50mg, 1 $0 100mg doxycycline (monohydrate) TABS 1 $0 doxycycline hyclate CAPS; SOLR; TABS 1 $0 minocycline hcl CAPS 1 $0 VIBRAMYCIN SYRP 2 $0 抗腫瘤藥劑 - 治療癌症的藥物 烷化劑 BICNU 2 $0 B/D BUSULFEX 2 $0 B/D cyclophosphamide SOLR; TABS 1 $0 B/D dacarbazine 200mg 1 $0 B/D EMCYT 2 $0 HEXALEN 2 $0 IFEX 3gm 2 $0 B/D ifosfamide inj 1gm 1 $0 B/D ifosfamide inj 1gm/20ml 1 $0 B/D IFOSFAMIDE INJ 3GM 2 $0 B/D ifosfamide inj 3gm/60ml 1 $0 B/D 10 如果您有任何疑問, 請致電 MetroPlus FIDA Plan, 電話 :1-844-288-FIDA (3432), TTY:711, 服務時間為週一至週六上午 8 時至晚上 8 時 晚上 8 時後 週日及假日 : 請撥打上列的 24 小時全年無休醫療諮詢服務專線 此電話號碼為免付費專線 如需詳細資訊, 請造訪 www.metroplusmedicare.org

LEUKERAN 2 $0 LOMUSTINE 1 $0 melphalan hcl 2 $0 B/D MUSTARGEN 2 $0 B/D TREANDA SOLR 2 $0 B/D, NM 蒽環黴素 adriamycin 50mg 1 $0 B/D adriamycin inj 20mg 1 $0 B/D daunorubicin hcl 1 $0 B/D doxorubicin hcl for inj 50 mg 1 $0 B/D doxorubicin hcl liposomal inj 2mg/ml 2 $0 B/D doxorubicin inj 50mg 1 $0 B/D epirubicin hcl SOLN 1 $0 B/D idarubicin hcl 2 $0 B/D 抗生素 bleomycin sulfate 1 $0 B/D mitomycin SOLR 1 $0 B/D 抗代謝物 adrucil 1 $0 B/D ALIMTA 2 $0 B/D azacitidine 2 $0 B/D, NM cladribine 2 $0 B/D cytarabine SOLN 20mg/ml 1 $0 B/D cytarabine SOLR 100mg 1 $0 B/D fludarabine phosphate 1 $0 B/D fluorouracil SOLN 1 $0 B/D GEMCITABINE HCL SOLN 2 $0 B/D gemcitabine hcl SOLR 2 $0 B/D mercaptopurine TABS 1 $0 methotrexate sodium inj 1 $0 B/D TABLOID 2 $0 抗有絲分裂藥,TAXOIDS DOCETAXEL CONC 20mg/0.5ml, 2 $0 B/D 20mg/ml, 80mg/4ml docetaxel CONC 140mg/7ml 2 $0 B/D DOCETAXEL SOLN 80mg/8ml 2 $0 B/D paclitaxel 1 $0 B/D TAXOTERE 80mg/2ml 2 $0 B/D 抗有絲分裂藥,VINCA ALKALOIDS PA - 事先授權 QL - 數量限制 ST - 階段式療法 NM - 不提供郵購 11 B/D - 根據 Medicare B 或 D 給付 LA - 有限的使用 * - 非 Part D 藥物, 或是 Medicaid 給付的 OTC 品項

vinblastine sulfate SOLN 2 $0 B/D vincasar 1 $0 B/D vincristine sulfate 1 $0 B/D vinorelbine tartrate 1 $0 B/D 生物反應調節劑 AVASTIN 2 $0 B/D, NM ERIVEDGE 2 $0 NM, LA, PA HERCEPTIN 2 $0 B/D, NM ISTODAX 2 $0 B/D, NM KADCYLA 2 $0 B/D, NM PROLEUKIN 2 $0 B/D, NM RITUXAN 2 $0 NM, PA VELCADE 2 $0 B/D, NM ZOLINZA 2 $0 NM, PA 賀爾蒙抗腫瘍劑 anastrozole TABS 1 $0 bicalutamide 1 $0 DEPO-PROVERA INJ 400/ML 2 $0 B/D exemestane 1 $0 FARESTON 2 $0 FASLODEX 2 $0 B/D flutamide 1 $0 letrozole TABS 1 $0 leuprolide acetate KIT 1 $0 NM, PA LUPR DEP-PED INJ 30MG (3-MONTH) 2 $0 NM, PA LUPRON DEPOT 3.75mg 2 $0 NM, PA LUPRON DEPOT INJ 11.25 MG 2 $0 NM, PA LUPRON DEPOT-PED 2 $0 NM, PA LYSODREN 2 $0 MEGACE ES 2 $0 PA megestrol acetate SUSP; TABS 2 $0 PA NILANDRON 2 $0 SOLTAMOX 2 $0 tamoxifen citrate TABS 1 $0 TRELSTAR DEP INJ 3.75MG 2 $0 NM, PA TRELSTAR LA INJ 11.25MG 2 $0 NM, PA XTANDI 2 $0 NM, LA, PA ZYTIGA 2 $0 NM, PA 激酶抑制劑 AFINITOR 2 $0 NM, PA 12 如果您有任何疑問, 請致電 MetroPlus FIDA Plan, 電話 :1-844-288-FIDA (3432), TTY:711, 服務時間為週一至週六上午 8 時至晚上 8 時 晚上 8 時後 週日及假日 : 請撥打上列的 24 小時全年無休醫療諮詢服務專線 此電話號碼為免付費專線 如需詳細資訊, 請造訪 www.metroplusmedicare.org

AFINITOR DISPERZ 2 $0 NM, PA BOSULIF 2 $0 NM, PA CAPRELSA 2 $0 NM, LA, PA COMETRIQ 2 $0 NM, PA GILOTRIF TAB 20MG 2 $0 NM, LA, PA GILOTRIF TAB 30MG 2 $0 NM, LA, PA GILOTRIF TAB 40MG 2 $0 NM, LA, PA GLEEVEC 2 $0 NM, PA ICLUSIG 2 $0 NM, LA, PA IMBRUVICA CAP 140MG 2 $0 NM, LA, PA INLYTA 2 $0 NM, LA, PA JAKAFI 2 $0 NM, LA, PA MEKINIST 2 $0 NM, PA NEXAVAR 2 $0 NM, LA, PA SPRYCEL 2 $0 NM, PA STIVARGA 2 $0 NM, LA, PA SUTENT 12.5mg, 25mg, 50mg 2 $0 NM, PA SUTENT 37.5mg 2 $0 PA TAFINLAR 2 $0 NM, PA TARCEVA 2 $0 NM, PA TASIGNA 2 $0 NM, PA TYKERB 2 $0 NM, LA, PA VOTRIENT 2 $0 NM, PA XALKORI 2 $0 NM, LA, PA ZELBORAF 2 $0 NM, LA, PA ZYKADIA 1 $0 NM, LA, PA 雜項 DROXIA 2 $0 hydroxyurea CAPS 1 $0 MATULANE 2 $0 mitoxantrone hcl 1 $0 B/D, NM POMALYST CAP 1MG 2 $0 NM, LA, PA POMALYST CAP 2MG 2 $0 NM, LA, PA POMALYST CAP 3MG 2 $0 NM, LA, PA POMALYST CAP 4MG 2 $0 NM, LA, PA SYLATRON KIT 296MCG 2 $0 NM, PA SYLATRON KIT 444MCG 2 $0 NM, PA SYLATRON KIT 888MCG 2 $0 NM, PA TARGRETIN CAPS 2 $0 NM, PA tretinoin (chemotherapy) 2 $0 PA - 事先授權 QL - 數量限制 ST - 階段式療法 NM - 不提供郵購 13 B/D - 根據 Medicare B 或 D 給付 LA - 有限的使用 * - 非 Part D 藥物, 或是 Medicaid 給付的 OTC 品項

TRISENOX 2 $0 B/D 含鉑藥物 carboplatin SOLN 1 $0 B/D cisplatin 1 $0 B/D oxaliplatin 2 $0 B/D 保護劑 amifostine crystalline 2 $0 B/D dexrazoxane 250mg 2 $0 B/D ELITEK 2 $0 B/D leucovorin calcium SOLN; SOLR 1 $0 B/D leucovorin calcium TABS 1 $0 leucovorin calcium for inj 500 mg 1 $0 B/D mesna 1 $0 B/D MESNEX TABS 2 $0 拓璞異構酵素抑制劑 etoposide SOLN 500mg/25ml 1 $0 B/D irinotecan hcl 2 $0 B/D toposar 1gm/50ml 1 $0 B/D topotecan hcl SOLR 2 $0 B/D 心血管藥物 - 治療心臟與循環情況的藥物 血管收縮素轉化酶抑制劑綜合藥物 - 治療高血壓的藥物 amlodipine--benazepril hcl cap 10-20 mg 1 $0 QL (30 caps / 30 days) amlodipine-benazepril hcl cap 2.5-10 mg 1 $0 QL (30 caps / 30 days) amlodipine-benazepril hcl cap 5-10 mg 1 $0 QL (30 caps / 30 days) amlodipine-benazepril hcl cap 5-20 mg 1 $0 QL (30 caps / 30 days) amlodipine-benazepril hcl cap 5-40 mg 1 $0 QL (30 caps / 30 days) amlodipine-benazepril hcl cap 10-40mg 1 $0 benazepril & hydrochlorothiazide 1 $0 captopril & hydrochlorothiazide 1 $0 enalapril maleate & hydrochlorothiazide 1 $0 fosinopril sodium & hydrochlorothiazide 1 $0 lisinopril & hydrochlorothiazide 1 $0 moexipril-hydrochlorothiazide 1 $0 quinapril-hydrochlorothiazide 1 $0 血管收縮素轉化酶抑制劑 - 治療高血壓的藥物 benazepril hcl TABS 1 $0 captopril TABS 1 $0 14 如果您有任何疑問, 請致電 MetroPlus FIDA Plan, 電話 :1-844-288-FIDA (3432), TTY:711, 服務時間為週一至週六上午 8 時至晚上 8 時 晚上 8 時後 週日及假日 : 請撥打上列的 24 小時全年無休醫療諮詢服務專線 此電話號碼為免付費專線 如需詳細資訊, 請造訪 www.metroplusmedicare.org

enalapril maleate TABS 1 $0 fosinopril sodium 1 $0 lisinopril TABS 1 $0 moexipril hcl 1 $0 perindopril erbumine 1 $0 quinapril hcl 1 $0 ramipril 1 $0 trandolapril 1 $0 醛固酮受體拮抗劑 - 治療高血壓的藥物 eplerenone 1 $0 spironolactone TABS 1 $0 甲型受體阻斷劑 - 治療高血壓的藥物 doxazosin mesylate 1mg, 2mg, 4mg 1 $0 QL (30 tabs / 30 days) doxazosin mesylate 8mg 1 $0 prazosin hcl 1 $0 terazosin hcl 1 $0 血管收縮素 II 接受器拮抗劑 - 治療高血壓的藥物 AZOR 10-40MG 2 $0 AZOR TAB 5-20MG 2 $0 QL (30 tabs / 30 days) AZOR TAB 5-40MG 2 $0 QL (30 tabs / 30 days) AZOR TAB 10-20MG 2 $0 QL (30 tabs / 30 days) BENICAR HCT 40-25MG 2 $0 BENICAR HCT TAB 20-12.5MG 2 $0 QL (30 tabs / 30 days) BENICAR HCT TAB 40-12.5MG 2 $0 QL (30 tabs / 30 days) EXFORGE HCT/5- TAB 160-12.5 2 $0 QL (30 tabs / 30 days) EXFORGE HCT/5- TAB 160-25 2 $0 QL (60 tabs / 30 days) EXFORGE HCT/10- TAB 160-12.5 2 $0 QL (30 tabs / 30 days) EXFORGE HCT/10- TAB 160-25 2 $0 QL (30 tabs / 30 days) EXFORGE HCT/10- TAB 320-25 2 $0 EXFORGE TAB 5-160MG 2 $0 QL (30 tabs / 30 days) EXFORGE TAB 5-320MG 2 $0 QL (30 tabs / 30 days) EXFORGE TAB 10-160MG 2 $0 QL (30 tabs / 30 days) EXFORGE TAB 10-320MG 2 $0 losartan-hctz 50-12.5mg 1 $0 QL (30 tabs / 30 days) losartan-hctz 100-12.5mg 1 $0 QL (30 tabs / 30 days) losartan-hctz 100-25mg 1 $0 TRIBENZOR40- TAB 10-25MG 2 $0 PA - 事先授權 QL - 數量限制 ST - 階段式療法 NM - 不提供郵購 15 B/D - 根據 Medicare B 或 D 給付 LA - 有限的使用 * - 非 Part D 藥物, 或是 Medicaid 給付的 OTC 品項

TRIBENZOR TAB 20-5-12.5MG 2 $0 QL (30 tabs / 30 days) TRIBENZOR TAB 40-5-12.5MG 2 $0 QL (30 tabs / 30 days) TRIBENZOR TAB 40-5-25MG 2 $0 QL (30 tabs / 30 days) TRIBENZOR TAB 40-10-12.5 2 $0 QL (30 tabs / 30 days) valsartan & hctz tab 80-12.5mg 1 $0 QL (30 tabs / 30 days) valsartan & hctz tab 160-12.5mg 1 $0 QL (30 tabs / 30 days) valsartan & hctz tab 160-25mg 1 $0 QL (30 tabs / 30 days) valsartan & hctz tab 320-12.5mg 1 $0 valsartan & hctz tab 320-25mg 1 $0 血管收縮素 II 接受器拮抗劑 - 治療高血壓的藥物 BENICAR 5mg 2 $0 QL (60 tabs / 30 days) BENICAR 20mg 2 $0 QL (30 tabs / 30 days) BENICAR 40mg 2 $0 DIOVAN 40mg, 80mg, 160mg 2 $0 QL (60 tabs / 30 days) DIOVAN 320mg 2 $0 losartan potassium 25mg, 50mg 1 $0 QL (60 tabs / 30 days) losartan potassium 100mg 1 $0 valsartan 40mg, 80mg, 160mg 1 $0 QL (60 tabs / 30 days) valsartan 320mg 1 $0 抗心律不整劑 - 控制心率的藥物 amiodarone hcl 1 $0 disopyramide phosphate 2 $0 PA flecainide acetate 1 $0 mexiletine hcl 1 $0 MULTAQ 2 $0 NORPACE CR 2 $0 PA pacerone 1 $0 propafenone hcl 1 $0 quinidine gluconate TBCR 1 $0 quinidine sulfate TABS 1 $0 sorine 1 $0 sotalol hcl 1 $0 sotalol hcl (afib/afl) 1 $0 TIKOSYN 2 $0 NM 降血脂藥,HMG-CoA 還原酶抑制劑 - 治療高膽固醇的藥物 atorvastatin calcium TABS 1 $0 QL (30 tabs / 30 days) CRESTOR 2 $0 QL (30 tabs / 30 days) 16 如果您有任何疑問, 請致電 MetroPlus FIDA Plan, 電話 :1-844-288-FIDA (3432), TTY:711, 服務時間為週一至週六上午 8 時至晚上 8 時 晚上 8 時後 週日及假日 : 請撥打上列的 24 小時全年無休醫療諮詢服務專線 此電話號碼為免付費專線 如需詳細資訊, 請造訪 www.metroplusmedicare.org

lovastatin 10mg 1 $0 QL (30 tabs / 30 days) lovastatin 20mg 1 $0 QL (120 tabs / 30 days) lovastatin 40mg 1 $0 QL (60 tabs / 30 days) pravastatin sodium 1 $0 QL (30 tabs / 30 days) simvastatin TABS 1 $0 QL (30 tabs / 30 days) 降血脂藥物, 雜項 - 治療高膽固醇的藥物 cholestyramine 1 $0 cholestyramine light 1 $0 choline fenofibrate 1 $0 colestipol hcl 1 $0 fenofibrate TABS 1 $0 fenofibrate micronized 1 $0 fenofibrate micronized cap 1 $0 gemfibrozil TABS 1 $0 niacin (antihyperlipidemic) 500mg 1 $0 QL (90 tabs / 30 days) niacin (antihyperlipidemic) 750mg, 1 $0 1000mg niacor 1 $0 omega-3-acid ethyl esters 1 $0 prevalite 1 $0 VASCEPA 2 $0 WELCHOL 2 $0 ZETIA TAB 10MG 2 $0 乙型受體阻斷劑 / 利尿複合劑 - 治療高血壓與心臟病的藥物 atenolol & chlorthalidone 1 $0 bisoprolol & hydrochlorothiazide 1 $0 metoprolol & hctz tab 50-25mg 1 $0 metoprolol & hctz tab 100-25mg 1 $0 metoprolol & hctz tab 100-50mg 1 $0 propranolol & hydrochlorothiazide 1 $0 乙型受體阻斷劑 - 治療高血壓與心臟病的藥物 acebutolol hcl CAPS 1 $0 atenolol TABS 1 $0 bisoprolol fumarate 1 $0 BYSTOLIC 2 $0 carvedilol 1 $0 PA - 事先授權 QL - 數量限制 ST - 階段式療法 NM - 不提供郵購 17 B/D - 根據 Medicare B 或 D 給付 LA - 有限的使用 * - 非 Part D 藥物, 或是 Medicaid 給付的 OTC 品項

labetalol hcl TABS 1 $0 metoprolol succinate 25mg, 50mg 1 $0 QL (60 tabs / 30 days) metoprolol succinate 100mg 1 $0 QL (45 tabs / 30 days) metoprolol succinate 200mg 1 $0 metoprolol tartrate SOLN; TABS 1 $0 nadolol TABS 1 $0 pindolol 1 $0 propranolol cap er 1 $0 propranolol hcl SOLN; TABS 1 $0 timolol maleate TABS 1 $0 鈣離子通道阻斷劑 - 治療高血壓與心臟病的藥物 afeditab cr 30mg 1 $0 QL (60 tabs / 30 days) afeditab cr 60mg 1 $0 amlodipine besylate TABS 2.5mg, 5mg 1 $0 QL (45 tabs / 30 days) amlodipine besylate TABS 10mg 1 $0 cartia xt cap 120/24hr 1 $0 cartia xt cap 180/24hr 1 $0 cartia xt cap 240/24hr 1 $0 cartia xt cap 300/24hr 1 $0 dilt-cd cap 1 $0 dilt-xr cap 1 $0 diltiazem cap 1 $0 diltiazem cap 120mg/24hr 1 $0 diltiazem cap er/12hr 1 $0 diltiazem hcl SOLN; TABS 1 $0 diltiazem hcl coated beads CP24 1 $0 diltzac 1 $0 felodipine 2.5mg 1 $0 QL (30 tabs / 30 days) felodipine 5mg 1 $0 QL (60 tabs / 30 days) felodipine 10mg 1 $0 isradipine 1 $0 nicardipine hcl CAPS 1 $0 nifedical 30mg 1 $0 QL (30 tabs / 30 days) nifedical 60mg 1 $0 nifedipine TB24 30mg 1 $0 QL (60 tabs / 30 days) nifedipine TB24 60mg, 90mg 1 $0 nifedipine er 30mg 1 $0 QL (30 tabs / 30 days) nifedipine er 60mg, 90mg 1 $0 nimodipine CAPS 1 $0 18 如果您有任何疑問, 請致電 MetroPlus FIDA Plan, 電話 :1-844-288-FIDA (3432), TTY:711, 服務時間為週一至週六上午 8 時至晚上 8 時 晚上 8 時後 週日及假日 : 請撥打上列的 24 小時全年無休醫療諮詢服務專線 此電話號碼為免付費專線 如需詳細資訊, 請造訪 www.metroplusmedicare.org

NYMALIZE 2 $0 taztia 1 $0 verapamil cap er 100mg, 120mg, 180mg, 1 $0 200mg, 240mg, 300mg VERAPAMIL CAP ER 360mg 1 $0 verapamil hcl SOLN; TABS 1 $0 verapamil tab er 1 $0 洋地黃苷類 - 治療心臟病的藥物 digoxin SOLN 1 $0 digoxin TABS 125mcg 1 $0 QL (30 tabs / 30 days) digoxin TABS 250mcg 1 $0 PA DIGOXIN SOL 50MCG/ML 1 $0 PA LANOXIN TABS 125mcg 2 $0 QL (30 tabs / 30 days) LANOXIN TABS 250mcg 2 $0 PA 直接腎素抑制劑 / 綜合藥物 - 治療心臟病的藥物 AMTURNIDE TAB 150-5-12.5 2 $0 QL (30 tabs / 30 days) AMTURNIDE TAB 300-5-12.5 2 $0 QL (30 tabs / 30 days) AMTURNIDE TAB 300-5-25MG 2 $0 QL (30 tabs / 30 days) AMTURNIDE TAB 300-10-12.5 2 $0 QL (30 tabs / 30 days) AMTURNIDE TAB 300-10-25 MG 2 $0 TEKAMLO 300-10MG 2 $0 TEKAMLO TAB 150-5MG 2 $0 QL (30 tabs / 30 days) TEKAMLO TAB 150-10MG 2 $0 QL (30 tabs / 30 days) TEKAMLO TAB 300-5MG 2 $0 QL (30 tabs / 30 days) TEKTURNA 150mg 2 $0 QL (30 tabs / 30 days) TEKTURNA 300mg 2 $0 TEKTURNA HCT TAB 150-12.5MG 2 $0 QL (30 tabs / 30 days) TEKTURNA HCT TAB 150-25MG 2 $0 QL (60 tabs / 30 days) TEKTURNA HCT TAB 300-12.5MG 2 $0 QL (30 tabs / 30 days) TEKTURNA HCT TAB 300-25MG 2 $0 利尿劑 - 治療心臟病的藥物 acetazolamide CP12; TABS 1 $0 amiloride & hydrochlorothiazide 1 $0 amiloride hcl 1 $0 bumetanide 1 $0 chlorothiazide 1 $0 chlorthalidone 25mg, 50mg 1 $0 DIURIL SUS 250/5ML 2 $0 DYRENIUM 2 $0 PA - 事先授權 QL - 數量限制 ST - 階段式療法 NM - 不提供郵購 19 B/D - 根據 Medicare B 或 D 給付 LA - 有限的使用 * - 非 Part D 藥物, 或是 Medicaid 給付的 OTC 品項

EDECRIN 2 $0 furosemide SOLN; TABS 1 $0 furosemide inj 1 $0 hydrochlorothiazide CAPS; TABS 1 $0 indapamide 1 $0 methazolamide TABS 1 $0 methyclothiazide 1 $0 metolazone 1 $0 spironolactone & hydrochlorothiazide 1 $0 torsemide inj 1 $0 torsemide tabs 1 $0 triamterene & hydrochlorothiazide TABS 1 $0 triamterene & hydrochlorothiazide cap 37.5-25 mg 1 $0 雜項 clonidine hcl PTWK; TABS 1 $0 DEMSER 2 $0 hydralazine hcl 1 $0 midodrine hcl 1 $0 minoxidil TABS 1 $0 RANEXA 2 $0 硝酸鹽 - 治療心臟病的藥物 isosorb mononitrate tab 1 $0 isosorbide dinitrate 1 $0 isosorbide mononitrate er tab 1 $0 minitran 1 $0 nitro-bid 2 $0 NITRO-DUR DIS 0.3MG/HR 2 $0 NITRO-DUR DIS 0.8MG/HR 2 $0 nitroglycerin PT24 1 $0 NITROLINGUAL PUMPSPRAY 2 $0 NITROSTAT 2 $0 肺動脈高壓 - 治療肺動脈高壓的藥物 ADCIRCA 2 $0 QL (60 tabs / 30 days), NM, PA ADEMPAS 2 $0 QL (90 tabs / 30 days), NM, PA LETAIRIS 2 $0 QL (30 tabs / 30 days), NM, LA, PA REMODULIN 2 $0 B/D, NM, LA sildenafil citrate (pulmonary hypertension) 2 $0 QL (90 tabs / 30 days), NM, PA TRACLEER 62.5mg 2 $0 QL (120 tabs / 30 days), NM, LA, PA 20 如果您有任何疑問, 請致電 MetroPlus FIDA Plan, 電話 :1-844-288-FIDA (3432), TTY:711, 服務時間為週一至週六上午 8 時至晚上 8 時 晚上 8 時後 週日及假日 : 請撥打上列的 24 小時全年無休醫療諮詢服務專線 此電話號碼為免付費專線 如需詳細資訊, 請造訪 www.metroplusmedicare.org

TRACLEER 125mg 2 $0 QL (60 tabs / 30 days), NM, LA, PA 中樞神經系統 - 治療神經系統失常的藥物 抗焦慮 - 治療焦慮的藥物 alprazolam CONC 1 $0 QL (300 ml / 30 days) alprazolam tab 0.5mg 1 $0 QL (240 tabs / 30 days) alprazolam tab 0.25mg 1 $0 QL (480 tabs / 30 days) alprazolam tab 1mg 1 $0 QL (120 tabs / 30 days) alprazolam tab 2mg 1 $0 QL (150 tabs / 30 days) buspirone hcl TABS 1 $0 fluvoxamine maleate TABS 25mg, 50mg 1 $0 QL (45 tabs / 30 days) fluvoxamine maleate TABS 100mg 1 $0 lorazepam CONC 1 $0 QL (150 ml / 30 days) lorazepam SOLN 1 $0 lorazepam TABS 1 $0 QL (150 tabs / 30 days) 抗癲癇藥物 - 治療癲癇的藥物 APTIOM 200mg 2 $0 QL (180 tabs / 30 days) APTIOM 400mg 2 $0 QL (90 tabs / 30 days) APTIOM 600mg 2 $0 QL (60 tabs / 30 days) APTIOM 800mg 2 $0 QL (30 tabs / 30 days) BANZEL SUS 40MG/ML 2 $0 PA BANZEL TAB 200MG 2 $0 PA BANZEL TAB 400MG 2 $0 PA carbamazepine CHEW; CP12; SUSP; 1 $0 TABS; TB12 CELONTIN 2 $0 clonazepam TABS 1mg 1 $0 QL (600 tabs / 30 days) clonazepam TABS 2mg 1 $0 QL (300 tabs / 30 days) clonazepam TABS.5mg 1 $0 QL (1200 tabs / 30 days) clonazepam TBDP 1mg 1 $0 QL (600 tabs / 30 days) clonazepam TBDP 2mg 1 $0 QL (300 tabs / 30 days) clonazepam TBDP.5mg 1 $0 QL (1200 tabs / 30 days) clonazepam TBDP.25mg 1 $0 QL (2400 tabs / 30 days) clonazepam TBDP.125mg 1 $0 QL (4800 tabs / 30 days) clorazepate dipotassium 3.75mg, 7.5mg 1 $0 QL (120 tabs / 30 days), PA clorazepate dipotassium 15mg 1 $0 QL (180 tabs / 30 days), PA diazepam CONC 1 $0 QL (240 ml / 30 days), PA diazepam SOLN 1 $0 QL (1200 ml / 30 days), PA diazepam TABS 1 $0 QL (120 tabs / 30 days), PA DIAZEPAM GEL 1 $0 PA - 事先授權 QL - 數量限制 ST - 階段式療法 NM - 不提供郵購 21 B/D - 根據 Medicare B 或 D 給付 LA - 有限的使用 * - 非 Part D 藥物, 或是 Medicaid 給付的 OTC 品項

diazepam inj 1 $0 dilantin 2 $0 DILANTIN-125 SUS 125/5ML 2 $0 divalproex sodium 1 $0 epitol 1 $0 ethosuximide CAPS; SOLN 1 $0 felbamate SUSP 2 $0 felbamate TABS 400mg 1 $0 felbamate TABS 600mg 2 $0 FYCOMPA 2mg 2 $0 QL (180 tabs / 30 days), PA FYCOMPA 4mg 2 $0 QL (90 tabs / 30 days), PA FYCOMPA 6mg 2 $0 QL (60 tabs / 30 days), PA FYCOMPA 8mg, 10mg, 12mg 2 $0 QL (30 tabs / 30 days), PA gabapentin CAPS 100mg 1 $0 QL (1080 caps / 30 days) gabapentin CAPS 300mg 1 $0 QL (360 caps / 30 days) gabapentin CAPS 400mg 1 $0 QL (270 caps / 30 days) gabapentin SOLN 1 $0 QL (2160 ml / 30 days) gabapentin TABS 600mg 1 $0 QL (180 tabs / 30 days) gabapentin TABS 800mg 1 $0 QL (120 tabs / 30 days) GABITRIL 12mg, 16mg 2 $0 lamotrigine CHEW; TABS; TB24 1 $0 levetiracetam SOLN; TABS; TB24 1 $0 LYRICA CAPS 25mg, 50mg, 75mg, 2 $0 QL (120 caps / 30 days) 100mg, LYRICA CAPS 200mg 2 $0 QL (90 caps / 30 days) LYRICA CAPS 225mg, 300mg 2 $0 QL (60 caps / 30 days) LYRICA SOLN 2 $0 QL (946 ml / 30 days) ONFI 2 $0 PA oxcarbazepine 1 $0 PEGANONE 2 $0 phenobarbital ELIX; TABS 2 $0 PA PHENOBARBITAL SODIUM 65mg/ml 2 $0 PA phenobarbital sodium 130mg/ml 2 $0 PA phenytek 2 $0 phenytoin CHEW; SUSP 1 $0 phenytoin sodium SOLN 1 $0 phenytoin sodium extended 1 $0 POTIGA 50mg 2 $0 POTIGA 200mg 2 $0 QL (180 tabs / 30 days) POTIGA 300mg, 400mg 2 $0 QL (90 tabs / 30 days) 22 如果您有任何疑問, 請致電 MetroPlus FIDA Plan, 電話 :1-844-288-FIDA (3432), TTY:711, 服務時間為週一至週六上午 8 時至晚上 8 時 晚上 8 時後 週日及假日 : 請撥打上列的 24 小時全年無休醫療諮詢服務專線 此電話號碼為免付費專線 如需詳細資訊, 請造訪 www.metroplusmedicare.org

primidone TABS 1 $0 SABRIL PACK 2 $0 QL (180 packets / 30 days), NM, LA, PA SABRIL TABS 2 $0 QL (180 tabs / 30 days), NM, LA, PA TEGRETOL 2 $0 TEGRETOL-XR 2 $0 tiagabine hcl 1 $0 topiramate CPSP; TABS 1 $0 valproate sodium SOLN; SYRP 1 $0 valproic acid CAPS 1 $0 VIMPAT SOLN 10mg/ml 2 $0 QL (1200 ml / 30 days) VIMPAT SOLN 200mg/20ml 2 $0 VIMPAT TABS 50mg 2 $0 QL (180 tabs / 30 days) VIMPAT TABS 100mg, 150mg, 200mg 2 $0 QL (60 tabs / 30 days) zonisamide CAPS 1 $0 抗失智藥物 - 治療失智症與記憶力喪失的藥物 donepezil hydrochloride TABS 5mg 1 $0 QL (30 tabs / 30 days) donepezil hydrochloride TABS 10mg, 1 $0 23mg donepezil hydrochloride TBDP 5mg 1 $0 QL (30 tabs / 30 days) donepezil hydrochloride TBDP 10mg 1 $0 EXELON PATCHES 2 $0 QL (30 patches / 30 days) galantamine hydrobromide CP24 8mg, 1 $0 QL (30 caps / 30 days) 16mg galantamine hydrobromide CP24 24mg 1 $0 galantamine hydrobromide SOLN 1 $0 galantamine hydrobromide TABS 4mg 1 $0 QL (180 tabs / 30 days) galantamine hydrobromide TABS 8mg 1 $0 QL (90 tabs / 30 days) galantamine hydrobromide TABS 12mg 1 $0 NAMENDA SOLN 2 $0 PA; PA if <30 yr NAMENDA XR 7mg, 14mg 2 $0 QL (30 caps / 30 days), PA; PA if <30 yr NAMENDA XR 21mg, 28mg 2 $0 PA; PA if <30 yr NAMENDA XR TITRATION PACK 2 $0 PA; PA if <30 yr rivastigmine tartrate 1 $0 抗憂鬱劑 - 治療憂鬱症的藥物 amitriptyline hcl TABS 2 $0 PA amoxapine tab 25mg 1 $0 amoxapine tab 50mg 1 $0 amoxapine tab 100mg 1 $0 PA - 事先授權 QL - 數量限制 ST - 階段式療法 NM - 不提供郵購 23 B/D - 根據 Medicare B 或 D 給付 LA - 有限的使用 * - 非 Part D 藥物, 或是 Medicaid 給付的 OTC 品項

amoxapine tab 150mg 1 $0 BRINTELLIX 5mg 2 $0 QL (120 tabs / 30 days) BRINTELLIX 10mg 2 $0 QL (60 tabs / 30 days) BRINTELLIX 20mg 2 $0 QL (30 tabs / 30 days) bupropion hcl TABS 1 $0 bupropion hcl TB12 1 $0 bupropion hcl TB24 150mg 1 $0 QL (90 tabs / 30 days) bupropion hcl TB24 300mg 1 $0 QL (30 tabs / 30 days) citalopram hydrobromide SOLN 1 $0 citalopram hydrobromide TABS 10mg, 1 $0 QL (45 tabs / 30 days) 20mg citalopram hydrobromide TABS 40mg 1 $0 QL (30 tabs / 30 days) clomipramine hcl CAPS 2 $0 PA desipramine hcl TABS 1 $0 doxepin hcl CAPS; CONC 2 $0 PA duloxetine hcl CPEP 1 $0 QL (60 caps / 30 days) EMSAM 2 $0 QL (30 patches / 30 days), PA escitalopram oxalate SOLN 1 $0 QL (600 ml / 30 days) escitalopram oxalate TABS 5mg, 10mg 1 $0 QL (45 tabs / 30 days) escitalopram oxalate TABS 20mg 1 $0 QL (60 tabs / 30 days) FETZIMA 20mg 2 $0 QL (180 caps / 30 days) FETZIMA 40mg 2 $0 QL (90 caps / 30 days) FETZIMA 80mg, 120mg 2 $0 QL (30 caps / 30 days) FETZIMA TITRATION PACK 2 $0 fluoxetine hcl CAPS 10mg 1 $0 QL (30 caps / 30 days) fluoxetine hcl CAPS 20mg 1 $0 QL (120 caps / 30 days) fluoxetine hcl CAPS 40mg 1 $0 fluoxetine hcl SOLN 1 $0 fluoxetine hcl TABS 10mg 1 $0 QL (45 tabs / 30 days) fluoxetine hcl TABS 20mg 1 $0 imipramine hcl TABS 2 $0 PA maprotiline hcl 1 $0 MARPLAN TAB 10MG 2 $0 QL (180 tabs / 30 days) mirtazapine TABS 7.5mg, 15mg 1 $0 QL (45 tabs / 30 days) mirtazapine TABS 30mg, 45mg 1 $0 mirtazapine TBDP 15mg 1 $0 QL (30 tabs / 30 days) mirtazapine TBDP 30mg, 45mg 1 $0 nefazodone hcl 1 $0 nortriptyline hcl CAPS; SOLN 1 $0 paroxetine hcl TABS 10mg, 20mg, 40mg 1 $0 QL (45 tabs / 30 days) 24 如果您有任何疑問, 請致電 MetroPlus FIDA Plan, 電話 :1-844-288-FIDA (3432), TTY:711, 服務時間為週一至週六上午 8 時至晚上 8 時 晚上 8 時後 週日及假日 : 請撥打上列的 24 小時全年無休醫療諮詢服務專線 此電話號碼為免付費專線 如需詳細資訊, 請造訪 www.metroplusmedicare.org

paroxetine hcl TABS 30mg 1 $0 QL (60 tabs / 30 days) PAXIL SUSP 2 $0 QL (900 ml / 30 days) phenelzine sulfate TABS 1 $0 PRISTIQ 2 $0 QL (30 tabs / 30 days) protriptyline hcl 1 $0 sertraline hcl CONC 1 $0 sertraline hcl TABS 25mg, 50mg 1 $0 QL (45 tabs / 30 days) sertraline hcl TABS 100mg 1 $0 SURMONTIL CAP 25MG 2 $0 QL (240 caps / 30 days), PA SURMONTIL CAP 50MG 2 $0 QL (120 caps / 30 days), PA SURMONTIL CAP 100MG 2 $0 QL (60 caps / 30 days), PA tranylcypromine sulfate 1 $0 trazodone hcl TABS 50mg, 100mg, 1 $0 venlafaxine hcl CP24 37.5mg, 75mg 1 $0 QL (30 caps / 30 days) venlafaxine hcl CP24 150mg 1 $0 QL (60 caps / 30 days) venlafaxine hcl TABS 1 $0 VIIBRYD KIT 2 $0 VIIBRYD TABS 2 $0 QL (30 tabs / 30 days) 抗巴金森症藥物 - 治療抗巴金森症的藥物 amantadine hcl CAPS; SYRP; TABS 1 $0 APOKYN 2 $0 NM, LA, PA AZILECT 2 $0 benztropine mesylate SOLN 1 $0 benztropine mesylate TABS 2 $0 PA bromocriptine mesylate CAPS; TABS 1 $0 carbidopa-levodopa 1 $0 CARBIDOPA/LEVODOPA/ENTACAPONE 1 $0 entacapone 1 $0 NEUPRO 2 $0 pramipexole dihydrochloride 1 $0 ropinirole hydrochloride TABS 1 $0 selegiline hcl CAPS; TABS 1 $0 抗精神病劑 - 治療精神病的藥物 ABILIFY SOLN 1mg/ml 2 $0 QL (900 ml / 30 days) ABILIFY SOLN 9.75mg/1.3ml 2 $0 QL (4 ml / 1 day) ABILIFY TABS 2 $0 QL (30 tabs / 30 days) ABILIFY DISCMELT 2 $0 QL (60 tabs / 30 days) ABILIFY MAIN INJ 300MG 2 $0 QL (1 vial / 28 days) ABILIFY MAIN INJ 400MG 2 $0 QL (1 vial / 28 days) PA - 事先授權 QL - 數量限制 ST - 階段式療法 NM - 不提供郵購 25 B/D - 根據 Medicare B 或 D 給付 LA - 有限的使用 * - 非 Part D 藥物, 或是 Medicaid 給付的 OTC 品項

chlorpromazine hcl SOLN 2 $0 chlorpromazine hcl TABS 1 $0 clozapine TABS 25mg, 50mg 1 $0 clozapine TABS 100mg 1 $0 QL (270 tabs / 30 days) clozapine TABS 200mg 1 $0 QL (135 tabs / 30 days) CLOZAPINE TBDP 12.5mg, 25mg 1 $0 PA CLOZAPINE TBDP 100mg 1 $0 QL (270 tabs / 30 days), PA FANAPT 2 $0 QL (60 tabs / 30 days), ST FANAPT TITRATION PACK 2 $0 ST FAZACLO TAB 12.5/ODT 2 $0 PA FAZACLO TAB 25MG ODT 2 $0 PA FAZACLO TAB 100/ODT 2 $0 QL (270 tabs / 30 days), PA FAZACLO TAB 150MG 2 $0 QL (180 tabs / 30 days), PA FAZACLO TAB 200MG 2 $0 QL (135 tabs / 30 days), PA fluphenazine decanoate SOLN 1 $0 fluphenazine hcl 1 $0 GEODON SOLR 2 $0 QL (6 ml / 3 days) haloperidol TABS 1 $0 haloperidol decanoate SOLN 1 $0 haloperidol lactate 1 $0 haloperidol lactate oral conc 2 mg/ml 1 $0 INVEGA 1.5mg, 3mg, 9mg 2 $0 QL (30 tabs / 30 days) INVEGA 6mg 2 $0 QL (60 tabs / 30 days) INVEGA SUST INJ 39 MG/0.25 ML 2 $0 QL (1 injection / 28 days) INVEGA SUST INJ 78 MG/0.5 ML 2 $0 QL (1 injection / 28 days) INVEGA SUST INJ 117 MG/0.75 ML 2 $0 QL (1 injection / 28 days) INVEGA SUST INJ 156MG/ML 2 $0 QL (1 injection / 28 days) INVEGA SUST INJ 234 MG/1.5 ML 2 $0 QL (1 injection / 28 days) LATUDA 20mg 2 $0 QL (240 tabs / 30 days) LATUDA 40mg, 120mg 2 $0 QL (30 tabs / 30 days) LATUDA 60mg, 80mg 2 $0 QL (60 tabs / 30 days) loxapine succinate 1 $0 olanzapine SOLR 1 $0 QL (3 vials / 1 day) olanzapine TABS 2.5mg, 5mg, 7.5mg 1 $0 QL (30 tabs / 30 days) olanzapine TABS 10mg, 15mg, 20mg 1 $0 QL (60 tabs / 30 days) olanzapine TBDP 5mg 1 $0 QL (30 tabs / 30 days) olanzapine TBDP 10mg, 15mg 1 $0 QL (60 tabs / 30 days) olanzapine TBDP 20mg 2 $0 QL (60 tabs / 30 days) ORAP 2 $0 perphenazine TABS 1 $0 26 如果您有任何疑問, 請致電 MetroPlus FIDA Plan, 電話 :1-844-288-FIDA (3432), TTY:711, 服務時間為週一至週六上午 8 時至晚上 8 時 晚上 8 時後 週日及假日 : 請撥打上列的 24 小時全年無休醫療諮詢服務專線 此電話號碼為免付費專線 如需詳細資訊, 請造訪 www.metroplusmedicare.org

quetiapine fumarate 1 $0 QL (90 tabs / 30 days) RISPERDAL INJ 12.5MG 2 $0 QL (2 injections / 28 days) RISPERDAL INJ 25MG 2 $0 QL (2 injections / 28 days) RISPERDAL INJ 37.5MG 2 $0 QL (2 injections / 28 days) RISPERDAL INJ 50MG 2 $0 QL (2 injections / 28 days) risperidone SOLN 1 $0 QL (240 ml / 30 days) risperidone TABS 1mg, 2mg, 3mg 1 $0 QL (60 tabs / 30 days) risperidone TABS 4mg 1 $0 QL (120 tabs / 30 days) risperidone TABS.25mg,.5mg 1 $0 QL (90 tabs / 30 days) risperidone TBDP 1mg, 2mg, 3mg 1 $0 QL (60 tabs / 30 days) risperidone TBDP 4mg 1 $0 QL (120 tabs / 30 days) risperidone TBDP.25mg,.5mg 1 $0 QL (90 tabs / 30 days) SAPHRIS 5mg 2 $0 QL (120 tabs / 30 days) SAPHRIS 10mg 2 $0 QL (60 tabs / 30 days) SEROQUEL XR 50mg 2 $0 QL (120 tabs / 30 days) SEROQUEL XR 150mg, 200mg 2 $0 QL (30 tabs / 30 days) SEROQUEL XR 300mg, 400mg 2 $0 QL (60 tabs / 30 days) thioridazine hcl TABS 2 $0 PA thiothixene 1 $0 trifluoperazine hcl 1 $0 VERSACLOZ 2 $0 QL (600 ml / 30 days), PA ziprasidone hcl 20mg, 40mg 1 $0 QL (60 caps / 30 days) ziprasidone hcl 60mg, 80mg 1 $0 QL (90 caps / 30 days) 注意力缺陷過動症 - 治療 ADHD 的藥物 amphetamine-dextroamphetamine cap sr 1 $0 QL (90 caps / 30 days) 24hr 5 mg amphetamine-dextroamphetamine cap sr 1 $0 QL (90 caps / 30 days) 24hr 10 mg amphetamine-dextroamphetamine cap sr 1 $0 QL (30 caps / 30 days) 24hr 15 mg amphetamine-dextroamphetamine cap sr 1 $0 QL (30 caps / 30 days) 24hr 20 mg amphetamine-dextroamphetamine cap sr 1 $0 QL (30 caps / 30 days) 24hr 25 mg amphetamine-dextroamphetamine cap sr 1 $0 QL (30 caps / 30 days) 24hr 30 mg amphetamine-dextroamphetamine tab 5 mg 1 $0 QL (360 tabs / 30 days) amphetamine-dextroamphetamine tab 7.5 1 $0 QL (240 tabs / 30 days) mg PA - 事先授權 QL - 數量限制 ST - 階段式療法 NM - 不提供郵購 27 B/D - 根據 Medicare B 或 D 給付 LA - 有限的使用 * - 非 Part D 藥物, 或是 Medicaid 給付的 OTC 品項

amphetamine-dextroamphetamine tab 10 mg 1 $0 QL (180 tabs / 30 days) amphetamine-dextroamphetamine tab 12.5 1 $0 QL (144 tabs / 30 days) mg amphetamine-dextroamphetamine tab 15 1 $0 QL (120 tabs / 30 days) mg amphetamine-dextroamphetamine tab 20 1 $0 QL (90 tabs / 30 days) mg amphetamine-dextroamphetamine tab 30 1 $0 QL (60 tabs / 30 days) mg INTUNIV 2 $0 metadate tab 20mg er 1 $0 QL (90 tabs / 30 days) methylphenidate hcl TABS 5mg, 10mg 1 $0 QL (180 tabs / 30 days) methylphenidate hcl TABS 20mg 1 $0 QL (90 tabs / 30 days) methylphenidate hcl TBCR 10mg, 20mg 1 $0 QL (90 tabs / 30 days) methylphenidate hcl oral soln 5mg/5ml 1 $0 QL (1800 ml / 30 days) methylphenidate hcl oral soln 10mg/5ml 1 $0 QL (900 ml / 30 days) STRATTERA 10mg, 18mg, 25mg 2 $0 QL (120 caps / 30 days) STRATTERA 40mg 2 $0 QL (60 caps / 30 days) STRATTERA 60mg, 80mg, 100mg 2 $0 QL (30 caps / 30 days) 安眠藥 - 治療失眠的藥物 ROZEREM 2 $0 QL (30 tabs / 30 days) SILENOR 3mg 2 $0 QL (60 tabs / 30 days) SILENOR 6mg 2 $0 QL (30 tabs / 30 days) temazepam 7.5mg 1 $0 QL (30 caps / 30 days), PA; 90 day limit if >64 yr temazepam 15mg 1 $0 QL (60 caps / 30 days), PA; 90 day limit if >64 yr zolpidem tartrate TABS 2 $0 QL (30 tabs / 30 days), PA; 90 day limit if >64 yr 偏頭痛 - 治療嚴重頭痛的藥物 cafergot 2 $0 dihydroergotamine mesylate 1 $0 naratriptan hcl 1 $0 QL (9 tabs / 30 days) RELPAX 2 $0 QL (12 tabs / 30 days) rizatriptan benzoate 1 $0 QL (18 tabs / 30 days) SUMATRIPTAN SOLN 5mg/act 1 $0 QL (24 inhalers / 30 days) SUMATRIPTAN SOLN 20mg/act 1 $0 QL (12 inhalers / 30 days) SUMATRIPTAN SUCCINATE SOCT 1 $0 QL (6 ml / 30 days) sumatriptan succinate SOSY 1 $0 QL (6 ml / 30 days) sumatriptan succinate TABS 1 $0 QL (9 tabs / 30 days) 28 如果您有任何疑問, 請致電 MetroPlus FIDA Plan, 電話 :1-844-288-FIDA (3432), TTY:711, 服務時間為週一至週六上午 8 時至晚上 8 時 晚上 8 時後 週日及假日 : 請撥打上列的 24 小時全年無休醫療諮詢服務專線 此電話號碼為免付費專線 如需詳細資訊, 請造訪 www.metroplusmedicare.org

SUMATRIPTAN SUCCINATE INJ SOAJ 1 $0 QL (6 ml / 30 days) 4mg/0.5ml sumatriptan succinate inj SOAJ 1 $0 QL (6 ml / 30 days) SUMATRIPTAN SUCCINATE INJ SOCT 1 $0 QL (6 ml / 30 days) sumatriptan succinate inj SOLN 1 $0 QL (6 ml / 30 days) zolmitriptan TABS 1 $0 QL (12 tabs / 30 days) zolmitriptan odt 1 $0 QL (12 tabs / 30 days) 雜項 LITHIUM 2 $0 lithium carbonate CAPS; TABS 1 $0 lithium carbonate er 1 $0 NUEDEXTA 2 $0 PA pyridostigmine bromide TABS 1 $0 riluzole 1 $0 XENAZINE 12.5mg 2 $0 QL (240 tabs / 30 days), NM, LA, PA XENAZINE 25mg 2 $0 QL (120 tabs / 30 days), NM, LA, PA 多發性硬化症藥劑 - 治療多發性硬化症的藥物 BETASERON 2 $0 QL (14 syringes / 28 days), NM, PA COPAXONE INJ 40MG/ML 2 $0 QL (12 syringes / 28 days), NM, PA COPAXONE KIT 20MG/ML 2 $0 QL (1 kit / 30 days), NM, PA GILENYA CAP 0.5MG 2 $0 QL (28 caps / 28 days), NM, PA TYSABRI 2 $0 NM, LA, PA 骨骼肌肉疾病治療藥劑 - 治療骨骼肌肉疾病的藥物 baclofen TABS 1 $0 cyclobenzaprine hcl TABS 5mg, 10mg 1 $0 PA dantrolene sodium CAPS 1 $0 tizanidine hcl TABS 1 $0 嗜睡症 / 猝倒症 - 治療睡眠障礙的藥物 NUVIGIL 50mg 2 $0 QL (150 tabs / 30 days), PA NUVIGIL 150mg 2 $0 QL (60 tabs / 30 days), PA NUVIGIL 200mg, 250mg 2 $0 QL (30 tabs / 30 days), PA XYREM 2 $0 QL (540 ml / 30 days), LA, PA 精神病醫療 - 雜項 acamprosate calcium 1 $0 buprenorphine hcl SUBL 1 $0 PA buprenorphine hcl-naloxone hcl sl 1 $0 QL (120 tabs / 30 days), PA buproban 1 $0 PA - 事先授權 QL - 數量限制 ST - 階段式療法 NM - 不提供郵購 29 B/D - 根據 Medicare B 或 D 給付 LA - 有限的使用 * - 非 Part D 藥物, 或是 Medicaid 給付的 OTC 品項

CHANTIX 2 $0 PA CHANTIX STARTER PACK 2 $0 PA diphenhydramine hcl (sleep) 3 $0 NM; * diphenhydramine-acetaminophen (sleep) 3 $0 NM; * disulfiram TABS 1 $0 doxylamine succinate (sleep) 3 $0 NM; * ibuprofen-diphenhydramine citrate 3 $0 NM; * naloxone hcl SOLN 1 $0 naltrexone hcl TABS 1 $0 nicotine 3 $0 NM; * nicotine polacrilex GUM 3 $0 NM; * nicotine polacrilex LOZG 2mg, 4mg 3 $0 NM; * NICOTINE POLACRILEX LOZG 2mg, 4mg 3 $0 NM; * NICOTINE TRANSDERMAL SYST 3 $0 NM; * NICOTROL INHALER 2 $0 NICOTROL NS 2 $0 SUBOXONE MIS 2-0.5MG 2 $0 QL (4 boxes / 30 days), PA SUBOXONE MIS 4-1MG 2 $0 QL (4 boxes / 30 days), PA SUBOXONE MIS 8-2MG 2 $0 QL (4 boxes / 30 days), PA SUBOXONE MIS 12-3MG 2 $0 QL (2 boxes / 30 days), PA 內分泌與代謝 - 治療糖尿病與調節賀爾蒙的藥物 男性賀爾蒙 - 調節男性賀爾蒙的藥物 ANDRODERM 2 $0 QL (30 patches / 30 days), PA androxy 2 $0 PA oxandrolone TABS 1 $0 PA TESTIM 2 $0 QL (300 grams / 30 days), PA testosterone cypionate SOLN 1 $0 testosterone enanthate SOLN 1 $0 抗糖尿病注射劑 - 治療糖尿病的藥物 ALCOHOL SWABS 2 $0 GAUZE PADS 2" X 2" 2 $0 HUMULIN R INJ U-500 2 $0 B/D INSULIN PEN NEEDLE 2 $0 INSULIN SAFETY NEEDLES 2 $0 INSULIN SYRINGE 2 $0 LANTUS 2 $0 LANTUS SOLOSTAR 2 $0 LEVEMIR 2 $0 LEVEMIR FLEXPEN 2 $0 30 如果您有任何疑問, 請致電 MetroPlus FIDA Plan, 電話 :1-844-288-FIDA (3432), TTY:711, 服務時間為週一至週六上午 8 時至晚上 8 時 晚上 8 時後 週日及假日 : 請撥打上列的 24 小時全年無休醫療諮詢服務專線 此電話號碼為免付費專線 如需詳細資訊, 請造訪 www.metroplusmedicare.org

NOVOLIN 70/30 2 $0 RELION not covered NOVOLIN N 2 $0 RELION not covered NOVOLIN R 2 $0 RELION not covered NOVOLOG 2 $0 NOVOLOG FLEXPEN 2 $0 NOVOLOG MIX 70/30 2 $0 NOVOLOG MIX 70/30 PREFILL 2 $0 NOVOLOG PENFILL 2 $0 SYMLINPEN 60 2 $0 QL (8 pens / 30 days), PA SYMLINPEN 120 2 $0 QL (4 pens / 30 days), PA VICTOZA 2 $0 QL (3 pens / 30 days) 抗糖尿病口服劑 - 治療糖尿病的藥物 acarbose 1 $0 glimepiride 1mg 1 $0 QL (240 tabs / 30 days) glimepiride 2mg 1 $0 QL (120 tabs / 30 days) glimepiride 4mg 1 $0 QL (60 tabs / 30 days) glip/metform tab 5-500mg 1 $0 QL (120 tabs / 30 days) glipizide TABS 5mg 1 $0 QL (240 tabs / 30 days) glipizide TABS 10mg 1 $0 QL (120 tabs / 30 days) glipizide TB24 2.5mg 1 $0 QL (240 tabs / 30 days) glipizide TB24 5mg 1 $0 QL (120 tabs / 30 days) glipizide TB24 10mg 1 $0 QL (60 tabs / 30 days) glipizide-metformin hcl tab 2.5-250 mg 1 $0 QL (240 tabs / 30 days) glipizide-metformin hcl tab 2.5-500 mg 1 $0 QL (120 tabs / 30 days) INVOKANA 100mg 2 $0 QL (90 tabs / 30 days) INVOKANA 300mg 2 $0 QL (30 tabs / 30 days) JANUMET 2 $0 QL (60 tabs / 30 days) JANUMET XR TAB 50-500MG 2 $0 QL (60 tabs / 30 days) JANUMET XR TAB 50-1000 2 $0 QL (60 tabs / 30 days) JANUMET XR TAB 100-1000 2 $0 QL (30 tabs / 30 days) JANUVIA 2 $0 QL (30 tabs / 30 days) JENTADUETO 2 $0 QL (60 tabs / 30 days) metformin hcl TABS 500mg 1 $0 QL (150 tabs / 30 days) metformin hcl TABS 850mg 1 $0 QL (90 tabs / 30 days) metformin hcl TABS 1000mg 1 $0 QL (75 tabs / 30 days) metformin hcl TB24 500mg 1 $0 QL (120 tabs / 30 days) metformin hcl TB24 750mg 1 $0 QL (60 tabs / 30 days) nateglinide 1 $0 QL (90 tabs / 30 days) pioglitazone hcl 1 $0 QL (30 tabs / 30 days) repaglinide 2mg 1 $0 QL (240 tabs / 30 days) PA - 事先授權 QL - 數量限制 ST - 階段式療法 NM - 不提供郵購 31 B/D - 根據 Medicare B 或 D 給付 LA - 有限的使用 * - 非 Part D 藥物, 或是 Medicaid 給付的 OTC 品項

repaglinide.5mg, 1mg 1 $0 QL (120 tabs / 30 days) RIOMET 2 $0 QL (946 ml / 30 days) TRADJENTA 2 $0 QL (30 tabs / 30 days) 雙磷酸鹽類藥物 - 治療 骨質流失的藥物 alendronate sodium TABS 5mg, 10mg, 1 $0 40mg alendronate sodium TABS 35mg, 70mg 1 $0 QL (4 tabs / 28 days) ibandronate sodium TABS 1 $0 B/D, QL (1 tab / 30 days) pamidronate disodium SOLN 1 $0 B/D zoledronic inj 4mg/5ml 2 $0 B/D, NM ZOMETA SOLN 2 $0 B/D, NM 鈣受體致效劑 SENSIPAR 30mg, 90mg 2 $0 QL (120 tabs / 30 days), NM SENSIPAR 60mg 2 $0 QL (60 tabs / 30 days), NM 螯合劑 CHEMET 2 $0 DEPEN TITRATABS 2 $0 EXJADE 2 $0 NM, LA, PA kionex 1 $0 sodium polystyrene sulfonate 1 $0 sps susp 15gm/60ml 1 $0 SYPRINE 2 $0 避孕藥 - 節育藥物 altavera 1 $0 apri 28 day 1 $0 aranelle 28 1 $0 aviane 28 1 $0 balziva 28 day 1 $0 briellyn 28 day 1 $0 camila 28 day 1 $0 cryselle 28 1 $0 cyclafem 1/35 28 day 1 $0 cyclafem 7/7/7 28 day 1 $0 drospirenone-ethinyl estradiol 1 $0 ELLA 2 $0 emoquette 1 $0 enpresse 28 day 1 $0 errin 28 day 1 $0 GIANVI 1 $0 gildagia 1 $0 32 如果您有任何疑問, 請致電 MetroPlus FIDA Plan, 電話 :1-844-288-FIDA (3432), TTY:711, 服務時間為週一至週六上午 8 時至晚上 8 時 晚上 8 時後 週日及假日 : 請撥打上列的 24 小時全年無休醫療諮詢服務專線 此電話號碼為免付費專線 如需詳細資訊, 請造訪 www.metroplusmedicare.org

heather 1 $0 introvale 91 day 1 $0 JOLIVETTE 1 $0 junel 1.5/30 21 day 1 $0 junel 1/20 21 day 1 $0 junel fe 1.5/30 28 day 1 $0 junel fe 1/20 28 day 1 $0 kariva 28 day 1 $0 larin 1/20 1 $0 larin fe 1.5/30 1 $0 larin fe 1/20 1 $0 LEENA 1 $0 lessina 28 day 1 $0 levonest 28 day 1 $0 levonorgestrel (emergency oc) 1.5mg 3 $0 NM; * levonorgestrel (emergency oc).75mg, 1 $0 1.5mg levonorgestrel-ethinyl estradiol (91-day) 1 $0 levora 0.15/30 28 day 1 $0 loryna 28 day 1 $0 low-ogestrel 28 day 1 $0 lutera 28 day 1 $0 lyza 1 $0 marlissa 28 day 1 $0 medroxyprogesterone acetate 150 mg/ml 1 $0 microgestin 1.5/30 21 day 1 $0 microgestin 1/20 21 day 1 $0 microgestin fe 1.5/30 28 day 1 $0 microgestin fe 1/20 28 day 1 $0 MONONESSA 1 $0 my way 1 $0 myzilra 1 $0 necon 0.5/35 28 day 1 $0 necon 1/35 28 day 1 $0 NECON 7/7/7 1 $0 necon 10/11 28 day 2 $0 NECON TAB 1/50-28 1 $0 next choice one dose 1 $0 NORA-BE TAB 1 $0 norethindrone (contraceptive) 1 $0 PA - 事先授權 QL - 數量限制 ST - 階段式療法 NM - 不提供郵購 33 B/D - 根據 Medicare B 或 D 給付 LA - 有限的使用 * - 非 Part D 藥物, 或是 Medicaid 給付的 OTC 品項

norgestimate-ethinyl estradiol (triphasic) 1 $0 nortrel 0.5/35 28 day 1 $0 nortrel 1/35 21 day 1 $0 nortrel 1/35 28 day 1 $0 nortrel 7/7/7 28 day 1 $0 NUVARING 2 $0 OCELLA TAB 3-0.03MG 1 $0 orsythia 28 day 1 $0 philith 1 $0 pimtrea pack 1 $0 pirmella 1/35 28 day 1 $0 portia 28 day 1 $0 previfem 28 day 1 $0 quasense 91 day 1 $0 reclipsen 28 day 1 $0 SOLIA 1 $0 sprintec 28 day 1 $0 sronyx 1 $0 tri-legest 28 day 1 $0 tri-previfem 28 day 1 $0 tri-sprintec 28 day 1 $0 TRINESSA 1 $0 trivora 28 day 1 $0 velivet 28 day 1 $0 vestura 1 $0 viorele 1 $0 vyfemia 28 day 1 $0 xulane 1 $0 zarah 1 $0 zenchent 28 day 1 $0 子宮內膜異位症 danazol CAPS 1 $0 SYNAREL 2 $0 酵素替代劑 - 治療酶缺損的藥物 ADAGEN 2 $0 NM, LA, PA ALDURAZYME 2 $0 NM, LA, PA CARBAGLU 2 $0 NM, LA, PA CEREZYME 2 $0 NM, PA CYSTADANE 2 $0 NM CYSTAGON 2 $0 NM, PA 34 如果您有任何疑問, 請致電 MetroPlus FIDA Plan, 電話 :1-844-288-FIDA (3432), TTY:711, 服務時間為週一至週六上午 8 時至晚上 8 時 晚上 8 時後 週日及假日 : 請撥打上列的 24 小時全年無休醫療諮詢服務專線 此電話號碼為免付費專線 如需詳細資訊, 請造訪 www.metroplusmedicare.org

FABRAZYME 2 $0 NM, PA KUVAN 2 $0 NM, PA levocarnitine (metabolic modifiers) 1 $0 B/D LUMIZYME 2 $0 NM, PA MYOZYME 2 $0 NM, PA NAGLAZYME 2 $0 NM, LA, PA ORFADIN 2 $0 NM, PA sodium phenylbutyrate 2 $0 NM ZAVESCA 2 $0 NM, LA, PA 女性賀爾蒙 - 調節女性賀爾蒙的藥物 COMBIPATCH 2 $0 PA estradiol PTWK; TABS 2 $0 PA ESTRADIOL VALERATE OIL 10mg/ml, 1 $0 40mg/ml estradiol valerate OIL 20mg/ml 1 $0 PREMARIN CREAM 2 $0 VAGIFEM 2 $0 葡萄糖皮質素 - 治療發炎反應的藥物 a-hydrocort 1 $0 cortisone acetate TABS 1 $0 dexamethasone CONC; ELIX; SOLN; TABS 1 $0 dexamethasone sodium phosphate 1 $0 fludrocortisone acetate TABS 1 $0 hydrocortisone TABS 1 $0 methylpr ace inj 40mg/ml 1 $0 B/D methylpr ace inj 80mg/ml 1 $0 B/D methylpr ss inj 1gm 1 $0 B/D methylpr ss inj 40mg 1 $0 B/D methylpr ss inj 125mg 1 $0 B/D methylpr ss inj 500mg 1 $0 B/D methylpred pak 4mg 1 $0 B/D methylpred tab 4mg 1 $0 B/D methylpred tab 8mg 1 $0 B/D methylpred tab 16mg 1 $0 B/D methylpred tab 32mg 1 $0 B/D pred sod pho sol 5mg/5ml 1 $0 B/D prednisolone sol 15mg/5ml 1 $0 B/D prednisolone sol 25mg/5ml 1 $0 B/D prednisolone syp 15mg/5ml 1 $0 B/D prednisone con 5mg/ml 2 $0 B/D PA - 事先授權 QL - 數量限制 ST - 階段式療法 NM - 不提供郵購 35 B/D - 根據 Medicare B 或 D 給付 LA - 有限的使用 * - 非 Part D 藥物, 或是 Medicaid 給付的 OTC 品項

prednisone pak 5mg 1 $0 B/D prednisone pak 10mg 1 $0 B/D prednisone sol 5mg/5ml 1 $0 B/D prednisone tab 1mg 1 $0 B/D prednisone tab 2.5mg 1 $0 B/D prednisone tab 5mg 1 $0 B/D prednisone tab 10mg 1 $0 B/D prednisone tab 20mg 1 $0 B/D prednisone tab 50mg 1 $0 B/D SOLU-CORTEF 250mg 2 $0 血糖提升劑 - 治療低血糖的藥物 GLUCAGEN HYPOKIT 2 $0 GLUCAGON EMERGENCY KIT 2 $0 PROGLYCEM 2 $0 生長賀爾蒙 - 調節腦下垂體賀爾蒙的藥物 NORDITROPIN FLEXPRO 2 $0 NM, PA NORDITROPIN NORDIFLEX PEN 2 $0 NM, PA TEV-TROPIN 2 $0 NM, PA cabergoline 1 $0 calcitonin (salmon) 1 $0 FORTICAL 2 $0 INCRELEX 2 $0 NM, LA, PA methylergonovine maleate TABS 1 $0 MIACALCIN 200unit/ml 2 $0 B/D octreotide acetate 50mcg/ml, 100mcg/ml, 1 $0 NM, PA 200mcg/ml, octreotide acetate 500mcg/ml, 2 $0 NM, PA 1000mcg/ml PROLIA 2 $0 QL (1 syringe / 180 days), NM raloxifene hcl 1 $0 SANDOSTATIN LAR DEPOT 2 $0 NM, PA SOMATULINE DEPOT 2 $0 NM, PA SOMAVERT 10mg, 15mg, 20mg 2 $0 NM, LA, PA XGEVA 2 $0 NM, PA 雜項 副甲狀腺素 - 調節副甲狀腺素高低的藥物 36 如果您有任何疑問, 請致電 MetroPlus FIDA Plan, 電話 :1-844-288-FIDA (3432), TTY:711, 服務時間為週一至週六上午 8 時至晚上 8 時 晚上 8 時後 週日及假日 : 請撥打上列的 24 小時全年無休醫療諮詢服務專線 此電話號碼為免付費專線 如需詳細資訊, 請造訪 www.metroplusmedicare.org

FORTEO 2 $0 QL (1 pen / 28 days), NM, PA 磷結合劑 - 調節鈣與磷數量的藥物 calcium acetate (phosphate binder) 1 $0 FOSRENOL 2 $0 PHOSLYRA 2 $0 RENVELA PAK 0.8GM 2 $0 RENVELA PAK 2.4GM 2 $0 RENVELA TAB 800MG 2 $0 黃體素 - 調節女性賀爾蒙的藥物 medroxyprogesterone acetate tab 1 $0 norethindrone acetate TABS 1 $0 甲狀腺藥劑 - 調節 levothyroxine sodium TABS 1 $0 LEVOXYL 1 $0 liothyronine sodium TABS 1 $0 methimazole TABS 1 $0 propylthiouracil TABS 1 $0 SYNTHROID 2 $0 UNITHROID 1 $0 甲狀腺分泌量的藥物 腦下垂體激素 - 調節腦下垂體賀爾蒙的藥物 desmopressin acetate spray 1 $0 desmopressin acetate spray refrigerated 1 $0 desmopressin acetate tabs 1 $0 desmopressin inj 4mcg/ml 1 $0 DESMOPRESSIN SOL 0.01% 1 $0 胃腸道 - 治療胃與腸道疾患的藥物 制酸劑 alum & mag hydrox-simethicone 3 $0 NM; * ALUMINUM HYDROXIDE 3 $0 NM; * aluminum hydroxide gel 3 $0 NM; * aluminum hydroxide-mag carb 3 $0 NM; * aluminum hydroxide-mag trisil 3 $0 NM; * CALCIUM CARBONATE TABS 648mg 3 $0 NM; * calcium carbonate (antacid) 3 $0 NM; * calcium carbonate-mag hydrox 3 $0 NM; * calcium carbonate-simethicone 3 $0 NM; * GAVISCON CHEW 3 $0 NM; * PA - 事先授權 QL - 數量限制 ST - 階段式療法 NM - 不提供郵購 37 B/D - 根據 Medicare B 或 D 給付 LA - 有限的使用 * - 非 Part D 藥物, 或是 Medicaid 給付的 OTC 品項

GAVISCON EXTRA STRENGTH R SUSP 3 $0 NM; * MAALOX TC 3 $0 NM; * MAG-AL 3 $0 NM; * MAGNESIUM OXIDE CAPS 3 $0 NM; * magnesium oxide TABS 3 $0 NM; * SODIUM BICARBONATE POWD 3 $0 NM; * sodium bicarbonate (antacid) 3 $0 NM; * URO-MAG 3 $0 NM; * 止瀉藥 bismuth subsalicylate CHEW; SUSP; TABS 3 $0 NM; * FLORASTOR KIDS 3 $0 NM; * lactobacillus 3 $0 NM; * lactobacillus rhamnosus (gg) 3 $0 NM; * loperamide hcl LIQD; SUSP; TABS 3 $0 NM; * PROBIOTIC FORMULA 3 $0 NM; * RISA-BID PROBIOTIC 3 $0 NM; * saccharomyces boulardii 3 $0 NM; * 止吐劑 - 緩解噁心與嘔吐的藥物 compro 1 $0 dimenhydrinate TABS 3 $0 NM; * dronabinol 2.5mg, 5mg 1 $0 B/D, QL (60 caps / 30 days) dronabinol 10mg 2 $0 B/D, QL (60 caps / 30 days) EMEND CAP 40MG 1 $0 PA EMEND CAP 80MG 2 $0 B/D EMEND CAP 125MG 2 $0 B/D EMEND PAK 80 & 125 2 $0 B/D granisetron hcl SOLN 1 $0 granisetron hcl TABS 1 $0 B/D meclizine hcl CHEW 3 $0 NM; * meclizine hcl TABS 12.5mg, 25mg 1 $0 meclizine hcl TABS 25mg, 32mg 3 $0 NM; * metoclopramide hcl SOLN; TABS 1 $0 metoclopramide inj 1 $0 ondansetron hcl SOLN 1 $0 ondansetron hcl TABS 1 $0 B/D ondansetron hcl inj 1 $0 ondansetron hcl oral soln 1 $0 B/D ondansetron odt 1 $0 B/D prochlorperazine inj 1 $0 prochlorperazine maleate TABS 1 $0 38 如果您有任何疑問, 請致電 MetroPlus FIDA Plan, 電話 :1-844-288-FIDA (3432), TTY:711, 服務時間為週一至週六上午 8 時至晚上 8 時 晚上 8 時後 週日及假日 : 請撥打上列的 24 小時全年無休醫療諮詢服務專線 此電話號碼為免付費專線 如需詳細資訊, 請造訪 www.metroplusmedicare.org

prochlorperazine supp 1 $0 promethazine hcl SOLN 25mg/ml, 2 $0 PA 50mg/ml TRANSDERM-SCOP 2 $0 QL (10 patches / 30 days), PA 抗痙攣藥 - 緩解胃痙攣的藥物 CUVPOSA 2 $0 dicyclomine hcl 1 $0 glycopyrrolate TABS 1 $0 glycopyrrolate inj 1 $0 H2 受體阻抗劑 - 治療胃潰瘍與胃酸的藥物 AXID AR 3 $0 NM; * cimetidine TABS 200mg 3 $0 NM; * famotidine SOLN 40mg/4ml, 200mg/20ml 1 $0 famotidine SUSR 1 $0 famotidine TABS 10mg, 20mg 3 $0 NM; * famotidine TABS 20mg, 40mg 1 $0 famotidine inj 1 $0 PEPCID AC CHEW 3 $0 NM; * ranitidine hcl SOLN 1 $0 ranitidine hcl TABS 75mg, 150mg 3 $0 NM; * ranitidine hcl TABS 150mg, 300mg 1 $0 ranitidine hcl inj 1 $0 ranitidine syrup 1 $0 發炎性腸道疾病 APRISO 2 $0 ASACOL HD 2 $0 balsalazide disodium 1 $0 budesonide ec 2 $0 CANASA 2 $0 colocort enema 100mg 1 $0 DELZICOL 2 $0 DIPENTUM 2 $0 HYDROCORTISONE (INTRARECTAL) 1 $0 LIALDA 2 $0 mesalamine enema 1 $0 mesalamine w/ cleanser 1 $0 PENTASA 2 $0 sulfasalazine TABS 1 $0 sulfasalazine ec 1 $0 PA - 事先授權 QL - 數量限制 ST - 階段式療法 NM - 不提供郵購 39 B/D - 根據 Medicare B 或 D 給付 LA - 有限的使用 * - 非 Part D 藥物, 或是 Medicaid 給付的 OTC 品項

UCERIS TB24 2 $0 緩瀉劑 BENEFIBER CHEW; POWD 3 $0 NM; * benzocaine-docusate sodium 3 $0 NM; * bisacodyl SUPP; TBEC 3 $0 NM; * BLACK DRAUGHT 3 $0 NM; * calcium polycarbophil 3 $0 NM; * COATS ALOE VERA JUICE DRI 3 $0 NM; * constulose 1 $0 corn dextrin 3 $0 NM; * docusate calcium 3 $0 NM; * docusate sodium CAPS; ENEM; LIQD; 3 $0 NM; * SYRP; TABS DULCOLAX BOWEL PREP KIT 3 $0 NM; * enulose 1 $0 EQL NATURAL FIBER 3 $0 NM; * EQUALACTIN 3 $0 NM; * fiber CHEW 3 $0 NM; * FIBER CHEW 3 $0 NM; * fiber POWD 3 $0 NM; * FIBER POWD 3 $0 NM; * FLEET BISACODYL 3 $0 NM; * gaviltye-g 1 $0 gavilyte-c 1 $0 gavilyte-n 1 $0 generlac 1 $0 GOLYTELY 2 $0 HYDROCIL INSTANT PACK 3 $0 NM; * KONSYL PACK 28.3%, 100% 3 $0 NM; * KONSYL POWD 60.3%, 71.67% 3 $0 NM; * KONSYL-D 3 $0 NM; * lactulose 1 $0 lactulose (encephalopathy) 1 $0 magnesium citrate SOLN 3 $0 NM; * magnesium hydroxide SUSP 3 $0 NM; * magnesium oxide (laxative) 3 $0 NM; * magnesium sulfate (laxative) 3 $0 NM; * METAMUCIL WAFR 3 $0 NM; * METAMUCIL MULTIHEALTH FIB POWD 63% 3 $0 NM; * 40 如果您有任何疑問, 請致電 MetroPlus FIDA Plan, 電話 :1-844-288-FIDA (3432), TTY:711, 服務時間為週一至週六上午 8 時至晚上 8 時 晚上 8 時後 週日及假日 : 請撥打上列的 24 小時全年無休醫療諮詢服務專線 此電話號碼為免付費專線 如需詳細資訊, 請造訪 www.metroplusmedicare.org

METAMUCIL SMOOTH TEXTURE 3 $0 NM; * methylcellulose (laxative) 3 $0 NM; * MILK OF MAGNESIA CONCENTR 3 $0 NM; * mineral oil ENEM 3 $0 NM; * MINERAL OIL OIL 3 $0 NM; * MOVIPREP 2 $0 NULYTELY/FLAVOR PACKS 2 $0 NUTRISOURCE FIBER PACK 3 $0 NM; * PEDIA-LAX LIQD 3 $0 NM; * peg 3350-kcl-sod bicarb-sod chloride-sod 1 $0 sulfate peg 3350-potassium chloride-sod 1 $0 bicarbonate-sod chloride PEG 3350/ELECTROLYTES 1 $0 PHILLIPS MILK OF MAGNESIA 3 $0 NM; * polyethylene glycol 3350 PACK; POWD 1 $0 psyllium CAPS 3 $0 NM; * psyllium POWD 28.3%, 30%, 30.9%, 3 $0 NM; * 33%, 48.57%, 58.6%, 68%, 95%, 100% PSYLLIUM POWD 49% 3 $0 NM; * RELISTOR 2 $0 PA SENNA SYRP 3 $0 NM; * senna TABS 187mg 3 $0 NM; * SENNA TABS 187mg 3 $0 NM; * SENNA PROMPT 3 $0 NM; * sennosides 3 $0 NM; * sennosides-docusate sodium 3 $0 NM; * sodium phosphates 3 $0 NM; * SUPREP BOWEL PREP 2 $0 trilyte 1 $0 wheat dextrin 3 $0 NM; * wheat dextrin-calcium 3 $0 NM; * 雜項 AMITIZA CAP 8MCG 2 $0 QL (60 caps / 30 days) AMITIZA CAP 24MCG 2 $0 QL (60 caps / 30 days) cromolyn sodium (mastocytosis) 2 $0 diphenoxylate w/ atropine 1 $0 LINZESS CAP 145MCG 2 $0 QL (60 caps / 30 days) LINZESS CAP 290MCG 2 $0 QL (30 caps / 30 days) loperamide hcl CAPS 1 $0 PA - 事先授權 QL - 數量限制 ST - 階段式療法 NM - 不提供郵購 41 B/D - 根據 Medicare B 或 D 給付 LA - 有限的使用 * - 非 Part D 藥物, 或是 Medicaid 給付的 OTC 品項

LOTRONEX 2 $0 PA misoprostol TABS 1 $0 SUCRAID 2 $0 sucralfate TABS 1 $0 ursodiol CAPS; TABS 1 $0 XIFAXAN 550mg 2 $0 PA 胰酶 CREON 2 $0 ZENPEP 2 $0 氫離子幫浦抑制劑 - 治療胃潰瘍與胃酸的藥物 DEXILANT 2 $0 QL (30 caps / 30 days) esomeprazole sodium 1 $0 famotidine-calcium carbonatemagnesium 3 $0 NM; * hydroxide lansoprazole CPDR 15mg 3 $0 NM; * NEXIUM CAP 2 $0 QL (30 caps / 30 days) NEXIUM GRA 2.5MG DR 2 $0 NEXIUM GRA 5MG DR 2 $0 NEXIUM GRA 10MG DR 2 $0 QL (30 packets / 30 days) NEXIUM GRA 20MG DR 2 $0 QL (30 packets / 30 days) NEXIUM GRA 40MG DR 2 $0 QL (30 packets / 30 days) omeprazole CPDR 10mg, 40mg 1 $0 QL (30 caps / 30 days) omeprazole CPDR 20mg 1 $0 QL (60 caps / 30 days) OMEPRAZOLE TBEC 3 $0 NM; * omeprazole magnesium 3 $0 NM; * omeprazole-sodium bicarbonate 3 $0 NM; * pantoprazole sodium TBEC 1 $0 QL (30 tabs / 30 days) PRILOSEC OTC 3 $0 NM; * 泌尿生殖器 - 治療生殖器與尿道情況的藥物 良性攝護腺肥大 - 治療攝護腺肥大的藥物 alfuzosin hcl 1 $0 QL (30 tabs / 30 days) AVODART 2 $0 QL (30 caps / 30 days) finasteride TABS 5mg 1 $0 JALYN 2 $0 QL (30 caps / 30 days) tamsulosin hcl 1 $0 QL (60 caps / 30 days) 雜項 42 如果您有任何疑問, 請致電 MetroPlus FIDA Plan, 電話 :1-844-288-FIDA (3432), TTY:711, 服務時間為週一至週六上午 8 時至晚上 8 時 晚上 8 時後 週日及假日 : 請撥打上列的 24 小時全年無休醫療諮詢服務專線 此電話號碼為免付費專線 如需詳細資訊, 請造訪 www.metroplusmedicare.org

bethanechol chloride TABS 1 $0 ELMIRON 2 $0 POTASSIUM CITRATE (ALKALINIZER) 1 $0 泌尿道抗痙攣藥物 - 治療泌尿道失禁的藥物 MYRBETRIQ 25mg 2 $0 QL (60 tabs / 30 days) MYRBETRIQ 50mg 2 $0 QL (30 tabs / 30 days) oxybutynin chloride SYRP 1 $0 oxybutynin chloride TABS 1 $0 oxybutynin chloride TB24 5mg 1 $0 QL (30 tabs / 30 days) oxybutynin chloride TB24 10mg, 15mg 1 $0 QL (60 tabs / 30 days) TOLTERODINE TARTRATE CAP ER 1 $0 QL (30 caps / 30 days) tolterodine tartrate tabs 1 $0 TOVIAZ 2 $0 QL (30 tabs / 30 days) trospium chloride TABS 1 $0 QL (60 tabs / 30 days) VESICARE 2 $0 QL (30 tabs / 30 days) 陰道抗感染藥 clindamycin phosphate vaginal 1 $0 clotrimazole vaginal 3 $0 NM; * metronidazole vaginal 1 $0 miconazole nitrate vaginal CREA 3 $0 NM; * miconazole nitrate vaginal KIT 3 $0 NM; * miconazole nitrate vaginal SUPP 100mg 3 $0 NM; * povidone-iodine vaginal 3 $0 NM; * terconazole vaginal 1 $0 tioconazole vaginal 3 $0 NM; * VANDAZOLE 1 $0 zazole.4% 1 $0 ZAZOLE.8% 1 $0 血液學 - 治療血液疾病的藥物 抗凝血藥物 - 血液稀釋劑 COUMADIN 2 $0 ELIQUIS 2 $0 enoxaparin sodium 30mg/0.3ml, 1 $0 40mg/0.4ml, 60mg/0.6ml, 80mg/0.8ml, 300mg/3ml enoxaparin sodium 100mg/ml, 2 $0 120mg/0.8ml, 150mg/ml fondaparinux sodium 2.5mg/0.5ml 1 $0 PA - 事先授權 QL - 數量限制 ST - 階段式療法 NM - 不提供郵購 43 B/D - 根據 Medicare B 或 D 給付 LA - 有限的使用 * - 非 Part D 藥物, 或是 Medicaid 給付的 OTC 品項

fondaparinux sodium 5mg/0.4ml, 2 $0 7.5mg/0.6ml, 10mg/0.8ml heparin sod inj 1000/ml 1 $0 B/D HEPARIN SOD INJ 2000/ML 2 $0 B/D HEPARIN SOD INJ 2500/ML 2 $0 B/D heparin sod inj 5000/ml 1 $0 B/D heparin sod inj 10000/ml 1 $0 B/D heparin sod inj 20000/ml 1 $0 B/D HEPARIN SODIUM/D5W 2 $0 HEPARIN SODIUM/NACL 0.45% 2 $0 HEPARIN SODIUM/SODIUM CHL 2 $0 jantoven 1 $0 PRADAXA 2 $0 warfarin sodium 1 $0 XARELTO 2 $0 造血生長因子 GRANIX 2 $0 NM, PA LEUKINE 2 $0 NM, PA MOZOBIL 2 $0 NM, PA NEUMEGA 2 $0 NM NEUPOGEN 2 $0 NM, PA PROCRIT 2 $0 NM, PA 鐵劑 BIFERA 3 $0 NM; * carbonyl iron 3 $0 NM; * CVS SLOW RELEASE IRON 3 $0 NM; * FEOSOL 45mg 3 $0 NM; * FERRETTS IPS 3 $0 NM; * FERRIMIN 150 3 $0 NM; * FERROUS FUMARATE TABS 29mg, 90mg 3 $0 NM; * ferrous fumarate TABS 325mg 3 $0 NM; * FERROUS GLUCONATE 225mg, 324mg 3 $0 NM; * ferrous gluconate 240mg, 324mg, 325mg 3 $0 NM; * ferrous sulfate ELIX 3 $0 NM; * FERROUS SULFATE LIQD 3 $0 NM; * ferrous sulfate SOLN 3 $0 NM; * FERROUS SULFATE SYRP 3 $0 NM; * ferrous sulfate TABS 3 $0 NM; * ferrous sulfate TBCR 45mg, 47.5mg, 50mg 3 $0 NM; * 44 如果您有任何疑問, 請致電 MetroPlus FIDA Plan, 電話 :1-844-288-FIDA (3432), TTY:711, 服務時間為週一至週六上午 8 時至晚上 8 時 晚上 8 時後 週日及假日 : 請撥打上列的 24 小時全年無休醫療諮詢服務專線 此電話號碼為免付費專線 如需詳細資訊, 請造訪 www.metroplusmedicare.org

FERROUS SULFATE TBCR 140mg 3 $0 NM; * FERROUS SULFATE TBEC 324mg 3 $0 NM; * ferrous sulfate TBEC 325mg 3 $0 NM; * ferrous sulfate dried 3 $0 NM; * FOLGARD 3 $0 NM; * folic acid-vitamin b6-vitamin b12 3 $0 NM; * FOLITAB 500 3 $0 NM; * INTEGRA 3 $0 NM; * IRON TABS 28mg, 90mg 3 $0 NM; * iron TABS 256mg 3 $0 NM; * IRON TBCR 3 $0 NM; * IRON DEXTRAN 3 $0 NM; * IRON UP 3 $0 NM; * iron-vitamin c 3 $0 NM; * iron-vitamin c-vitamin b12-folic acid 3 $0 NM; * MYKIDZ IRON 10 3 $0 NM; * NOVAFERRUM 125 3 $0 NM; * NOVAFERRUM PEDIATRIC DROP 3 $0 NM; * polysaccharide iron complex 3 $0 NM; * PROFE 3 $0 NM; * SLOW RELEASE IRON 3 $0 NM; * SM SLOW RELEASE IRON 3 $0 NM; * VITAMIN B12/FOLIC ACID 3 $0 NM; * 雜項 anagrelide hcl 1 $0 cilostazol 1 $0 CINRYZE 2 $0 NM, LA, PA FIRAZYR 2 $0 NM, PA pentoxifylline TBCR 1 $0 PROMACTA 12.5mg 2 $0 QL (240 tabs / 30 days), NM, LA, PA PROMACTA 25mg 2 $0 QL (120 tabs / 30 days), NM, LA, PA PROMACTA 50mg 2 $0 QL (60 tabs / 30 days), NM, LA, PA PROMACTA 75mg 2 $0 QL (30 tabs / 30 days), NM, LA, PA tranexamic acid SOLN; TABS 1 $0 血小板凝集抑制劑 AGGRENOX 2 $0 BRILINTA 2 $0 clopidogrel bisulfate 75mg 1 $0 QL (30 tabs / 30 days) EFFIENT 2 $0 PA - 事先授權 QL - 數量限制 ST - 階段式療法 NM - 不提供郵購 45 B/D - 根據 Medicare B 或 D 給付 LA - 有限的使用 * - 非 Part D 藥物, 或是 Medicaid 給付的 OTC 品項

免疫製劑 - 治療免疫系統失常的藥物 疾病調節抗風濕藥物 (DMARDS) - 治療風濕性關節炎的藥物 CIMZIA 2 $0 NM, PA CIMZIA STARTER KIT 2 $0 NM, PA HUMIRA KIT 2 $0 NM, PA HUMIRA KIT 40MG/0.8 1 $0 NM, PA HUMIRA PEN 2 $0 NM, PA HUMIRA PEN-CROHNS DISEASE 2 $0 NM, PA HUMIRA PEN-PSORIASIS STAR 2 $0 NM, PA hydroxychloroquine sulfate 1 $0 leflunomide TABS 1 $0 methotrexate sodium tabs 1 $0 REMICADE 2 $0 NM, PA 免疫球蛋白 BIVIGAM 10gm/100ml 2 $0 NM, PA CARIMUNE NANOFILTERED 2 $0 NM, PA FLEBOGAMMA 2 $0 NM, PA FLEBOGAMMA DIF 2 $0 NM, PA GAMASTAN S/D 2 $0 B/D, NM GAMMAGARD LIQUID 2 $0 NM, PA GAMMAGARD S/D 2 $0 NM, PA GAMMAKED 2 $0 NM, PA GAMMAPLEX 2.5gm/50ml, 5gm/100ml, 2 $0 NM, PA 10gm/200ml GAMUNEX-C 2.5gm/25ml, 5gm/50ml, 2 $0 NM, PA 10gm/100ml, 20gm/200ml GAMUNEX-C 1GM/10ML 2 $0 NM, PA OCTAGAM 1gm/20ml, 2.5gm/50ml, 2 $0 NM, PA 5gm/100ml, 10gm/200ml, 25gm/500ml PRIVIGEN 2 $0 NM, PA 免疫調節劑 ACTIMMUNE 2 $0 NM, LA, PA ARCALYST 2 $0 NM, PA INTRON-A INJ 10MU 2 $0 B/D, NM INTRON-A INJ 18MU 2 $0 B/D, NM INTRON-A INJ 25MU 2 $0 B/D, NM INTRON-A INJ 50MU 2 $0 B/D, NM PEG-INTRON 2 $0 NM, PA 46 如果您有任何疑問, 請致電 MetroPlus FIDA Plan, 電話 :1-844-288-FIDA (3432), TTY:711, 服務時間為週一至週六上午 8 時至晚上 8 時 晚上 8 時後 週日及假日 : 請撥打上列的 24 小時全年無休醫療諮詢服務專線 此電話號碼為免付費專線 如需詳細資訊, 請造訪 www.metroplusmedicare.org

PEG-INTRON REDIPEN 2 $0 NM, PA PEGASYS SOLN 2 $0 NM, PA PEGASYS PROCLICK 2 $0 NM, PA REVLIMID 2 $0 NM, LA, PA THALOMID 2 $0 NM, PA 免疫抑制劑 azathioprine TABS 1 $0 B/D CELLCEPT SUSR 2 $0 B/D cyclosporine CAPS; SOLN 1 $0 B/D cyclosporine modified (for microemulsion) 1 $0 B/D gengraf 1 $0 B/D mycophenolate mofetil CAPS; TABS 1 $0 B/D mycophenolate sodium 180mg 1 $0 B/D mycophenolate sodium 360mg 2 $0 B/D NEORAL 2 $0 B/D NULOJIX 2 $0 B/D PROGRAF CAPS 2 $0 B/D RAPAMUNE SOLN 2 $0 B/D RAPAMUNE TABS 1mg, 2mg 2 $0 B/D SANDIMMUNE CAPS 2 $0 B/D SANDIMMUNE SOLN 100mg/ml 2 $0 B/D sirolimus TABS.5mg 1 $0 B/D tacrolimus CAPS 5mg 2 $0 B/D tacrolimus CAPS.5mg, 1mg 1 $0 B/D ZORTRESS 2 $0 B/D ZORTRESS TAB 0.5MG 2 $0 B/D ZORTRESS TAB 0.75MG 2 $0 B/D 疫苗 ACTHIB 2 $0 ADACEL 2 $0 BCG VACCINE 2 $0 BOOSTRIX 2 $0 CERVARIX 2 $0 COMVAX 2 $0 DAPTACEL 2 $0 DIPHTHERIA/TETANUS TOXOID 2 $0 B/D ENGERIX-B SUSP 2 $0 B/D GARDASIL 2 $0 HAVRIX 2 $0 HIBERIX 2 $0 PA - 事先授權 QL - 數量限制 ST - 階段式療法 NM - 不提供郵購 47 B/D - 根據 Medicare B 或 D 給付 LA - 有限的使用 * - 非 Part D 藥物, 或是 Medicaid 給付的 OTC 品項

IMOVAX RABIES (H.D.C.V.) 2 $0 INFANRIX 2 $0 IPOL INACTIVATED IPV 2 $0 IXIARO 2 $0 M-M-R II W/DILUENT 10 DOS 2 $0 MENACTRA 2 $0 MENOMUNE-A/C/Y/W-135 2 $0 MENVEO 2 $0 PEDVAX HIB 2 $0 PROQUAD 2 $0 RABAVERT 2 $0 RECOMBIVAX HB 2 $0 B/D ROTARIX 2 $0 ROTATEQ 2 $0 SYNAGIS 2 $0 TENIVAC 2 $0 B/D TETANUS TOXOID ADSORBED 2 $0 B/D TETANUS/DIPHTHERIA TOXOID 2 $0 B/D TWINRIX INJ 2 $0 TYPHIM VI 2 $0 VAQTA 2 $0 VARIVAX 2 $0 YF-VAX 2 $0 ZOSTAVAX 2 $0 QL (1 vial per lifetime) 營養劑 / 補充劑 - 維他命與補充劑 電解質 KLOR-CON 8 1 $0 KLOR-CON 10 1 $0 klor-con m15 1 $0 klor-con m20 1 $0 klor-con pow 20meq 1 $0 MAGNESIUM SULFATE SOLN 2 $0 MAGNESIUM SULFATE IN D5W 2 $0 magnesium sulfate inj 50% 1 $0 oral electrolytes SOLN 3 $0 NM; * potassium chloride CPCR 1 $0 potassium chloride LIQD 1 $0 POTASSIUM CHLORIDE TBCR 1 $0 POTASSIUM CHLORIDE ER 1 $0 48 如果您有任何疑問, 請致電 MetroPlus FIDA Plan, 電話 :1-844-288-FIDA (3432), TTY:711, 服務時間為週一至週六上午 8 時至晚上 8 時 晚上 8 時後 週日及假日 : 請撥打上列的 24 小時全年無休醫療諮詢服務專線 此電話號碼為免付費專線 如需詳細資訊, 請造訪 www.metroplusmedicare.org

potassium chloride microencapsulated 1 $0 crystals cr SODIUM CHLORIDE SOLN 2.5meq/ml 1 $0 SODIUM FLUORIDE CHEW; TAB; 1.1 (0.5 1 $0 F) MG/ML SOLN TPN ELECTROLYTES 2 $0 B/D 靜脈營養 AMINOSYN 2 $0 B/D AMINOSYN 7%/ELECTROLYTES 2 $0 B/D AMINOSYN 8.5%/ELECTROLYTE 2 $0 B/D AMINOSYN II 2 $0 B/D AMINOSYN II 8.5%/ELECTROL 2 $0 B/D AMINOSYN M 2 $0 B/D AMINOSYN-HBC 2 $0 B/D AMINOSYN-PF 2 $0 B/D AMINOSYN-PF 7% 2 $0 B/D AMINOSYN-RF 2 $0 B/D CLINIMIX 2.75%/DEXTROSE 5% 2 $0 B/D CLINIMIX 4.25%/DEXTROSE 5% 2 $0 B/D CLINIMIX 4.25%/DEXTROSE 25% 2 $0 B/D CLINIMIX 5%/DEXTROSE 15% 2 $0 B/D CLINIMIX 5%/DEXTROSE 20% 2 $0 B/D CLINIMIX 5%/DEXTROSE 25% 2 $0 B/D CLINIMIX INJ 4.25/D10 2 $0 B/D CLINIMIX INJ 4.25/D20 2 $0 B/D FREAMINE HBC 6.9% 2 $0 B/D FREAMINE III 2 $0 B/D HEPATAMINE 2 $0 B/D hepatasol 8 1 $0 B/D INTRALIPID INJ 20% 2 $0 B/D INTRALIPID INJ 30% 2 $0 B/D NEPHRAMINE 2 $0 B/D premasol sol 6% 1 $0 B/D premasol sol 10% 2 $0 B/D PROCALAMINE 2 $0 B/D PROSOL 2 $0 B/D travasol 10 2 $0 B/D TROPHAMINE INJ 10% 2 $0 B/D 靜脈替代治療補充液 DEXTROSE 2.5%/NACL 0.45% 1 $0 PA - 事先授權 QL - 數量限制 ST - 階段式療法 NM - 不提供郵購 49 B/D - 根據 Medicare B 或 D 給付 LA - 有限的使用 * - 非 Part D 藥物, 或是 Medicaid 給付的 OTC 品項

DEXTROSE 5% 1 $0 DEXTROSE 5% /ELECTROLYTE 2 $0 DEXTROSE 5%/LACTATED RING 1 $0 DEXTROSE 5%/NACL 0.2% 1 $0 DEXTROSE 5%/NACL 0.3% 1 $0 DEXTROSE 5%/NACL 0.9% 1 $0 DEXTROSE 5%/NACL 0.33% 1 $0 DEXTROSE 5%/NACL 0.45% 1 $0 DEXTROSE 5%/NACL 0.225% 1 $0 DEXTROSE 5%/POTASSIUM CHL 1 $0 DEXTROSE 10% FLEX CONTAIN 1 $0 DEXTROSE 10%/NACL 0.2% 2 $0 DEXTROSE 10%/NACL 0.45% 1 $0 DEXTROSE 50% 1 $0 dextrose inj 70% 1 $0 IONOSOL-B/DEXTROSE 5% 2 $0 IONOSOL-MB/DEXTROSE 5% 2 $0 ISOLYTE P 2 $0 isolyte s 2 $0 KCL0.15%/D5W/NACL0.2% 1 $0 KCL0.15%/D5W/NACL0.225% 2 $0 KCL 0.3%/D5W/NACL 0.9% 1 $0 KCL 0.3%/D5W/NACL 0.45% 1 $0 KCL 0.15%/D5W/NACL 0.9% 1 $0 KCL 0.075%/D5W/NACL 0.45% 1 $0 KCL/D5W INJ 0.3% 1 $0 KCL/NACL INJ 0.3-0.9 1 $0 LACTATED RINGER'S INJ 1 $0 normosol-m 1 $0 NORMOSOL-R 2 $0 NORMOSOL-R IN D5W 2 $0 PLASMA-LYTE A 2 $0 PLASMA-LYTE-56/D5W 2 $0 PLASMA-LYTE-148 2 $0 POTASSIUM CHLORIDE SOLN 1 $0 10meq/100ml, 20meq/100ml potassium chloride SOLN.4meq/ml, 1 $0 2meq/ml, 10meq/50ml, 40meq/100ml POTASSIUM CHLORIDE 0.15% 1 $0 POTASSIUM CHLORIDE 0.22% 1 $0 50 如果您有任何疑問, 請致電 MetroPlus FIDA Plan, 電話 :1-844-288-FIDA (3432), TTY:711, 服務時間為週一至週六上午 8 時至晚上 8 時 晚上 8 時後 週日及假日 : 請撥打上列的 24 小時全年無休醫療諮詢服務專線 此電話號碼為免付費專線 如需詳細資訊, 請造訪 www.metroplusmedicare.org

potassium chloride in nacl 1 $0 RINGER'S 1 $0 SODIUM CHLORIDE SOLN 3%, 5% 1 $0 SODIUM CHLORIDE 0.45% VIA 1 $0 SODIUM CHLORIDE INJ 0.9% 1 $0 礦物質 ADVANCED CALCIUM FORMULA 3 $0 NM; * BEELITH 3 $0 NM; * BONE DENSITY 3 $0 NM; * bone meal w/ vitamin d 3 $0 NM; * CAL-CITRATE PLUS VITAMIN 3 $0 NM; * CAL-GLU 3 $0 NM; * CAL-QUICK 3 $0 NM; * CAL/MAG 3 $0 NM; * CALCET CREAMY BITES 3 $0 NM; * CALCET PETITES 3 $0 NM; * CALCI-MIX 3 $0 NM; * CALCIONATE 3 $0 NM; * calcium TABS 3 $0 NM; * CALCIUM 500 3 $0 NM; * CALCIUM 1000 + D 3 $0 NM; * CALCIUM & MAGNESIUM 3 $0 NM; * calcium & phosphorus w/ vitamin d 3 $0 NM; * CALCIUM CARBONATE CHEW 3 $0 NM; * CALCIUM CARBONATE POWD 3 $0 NM; * calcium carbonate SUSP 3 $0 NM; * calcium carbonate TABS 600mg, 1250mg, 3 $0 NM; * 1500mg calcium carbonate-cholecalciferol CAPS 3 $0 NM; * calcium carbonate-cholecalciferol CHEW 3 $0 NM; * CALCIUM CARBONATE-CHOLECALCIFEROL 3 $0 NM; * CHEW calcium carbonate-cholecalciferol TABS 3 $0 NM; * calcium carbonate-ergocalciferol 3 $0 NM; * calcium carbonate-vitamin d 3 $0 NM; * calcium carbonate-vitamin d w/ minerals 3 $0 NM; * CALCIUM CITRATE GRAN 3 $0 NM; * CALCIUM CITRATE TABS 250mg 3 $0 NM; * calcium citrate TABS 950mg 3 $0 NM; * CALCIUM CITRATE MALATE/VI 3 $0 NM; * PA - 事先授權 QL - 數量限制 ST - 階段式療法 NM - 不提供郵購 51 B/D - 根據 Medicare B 或 D 給付 LA - 有限的使用 * - 非 Part D 藥物, 或是 Medicaid 給付的 OTC 品項

CALCIUM CITRATE W/D 3 $0 NM; * calcium citrate-vitamin d 3 $0 NM; * CALCIUM GLUCONATE TABS 50mg, 3 $0 NM; * 500mg calcium gluconate TABS 500mg 3 $0 NM; * CALCIUM GUMMIES 3 $0 NM; * CALCIUM LACTATE 100mg, 648mg 3 $0 NM; * calcium lactate 650mg 3 $0 NM; * calcium w/ magnesium 3 $0 NM; * calcium w/ vitamin d 3 $0 NM; * calcium w/ vitamins d & k 3 $0 NM; * calcium-magnesium w/ vitamin d 3 $0 NM; * calcium-magnesium-zinc 3 $0 NM; * CALCIUM/C/D 3 $0 NM; * CALCIUM/MAGNESIUM 3 $0 NM; * CALCIUM/MAGNESIUM/VITAMIN 3 $0 NM; * CALCIUM/MAGNESIUM/ZINC 3 $0 NM; * CALMAG THINS 3 $0 NM; * CALTRATE 600+D PLUS MINER CHEW 3 $0 NM; * caltrate 600+d soft chews 3 $0 NM; * CHELATED CALCIUM 3 $0 NM; * CITRACAL CALCIUM GUMMIES 3 $0 NM; * CITRACAL PLUS HEART HEALT 3 $0 NM; * CORAL CALCIUM CAPS 3 $0 NM; * CORAL CALCIUM PLUS 3 $0 NM; * coral calcium-magnesium w/ vitamin d 3 $0 NM; * CVS CALCIUM CITRATE 3 $0 NM; * EQL CALCIUM/VITAMIN D 3 $0 NM; * EQL CHILDRENS CALCIUM GUM 3 $0 NM; * GNP CALCIUM 500 +D3 3 $0 NM; * LIQUID CALCIUM WITH D3 MA 3 $0 NM; * LOCALNESIUM 3 $0 NM; * LOCALNESIUM-C 3 $0 NM; * MAG-200 3 $0 NM; * MAG-TAB SR 3 $0 NM; * MAGINEX 3 $0 NM; * MAGNEBIND 200 3 $0 NM; * MAGNEBIND 300 3 $0 NM; * magnesium CAPS 100mg 3 $0 NM; * MAGNESIUM CAPS 400mg 3 $0 NM; * 52 如果您有任何疑問, 請致電 MetroPlus FIDA Plan, 電話 :1-844-288-FIDA (3432), TTY:711, 服務時間為週一至週六上午 8 時至晚上 8 時 晚上 8 時後 週日及假日 : 請撥打上列的 24 小時全年無休醫療諮詢服務專線 此電話號碼為免付費專線 如需詳細資訊, 請造訪 www.metroplusmedicare.org

magnesium TABS 100mg, 200mg, 250mg 3 $0 NM; * magnesium chloride TBCR 3 $0 NM; * magnesium chloride-calcium 3 $0 NM; * MAGNESIUM CITRATE TABS 3 $0 NM; * MAGNESIUM ELEMENTAL 3 $0 NM; * MAGNESIUM GLUCONATE TABS 250mg, 3 $0 NM; * 550mg magnesium oxide (mg supplement) 3 $0 NM; * MAGNESIUM SULFATE CAPS 3 $0 NM; * oral electrolytes TABS 3 $0 NM; * OSTEO-PORETICAL 3 $0 NM; * oyster shell 3 $0 NM; * PARVA-CAL 3 $0 NM; * PARVA-CAL 250 3 $0 NM; * PHOS-NAK POWDER CONCENTRA 3 $0 NM; * RA CALCIUM/BORON 3 $0 NM; * RA OYSTER SHELL CALCIUM/V 3 $0 NM; * selenium TABS 100mcg 3 $0 NM; * SELENIUM TBCR 3 $0 NM; * SLOW-MAG 3 $0 NM; * SM CORAL CALCIUM 3 $0 NM; * UPCAL D 3 $0 NM; * 維他命 A-25 3 $0 NM; * ACEROLA C 500 3 $0 NM; * ANTIOXIDANT FORMULA SG 3 $0 NM; * APATATE 3 $0 NM; * AQUA-Es 3 $0 NM; * ascorbic acid CHEW; CPCR; LOZG; SYRP; 3 $0 NM; * TABS; TBCR ASCORBIC ACID POWD 3 $0 NM; * b complex w/ c 3 $0 NM; * B-1 3 $0 NM; * B-12 TABS 3 $0 NM; * B-12 DOTS 3 $0 NM; * B-12 QUICK DISSOLVE 3 $0 NM; * b-complex vitamins 3 $0 NM; * b-complex w/ c & calcium 3 $0 NM; * b-complex w/ c & e + zn 3 $0 NM; * b-complex w/ c & folic acid 3 $0 NM; * PA - 事先授權 QL - 數量限制 ST - 階段式療法 NM - 不提供郵購 53 B/D - 根據 Medicare B 或 D 給付 LA - 有限的使用 * - 非 Part D 藥物, 或是 Medicaid 給付的 OTC 品項

b-complex w/ folic acid 3 $0 NM; * b-complex w/ minerals 3 $0 NM; * b-complex w/biotin & folic acid 3 $0 NM; * B-NATAL 3 $0 NM; * beta carotene CAPS 15mg, 25000unit 3 $0 NM; * biotin CAPS 5mg 3 $0 NM; * biotin TABS 2.5mg, 300mcg 3 $0 NM; * brewers yeast TABS 3 $0 NM; * calcitriol CAPS 1 $0 B/D calcitriol inj 1 $0 B/D calcitriol oral soln 1 mcg/ml 1 $0 B/D calcium ascorbate TABS 3 $0 NM; * calcium pantothenate TABS 500mg 3 $0 NM; * CALNA 3 $0 NM; * CENTRUM SILVER CHEW 3 $0 NM; * cholecalciferol CAPS; CHEW; LIQD; TABS 3 $0 NM; * CLASSIC PRENATAL 3 $0 NM; * cod liver oil CAPS 3 $0 NM; * COD LIVER OIL OIL 3 $0 NM; * CVS VITAMIN C 3 $0 NM; * cyanocobalamin LIQD; SOLN; SUBL; 3 $0 NM; * TABS; TBCR; TBDP CYTO B2 3 $0 NM; * D3 DOTS 3 $0 NM; * DECARA 25000unit 3 $0 NM; * DIALYVITE 800/ZINC 15 3 $0 NM; * DIALYVITE VITAMIN D3 MAX 3 $0 NM; * ELDERTONIC 3 $0 NM; * EQL CHILDRENS MULTIVITAMI 3 $0 NM; * ergocalciferol CAPS; SOLN 3 $0 NM; * EZFE FORTE 3 $0 NM; * FA-8 3 $0 NM; * FOLIC ACID CAPS 3 $0 NM; * folic acid SOLN 3 $0 NM; * FOLIC ACID TABS 1mg 3 $0 NM; * folic acid TABS 1mg, 400mcg, 800mcg 3 $0 NM; * GERIATRIC VITAMIN 3 $0 NM; * GNP DAILY PRENATAL 3 $0 NM; * HONEY BEARS 3 $0 NM; * HONEY BEARS W/IRON AND ZI 3 $0 NM; * 54 如果您有任何疑問, 請致電 MetroPlus FIDA Plan, 電話 :1-844-288-FIDA (3432), TTY:711, 服務時間為週一至週六上午 8 時至晚上 8 時 晚上 8 時後 週日及假日 : 請撥打上列的 24 小時全年無休醫療諮詢服務專線 此電話號碼為免付費專線 如需詳細資訊, 請造訪 www.metroplusmedicare.org

hydroxocobalamin SOLN 3 $0 NM; * ICAPS LUTEIN/ZEAXANTHIN F 3 $0 NM; * iron w/ vitamins 3 $0 NM; * KPN PRENATAL 3 $0 NM; * LUMITENE 3 $0 NM; * MEPHYTON 3 $0 NM; * MISSION PRENATAL 3 $0 NM; * MISSION PRENATAL HP 3 $0 NM; * MULTI-DELYN/IRON 3 $0 NM; * multiple vitamin 3 $0 NM; * multiple vitamins w/ iron 3 $0 NM; * multiple vitamins w/ minerals 3 $0 NM; * MYKIDZ IRON 3 $0 NM; * NASCOBAL 3 $0 NM; * NEPHRONEX LIQD 3 $0 NM; * niacin CPCR; TABS; TBCR 3 $0 NM; * NIACIN TR 3 $0 NM; * niacinamide TABS 3 $0 NM; * NUTRICION PORVIDA 3 $0 NM; * pantothenic acid 3 $0 NM; * paricalcitol CAPS 1 $0 B/D pediatric multiple vitamin w/ c 3 $0 NM; * pediatric multiple vitamin w/ c & fa 3 $0 NM; * pediatric multiple vitamin w/ extra c & fa 3 $0 NM; * pediatric multiple vitamin w/ minerals & c 3 $0 NM; * pediatric multiple vitamins 3 $0 NM; * pediatric multiple vitamins w/ iron 3 $0 NM; * pediatric vitamins adc 3 $0 NM; * PERRY PRENATAL 3 $0 NM; * phytonadione SOLN; TABS 3 $0 NM; * PRENATAL 3 $0 NM; * PRENATAL VITAMIN/FOLIC ACID > 0.8 MG 1 $0 (GENERIC) PROTEXIN 3 $0 NM; * pyridoxine hcl SOLN; TABS; TBCR 3 $0 NM; * riboflavin TABS 25mg, 50mg, 100mg 3 $0 NM; * ROCALTROL 2 $0 B/D SCOOBY-DOO ONE A DAY 3 $0 NM; * SM VITAMIN D3 MAXIMUM STR 3 $0 NM; * specialty vitamins products 3 $0 NM; * PA - 事先授權 QL - 數量限制 ST - 階段式療法 NM - 不提供郵購 55 B/D - 根據 Medicare B 或 D 給付 LA - 有限的使用 * - 非 Part D 藥物, 或是 Medicaid 給付的 OTC 品項

STUART PRENATAL + DHA 3 $0 NM; * SUPER NU-THERA 3 $0 NM; * TAB-A-VITE WOMENS 3 $0 NM; * THERA-D 4000 3 $0 NM; * THERA/BETA-CAROTENE 3 $0 NM; * THERANATAL CORE NUTRITION 3 $0 NM; * thiamine hcl SOLN; TABS 3 $0 NM; * thiamine mononitrate 3 $0 NM; * TRI-VI-SOL 3 $0 NM; * TRI-VI-SOL/IRON 3 $0 NM; * VITA-MAG 3 $0 NM; * VITALETS 3 $0 NM; * vitamin a CAPS 8000unit, 10000unit 3 $0 NM; * VITAMIN A TABS 3 $0 NM; * vitamin a TABS 10000unit 3 $0 NM; * VITAMIN A PALMITATE TABS 3 $0 NM; * VITAMIN C SOLR 3 $0 NM; * VITAMIN D2 3 $0 NM; * VITAMIN D3 LIQD 1200unit/15ml 3 $0 NM; * VITAMIN D3 TABS 3 $0 NM; * VITAMIN D3 400 3 $0 NM; * vitamin e CAPS 3 $0 NM; * VITAMIN E CHEW 3 $0 NM; * vitamin e LIQD 400unit/15ml 3 $0 NM; * vitamin e OIL 3 $0 NM; * vitamin e SOLN 3 $0 NM; * VITAMIN E TABS 100unit, 200unit 3 $0 NM; * vitamin e TABS 400unit 3 $0 NM; * VITAMIN K 3 $0 NM; * vitamin mixture 3 $0 NM; * vitamins a & d CAPS 3 $0 NM; * vitamins c & e 3 $0 NM; * ZOO FRIENDS COMPLETE 3 $0 NM; * 硝酸鹽 - 治療心臟病的藥物 抗感染藥 / 抗發炎藥 - 治療感染與發炎的藥物 bacitracin-poly-neomycin-hc 1 $0 blephamide OINT 2 $0 neomycin-polymy-dexameth 1 $0 neomycin-polymyxin-hc (ophth) 1 $0 56 如果您有任何疑問, 請致電 MetroPlus FIDA Plan, 電話 :1-844-288-FIDA (3432), TTY:711, 服務時間為週一至週六上午 8 時至晚上 8 時 晚上 8 時後 週日及假日 : 請撥打上列的 24 小時全年無休醫療諮詢服務專線 此電話號碼為免付費專線 如需詳細資訊, 請造訪 www.metroplusmedicare.org

sulfacetamide sod-prednisolone 1 $0 TOBRADEX OINT 2 $0 TOBRADEX ST 2 $0 tobramycin-dexamethasone 1 $0 ZYLET 2 $0 抗感染藥 - 用於治療感染的藥物 bacitracin (ophthalmic) 1 $0 bacitracin-polymyxin b (ophth) 1 $0 BESIVANCE 2 $0 CILOXAN OINT 2 $0 ciprofloxacin hcl (ophth) 1 $0 erythromycin (ophth) 1 $0 gatifloxacin (ophth) 1 $0 gentak 1 $0 gentamicin sulfate (ophth) 1 $0 MOXEZA 2 $0 NATACYN 2 $0 neomycin-bacitracin zn-polymyxin 1 $0 neomycin-polymyxin-gramicidin 1 $0 ofloxacin (ophth) 1 $0 polymyxin b-trimethoprim 1 $0 sulfacetamide sodium (ophth) 1 $0 tobramycin (ophth) 1 $0 TOBREX OINT 2 $0 trifluridine SOLN 1 $0 VIGAMOX 2 $0 抗發炎藥 - 用於治療發炎的藥物 ALREX 2 $0 BROMFENAC SODIUM (OPHTH)(ONCE-DAILY) 1 $0 dexamethasone sodium phosphate (ophth) 1 $0 diclofenac sodium (ophth) 1 $0 DUREZOL 2 $0 FLUOROMETHOLONE 1 $0 flurbiprofen sodium 1 $0 ILEVRO 2 $0 ketorolac tromethamine (ophth) 1 $0 LOTEMAX 2 $0 MAXIDEX 2 $0 NEVANAC 2 $0 PA - 事先授權 QL - 數量限制 ST - 階段式療法 NM - 不提供郵購 57 B/D - 根據 Medicare B 或 D 給付 LA - 有限的使用 * - 非 Part D 藥物, 或是 Medicaid 給付的 OTC 品項

PREDNISOLONE ACETATE (OPHTH) 1 $0 prednisolone sodium phosphate (ophth) 2 $0 抗過敏藥 - 治療過敏的藥物 azelastine hcl (ophth) 1 $0 BEPREVE 2 $0 cromolyn sodium (ophth) 1 $0 ketotifen fumarate (ophth) 3 $0 NM; * LASTACAFT 2 $0 naphazoline w/ pheniramine 3 $0 NM; * NAPHAZOLINE W/ PHENIRAMINE 3 $0 NM; * PATADAY 2 $0 PATANOL 2 $0 phenylephrine hcl (ophth) 3 $0 NM; * tetrahydrozoline hcl (ophth) 3 $0 NM; * tetrahydrozoline w/ zinc sulfate 3 $0 NM; * VASOCLEAR A 3 $0 NM; * VISINE-LR 3 $0 NM; * 抗青光眼藥 - 治療青光眼的藥物 ALPHAGAN P SOL 0.1% 2 $0 AZOPT 2 $0 betaxolol hcl (ophth) 1 $0 BETOPTIC-S 2 $0 brimonidine sol 0.2% 1 $0 BRIMONIDINE SOL 0.15% 1 $0 carteolol hcl (ophth) 1 $0 COMBIGAN 2 $0 dorzolamide hcl 1 $0 dorzolamide hcl-timolol maleate 1 $0 ISTALOL 2 $0 latanoprost SOLN 1 $0 levobunolol hcl.5% 1 $0 LEVOBUNOLOL HCL.25% 1 $0 LUMIGAN 2 $0 metipranolol 1 $0 PHOSPHOLINE IODIDE 2 $0 PILOCARPINE HCL SOLN 1 $0 SIMBRINZA 2 $0 timolol maleate (ophth) 1 $0 TIMOLOL MALEATE GEL 1 $0 TRAVATAN Z 2 $0 58 如果您有任何疑問, 請致電 MetroPlus FIDA Plan, 電話 :1-844-288-FIDA (3432), TTY:711, 服務時間為週一至週六上午 8 時至晚上 8 時 晚上 8 時後 週日及假日 : 請撥打上列的 24 小時全年無休醫療諮詢服務專線 此電話號碼為免付費專線 如需詳細資訊, 請造訪 www.metroplusmedicare.org

雜項 artificial tear ointment 3 $0 NM; * artificial tear solution 3 $0 NM; * BLINK TEARS LUBRICATING E 3 $0 NM; * carboxymethylcellulose sodium (ophth) 3 $0 NM; * carboxymethylcellulose-glycerin 3 $0 NM; * CLEAR EYES FOR DRY EYES 3 $0 NM; * COMPUTER EYE DROPS 3 $0 NM; * ENUCLENE 3 $0 NM; * FRESHKOTE 3 $0 NM; * GENTEAL 3 $0 NM; * GENTEAL MILD 3 $0 NM; * glycerin-hypromellose-polyethylene glycol 3 $0 NM; * 400 GONIOVISC 3 $0 NM; * HYPOTEARS 3 $0 NM; * hypromellose (gonioscopic) 3 $0 NM; * hypromellose (ophth) 3 $0 NM; * ISOPTO TEARS 3 $0 NM; * MURO 128 SOLN 2% 3 $0 NM; * naphazoline 0.1% 1 $0 NUTRATEAR 3 $0 NM; * ophthalmic irrigation solution 3 $0 NM; * polyethylene glycol-propylene glycol 3 $0 NM; * (ophth) polyvinyl alcohol SOLN 3 $0 NM; * polyvinyl alcohol-povidone (ophth) 3 $0 NM; * PROLENSA 2 $0 proparacaine hcl SOLN 1 $0 propylene glycol-glycerin 3 $0 NM; * REFRESH CELLUVISC 3 $0 NM; * REFRESH OPTIVE ADVANCED 3 $0 NM; * RESTASIS 2 $0 QL (64 vials / 30 days) RETAINE MGD 3 $0 NM; * sodium chloride hypertonic 3 $0 NM; * SOOTHE 3 $0 NM; * STERILE LUBRICANT DROPS 3 $0 NM; * SYSTANE BALANCE RESTORATI 3 $0 NM; * SYSTANE LIQUID GEL 3 $0 NM; * SYSTANE OVERNIGHT THERAPY 3 $0 NM; * PA - 事先授權 QL - 數量限制 ST - 階段式療法 NM - 不提供郵購 59 B/D - 根據 Medicare B 或 D 給付 LA - 有限的使用 * - 非 Part D 藥物, 或是 Medicaid 給付的 OTC 品項

TEARS AGAIN NIGHT & DAY 3 $0 NM; * THERATEARS SOLN 3 $0 NM; * VIVA DROPS 3 $0 NM; * white petrolatum-mineral oil 3 $0 NM; * 呼吸 - 治療呼吸疾病的藥物 抗膽鹼藥物 / 乙二型致效組合劑 - 治療 COPD 的藥物 ANORO ELLIPTA 2 $0 QL (1 inhaler / 30 days) COMBIVENT RESPIMAT 2 $0 QL (2 inhalers / 30 days) ipratropium-albuterol nebu 1 $0 B/D 抗膽鹼藥物 - 治療 COPD 的藥物 ATROVENT HFA 2 $0 QL (2 inhalers / 30 days) ipratropium bromide SOLN 1 $0 B/D ipratropium bromide (nasal) 1 $0 SPIRIVA HANDIHALER 2 $0 QL (30 caps / 30 days) TUDORZA PRESSAIR 2 $0 QL (1 inhaler / 30 days) 抗組織胺藥物 - 治療過敏的藥物 ALA-HIST IR 3 $0 NM; * ALDEX AN 3 $0 NM; * ALLEGRA ALLERGY CHILDRENS SUSP; 3 $0 NM; * TABS ASTEPRO 2 $0 azelastine hcl SOLN 1 $0 azelastine spr 0.1% 1 $0 cetirizine hcl 3 $0 NM; * cetirizine syrup 1 $0 chlorpheniramine maleate SYRP; TABS; 3 $0 NM; * TBCR CLARITIN CAPS; CHEW 3 $0 NM; * CLARITIN REDITABS 5mg 3 $0 NM; * clemastine fumarate TABS 1.34mg 3 $0 NM; * diphenhydramine hcl CAPS; CHEW; ELIX; 3 $0 NM; * LIQD; TABS; TBDP diphenhydramine inj 1 $0 ED CHLORPED 3 $0 NM; * fexofenadine hcl TABS 3 $0 NM; * hydroxyzine hcl SOLN 25mg/ml, 50mg/ml 2 $0 PA J-TAN PD 3 $0 NM; * levocetirizine dihydrochloride 1 $0 loratadine SYRP; TABS; TBDP 3 $0 NM; * 60 如果您有任何疑問, 請致電 MetroPlus FIDA Plan, 電話 :1-844-288-FIDA (3432), TTY:711, 服務時間為週一至週六上午 8 時至晚上 8 時 晚上 8 時後 週日及假日 : 請撥打上列的 24 小時全年無休醫療諮詢服務專線 此電話號碼為免付費專線 如需詳細資訊, 請造訪 www.metroplusmedicare.org

PATANASE 2 $0 TRIAMINIC COUGH & RUNNY N STRP 3 $0 NM; * 乙型致效劑 - 治療氣喘與 COPD 的藥物 albuterol sulfate NEBU 1 $0 B/D albuterol sulfate SYRP; TABS; TB12 1 $0 FORADIL AEROLIZER 2 $0 QL (60 caps / 30 days) levalbuterol conc 1.25mg/0.5ml 1 $0 B/D PERFOROMIST 2 $0 B/D PROAIR HFA 2 $0 QL (2 inhalers / 30 days) SEREVENT DISKUS 2 $0 QL (1 inhaler / 30 days) terbutaline sulfate SOLN; TABS 1 $0 XOPENEX HFA 2 $0 QL (2 inhalers / 30 days) 咳嗽與感冒 acetaminophen w/ dm 3 $0 NM; * acetaminophen-guaifenesin 3 $0 NM; * ADVIL ALLERGY & CONGESTIO 3 $0 NM; * ADVIL ALLERGY SINUS 3 $0 NM; * ADVIL COLD & SINUS CAPS 3 $0 NM; * AFRIN MENTHOL 3 $0 NM; * ALA-HIST PE 3 $0 NM; * ALDEX GS 3 $0 NM; * ALDEX GS DM 3 $0 NM; * ALDEX-CT 3 $0 NM; * AYR NASAL DROPS 3 $0 NM; * AYR SALINE NASAL 3 $0 NM; * benzonatate 3 $0 NM; * BICLORA 3 $0 NM; * BIOSPEC DMX 3 $0 NM; * BROHIST D 3 $0 NM; * brompheniramine & phenyleph 3 $0 NM; * brompheniramine & pseudoeph 3 $0 NM; * BROVEX PSB 3 $0 NM; * BROVEX PSB DM 3 $0 NM; * CAPCOF 3 $0 NM; * CAPMIST DM 3 $0 NM; * cetirizine-pseudoephedrine 3 $0 NM; * CHLO TUSS EX 3 $0 NM; * chlorpheniramine & phenylephrine 3 $0 NM; * chlorpheniramine & pseudoeph 3 $0 NM; * chlorpheniramine-dm 3 $0 NM; * PA - 事先授權 QL - 數量限制 ST - 階段式療法 NM - 不提供郵購 61 B/D - 根據 Medicare B 或 D 給付 LA - 有限的使用 * - 非 Part D 藥物, 或是 Medicaid 給付的 OTC 品項

chlorpheniramine-phenylephrine-acetamino 3 $0 NM; * phen chlorpheniramine-pseudoephedrine-acetam 3 $0 NM; * inophen CLOFERA 3 $0 NM; * CODAR AR 3 $0 NM; * CODAR D 3 $0 NM; * CODITUSS DM 3 $0 NM; * COMPLETE SINUS RELIEF 3 $0 NM; * CONEX COLD/ALLERGY 3 $0 NM; * CONTAC COLD/FLU DAY & NIG 3 $0 NM; * CONTAC COLD/FLU MAXIMUM S 3 $0 NM; * COUGH SYRUP D 3 $0 NM; * cromolyn sodium (nasal) 3 $0 NM; * cvs nasal mist.9% 3 $0 NM; * DALLERGY SYRP 3 $0 NM; * DECON-A LIQD 3 $0 NM; * DELTUSS DP 3 $0 NM; * DEX-TUSS 3 $0 NM; * DEXATREX D NASAL 3 $0 NM; * dextromethorphan hbr CAPS; LIQD; SYRP 3 $0 NM; * dextromethorphan polistirex 3 $0 NM; * dextromethorphan-doxylamine-acetaminop 3 $0 NM; * hen dextromethorphan-guaifenesin 3 $0 NM; * dextromethorphan-phenylephrine-acetami 3 $0 NM; * nophen DIABETIC TUSSIN COLD/FLU 3 $0 NM; * DICEL CD 3 $0 NM; * DIMETAPP LONG ACTING COUG 3 $0 NM; * diphenhydramine-acetaminophen 3 $0 NM; * diphenhydramine-phenylephrine 3 $0 NM; * diphenhydramine-phenylephrine-acetamino 3 $0 NM; * phen DONATUSSIN 3 $0 NM; * doxylamine-dm 3 $0 NM; * doxylamine-phenylephrine-acetaminophen 3 $0 NM; * DRYMAX AF 3 $0 NM; * DURAFLU 3 $0 NM; * ED CHLORPED D 3 $0 NM; * ENTSOL NASAL GEL 3 $0 NM; * 62 如果您有任何疑問, 請致電 MetroPlus FIDA Plan, 電話 :1-844-288-FIDA (3432), TTY:711, 服務時間為週一至週六上午 8 時至晚上 8 時 晚上 8 時後 週日及假日 : 請撥打上列的 24 小時全年無休醫療諮詢服務專線 此電話號碼為免付費專線 如需詳細資訊, 請造訪 www.metroplusmedicare.org

ephedrine-guaifenesin 3 $0 NM; * fexofenadine-pseudoephedrine 3 $0 NM; * guaifenesin LIQD; SYRP; TABS; TB12 3 $0 NM; * guaifenesin-codeine LIQD 3 $0 NM; * GUAIFENESIN-CODEINE LIQD 3 $0 NM; * guaifenesin-codeine SOLN 3 $0 NM; * J-MAX 3 $0 NM; * J-TAN D PD 3 $0 NM; * LITTLE NOSES DECONGESTANT 3 $0 NM; * LODRANE D 3 $0 NM; * LOHIST-D 3 $0 NM; * loratadine & pseudoephedrine 3 $0 NM; * LORTUSS DM 3 $0 NM; * LORTUSS EX 3 $0 NM; * LORTUSS LQ 3 $0 NM; * LUSAIR 3 $0 NM; * M-END DMX 3 $0 NM; * M-END MAX D 3 $0 NM; * M-END PE 3 $0 NM; * MAR-COF BP 3 $0 NM; * MEDI-GRAINE 3 $0 NM; * MUCINEX COUGH FOR KIDS 3 $0 NM; * MUCINEX D 3 $0 NM; * MUCINEX FOR KIDS 3 $0 NM; * MUCINEX MAXIMUM STRENGTH 3 $0 NM; * NASAL DECONGESTANT 3 $0 NM; * NASOHIST DM 3 $0 NM; * NASOPEN PE 3 $0 NM; * NEO-SYNEPHRINE.5% 3 $0 NM; * NOREL AD 3 $0 NM; * NOREL CS 3 $0 NM; * ONSET FORTE 3 $0 NM; * oxymetazoline hcl SOLN 3 $0 NM; * PHENAGIL 3 $0 NM; * phenylephrine hcl SOLN.25%, 1% 3 $0 NM; * phenylephrine hcl (oral) 3 $0 NM; * phenylephrine w/ acetaminophen 3 $0 NM; * phenylephrine w/ dm-gg 3 $0 NM; * phenylephrine-acetaminophen-guaifenesin 3 $0 NM; * phenylephrine-brompheniramine-dm 3 $0 NM; * PA - 事先授權 QL - 數量限制 ST - 階段式療法 NM - 不提供郵購 63 B/D - 根據 Medicare B 或 D 給付 LA - 有限的使用 * - 非 Part D 藥物, 或是 Medicaid 給付的 OTC 品項

phenylephrine-chlorphen-dm 3 $0 NM; * phenylephrine-chlorpheniramine-dm w/ 3 $0 NM; * apap phenylephrine-dm 3 $0 NM; * phenylephrine-dm-gg w/ apap 3 $0 NM; * phenylephrine-doxylamine-dextromethorph 3 $0 NM; * an-acetaminophen phenylephrine-guaifenesin 3 $0 NM; * PHENYLHISTINE DH 3 $0 NM; * POLY-TUSSIN 3 $0 NM; * POLY-TUSSIN AC 3 $0 NM; * POLY-TUSSIN D 3 $0 NM; * PRETZ 3 $0 NM; * PRO-CHLO 3 $0 NM; * PRO-CLEAR AC 3 $0 NM; * pseudoephed-bromphen-dm 3 $0 NM; * pseudoephed-doxyl-dm w/apap 3 $0 NM; * pseudoephedrine hcl LIQD; SYRP; TABA; 3 $0 NM; * TABS; TB12 pseudoephedrine w/ codeine-gg 3 $0 NM; * pseudoephedrine w/ dm-gg 3 $0 NM; * pseudoephedrine-acetaminophen 3 $0 NM; * pseudoephedrine-brompheniramine-codein 3 $0 NM; * e pseudoephedrine-chlorphen-dm 3 $0 NM; * pseudoephedrine-dexchlorpheniramine-chl 3 $0 NM; * ophedianol pseudoephedrine-guaifenesin 3 $0 NM; * PSEUDOEPHEDRINE-IBUPROFEN SUSP 3 $0 NM; * pseudoephedrine-ibuprofen TABS 3 $0 NM; * PYRIL DM 3 $0 NM; * pyrilamine maleate-phenylephrine hcl 3 $0 NM; * tannate RESCON 3 $0 NM; * RESCON DM 3 $0 NM; * RESPAIRE-30 3 $0 NM; * RHINARIS 3 $0 NM; * ROBITUSSIN CHILDRENS COUG 3 $0 NM; * ROBITUSSIN PEAK COLD NIGH 3 $0 NM; * RU-HIST-D 3 $0 NM; * RYMED 3 $0 NM; * 64 如果您有任何疑問, 請致電 MetroPlus FIDA Plan, 電話 :1-844-288-FIDA (3432), TTY:711, 服務時間為週一至週六上午 8 時至晚上 8 時 晚上 8 時後 週日及假日 : 請撥打上列的 24 小時全年無休醫療諮詢服務專線 此電話號碼為免付費專線 如需詳細資訊, 請造訪 www.metroplusmedicare.org

saline 3 $0 NM; * SCOT-TUSSIN 3 $0 NM; * SCOT-TUSSIN SENIOR 3 $0 NM; * STAHIST AD 3 $0 NM; * STATUSS GREEN 3 $0 NM; * SUDAFED 24 HOUR 3 $0 NM; * THERAFLU FLU & SORE THROA 3 $0 NM; * THERAFLU MAX-D SEVERE COL 3 $0 NM; * THERAFLU SINUS & COLD 3 $0 NM; * TRIAMINIC CHEST & NASAL C 3 $0 NM; * TRIAMINIC COLD & ALLERGY 3 $0 NM; * TRIAMINIC COLD & COUGH DA SOLN 3 $0 NM; * TRIAMINIC COLD/COUGH NIGH 3 $0 NM; * TRIAMINIC MULTI-SYMPTOM F 3 $0 NM; * TRIAMINIC NIGHT TIME COLD 3 $0 NM; * TRICODE AR 3 $0 NM; * TRICODE GF 3 $0 NM; * triprolidine & pseudoephedrine 3 $0 NM; * TUSNEL LIQD 3 $0 NM; * TUSNEL PEDIATRIC 3 $0 NM; * TUSNEL-DM PEDIATRIC 3 $0 NM; * VICKS VAPORUB 3 $0 NM; * Z-TUSS AC 3 $0 NM; * Z-TUSS E 3 $0 NM; * ZODRYL AC 25 3 $0 NM; * ZODRYL AC 30 3 $0 NM; * ZODRYL AC 35 3 $0 NM; * ZODRYL AC 40 3 $0 NM; * ZODRYL DAC 25 3 $0 NM; * ZODRYL DAC 30 3 $0 NM; * ZODRYL DAC 35 3 $0 NM; * ZODRYL DAC 40 3 $0 NM; * ZODRYL DEC 25 3 $0 NM; * ZODRYL DEC 30 3 $0 NM; * ZODRYL DEC 35 3 $0 NM; * ZODRYL DEC 40 3 $0 NM; * zonatuss 3 $0 NM; * 白三烯素接受器拮抗劑 - 治療氣喘與過敏的藥物 montelukast sodium CHEW; PACK; TABS 1 $0 PA - 事先授權 QL - 數量限制 ST - 階段式療法 NM - 不提供郵購 65 B/D - 根據 Medicare B 或 D 給付 LA - 有限的使用 * - 非 Part D 藥物, 或是 Medicaid 給付的 OTC 品項

zafirlukast 1 $0 肥大細胞穩定劑 - 治療過敏的藥物 cromolyn sodium nebu 1 $0 B/D 雜項 acetylcysteine SOLN 10%, 20% 1 $0 B/D ARALAST NP 2 $0 NM, LA, PA AUVI-Q 2 $0 DALIRESP 2 $0 EPIPEN 2-PAK 2 $0 EPIPEN-JR 2-PAK 2 $0 PROLASTIN-C 2 $0 NM, LA, PA PULMOZYME 2 $0 B/D, NM SODIUM CHLORIDE NEBU.45% 3 $0 NM; * XOLAIR 2 $0 NM, LA, PA ZEMAIRA 2 $0 NM, LA, PA 鼻腔類固醇 - 治療過敏的藥物 flunisolide (nasal) 1 $0 QL (2 bottles / 30 days) fluticasone propionate (nasal) 1 $0 QL (1 bottle / 30 days) NASONEX 2 $0 QL (2 bottles / 30 days) 類固醇吸入劑 - 治療氣喘的藥物 ASMANEX 14 METERED DOSES 2 $0 QL (2 inhalers / 30 days) ASMANEX 30 METERED DOSES 2 $0 QL (2 inhalers / 30 days) ASMANEX 60 METERED DOSES 2 $0 QL (2 inhalers / 30 days) ASMANEX 120 METERED DOSES 2 $0 QL (2 inhalers / 30 days) ASMANEX TWISTHALER 30 ME 2 $0 QL (2 inhalers / 30 days) budesonide (inhalation) 1 $0 B/D FLOVENT DISKUS 50mcg/blist, 2 $0 QL (2 inhalers / 30 days) 100mcg/blist FLOVENT DISKUS 250mcg/blist 2 $0 QL (4 inhalers / 30 days) FLOVENT HFA 2 $0 QL (2 inhalers / 30 days) QVAR 40mcg/act 2 $0 QL (1 inhaler / 30 days) QVAR 80mcg/act 2 $0 QL (2 inhalers / 30 days) 類固醇 / 乙型致效組合劑 - 治療氣喘與 COPD 的藥物 ADVAIR DISKUS 2 $0 QL (1 inhaler / 30 days) ADVAIR HFA 2 $0 QL (1 inhaler / 30 days) BREO ELLIPTA 2 $0 QL (1 inhaler / 30 days) DULERA 2 $0 QL (1 inhaler / 30 days) SYMBICORT 2 $0 QL (1 inhaler / 30 days) 66 如果您有任何疑問, 請致電 MetroPlus FIDA Plan, 電話 :1-844-288-FIDA (3432), TTY:711, 服務時間為週一至週六上午 8 時至晚上 8 時 晚上 8 時後 週日及假日 : 請撥打上列的 24 小時全年無休醫療諮詢服務專線 此電話號碼為免付費專線 如需詳細資訊, 請造訪 www.metroplusmedicare.org

XANTHINES( 黃嘌呤 ) - 治療 COPD 的藥物 aminophylline inj 1 $0 elixophyllin 2 $0 theo-24 2 $0 theophylline 1 $0 體表用藥 - 治療耳朵 皮膚科, 青春痘 adapalene CREA 1 $0 adapalene GEL.1% 1 $0 amnesteem 1 $0 AVITA 1 $0 benzoyl peroxide-erythromycin 1 $0 claravis 1 $0 clindamycin phosphate (topical) GEL; 1 $0 LOTN; SOLN; SWAB ery pad 2% 1 $0 erythromycin (acne aid) 1 $0 myorisan 1 $0 sulfacetamide sodium (acne) 1 $0 tretinoin CREA; GEL 1 $0 zenatane 1 $0 皮膚科, 抗生素 與皮膚狀況 ACNE MEDICATION 3 $0 NM; * ACNE MEDICATION 5 3 $0 NM; * bacitracin (topical) 3 $0 NM; * bacitracin zinc OINT 3 $0 NM; * bacitracin-polymyxin b 3 $0 NM; * BENZOYL PEROXIDE BAR 3 $0 NM; * benzoyl peroxide CREA 3 $0 NM; * BENZOYL PEROXIDE GEL 2.5% 3 $0 NM; * benzoyl peroxide GEL 5%, 10% 3 $0 NM; * benzoyl peroxide LIQD 3 $0 NM; * benzoyl peroxide LOTN 3 $0 NM; * BP CLEANSING LOTION 3 $0 NM; * gentamicin sulfate (topical) 1 $0 mafenide acetate PACK 1 $0 mupirocin OINT 1 $0 neomycin-bacitracin-polymyxin 3 $0 NM; * neomycin-bacitracin-polymyxin w/ lidocaine 3 $0 NM; * neomycin-bacitracin-polymyxin-pramoxine 3 $0 NM; * PA - 事先授權 QL - 數量限制 ST - 階段式療法 NM - 不提供郵購 67 B/D - 根據 Medicare B 或 D 給付 LA - 有限的使用 * - 非 Part D 藥物, 或是 Medicaid 給付的 OTC 品項

的 藥物費用 neomycin-polymyxin w/ pramoxine 3 $0 NM; * PANOXYL-4 CREAMY WASH 3 $0 NM; * PANOXYL-8 CREAMY WASH 3 $0 NM; * SILVER SULFADIAZINE CREA 1 $0 SSD 1 $0 SULFAMYLON CREA 2 $0 皮膚科, 抗真菌藥 castellani paint 3 $0 NM; * ciclopirox CREA; GEL; SUSP 1 $0 ciclopirox shampoo 1% 1 $0 clotrimazole (topical) CREA 1% 1 $0 clotrimazole (topical) CREA 1% 3 $0 NM; * clotrimazole (topical) SOLN 1% 1 $0 clotrimazole (topical) SOLN 1% 3 $0 NM; * econazole nitrate CREA 1 $0 FUNGOID TINCTURE 3 $0 NM; * GENTIAN VIOLET SOLN 3 $0 NM; * ketoconazole cream 1 $0 LAMISIL ADVANCED 3 $0 NM; * LAMISIL AT SPRAY 3 $0 NM; * LOTRIMIN ULTRA 3 $0 NM; * miconazole nitrate (topical) 3 $0 NM; * NIZORAL A-D 3 $0 NM; * nyamyc 1 $0 nystatin (topical) 1 $0 nystop 1 $0 pedi-dri 1 $0 terbinafine hcl (topical) 3 $0 NM; * tolnaftate 3 $0 NM; * 皮膚科, 止癢劑 procto-pak 1 $0 proctozone hc 1 $0 PRUDOXIN CRE 5% 1 $0 皮膚科, 抗牛皮癬藥 acitretin 2 $0 PA calcipotriene CREA; OINT; SOLN 1 $0 calcitrene oin 0.005% 1 $0 8-MOP 2 $0 TAZORAC CREA 2 $0 PA 皮膚科, 抗皮脂漏劑 68 如果您有任何疑問, 請致電 MetroPlus FIDA Plan, 電話 :1-844-288-FIDA (3432), TTY:711, 服務時間為週一至週六上午 8 時至晚上 8 時 晚上 8 時後 週日及假日 : 請撥打上列的 24 小時全年無休醫療諮詢服務專線 此電話號碼為免付費專線 如需詳細資訊, 請造訪 www.metroplusmedicare.org

ketoconazole shampoo 1 $0 selenium sulfide LOTN 1 $0 皮膚科, 抗病毒藥 acyclovir topical 1 $0 DENAVIR 2 $0 皮膚科, 皮質類固醇 ala-cort 1 $0 alclometasone dipropionate 1 $0 amcinonide CREA; LOTN 1 $0 amcinonide OINT 2 $0 betamethasone dipropionate (topical) 1 $0 betamethasone dipropionate augmented 1 $0 betamethasone valerate CREA; LOTN; 1 $0 OINT clobetasol propionate CREA 1 $0 clobetasol propionate GEL 1 $0 clobetasol propionate OINT 1 $0 clobetasol propionate SOLN 1 $0 CVS HDYROCORTISONE ACETAT 3 $0 NM; * DESONIDE CREA 1 $0 desonide LOTN; OINT 1 $0 desoximetasone CREA 1 $0 desoximetasone GEL 1 $0 DESOXIMETASONE OINT.05% 1 $0 desoximetasone OINT.25% 1 $0 diflorasone diacetate 1 $0 fluocinolone acetonide CREA; OIL; OINT; 1 $0 SOLN fluocinonide CREA.05% 1 $0 fluocinonide GEL 1 $0 fluocinonide OINT 1 $0 fluocinonide SOLN 1 $0 fluocinonide emulsified base 1 $0 fluticasone propionate CREA 1 $0 fluticasone propionate OINT 1 $0 halobetasol propionate 1 $0 hydrocortisone (topical) CREA 1%, 2.5% 1 $0 hydrocortisone (topical) CREA.5%, 1% 3 $0 NM; * hydrocortisone (topical) GEL 3 $0 NM; * hydrocortisone (topical) LOTN 1% 3 $0 NM; * PA - 事先授權 QL - 數量限制 ST - 階段式療法 NM - 不提供郵購 69 B/D - 根據 Medicare B 或 D 給付 LA - 有限的使用 * - 非 Part D 藥物, 或是 Medicaid 給付的 OTC 品項

hydrocortisone (topical) LOTN 2.5% 1 $0 hydrocortisone (topical) OINT 1%, 2.5% 1 $0 hydrocortisone (topical) OINT.5%, 1% 3 $0 NM; * hydrocortisone (topical) SOLN 3 $0 NM; * hydrocortisone acetate (topical) 3 $0 NM; * hydrocortisone acetate-aloe vera 3 $0 NM; * hydrocortisone butyrate 1 $0 hydrocortisone valerate 1 $0 hydrocortisone-aloe vera 3 $0 NM; * HYDROCORTISONE/ALOE 3 $0 NM; * LOKARA LOTN 0.05% 1 $0 mometasone furoate CREA; OINT; SOLN 1 $0 texacort soln 2.5% 2 $0 triamcinolone acetonide (topical) 1 $0 triderm 1 $0 TUCKS ANTI-ITCH 3 $0 NM; * 皮膚科, 局部麻醉劑 lidocaine PTCH 1 $0 QL (3 patches / 1 day), PA lidocaine hcl GEL 1 $0 lidocaine hcl SOLN 4% 1 $0 lidocaine oint 5% 1 $0 lidocaine-prilocaine 1 $0 B/D 皮膚科, 雜項皮膚與黏膜 ABREVA 3 $0 NM; * ammonium lactate CREA; LOTN 1 $0 BOUDREAUXS BUTT PASTE 3 $0 NM; * DESITIN CREA 3 $0 NM; * ELIDEL 2 $0 PA fluorouracil (topical) 1 $0 imiquimod CREA 1 $0 laclotion lotn 12% 1 $0 menthol-zinc oxide 3 $0 NM; * metronidazole (topical) CREA; LOTN 1 $0 metronidazole gel 0.75% 1 $0 MEXSANA 3 $0 NM; * PANRETIN 2 $0 podofilox SOLN 1 $0 RA CALAMINE LOTN 3 $0 NM; * rosadan cre 0.75% 1 $0 SECURA EXTRA PROTECTIVE 3 $0 NM; * 70 如果您有任何疑問, 請致電 MetroPlus FIDA Plan, 電話 :1-844-288-FIDA (3432), TTY:711, 服務時間為週一至週六上午 8 時至晚上 8 時 晚上 8 時後 週日及假日 : 請撥打上列的 24 小時全年無休醫療諮詢服務專線 此電話號碼為免付費專線 如需詳細資訊, 請造訪 www.metroplusmedicare.org

SENSI-CARE PROTECTIVE BAR 3 $0 NM; * TARGRETIN GEL 2 $0 NM, PA TRIPLE PASTE 3 $0 NM; * VALCHLOR 2 $0 NM, LA, PA VOLTAREN 2 $0 ZINC OXIDE PSTE 3 $0 NM; * zinc oxide (topical) 3 $0 NM; * 皮膚科, 滅疥癬藥與滅虱藥 A-200 GEL 3 $0 NM; * BARC 3 $0 NM; * EURAX 2 $0 LICIDE TREATMENT KIT 3 $0 NM; * malathion 1 $0 permethrin AERO; LIQD; LOTN 3 $0 NM; * permethrin CREA 1 $0 permethrin & pyrethrins-piperonyl butoxide 3 $0 NM; * PRONTO AERO 3 $0 NM; * PYRETHINS/PIPERONYL BUTO 3 $0 NM; * pyrethrins-piperonyl butoxide 3 $0 NM; * pyrethrins-piperonyl 3 $0 NM; * butoxide-permethrin-nit remover SCHOOLTIME SHAMPOO 3 $0 NM; * 皮膚科, 傷口照護藥劑 acetic acid.25% 1 $0 REGRANEX 2 $0 PA SANTYL 2 $0 SODIUM CHLORIDE 0.9% 1 $0 STERILE WATER IRRIGATION 1 $0 口 / 喉嚨 / 牙齒藥劑 cevimeline hcl 1 $0 chlorhexidine gluconate (mouth-throat) 1 $0 clotrimazole TROC 1 $0 lidocaine hcl (mouth-throat) 1 $0 nystatin (mouth-throat) 1 $0 periogard 1 $0 pilocarpine hcl (oral) 1 $0 triamcinolone acetonide (mouth) 1 $0 OTIC - 用於治療耳朵情況的藥物 acetic acid (otic) 1 $0 acetic acid-aluminum acetate 1 $0 PA - 事先授權 QL - 數量限制 ST - 階段式療法 NM - 不提供郵購 71 B/D - 根據 Medicare B 或 D 給付 LA - 有限的使用 * - 非 Part D 藥物, 或是 Medicaid 給付的 OTC 品項

CIPRODEX 2 $0 fluocinolone acetonide (otic) 1 $0 neomycin-polymyxin-hc (otic) 1 $0 ofloxacin (otic) 1 $0 藥物索引 : 8-MOP, 68 A-200, 71 A-25, 53 abacavir sulfate, 6 abacavir sulfate-lamivudine-zidovudine, 6 ABELCET, 5 ABILIFY, 25 ABILIFY DISCMELT, 25 ABILIFY MAIN INJ 300MG, 25 ABILIFY MAIN INJ 400MG, 25 ABREVA, 70 acamprosate calcium, 29 acarbose, 31 acebutolol hcl, 17 ACEROLA C 500, 53 acetaminophen, 1 ACETAMINOPHEN, 1 ACETAMINOPHEN 8 HOUR, 1 acetaminophen w/ codeine, 2 acetaminophen w/ dm, 61 acetaminophen-guaifenesin, 61 acetazolamide, 19 acetic acid, 71 acetic acid (otic), 71 acetic acid-aluminum acetate, 71 acetylcysteine, 66 acitretin, 68 ACNE MEDICATION, 67 ACNE MEDICATION 5, 67 ACTHIB, 47 ACTIMMUNE, 46 acyclovir, 7 acyclovir sodium, 7 acyclovir topical, 69 ADACEL, 47 ADAGEN, 34 adapalene, 67 ADCIRCA, 20 adefovir dipivoxil, 7 ADEMPAS, 20 adriamycin, 11 adriamycin inj 20mg, 11 adrucil, 11 ADULT ASPIRIN LOW STRENGT, 1 ADVAIR DISKUS, 66 ADVAIR HFA, 66 ADVANCED CALCIUM FORMULA, 51 ADVIL ALLERGY & CONGESTIO, 61 ADVIL ALLERGY SINUS, 61 ADVIL COLD & SINUS, 61 afeditab cr, 18 AFINITOR, 12 AFINITOR DISPERZ, 13 AFRIN MENTHOL, 61 AGGRENOX, 45 a-hydrocort, 35 ala-cort, 69 ALA-HIST IR, 60 ALA-HIST PE, 61 ALBENZA, 4 albuterol sulfate, 61 alclometasone dipropionate, 69 ALCOHOL SWABS, 30 ALDEX AN, 60 ALDEX GS, 61 ALDEX GS DM, 61 72 如果您有任何疑問, 請致電 MetroPlus FIDA Plan, 電話 :1-844-288-FIDA (3432), TTY:711, 服務時間為週一至週六上午 8 時至晚上 8 時 晚上 8 時後 週日及假日 : 請撥打上列的 24 小時全年無休醫療諮詢服務專線 此電話號碼為免付費專線 如需詳細資訊, 請造訪 www.metroplusmedicare.org

ALDEX-CT, 61 ALDURAZYME, 34 alendronate sodium, 32 alfuzosin hcl, 42 ALIMTA, 11 ALINIA, 4 ALLEGRA ALLERGY CHILDRENS, 60 allopurinol tab, 1 ALPHAGAN P SOL 0.1%, 58 alprazolam, 21 alprazolam tab 0.25mg, 21 alprazolam tab 0.5mg, 21 alprazolam tab 1mg, 21 alprazolam tab 2mg, 21 ALREX, 57 altavera, 32 alum & mag hydrox-simethicone, 37 ALUMINUM HYDROXIDE, 37 aluminum hydroxide gel, 37 aluminum hydroxide-mag carb, 37 aluminum hydroxide-mag trisil, 37 amantadine hcl, 25 AMBISOME, 5 amcinonide, 69 amifostine crystalline, 14 amikacin sulfate, 4 amiloride & hydrochlorothiazide, 19 amiloride hcl, 19 aminophylline inj, 67 AMINOSYN, 49 AMINOSYN 7%/ELECTROLYTES, 49 AMINOSYN 8.5%/ELECTROLYTE, 49 AMINOSYN II, 49 AMINOSYN II 8.5%/ELECTROL, 49 AMINOSYN M, 49 AMINOSYN-HBC, 49 AMINOSYN-PF, 49 AMINOSYN-PF 7%, 49 AMINOSYN-RF, 49 amiodarone hcl, 16 AMITIZA CAP 24MCG, 41 AMITIZA CAP 8MCG, 41 amitriptyline hcl, 23 amlodipine besylate, 18 amlodipine--benazepril hcl cap 10-20 mg, 14 amlodipine-benazepril hcl cap 10-40mg, 14 amlodipine-benazepril hcl cap 2.5-10 mg, 14 amlodipine-benazepril hcl cap 5-10 mg, 14 amlodipine-benazepril hcl cap 5-20 mg, 14 amlodipine-benazepril hcl cap 5-40 mg, 14 ammonium lactate, 70 amnesteem, 67 amoxapine tab 100mg, 23 amoxapine tab 150mg, 24 amoxapine tab 25mg, 23 amoxapine tab 50mg, 23 amoxicillin, 9 amoxicillin & pot clavulanate, 9 amphetamine-dextroamphetamine cap sr 24hr 10 mg, 27 amphetamine-dextroamphetamine cap sr 24hr 15 mg, 27 amphetamine-dextroamphetamine cap sr 24hr 20 mg, 27 amphetamine-dextroamphetamine cap sr 24hr 25 mg, 27 amphetamine-dextroamphetamine cap sr 24hr 30 mg, 27 amphetamine-dextroamphetamine cap sr 24hr 5 mg, 27 amphetamine-dextroamphetamine tab 10 mg, 28 amphetamine-dextroamphetamine tab 12.5 mg, 28 amphetamine-dextroamphetamine tab 15 mg, 28 amphetamine-dextroamphetamine tab 20 mg, 28 amphetamine-dextroamphetamine tab 30 mg, 28 amphetamine-dextroamphetamine tab 5 mg, 27 amphetamine-dextroamphetamine tab 7.5 mg, 27 amphotericin b, 5 ampicillin & sulbactam sodium, 9 ampicillin cap 250 mg, 9 ampicillin cap 500 mg, 10 ampicillin for susp 125 mg/5ml, 10 ampicillin for susp 250 mg/5ml, 10 73

ampicillin inj, 10 ampicillin sodium, 10 AMTURNIDE TAB 150-5-12.5, 19 AMTURNIDE TAB 300-10-12.5, 19 AMTURNIDE TAB 300-10-25 MG, 19 AMTURNIDE TAB 300-5-12.5, 19 AMTURNIDE TAB 300-5-25MG, 19 anagrelide hcl, 45 anastrozole, 12 ANDRODERM, 30 androxy, 30 ANORO ELLIPTA, 60 ANTIOXIDANT FORMULA SG, 53 APAP 500, 1 APATATE, 53 APOKYN, 25 apri 28 day, 32 APRISO, 39 APTIOM, 21 APTIVUS, 6 AQUA-E, 53 ARALAST NP, 66 aranelle 28, 32 ARCALYST, 46 artificial tear ointment, 59 artificial tear solution, 59 ASACOL HD, 39 ascorbic acid, 53 ASCORBIC ACID, 53 ASCRIPTIN, 1 ASMANEX 120 METERED DOSES, 66 ASMANEX 14 METERED DOSES, 66 ASMANEX 30 METERED DOSES, 66 ASMANEX 60 METERED DOSES, 66 ASMANEX TWISTHALER 30 ME, 66 aspirin, 1 ASPIRIN, 1 aspirin buffered (cal carb-mag carb-mag oxide), 1 aspirin effervescent, 1 ASTEPRO, 60 atenolol, 17 atenolol & chlorthalidone, 17 atorvastatin calcium, 16 atovaquone, 4 atovaquone-proguanil hcl, 5 ATRIPLA, 7 ATROVENT HFA, 60 AUVI-Q, 66 AVASTIN, 12 aviane 28, 32 AVITA, 67 AVODART, 42 AXID AR, 39 AYR NASAL DROPS, 61 AYR SALINE NASAL, 61 azacitidine, 11 AZACTAM, 4 AZACTAM/DEX INJ 1GM, 4 AZACTAM/DEX INJ 2GM, 4 azathioprine, 47 azelastine hcl, 60 azelastine hcl (ophth), 58 azelastine spr 0.1%, 60 AZILECT, 25 azithromycin, 9 AZITHROMYCIN, 9 AZOPT, 58 AZOR 10-40MG, 15 AZOR TAB 10-20MG, 15 AZOR TAB 5-20MG, 15 AZOR TAB 5-40MG, 15 aztreonam, 4 b complex w/ c, 53 B-1, 53 B-12, 53 B-12 DOTS, 53 B-12 QUICK DISSOLVE, 53 bacitracin (ophthalmic), 57 bacitracin (topical), 67 bacitracin zinc, 67 bacitracin-polymyxin b, 67 bacitracin-polymyxin b (ophth), 57 bacitracin-poly-neomycin-hc, 56 baclofen, 29 balsalazide disodium, 39 balziva 28 day, 32 BANZEL SUS 40MG/ML, 21 BANZEL TAB 200MG, 21 BANZEL TAB 400MG, 21 74

BARACLUDE, 7 BLACK DRAUGHT, 40 BARC, 71 bleomycin sulfate, 11 BCG VACCINE, 47 blephamide, 56 b-complex vitamins, 53 BLINK TEARS LUBRICATING E, 59 b-complex w/ c & calcium, 53 B-NATAL, 54 b-complex w/ c & e + zn, 53 BONE DENSITY, 51 b-complex w/ c & folic acid, 53 bone meal w/ vitamin d, 51 b-complex w/ folic acid, 54 BOOSTRIX, 47 b-complex w/ minerals, 54 BOSULIF, 13 b-complex w/biotin & folic acid, 54 BOUDREAUXS BUTT PASTE, 70 BEELITH, 51 BP CLEANSING LOTION, 67 benazepril & hydrochlorothiazide, 14 BREO ELLIPTA, 66 benazepril hcl, 14 brewers yeast, 54 BENEFIBER, 40 briellyn 28 day, 32 BENICAR, 16 BRILINTA, 45 BENICAR HCT 40-25MG, 15 BRIMONIDINE SOL 0.15%, 58 BENICAR HCT TAB 20-12.5MG, 15 brimonidine sol 0.2%, 58 BENICAR HCT TAB 40-12.5MG, 15 BRINTELLIX, 24 benzocaine-docusate sodium, 40 BROHIST D, 61 benzonatate, 61 BROMFENAC SODIUM benzoyl peroxide, 67 (OPHTH)(ONCE-DAILY), 57 BENZOYL PEROXIDE, 67 bromocriptine mesylate, 25 benzoyl peroxide-erythromycin, 67 brompheniramine & phenyleph, 61 benztropine mesylate, 25 brompheniramine & pseudoeph, 61 BEPREVE, 58 BROVEX PSB, 61 BESIVANCE, 57 BROVEX PSB DM, 61 beta carotene, 54 budesonide (inhalation), 66 betamethasone dipropionate (topical), 69 budesonide ec, 39 betamethasone dipropionate augmented, BUFFERIN EXTRA STRENGTH, 1 69 BUFFERIN LOW DOSE, 1 betamethasone valerate, 69 bumetanide, 19 BETASERON, 29 buprenorphine hcl, 29 betaxolol hcl (ophth), 58 buprenorphine hcl-naloxone hcl sl, 29 bethanechol chloride, 43 buproban, 29 BETOPTIC-S, 58 bupropion hcl, 24 bicalutamide, 12 buspirone hcl, 21 BICILLIN L-A, 10 BUSULFEX, 10 BICLORA, 61 butorphanol tartrate, 2 BICNU, 10 BYSTOLIC, 17 BIFERA, 44 cabergoline, 36 BILTRICIDE, 4 cafergot, 28 BIOSPEC DMX, 61 CAL/MAG, 51 biotin, 54 CALCET CREAMY BITES, 51 bisacodyl, 40 CALCET PETITES, 51 bismuth subsalicylate, 38 CALCI-MIX, 51 bisoprolol & hydrochlorothiazide, 17 CALCIONATE, 51 bisoprolol fumarate, 17 calcipotriene, 68 BIVIGAM, 46 calcitonin (salmon), 36 75

CAL-CITRATE PLUS VITAMIN, 51 calcitrene oin 0.005%, 68 calcitriol, 54 calcitriol inj, 54 calcitriol oral soln 1 mcg/ml, 54 calcium, 51 CALCIUM & MAGNESIUM, 51 calcium & phosphorus w/ vitamin d, 51 CALCIUM 1000 + D, 51 CALCIUM 500, 51 calcium acetate (phosphate binder), 37 calcium ascorbate, 54 calcium carbonate, 51 CALCIUM CARBONATE, 37, 51 calcium carbonate (antacid), 37 calcium carbonate-cholecalciferol, 51 CALCIUM CARBONATE-CHOLECALCIFEROL, 51 calcium carbonate-ergocalciferol, 51 calcium carbonate-mag hydrox, 37 calcium carbonate-simethicone, 37 calcium carbonate-vitamin d, 51 calcium carbonate-vitamin d w/ minerals, 51 calcium citrate, 51 CALCIUM CITRATE, 51 CALCIUM CITRATE MALATE/VI, 51 CALCIUM CITRATE W/D, 52 calcium citrate-vitamin d, 52 calcium gluconate, 52 CALCIUM GLUCONATE, 52 CALCIUM GUMMIES, 52 calcium lactate, 52 CALCIUM LACTATE, 52 calcium pantothenate, 54 calcium polycarbophil, 40 calcium w/ magnesium, 52 calcium w/ vitamin d, 52 calcium w/ vitamins d & k, 52 CALCIUM/C/D, 52 CALCIUM/MAGNESIUM, 52 CALCIUM/MAGNESIUM/VITAMIN, 52 CALCIUM/MAGNESIUM/ZINC, 52 calcium-magnesium w/ vitamin d, 52 calcium-magnesium-zinc, 52 CAL-GLU, 51 CALMAG THINS, 52 CALNA, 54 CAL-QUICK, 51 CALTRATE 600+D PLUS MINER, 52 caltrate 600+d soft chews, 52 camila 28 day, 32 CANASA, 39 CANCIDAS, 5 CAPASTAT SULFATE, 7 CAPCOF, 61 CAPMIST DM, 61 CAPRELSA, 13 captopril, 14 captopril & hydrochlorothiazide, 14 CARBAGLU, 34 carbamazepine, 21 CARBIDOPA/LEVODOPA/ENTACAPONE, 25 carbidopa-levodopa, 25 carbonyl iron, 44 carboplatin, 14 carboxymethylcellulose sodium (ophth), 59 carboxymethylcellulose-glycerin, 59 CARIMUNE NANOFILTERED, 46 carteolol hcl (ophth), 58 cartia xt cap 120/24hr, 18 cartia xt cap 180/24hr, 18 cartia xt cap 240/24hr, 18 cartia xt cap 300/24hr, 18 carvedilol, 17 castellani paint, 68 CAYSTON, 4 cefaclor, 8 cefaclor monohydrate er, 8 cefadroxil, 8 cefazolin in d5w, 8 cefazolin inj, 8 cefazolin sodium, 8 cefdinir, 8 cefepime hcl, 8 cefotaxime sodium, 8 cefoxitin sodium, 8 cefpodoxime proxetil, 8 76

cefprozil, 8 ceftazidime, 8 CEFTAZIDIME/DEXTROSE, 8 ceftriaxone sodium, 8 cefuroxime axetil, 8 cefuroxime sodium, 8 CELEBREX CAP 100MG, 2 CELEBREX CAP 200MG, 2 CELEBREX CAP 400MG, 2 CELEBREX CAP 50MG, 2 CELLCEPT, 47 CELONTIN, 21 CENTRUM SILVER, 54 cephalexin, 8 CEREZYME, 34 CERVARIX, 47 cetirizine hcl, 60 cetirizine syrup, 60 cetirizine-pseudoephedrine, 61 cevimeline hcl, 71 CHANTIX, 30 CHANTIX STARTER PACK, 30 CHELATED CALCIUM, 52 CHEMET, 32 CHILDRENS MOTRIN, 1 CHLO TUSS EX, 61 chlorhexidine gluconate (mouth-throat), 71 chloroquine phosphate, 5 chlorothiazide, 19 chlorpheniramine & phenylephrine, 61 chlorpheniramine & pseudoeph, 61 chlorpheniramine maleate, 60 chlorpheniramine-dm, 61 chlorpheniramine-phenylephrine-acetami nophen, 62 chlorpheniramine-pseudoephedrine-aceta minophen, 62 chlorpromazine hcl, 26 chlorthalidone, 19 cholecalciferol, 54 cholestyramine, 17 cholestyramine light, 17 choline fenofibrate, 17 ciclopirox, 68 ciclopirox shampoo 1%, 68 cilostazol, 45 CILOXAN, 57 cimetidine, 39 CIMZIA, 46 CIMZIA STARTER KIT, 46 CINRYZE, 45 CIPRODEX, 72 ciprofloxacin, 9 ciprofloxacin er, 9 ciprofloxacin hcl (ophth), 57 ciprofloxacin hcl tab, 9 ciprofloxacin in d5w, 9 ciprofloxacin inj, 9 cisplatin, 14 citalopram hydrobromide, 24 CITRACAL CALCIUM GUMMIES, 52 CITRACAL PLUS HEART HEALT, 52 cladribine, 11 claravis, 67 clarithromycin, 9 clarithromycin er, 9 clarithromycin for susp, 9 CLARITIN, 60 CLARITIN REDITABS, 60 CLASSIC PRENATAL, 54 CLEAR EYES FOR DRY EYES, 59 clemastine fumarate, 60 clindamycin cap 300mg, 4 clindamycin cap 75mg, 4 clindamycin hcl cap 150 mg, 4 clindamycin phosphate (topical), 67 clindamycin phosphate inj, 4 clindamycin phosphate vaginal, 43 clindamycin sol 75mg/5ml, 4 CLINIMIX 2.75%/DEXTROSE 5%, 49 CLINIMIX 4.25%/DEXTROSE 25%, 49 CLINIMIX 4.25%/DEXTROSE 5%, 49 CLINIMIX 5%/DEXTROSE 15%, 49 CLINIMIX 5%/DEXTROSE 20%, 49 CLINIMIX 5%/DEXTROSE 25%, 49 CLINIMIX INJ 4.25/D10, 49 CLINIMIX INJ 4.25/D20, 49 clobetasol propionate, 69 CLOFERA, 62 clomipramine hcl, 24 clonazepam, 21 clonidine hcl, 20 clopidogrel bisulfate, 45 clorazepate dipotassium, 21 clotrimazole, 71 77

clotrimazole (topical), 68 clotrimazole vaginal, 43 clozapine, 26 CLOZAPINE, 26 COARTEM, 6 COATS ALOE VERA JUICE DRI, 40 cod liver oil, 54 COD LIVER OIL, 54 CODAR AR, 62 CODAR D, 62 CODITUSS DM, 62 colchicine w/ probenecid, 1 COLCRYS, 1 colestipol hcl, 17 colistimethate sodium, 4 colocort enema 100mg, 39 COMBIGAN, 58 COMBIPATCH, 35 COMBIVENT RESPIMAT, 60 COMETRIQ, 13 COMPLERA, 7 COMPLETE SINUS RELIEF, 62 compro, 38 COMPUTER EYE DROPS, 59 COMVAX, 47 CONEX COLD/ALLERGY, 62 constulose, 40 CONTAC COLD/FLU DAY & NIG, 62 CONTAC COLD/FLU MAXIMUM S, 62 COPAXONE INJ 40MG/ML, 29 COPAXONE KIT 20MG/ML, 29 CORAL CALCIUM, 52 CORAL CALCIUM PLUS, 52 coral calcium-magnesium w/ vitamin d, 52 corn dextrin, 40 cortisone acetate, 35 COUGH SYRUP D, 62 COUMADIN, 43 CREON, 42 CRESTOR, 16 CRIXIVAN, 6 cromolyn sodium (mastocytosis), 41 cromolyn sodium (nasal), 62 cromolyn sodium (ophth), 58 cromolyn sodium nebu, 66 cryselle 28, 32 CUBICIN, 4 CUVPOSA, 39 CVS CALCIUM CITRATE, 52 CVS HDYROCORTISONE ACETAT, 69 cvs nasal mist, 62 CVS SLOW RELEASE IRON, 44 CVS VITAMIN C, 54 cyanocobalamin, 54 cyclafem 1/35 28 day, 32 cyclafem 7/7/7 28 day, 32 cyclobenzaprine hcl, 29 cyclophosphamide, 10 cyclosporine, 47 cyclosporine modified (for microemulsion), 47 CYSTADANE, 34 CYSTAGON, 34 cytarabine, 11 CYTO B2, 54 D3 DOTS, 54 dacarbazine, 10 DALIRESP, 66 DALLERGY, 62 danazol, 34 dantrolene sodium, 29 dapsone, 4 DAPTACEL, 47 DARAPRIM, 4 daunorubicin hcl, 11 DECARA, 54 DECON-A, 62 DELTUSS DP, 62 DELZICOL, 39 DEMSER, 20 DENAVIR, 69 DEPEN TITRATABS, 32 DEPO-PROVERA INJ 400/ML, 12 desipramine hcl, 24 DESITIN, 70 desmopressin acetate spray, 37 desmopressin acetate spray refrigerated, 37 desmopressin acetate tabs, 37 78

desmopressin inj 4mcg/ml, 37 DESMOPRESSIN SOL 0.01%, 37 desonide, 69 DESONIDE, 69 desoximetasone, 69 DESOXIMETASONE, 69 dexamethasone, 35 dexamethasone sodium phosphate, 35 dexamethasone sodium phosphate (ophth), 57 DEXATREX D NASAL, 62 DEXILANT, 42 dexrazoxane, 14 dextromethorphan hbr, 62 dextromethorphan polistirex, 62 dextromethorphan-doxylamine-acetamin ophen, 62 dextromethorphan-guaifenesin, 62 dextromethorphan-phenylephrine-aceta minophen, 62 DEXTROSE 10% FLEX CONTAIN, 50 DEXTROSE 10%/NACL 0.2%, 50 DEXTROSE 10%/NACL 0.45%, 50 DEXTROSE 2.5%/NACL 0.45%, 49 DEXTROSE 5%, 50 DEXTROSE 5% /ELECTROLYTE, 50 DEXTROSE 5%/LACTATED RING, 50 DEXTROSE 5%/NACL 0.2%, 50 DEXTROSE 5%/NACL 0.225%, 50 DEXTROSE 5%/NACL 0.3%, 50 DEXTROSE 5%/NACL 0.33%, 50 DEXTROSE 5%/NACL 0.45%, 50 DEXTROSE 5%/NACL 0.9%, 50 DEXTROSE 5%/POTASSIUM CHL, 50 DEXTROSE 50%, 50 dextrose inj 70%, 50 DEX-TUSS, 62 DIABETIC TUSSIN COLD/FLU, 62 DIALYVITE 800/ZINC 15, 54 DIALYVITE VITAMIN D3 MAX, 54 diazepam, 21 DIAZEPAM GEL, 21 diazepam inj, 22 DICEL CD, 62 diclofenac potassium, 2 diclofenac sodium, 2 diclofenac sodium (ophth), 57 dicloxacillin sodium, 10 dicyclomine hcl, 39 didanosine, 6 DIFICID, 9 diflorasone diacetate, 69 diflunisal, 2 digoxin, 19 DIGOXIN SOL 50MCG/ML, 19 dihydroergotamine mesylate, 28 dilantin, 22 DILANTIN-125 SUS 125/5ML, 22 dilt-cd cap, 18 diltiazem cap, 18 diltiazem cap 120mg/24hr, 18 diltiazem cap er/12hr, 18 diltiazem hcl, 18 diltiazem hcl coated beads, 18 dilt-xr cap, 18 diltzac, 18 dimenhydrinate, 38 DIMETAPP LONG ACTING COUG, 62 DIOVAN, 16 DIPENTUM, 39 diphenhydramine hcl, 60 diphenhydramine hcl (sleep), 30 diphenhydramine inj, 60 diphenhydramine-acetaminophen, 62 diphenhydramine-acetaminophen (sleep), 30 diphenhydramine-phenylephrine, 62 diphenhydramine-phenylephrine-acetami nophen, 62 diphenoxylate w/ atropine, 41 DIPHTHERIA/TETANUS TOXOID, 47 disopyramide phosphate, 16 disulfiram, 30 DIURIL SUS 250/5ML, 19 divalproex sodium, 22 docetaxel, 11 DOCETAXEL, 11 docusate calcium, 40 docusate sodium, 40 DONATUSSIN, 62 donepezil hydrochloride, 23 dorzolamide hcl, 58 dorzolamide hcl-timolol maleate, 58 doxazosin mesylate, 15 doxepin hcl, 24 doxorubicin hcl for inj 50 mg, 11 79

doxorubicin hcl liposomal inj 2mg/ml, 11 doxorubicin inj 50mg, 11 doxycycline (monohydrate), 10 doxycycline hyclate, 10 doxylamine succinate (sleep), 30 doxylamine-dm, 62 doxylamine-phenylephrine-acetaminophe n, 62 dronabinol, 38 drospirenone-ethinyl estradiol, 32 DROXIA, 13 DRYMAX AF, 62 DULCOLAX BOWEL PREP KIT, 40 DULERA, 66 duloxetine hcl, 24 DURAFLU, 62 DURAMORPH, 3 DUREZOL, 57 DYRENIUM, 19 e.e.s., 9 e.e.s. 400, 9 E.E.S. GRANULES, 9 e.s.p., 4 econazole nitrate, 68 ED CHLORPED, 60 ED CHLORPED D, 62 EDECRIN, 20 EDURANT, 6 ees/sulfisox sus 200-600, 4 EFFIENT, 45 ELDERTONIC, 54 ELIDEL, 70 ELIQUIS, 43 ELITEK, 14 elixophyllin, 67 ELIXSURE FEVER/PAIN, 1 ELLA, 32 ELMIRON, 43 EMCYT, 10 EMEND CAP 125MG, 38 EMEND CAP 40MG, 38 EMEND CAP 80MG, 38 EMEND PAK 80 & 125, 38 emoquette, 32 EMSAM, 24 EMTRIVA, 6 enalapril maleate, 15 enalapril maleate & hydrochlorothiazide, 14 endocet, 3 ENGERIX-B, 47 enoxaparin sodium, 43 enpresse 28 day, 32 entacapone, 25 ENTSOL NASAL GEL, 62 ENUCLENE, 59 enulose, 40 ephedrine-guaifenesin, 63 EPIPEN 2-PAK, 66 EPIPEN-JR 2-PAK, 66 epirubicin hcl, 11 epitol, 22 EPIVIR, 6 EPIVIR HBV, 7 eplerenone, 15 EPZICOM, 7 EQL CALCIUM/VITAMIN D, 52 EQL CHILDRENS CALCIUM GUM, 52 EQL CHILDRENS MULTIVITAMI, 54 EQL NATURAL FIBER, 40 EQUALACTIN, 40 ERAXIS, 5 ergocalciferol, 54 ERIVEDGE, 12 errin 28 day, 32 ery pad 2%, 67 ERYPED 200, 9 ERYPED 400, 9 ery-tab, 9 erythrocin lactobionate, 9 erythrocin stearate, 9 erythromycin (acne aid), 67 erythromycin (ophth), 57 erythromycin base, 9 erythromycin cap 250mg ec, 9 escitalopram oxalate, 24 esomeprazole sodium, 42 estradiol, 35 estradiol valerate, 35 ESTRADIOL VALERATE, 35 80

ethambutol hcl, 7 ferrous gluconate, 44 ethosuximide, 22 FERROUS GLUCONATE, 44 etodolac, 2 ferrous sulfate, 44, 45 etodolac er, 2 FERROUS SULFATE, 44, 45 etoposide, 14 ferrous sulfate dried, 45 EURAX, 71 FETZIMA, 24 EXELON PATCHES, 23 FETZIMA TITRATION PACK, 24 exemestane, 12 FEVERALL INFANTS, 1 EXFORGE HCT/10- TAB 160-12.5, 15 fexofenadine hcl, 60 EXFORGE HCT/10- TAB 160-25, 15 fexofenadine-pseudoephedrine, 63 EXFORGE HCT/10- TAB 320-25, 15 fiber, 40 EXFORGE HCT/5- TAB 160-12.5, 15 FIBER, 40 EXFORGE HCT/5- TAB 160-25, 15 finasteride, 42 EXFORGE TAB 10-160MG, 15 FIRAZYR, 45 EXFORGE TAB 10-320MG, 15 FLEBOGAMMA, 46 EXFORGE TAB 5-160MG, 15 FLEBOGAMMA DIF, 46 EXFORGE TAB 5-320MG, 15 flecainide acetate, 16 EXJADE, 32 FLEET BISACODYL, 40 EZFE FORTE, 54 FLORASTOR KIDS, 38 FA-8, 54 FLOVENT DISKUS, 66 FABRAZYME, 35 FLOVENT HFA, 66 famciclovir, 7 fluconazole, 5 famotidine, 39 fluconazole in dextrose, 5 famotidine inj, 39 fluconazole in nacl, 5 famotidine-calcium flucytosine, 5 carbonate-magnesium hydroxide, 42 fludarabine phosphate, 11 FANAPT, 26 fludrocortisone acetate, 35 FANAPT TITRATION PACK, 26 flunisolide (nasal), 66 FARESTON, 12 fluocinolone acetonide, 69 FASLODEX, 12 fluocinolone acetonide (otic), 72 FAZACLO TAB 100/ODT, 26 fluocinonide, 69 FAZACLO TAB 12.5/ODT, 26 fluocinonide emulsified base, 69 FAZACLO TAB 150MG, 26 FLUOROMETHOLONE, 57 FAZACLO TAB 200MG, 26 fluorouracil, 11 FAZACLO TAB 25MG ODT, 26 fluorouracil (topical), 70 FEBROL, 1 fluoxetine hcl, 24 felbamate, 22 fluphenazine decanoate, 26 felodipine, 18 fluphenazine hcl, 26 fenofibrate, 17 flurbiprofen, 2 fenofibrate micronized, 17 flurbiprofen sodium, 57 fenofibrate micronized cap, 17 flutamide, 12 fentanyl, 3 fluticasone propionate, 69 fentanyl citrate, 3 fluticasone propionate (nasal), 66 FEOSOL, 44 fluvoxamine maleate, 21 FERRETTS IPS, 44 FOLGARD, 45 FERRIMIN 150, 44 folic acid, 54 ferrous fumarate, 44 FOLIC ACID, 54 FERROUS FUMARATE, 44 folic acid-vitamin b6-vitamin b12, 45 81

FOLITAB 500, 45 fondaparinux sodium, 43, 44 FORADIL AEROLIZER, 61 FORTEO, 37 FORTICAL, 36 foscarnet sodium, 7 fosinopril sodium, 15 fosinopril sodium & hydrochlorothiazide, 14 FOSRENOL, 37 FREAMINE HBC 6.9%, 49 FREAMINE III, 49 FRESHKOTE, 59 FUNGOID TINCTURE, 68 furosemide, 20 furosemide inj, 20 FUZEON, 6 FYCOMPA, 22 gabapentin, 22 GABITRIL, 22 galantamine hydrobromide, 23 GAMASTAN S/D, 46 GAMMAGARD LIQUID, 46 GAMMAGARD S/D, 46 GAMMAKED, 46 GAMMAPLEX, 46 GAMUNEX-C, 46 GAMUNEX-C 1GM/10ML, 46 ganciclovir inj 500mg, 7 GARDASIL, 47 gatifloxacin (ophth), 57 GAUZE PADS 2" X 2", 30 gaviltye-g, 40 gavilyte-c, 40 gavilyte-n, 40 GAVISCON, 37 GAVISCON EXTRA STRENGTH R, 38 gemcitabine hcl, 11 GEMCITABINE HCL, 11 gemfibrozil, 17 generlac, 40 gengraf, 47 gentak, 57 gentamicin in saline, 4 gentamicin sulfate, 4 gentamicin sulfate (ophth), 57 gentamicin sulfate (topical), 67 GENTEAL, 59 GENTEAL MILD, 59 GENTIAN VIOLET, 68 GEODON, 26 GERIATRIC VITAMIN, 54 GIANVI, 32 gildagia, 32 GILENYA CAP 0.5MG, 29 GILOTRIF TAB 20MG, 13 GILOTRIF TAB 30MG, 13 GILOTRIF TAB 40MG, 13 GLEEVEC, 13 glimepiride, 31 glip/metform tab 5-500mg, 31 glipizide, 31 glipizide-metformin hcl tab 2.5-250 mg, 31 glipizide-metformin hcl tab 2.5-500 mg, 31 GLUCAGEN HYPOKIT, 36 GLUCAGON EMERGENCY KIT, 36 glycerin-hypromellose-polyethylene glycol 400, 59 glycopyrrolate, 39 glycopyrrolate inj, 39 GNP CALCIUM 500 +D3, 52 GNP DAILY PRENATAL, 54 GOLYTELY, 40 GONIOVISC, 59 granisetron hcl, 38 GRANIX, 44 griseofulvin microsize, 5 griseofulvin ultramicrosize, 5 guaifenesin, 63 guaifenesin-codeine, 63 GUAIFENESIN-CODEINE, 63 halobetasol propionate, 69 haloperidol, 26 haloperidol decanoate, 26 haloperidol lactate, 26 haloperidol lactate oral conc 2 mg/ml, 26 HAVRIX, 47 heather, 33 82

heparin sod inj 1000/ml, 44 heparin sod inj 10000/ml, 44 HEPARIN SOD INJ 2000/ML, 44 heparin sod inj 20000/ml, 44 HEPARIN SOD INJ 2500/ML, 44 heparin sod inj 5000/ml, 44 HEPARIN SODIUM/D5W, 44 HEPARIN SODIUM/NACL 0.45%, 44 HEPARIN SODIUM/SODIUM CHL, 44 HEPATAMINE, 49 hepatasol 8, 49 HERCEPTIN, 12 HEXALEN, 10 HIBERIX, 47 HONEY BEARS, 54 HONEY BEARS W/IRON AND ZI, 54 HUMIRA, 46 HUMIRA KIT 40MG/0.8, 46 HUMIRA PEN, 46 HUMIRA PEN-CROHNS DISEASE, 46 HUMIRA PEN-PSORIASIS STAR, 46 HUMULIN R INJ U-500, 30 hydralazine hcl, 20 hydrochlorothiazide, 20 HYDROCIL INSTANT, 40 hydroco/apap tab 10-325mg, 2 hydroco/apap tab 5-325mg, 2 hydroco/apap tab 7.5-325, 2 hydrocodone-acetaminophen 7.5-325 mg/15ml, 2 hydrocodone-ibuprofen tab 7.5-200 mg, 2 hydrocortisone, 35 HYDROCORTISONE (INTRARECTAL), 39 hydrocortisone (topical), 69, 70 hydrocortisone acetate (topical), 70 hydrocortisone acetate-aloe vera, 70 hydrocortisone butyrate, 70 hydrocortisone valerate, 70 HYDROCORTISONE/ALOE, 70 hydrocortisone-aloe vera, 70 hydromorphon inj 10mg/ml, 3 hydromorphone hcl, 3 hydroxocobalamin, 55 hydroxychloroquine sulfate, 46 hydroxyurea, 13 hydroxyzine hcl, 60 HYPOTEARS, 59 hypromellose (gonioscopic), 59 hypromellose (ophth), 59 ibandronate sodium, 32 ibuprofen, 1, 2 IBUPROFEN, 1 ibuprofen tab 800 mg, 2 ibuprofen-diphenhydramine citrate, 30 ICAPS LUTEIN/ZEAXANTHIN F, 55 ICLUSIG, 13 idarubicin hcl, 11 IFEX, 10 ifosfamide inj 1gm, 10 ifosfamide inj 1gm/20ml, 10 IFOSFAMIDE INJ 3GM, 10 ifosfamide inj 3gm/60ml, 10 ILEVRO, 57 IMBRUVICA CAP 140MG, 13 imipenem-cilastatin, 4 imipramine hcl, 24 imiquimod, 70 IMOVAX RABIES (H.D.C.V.), 48 INCRELEX, 36 indapamide, 20 INFANRIX, 48 INLYTA, 13 INSULIN PEN NEEDLE, 30 INSULIN SAFETY NEEDLES, 30 INSULIN SYRINGE, 30 INTEGRA, 45 INTELENCE, 6 INTRALIPID INJ 20%, 49 INTRALIPID INJ 30%, 49 INTRON-A INJ 10MU, 46 INTRON-A INJ 18MU, 46 INTRON-A INJ 25MU, 46 INTRON-A INJ 50MU, 46 introvale 91 day, 33 INTUNIV, 28 INVANZ, 5 INVEGA, 26 INVEGA SUST INJ 117 MG/0.75 ML, 26 INVEGA SUST INJ 156MG/ML, 26 INVEGA SUST INJ 234 MG/1.5 ML, 26 INVEGA SUST INJ 39 MG/0.25 ML, 26 INVEGA SUST INJ 78 MG/0.5 ML, 26 INVIRASE, 6 INVOKANA, 31 IONOSOL-B/DEXTROSE 5%, 50 IONOSOL-MB/DEXTROSE 5%, 50 83

IPOL INACTIVATED IPV, 48 ipratropium bromide, 60 ipratropium bromide (nasal), 60 ipratropium-albuterol nebu, 60 irinotecan hcl, 14 iron, 45 IRON, 45 IRON DEXTRAN, 45 IRON UP, 45 iron w/ vitamins, 55 iron-vitamin c, 45 iron-vitamin c-vitamin b12-folic acid, 45 ISENTRESS, 6 ISOLYTE P, 50 isolyte s, 50 isoniazid, 7 isoniazid inj 100 mg/ml, 7 isoniazid syp 50mg/5ml, 7 ISOPTO TEARS, 59 isosorb mononitrate tab, 20 isosorbide dinitrate, 20 isosorbide mononitrate er tab, 20 isradipine, 18 ISTALOL, 58 ISTODAX, 12 itraconazole, 5 IXIARO, 48 JAKAFI, 13 JALYN, 42 jantoven, 44 JANUMET, 31 JANUMET XR TAB 100-1000, 31 JANUMET XR TAB 50-1000, 31 JANUMET XR TAB 50-500MG, 31 JANUVIA, 31 JENTADUETO, 31 J-MAX, 63 JOLIVETTE, 33 J-TAN D PD, 63 J-TAN PD, 60 junel 1.5/30 21 day, 33 junel 1/20 21 day, 33 junel fe 1.5/30 28 day, 33 junel fe 1/20 28 day, 33 KADCYLA, 12 KALETRA SOL, 7 KALETRA TAB 100-25MG, 7 KALETRA TAB 200-50MG, 7 kariva 28 day, 33 KCL 0.075%/D5W/NACL 0.45%, 50 KCL 0.15%/D5W/NACL 0.9%, 50 KCL 0.3%/D5W/NACL 0.45%, 50 KCL 0.3%/D5W/NACL 0.9%, 50 KCL/D5W INJ 0.3%, 50 KCL/NACL INJ 0.3-0.9, 50 KCL0.15%/D5W/NACL0.2%, 50 KCL0.15%/D5W/NACL0.225%, 50 ketoconazole, 5 ketoconazole cream, 68 ketoconazole shampoo, 69 ketoprofen, 2 ketorolac tromethamine (ophth), 57 ketotifen fumarate (ophth), 58 kionex, 32 KLOR-CON 10, 48 KLOR-CON 8, 48 klor-con m15, 48 klor-con m20, 48 klor-con pow 20meq, 48 KONSYL, 40 KONSYL-D, 40 KPN PRENATAL, 55 KUVAN, 35 labetalol hcl, 18 laclotion lotn 12%, 70 LACTATED RINGER'S INJ, 50 lactobacillus, 38 lactobacillus rhamnosus (gg), 38 lactulose, 40 lactulose (encephalopathy), 40 LAMISIL ADVANCED, 68 LAMISIL AT SPRAY, 68 lamivudine, 6, 7 lamivudine-zidovudine, 7 lamotrigine, 22 LANOXIN, 19 lansoprazole, 42 LANTUS, 30 LANTUS SOLOSTAR, 30 larin 1/20, 33 84

larin fe 1.5/30, 33 larin fe 1/20, 33 LASTACAFT, 58 latanoprost, 58 LATUDA, 26 LAZANDA SPR 100MCG, 3 LAZANDA SPR 400MCG, 3 LEENA, 33 leflunomide, 46 lessina 28 day, 33 LETAIRIS, 20 letrozole, 12 leucovorin calcium, 14 leucovorin calcium for inj 500 mg, 14 LEUKERAN, 11 LEUKINE, 44 leuprolide acetate, 12 levalbuterol conc 1.25mg/0.5ml, 61 LEVEMIR, 30 LEVEMIR FLEXPEN, 30 levetiracetam, 22 levobunolol hcl, 58 LEVOBUNOLOL HCL, 58 levocarnitine (metabolic modifiers), 35 levocetirizine dihydrochloride, 60 levofloxacin, 9 levofloxacin in d5w, 9 levofloxacin inj 25mg/ml, 9 levofloxacin oral soln 25 mg/ml, 9 levonest 28 day, 33 levonorgestrel (emergency oc), 33 levonorgestrel-ethinyl estradiol (91-day), 33 levora 0.15/30 28 day, 33 levothyroxine sodium, 37 LEVOXYL, 37 LEXIVA, 6 LIALDA, 39 LICIDE TREATMENT KIT, 71 lidocaine, 70 lidocaine hcl, 70 lidocaine hcl (local anesth.), 4 lidocaine hcl (mouth-throat), 71 lidocaine inj 0.5%, 4 lidocaine inj 1%, 4 lidocaine inj 1.5%, 4 lidocaine inj 2%, 4 lidocaine oint 5%, 70 lidocaine-prilocaine, 70 LINZESS CAP 145MCG, 41 LINZESS CAP 290MCG, 41 liothyronine sodium, 37 LIQUID CALCIUM WITH D3 MA, 52 lisinopril, 15 lisinopril & hydrochlorothiazide, 14 LITHIUM, 29 lithium carbonate, 29 lithium carbonate er, 29 LITTLE NOSES DECONGESTANT, 63 LOCALNESIUM, 52 LOCALNESIUM-C, 52 LODRANE D, 63 LOHIST-D, 63 LOKARA LOTN 0.05%, 70 LOMUSTINE, 11 loperamide hcl, 38, 41 loratadine, 60 loratadine & pseudoephedrine, 63 lorazepam, 21 LORTUSS DM, 63 LORTUSS EX, 63 LORTUSS LQ, 63 loryna 28 day, 33 losartan potassium, 16 losartan-hctz 100-12.5mg, 15 losartan-hctz 100-25mg, 15 losartan-hctz 50-12.5mg, 15 LOTEMAX, 57 LOTRIMIN ULTRA, 68 LOTRONEX, 42 lovastatin, 17 low-ogestrel 28 day, 33 loxapine succinate, 26 LUMIGAN, 58 LUMITENE, 55 LUMIZYME, 35 LUPR DEP-PED INJ 30MG (3-MONTH), 12 LUPRON DEPOT, 12 LUPRON DEPOT INJ 11.25 MG, 12 LUPRON DEPOT-PED, 12 LUSAIR, 63 lutera 28 day, 33 LYRICA, 22 LYSODREN, 12 lyza, 33 MAALOX TC, 38 85

mafenide acetate, 67 MAG-200, 52 MAG-AL, 38 MAGINEX, 52 MAGNEBIND 200, 52 MAGNEBIND 300, 52 magnesium, 52, 53 MAGNESIUM, 52 magnesium chloride, 53 magnesium chloride-calcium, 53 magnesium citrate, 40 MAGNESIUM CITRATE, 53 MAGNESIUM ELEMENTAL, 53 MAGNESIUM GLUCONATE, 53 magnesium hydroxide, 40 magnesium oxide, 38 MAGNESIUM OXIDE, 38 magnesium oxide (laxative), 40 magnesium oxide (mg supplement), 53 magnesium salicylate tetrahydrate, 1 MAGNESIUM SULFATE, 48, 53 magnesium sulfate (laxative), 40 MAGNESIUM SULFATE IN D5W, 48 magnesium sulfate inj 50%, 48 MAG-TAB SR, 52 malathion, 71 maprotiline hcl, 24 MAR-COF BP, 63 marlissa 28 day, 33 MARPLAN TAB 10MG, 24 MATULANE, 13 MAXIDEX, 57 meclizine hcl, 38 MEDI-GRAINE, 63 medroxyprogesterone acetate 150 mg/ml, 33 medroxyprogesterone acetate tab, 37 mefloquine hcl, 6 MEGACE ES, 12 megestrol acetate, 12 MEKINIST, 13 meloxicam, 2 MELOXICAM, 2 melphalan hcl, 11 MENACTRA, 48 M-END DMX, 63 M-END MAX D, 63 M-END PE, 63 MENOMUNE-A/C/Y/W-135, 48 menthol-zinc oxide, 70 MENVEO, 48 MEPHYTON, 55 mercaptopurine, 11 meropenem, 5 mesalamine enema, 39 mesalamine w/ cleanser, 39 mesna, 14 MESNEX, 14 metadate tab 20mg er, 28 METAMUCIL, 40 METAMUCIL MULTIHEALTH FIB, 40 METAMUCIL SMOOTH TEXTURE, 41 metformin hcl, 31 methadone hcl, 3 methazolamide, 20 methenamine hippurate, 5 methimazole, 37 methotrexate sodium inj, 11 methotrexate sodium tabs, 46 methyclothiazide, 20 methylcellulose (laxative), 41 methylergonovine maleate, 36 methylphenidate hcl, 28 methylphenidate hcl oral soln, 28 methylpr ace inj 40mg/ml, 35 methylpr ace inj 80mg/ml, 35 methylpr ss inj 125mg, 35 methylpr ss inj 1mg, 35 methylpr ss inj 40mg, 35 methylpr ss inj 500mg, 35 methylpred pak 4mg, 35 methylpred tab 16mg, 35 methylpred tab 32mg, 35 methylpred tab 4mg, 35 methylpred tab 8mg, 35 metipranolol, 58 metoclopramide hcl, 38 metoclopramide inj, 38 metolazone, 20 metoprolol & hctz tab 100-25mg, 17 86

metoprolol & hctz tab 100-50mg, 17 morphine sulfate cap 100mg er, 3 metoprolol & hctz tab 50-25mg, 17 MORPHINE SULFATE ORAL SOL, 3 metoprolol succinate, 18 MOVIPREP, 41 metoprolol tartrate, 18 MOXEZA, 57 metronidazole, 5 MOZOBIL, 44 metronidazole (topical), 70 MUCINEX COUGH FOR KIDS, 63 metronidazole gel 0.75%, 70 MUCINEX D, 63 metronidazole in nacl, 5 MUCINEX FOR KIDS, 63 metronidazole vaginal, 43 MUCINEX MAXIMUM STRENGTH, 63 mexiletine hcl, 16 MULTAQ, 16 MEXSANA, 70 MULTI-DELYN/IRON, 55 MIACALCIN, 36 multiple vitamin, 55 miconazole nitrate (topical), 68 multiple vitamins w/ iron, 55 miconazole nitrate vaginal, 43 multiple vitamins w/ minerals, 55 microgestin 1.5/30 21 day, 33 mupirocin, 67 microgestin 1/20 21 day, 33 MURO 128, 59 microgestin fe 1.5/30 28 day, 33 MUSTARGEN, 11 microgestin fe 1/20 28 day, 33 my way, 33 midodrine hcl, 20 MYCAMINE, 5 MILK OF MAGNESIA CONCENTR, 41 mycophenolate mofetil, 47 mineral oil, 41 mycophenolate sodium, 47 MINERAL OIL, 41 MYKIDZ IRON, 55 minitran, 20 MYKIDZ IRON 10, 45 minocycline hcl, 10 myorisan, 67 minoxidil, 20 MYOZYME, 35 mirtazapine, 24 MYRBETRIQ, 43 misoprostol, 42 myzilra, 33 MISSION PRENATAL, 55 nabumetone, 2 MISSION PRENATAL HP, 55 nadolol, 18 mitomycin, 11 nafcillin sodium, 10 mitoxantrone hcl, 13 NAGLAZYME, 35 M-M-R II W/DILUENT 10 DOS, 48 naloxone hcl, 30 moderiba 800 dose pack, 7 naltrexone hcl, 30 moderiba pak 1000/day, 7 NAMENDA, 23 moderiba pak 1200/day, 7 NAMENDA XR, 23 moderiba pak 600/day, 7 NAMENDA XR TITRATION PACK, 23 moderiba tab 200mg, 7 naphazoline 0.1%, 59 moexipril hcl, 15 naphazoline w/ pheniramine, 58 moexipril-hydrochlorothiazide, 14 NAPHAZOLINE W/ PHENIRAMINE, 58 mometasone furoate, 70 naproxen, 2 MONONESSA, 33 naproxen sodium, 1, 2 montelukast sodium, 65 NAPROXEN SODIUM, 1 morphine ext-rel tab, 3 naratriptan hcl, 28 morphine sul inj, 3 NASAL DECONGESTANT, 63 MORPHINE SUL INJ, 3 NASCOBAL, 55 morphine sulfate, 3 NASOHIST DM, 63 MORPHINE SULFATE, 3 NASONEX, 66 morphine sulfate beads, 3 NASOPEN PE, 63 87

NATACYN, 57 nateglinide, 31 NEBUPENT, 5 necon 0.5/35 28 day, 33 necon 1/35 28 day, 33 necon 10/11 28 day, 33 NECON 7/7/7, 33 NECON TAB 1/50-28, 33 nefazodone hcl, 24 neomycin sulfate, 4 neomycin-bacitracin zn-polymyxin, 57 neomycin-bacitracin-polymyxin, 67 neomycin-bacitracin-polymyxin w/ lidocaine, 67 neomycin-bacitracin-polymyxin-pramoxin e, 67 neomycin-polymy-dexameth, 56 neomycin-polymyxin w/ pramoxine, 68 neomycin-polymyxin-gramicidin, 57 neomycin-polymyxin-hc (ophth), 56 neomycin-polymyxin-hc (otic), 72 NEORAL, 47 NEO-SYNEPHRINE, 63 NEPHRAMINE, 49 NEPHRONEX, 55 NEUMEGA, 44 NEUPOGEN, 44 NEUPRO, 25 NEVANAC, 57 nevirapine, 6 NEVIRAPINE, 6 NEXAVAR, 13 NEXIUM CAP, 42 NEXIUM GRA 10MG DR, 42 NEXIUM GRA 2.5MG DR, 42 NEXIUM GRA 20MG DR, 42 NEXIUM GRA 40MG DR, 42 NEXIUM GRA 5MG DR, 42 next choice one dose, 33 niacin, 55 niacin (antihyperlipidemic), 17 NIACIN TR, 55 niacinamide, 55 niacor, 17 nicardipine hcl, 18 nicotine, 30 nicotine polacrilex, 30 NICOTINE POLACRILEX, 30 NICOTINE TRANSDERMAL SYST, 30 NICOTROL INHALER, 30 NICOTROL NS, 30 nifedical, 18 nifedipine, 18 nifedipine er, 18 NILANDRON, 12 nimodipine, 18 nitro-bid, 20 NITRO-DUR DIS 0.3MG/HR, 20 NITRO-DUR DIS 0.8MG/HR, 20 nitrofurantoin macrocrystal, 5 nitrofurantoin monohyd macro, 5 nitroglycerin, 20 NITROLINGUAL PUMPSPRAY, 20 NITROSTAT, 20 NIZORAL A-D, 68 NON-ASPIRIN EXTRA STRENGT, 2 NORA-BE TAB, 33 NORDITROPIN FLEXPRO, 36 NORDITROPIN NORDIFLEX PEN, 36 NOREL AD, 63 NOREL CS, 63 norethindrone (contraceptive), 33 norethindrone acetate, 37 norgestimate-ethinyl estradiol (triphasic), 34 normosol-m, 50 NORMOSOL-R, 50 NORMOSOL-R IN D5W, 50 NORPACE CR, 16 nortrel 0.5/35 28 day, 34 nortrel 1/35 21 day, 34 nortrel 1/35 28 day, 34 nortrel 7/7/7 28 day, 34 nortriptyline hcl, 24 NORVIR, 6 NOVAFERRUM 125, 45 NOVAFERRUM PEDIATRIC DROP, 45 NOVOLIN 70/30, 31 NOVOLIN N, 31 NOVOLIN R, 31 88

NOVOLOG, 31 NOVOLOG FLEXPEN, 31 NOVOLOG MIX 70/30, 31 NOVOLOG MIX 70/30 PREFILL, 31 NOVOLOG PENFILL, 31 NOXAFIL, 5 NUEDEXTA, 29 NULOJIX, 47 NULYTELY/FLAVOR PACKS, 41 NUTRATEAR, 59 NUTRICION PORVIDA, 55 NUTRISOURCE FIBER, 41 NUVARING, 34 NUVIGIL, 29 nyamyc, 68 NYMALIZE, 19 nystatin, 5 nystatin (mouth-throat), 71 nystatin (topical), 68 nystop, 68 OCELLA TAB 3-0.03MG, 34 OCTAGAM, 46 octreotide acetate, 36 ofloxacin (ophth), 57 ofloxacin (otic), 72 olanzapine, 26 OLYSIO, 7 omega-3-acid ethyl esters, 17 omeprazole, 42 OMEPRAZOLE, 42 omeprazole magnesium, 42 omeprazole-sodium bicarbonate, 42 ondansetron hcl, 38 ondansetron hcl inj, 38 ondansetron hcl oral soln, 38 ondansetron odt, 38 ONFI, 22 ONSET FORTE, 63 ophthalmic irrigation solution, 59 oral electrolytes, 48, 53 ORAP, 26 ORFADIN, 35 orsythia 28 day, 34 OSTEO-PORETICAL, 53 oxacillin sodium, 10 oxaliplatin, 14 oxandrolone, 30 oxcarbazepine, 22 oxybutynin chloride, 43 oxycodone hcl, 3 OXYCODONE HCL, 3 oxycodone hcl tab 5 mg, 3 oxycodone w/ acetaminophen 10-325mg, 3 oxycodone w/ acetaminophen 2.5-325mg, 3 oxycodone w/ acetaminophen 5-325mg, 3 oxycodone w/ acetaminophen 7.5-325mg, 3 oxymetazoline hcl, 63 oyster shell, 53 pacerone, 16 paclitaxel, 11 pamidronate disodium, 32 PANOXYL-4 CREAMY WASH, 68 PANOXYL-8 CREAMY WASH, 68 PANRETIN, 70 pantoprazole sodium, 42 pantothenic acid, 55 paricalcitol, 55 paromomycin sulfate, 4 paroxetine hcl, 24, 25 PARVA-CAL, 53 PARVA-CAL 250, 53 paser d/r, 7 PATADAY, 58 PATANASE, 61 PATANOL, 58 PAXIL, 25 PEDIA-LAX, 41 pediatric multiple vitamin w/ c, 55 pediatric multiple vitamin w/ c & fa, 55 pediatric multiple vitamin w/ extra c & fa, 55 pediatric multiple vitamin w/ minerals & c, 55 pediatric multiple vitamins, 55 pediatric multiple vitamins w/ iron, 55 pediatric vitamins adc, 55 pedi-dri, 68 PEDVAX HIB, 48 PEG 3350/ELECTROLYTES, 41 peg 3350-kcl-sod bicarb-sod chloride-sod sulfate, 41 peg 3350-potassium chloride-sod bicarbonate-sod chloride, 41 89

PEGANONE, 22 PEGASYS, 47 PEGASYS PROCLICK, 47 PEG-INTRON, 46 PEG-INTRON REDIPEN, 47 PENICILLIN G POT IN DEXTROSE, 10 penicillin g potassium, 10 penicillin g procaine, 10 penicillin g sodium, 10 penicillin v potassium, 10 penicilln gk inj 5mu, 10 PENTAM 300, 5 PENTASA, 39 pentoxifylline, 45 PEPCID AC, 39 PERFOROMIST, 61 perindopril erbumine, 15 periogard, 71 permethrin, 71 permethrin & pyrethrins-piperonyl butoxide, 71 perphenazine, 26 PERRY PRENATAL, 55 PHENAGIL, 63 phenelzine sulfate, 25 phenobarbital, 22 phenobarbital sodium, 22 PHENOBARBITAL SODIUM, 22 phenylephrine hcl, 63 phenylephrine hcl (ophth), 58 phenylephrine hcl (oral), 63 phenylephrine w/ acetaminophen, 63 phenylephrine w/ dm-gg, 63 phenylephrine-acetaminophen-guaifenesi n, 63 phenylephrine-brompheniramine-dm, 63 phenylephrine-chlorphen-dm, 64 phenylephrine-chlorpheniramine-dm w/ apap, 64 phenylephrine-dm, 64 phenylephrine-dm-gg w/ apap, 64 phenylephrine-doxylamine-dextromethor phan-acetaminophen, 64 phenylephrine-guaifenesin, 64 PHENYLHISTINE DH, 64 phenytek, 22 phenytoin, 22 phenytoin sodium, 22 phenytoin sodium extended, 22 philith, 34 PHILLIPS MILK OF MAGNESIA, 41 PHOSLYRA, 37 PHOS-NAK POWDER CONCENTRA, 53 PHOSPHOLINE IODIDE, 58 phytonadione, 55 PILOCARPINE HCL, 58 pilocarpine hcl (oral), 71 pimtrea pack, 34 pindolol, 18 pioglitazone hcl, 31 piperacillin sodium-tazobactam sodium, 10 pirmella 1/35 28 day, 34 piroxicam, 2 PLASMA-LYTE A, 50 PLASMA-LYTE-148, 50 PLASMA-LYTE-56/D5W, 50 podofilox, 70 polyethylene glycol 3350, 41 polyethylene glycol-propylene glycol (ophth), 59 polymyxin b-trimethoprim, 57 polysaccharide iron complex, 45 POLY-TUSSIN, 64 POLY-TUSSIN AC, 64 POLY-TUSSIN D, 64 polyvinyl alcohol, 59 polyvinyl alcohol-povidone (ophth), 59 POMALYST CAP 1MG, 13 POMALYST CAP 2MG, 13 POMALYST CAP 3MG, 13 POMALYST CAP 4MG, 13 portia 28 day, 34 potassium chloride, 48, 50 POTASSIUM CHLORIDE, 48, 50 POTASSIUM CHLORIDE 0.15%, 50 POTASSIUM CHLORIDE 0.22%, 50 POTASSIUM CHLORIDE ER, 48 potassium chloride in nacl, 51 potassium chloride microencapsulated 90

crystals cr, 49 POTASSIUM CITRATE (ALKALINIZER), 43 POTIGA, 22 povidone-iodine vaginal, 43 PRADAXA, 44 pramipexole dihydrochloride, 25 pravastatin sodium, 17 prazosin hcl, 15 pred sod pho sol 5mg/5ml, 35 PREDNISOLONE ACETATE (OPHTH), 58 prednisolone sodium phosphate (ophth), 58 prednisolone sol 15mg/5ml, 35 prednisolone sol 25mg/5ml, 35 prednisolone syp 15mg/5ml, 35 prednisone con 5mg/ml, 35 prednisone pak 10mg, 36 prednisone pak 5mg, 36 prednisone sol 5mg/5ml, 36 prednisone tab 10mg, 36 prednisone tab 1mg, 36 prednisone tab 2.5mg, 36 prednisone tab 20mg, 36 prednisone tab 50mg, 36 prednisone tab 5mg, 36 PREMARIN CREAM, 35 premasol sol 10%, 49 premasol sol 6%, 49 PRENATAL, 55 PRENATAL VITAMIN/FOLIC ACID > 0.8 MG (GENERIC), 55 PRETZ, 64 prevalite, 17 previfem 28 day, 34 PREZISTA, 6 PRIFTIN, 7 PRILOSEC OTC, 42 PRIMAQUINE PHOSPHATE, 6 primidone, 23 PRISTIQ, 25 PRIVIGEN, 46 PROAIR HFA, 61 probenecid, 1 PROBIOTIC FORMULA, 38 PROCALAMINE, 49 PRO-CHLO, 64 prochlorperazine inj, 38 prochlorperazine maleate, 38 prochlorperazine supp, 39 PRO-CLEAR AC, 64 PROCRIT, 44 procto-pak, 68 proctozone hc, 68 PROFE, 45 PROGLYCEM, 36 PROGRAF, 47 PROLASTIN-C, 66 PROLENSA, 59 PROLEUKIN, 12 PROLIA, 36 PROMACTA, 45 promethazine hcl, 39 PRONTO, 71 propafenone hcl, 16 proparacaine hcl, 59 propranolol & hydrochlorothiazide, 17 propranolol cap er, 18 propranolol hcl, 18 propylene glycol-glycerin, 59 propylthiouracil, 37 PROQUAD, 48 PROSOL, 49 PROTEXIN, 55 protriptyline hcl, 25 PRUDOXIN CRE 5%, 68 pseudoephed-bromphen-dm, 64 pseudoephed-doxyl-dm w/apap, 64 pseudoephedrine hcl, 64 pseudoephedrine w/ codeine-gg, 64 pseudoephedrine w/ dm-gg, 64 pseudoephedrine-acetaminophen, 64 pseudoephedrine-brompheniramine-code ine, 64 pseudoephedrine-chlorphen-dm, 64 pseudoephedrine-dexchlorpheniramine-c hlophedianol, 64 pseudoephedrine-guaifenesin, 64 pseudoephedrine-ibuprofen, 64 PSEUDOEPHEDRINE-IBUPROFEN, 64 psyllium, 41 PSYLLIUM, 41 PULMOZYME, 66 pyrazinamide, 7 PYRETHINS/PIPERONYL BUTO, 71 pyrethrins-piperonyl butoxide, 71 pyrethrins-piperonyl 91

butoxide-permethrin-nit remover, 71 pyridostigmine bromide, 29 pyridoxine hcl, 55 PYRIL DM, 64 pyrilamine maleate-phenylephrine hcl tannate, 64 quasense 91 day, 34 quetiapine fumarate, 27 quinapril hcl, 15 quinapril-hydrochlorothiazide, 14 quinidine gluconate, 16 quinidine sulfate, 16 quinine sulfate, 6 QVAR, 66 RA CALAMINE, 70 RA CALCIUM/BORON, 53 RA OYSTER SHELL CALCIUM/V, 53 RABAVERT, 48 raloxifene hcl, 36 ramipril, 15 RANEXA, 20 ranitidine hcl, 39 ranitidine hcl inj, 39 ranitidine syrup, 39 RAPAMUNE, 47 REBETOL SOLN, 8 reclipsen 28 day, 34 RECOMBIVAX HB, 48 REFRESH CELLUVISC, 59 REFRESH OPTIVE ADVANCED, 59 REGRANEX, 71 RELENZA DISKHALER, 8 RELISTOR, 41 RELPAX, 28 REMICADE, 46 REMODULIN, 20 RENVELA PAK 0.8GM, 37 RENVELA PAK 2.4GM, 37 RENVELA TAB 800MG, 37 repaglinide, 31, 32 RESCON, 64 RESCON DM, 64 RESCRIPTOR, 6 RESPAIRE-30, 64 RESTASIS, 59 RETAINE MGD, 59 RETROVIR IV INFUSION, 6 REVLIMID, 47 REYATAZ, 6 RHINARIS, 64 ribapak mis 600/day, 8 ribasphere, 8 ribasphere ribapak 1000, 8 ribasphere ribapak 1200, 8 ribasphere ribapak 800, 8 ribavirin 200mg, 8 riboflavin, 55 rifabutin, 7 rifampin, 7 RIFATER, 7 riluzole, 29 rimantadine hydrochloride, 8 RINGER'S, 51 RIOMET, 32 RISA-BID PROBIOTIC, 38 RISPERDAL INJ 12.5MG, 27 RISPERDAL INJ 25MG, 27 RISPERDAL INJ 37.5MG, 27 RISPERDAL INJ 50MG, 27 risperidone, 27 RITUXAN, 12 rivastigmine tartrate, 23 rizatriptan benzoate, 28 ROBITUSSIN CHILDRENS COUG, 64 ROBITUSSIN PEAK COLD NIGH, 64 ROCALTROL, 55 ropinirole hydrochloride, 25 rosadan cre 0.75%, 70 ROTARIX, 48 ROTATEQ, 48 roxicet soln, 3 roxicet tab 5-325mg, 3 ROZEREM, 28 RU-HIST-D, 64 RYMED, 64 SABRIL, 23 saccharomyces boulardii, 38 saline, 65 SANDIMMUNE, 47 SANDOSTATIN LAR DEPOT, 36 92

SANTYL, 71 SAPHRIS, 27 SCHOOLTIME SHAMPOO, 71 SCOOBY-DOO ONE A DAY, 55 SCOT-TUSSIN, 65 SCOT-TUSSIN SENIOR, 65 SECURA EXTRA PROTECTIVE, 70 selegiline hcl, 25 selenium, 53 SELENIUM, 53 selenium sulfide, 69 SELZENTRY, 6 senna, 41 SENNA, 41 SENNA PROMPT, 41 sennosides, 41 sennosides-docusate sodium, 41 SENSI-CARE PROTECTIVE BAR, 71 SENSIPAR, 32 SEREVENT DISKUS, 61 SEROQUEL XR, 27 sertraline hcl, 25 sildenafil citrate (pulmonary hypertension), 20 SILENOR, 28 SILVER SULFADIAZINE, 68 SIMBRINZA, 58 simvastatin, 17 sirolimus, 47 SIRTURO, 7 SLOW RELEASE IRON, 45 SLOW-MAG, 53 SM CORAL CALCIUM, 53 SM SLOW RELEASE IRON, 45 SM VITAMIN D3 MAXIMUM STR, 55 SODIUM BICARBONATE, 38 sodium bicarbonate (antacid), 38 SODIUM CHLORIDE, 49, 51, 66 SODIUM CHLORIDE 0.45% VIA, 51 SODIUM CHLORIDE 0.9%, 71 sodium chloride hypertonic, 59 SODIUM CHLORIDE INJ 0.9%, 51 SODIUM FLUORIDE CHEW; TAB; 1.1 (0.5 F) MG/ML SOLN, 49 sodium phenylbutyrate, 35 sodium phosphates, 41 sodium polystyrene sulfonate, 32 SOLIA, 34 SOLTAMOX, 12 SOLU-CORTEF, 36 SOMATULINE DEPOT, 36 SOMAVERT, 36 SOOTHE, 59 sorine, 16 sotalol hcl, 16 sotalol hcl (afib/afl), 16 SOVALDI, 8 specialty vitamins products, 55 SPIRIVA HANDIHALER, 60 spironolactone, 15 spironolactone & hydrochlorothiazide, 20 sprintec 28 day, 34 SPRYCEL, 13 sps susp 15gm/60ml, 32 sronyx, 34 SSD, 68 ST JOSEPH ADULT ANALGESIC, 2 STAHIST AD, 65 STANBACK ASPIRIN FREE, 2 STATUSS GREEN, 65 stavudine, 6 STERILE LUBRICANT DROPS, 59 STERILE WATER IRRIGATION, 71 STIVARGA, 13 STRATTERA, 28 streptomycin sulfate, 4 STRIBILD, 7 STUART PRENATAL + DHA, 56 SUBOXONE MIS 12-3MG, 30 SUBOXONE MIS 2-0.5MG, 30 SUBOXONE MIS 4-1MG, 30 SUBOXONE MIS 8-2MG, 30 SUCRAID, 42 sucralfate, 42 SUDAFED 24 HOUR, 65 sulfacetamide sodium (acne), 67 sulfacetamide sodium (ophth), 57 sulfacetamide sod-prednisolone, 57 sulfadiazine, 4 sulfamethoxazole-trimethoprim, 5 sulfamethoxazole-trimethoprim inj, 5 SULFAMYLON, 68 sulfasalazine, 39 sulfasalazine ec, 39 sulindac, 2 SUMATRIPTAN, 28 93

sumatriptan succinate, 28 SUMATRIPTAN SUCCINATE, 28 sumatriptan succinate inj, 29 SUMATRIPTAN SUCCINATE INJ, 29 SUPER NU-THERA, 56 suprax, 8, 9 SUPRAX, 8, 9 SUPREP BOWEL PREP, 41 SURMONTIL CAP 100MG, 25 SURMONTIL CAP 25MG, 25 SURMONTIL CAP 50MG, 25 SUSTIVA, 6 SUTENT, 13 SYLATRON KIT 296MCG, 13 SYLATRON KIT 444MCG, 13 SYLATRON KIT 888MCG, 13 SYMBICORT, 66 SYMLINPEN 120, 31 SYMLINPEN 60, 31 SYNAGIS, 48 SYNAREL, 34 SYNERCID, 5 SYNTHROID, 37 SYPRINE, 32 SYSTANE BALANCE RESTORATI, 59 SYSTANE LIQUID GEL, 59 SYSTANE OVERNIGHT THERAPY, 59 TAB-A-VITE WOMENS, 56 TABLOID, 11 tacrolimus, 47 TAFINLAR, 13 TAMIFLU, 8 tamoxifen citrate, 12 tamsulosin hcl, 42 TARCEVA, 13 TARGRETIN, 13, 71 TASIGNA, 13 TAXOTERE, 11 tazicef, 9 tazicef vial, 9 TAZORAC, 68 taztia, 19 TEARS AGAIN NIGHT & DAY, 60 TEFLARO, 9 TEGRETOL, 23 TEGRETOL-XR, 23 TEKAMLO 300-10MG, 19 TEKAMLO TAB 150-10MG, 19 TEKAMLO TAB 150-5MG, 19 TEKAMLO TAB 300-5MG, 19 TEKTURNA, 19 TEKTURNA HCT TAB 150-12.5MG, 19 TEKTURNA HCT TAB 150-25MG, 19 TEKTURNA HCT TAB 300-12.5MG, 19 TEKTURNA HCT TAB 300-25MG, 19 temazepam, 28 TENIVAC, 48 terazosin hcl, 15 terbinafine hcl, 5 terbinafine hcl (topical), 68 terbutaline sulfate, 61 terconazole vaginal, 43 TESTIM, 30 testosterone cypionate, 30 testosterone enanthate, 30 TETANUS TOXOID ADSORBED, 48 TETANUS/DIPHTHERIA TOXOID, 48 tetrahydrozoline hcl (ophth), 58 tetrahydrozoline w/ zinc sulfate, 58 TEV-TROPIN, 36 texacort soln 2.5%, 70 THALOMID, 47 theo-24, 67 theophylline, 67 THERA/BETA-CAROTENE, 56 THERA-D 4000, 56 THERAFLU FLU & SORE THROA, 65 THERAFLU MAX-D SEVERE COL, 65 THERAFLU SINUS & COLD, 65 THERANATAL CORE NUTRITION, 56 THERATEARS, 60 thiamine hcl, 56 thiamine mononitrate, 56 thioridazine hcl, 27 thiothixene, 27 tiagabine hcl, 23 TIKOSYN, 16 TIMENTIN, 10 TIMENTIN INJ 3.1GM, 10 timolol maleate, 18 94

timolol maleate (ophth), 58 TIMOLOL MALEATE GEL, 58 tioconazole vaginal, 43 TIVICAY, 6 tizanidine hcl, 29 TOBRADEX, 57 TOBRADEX ST, 57 tobramycin, 4 tobramycin (ophth), 57 tobramycin sulfate, 4 tobramycin sulfate in saline, 4 tobramycin-dexamethasone, 57 TOBREX, 57 tolnaftate, 68 TOLTERODINE TARTRATE CAP ER, 43 tolterodine tartrate tabs, 43 topiramate, 23 toposar, 14 topotecan hcl, 14 torsemide inj, 20 torsemide tabs, 20 TOVIAZ, 43 TPN ELECTROLYTES, 49 TRACLEER, 20, 21 TRADJENTA, 32 tramadol hcl, 2 tramadol-acetaminophen, 2 trandolapril, 15 tranexamic acid, 45 TRANSDERM-SCOP, 39 tranylcypromine sulfate, 25 travasol 10, 49 TRAVATAN Z, 58 trazodone hcl, 25 TREANDA, 11 TRECATOR, 7 TRELSTAR DEP INJ 3.75MG, 12 TRELSTAR LA INJ 11.25MG, 12 tretinoin, 67 tretinoin (chemotherapy), 13 triamcinolone acetonide (mouth), 71 triamcinolone acetonide (topical), 70 TRIAMINIC CHEST & NASAL C, 65 TRIAMINIC COLD & ALLERGY, 65 TRIAMINIC COLD & COUGH DA, 65 TRIAMINIC COLD/COUGH NIGH, 65 TRIAMINIC COUGH & RUNNY N, 61 TRIAMINIC FEVER REDUCER P, 2 TRIAMINIC MULTI-SYMPTOM F, 65 TRIAMINIC NIGHT TIME COLD, 65 triamterene & hydrochlorothiazide, 20 triamterene & hydrochlorothiazide cap 37.5-25 mg, 20 TRIBENZOR TAB 20-5-12.5MG, 16 TRIBENZOR TAB 40-10-12.5, 16 TRIBENZOR TAB 40-5-12.5MG, 16 TRIBENZOR TAB 40-5-25MG, 16 TRIBENZOR40- TAB 10-25MG, 15 TRICODE AR, 65 TRICODE GF, 65 triderm, 70 trifluoperazine hcl, 27 trifluridine, 57 tri-legest 28 day, 34 trilyte, 41 trimethoprim, 5 TRINESSA, 34 TRIPLE PASTE, 71 tri-previfem 28 day, 34 triprolidine & pseudoephedrine, 65 TRISENOX, 14 tri-sprintec 28 day, 34 TRI-VI-SOL, 56 TRI-VI-SOL/IRON, 56 trivora 28 day, 34 TROPHAMINE INJ 10%, 49 trospium chloride, 43 TRUVADA, 7 TUCKS ANTI-ITCH, 70 TUDORZA PRESSAIR, 60 TUSNEL, 65 TUSNEL PEDIATRIC, 65 TUSNEL-DM PEDIATRIC, 65 TWINRIX INJ, 48 TYGACIL, 5 TYKERB, 13 TYPHIM VI, 48 TYSABRI, 29 TYZEKA, 8 UCERIS, 40 ULORIC, 1 UNITHROID, 37 UPCAL D, 53 URO-MAG, 38 ursodiol, 42 VAGIFEM, 35 95

valacyclovir hcl, 8 VALCHLOR, 71 VALCYTE, 8 valproate sodium, 23 valproic acid, 23 valsartan, 16 valsartan & hctz tab 160-12.5mg, 16 valsartan & hctz tab 160-25mg, 16 valsartan & hctz tab 320-12.5mg, 16 valsartan & hctz tab 320-25mg, 16 valsartan & hctz tab 80-12.5mg, 16 vancomycin hcl, 5 VANDAZOLE, 43 VAQTA, 48 VARIVAX, 48 VASCEPA, 17 VASOCLEAR A, 58 VELCADE, 12 velivet 28 day, 34 venlafaxine hcl, 25 verapamil cap er, 19 VERAPAMIL CAP ER, 19 verapamil hcl, 19 verapamil tab er, 19 VERSACLOZ, 27 VESICARE, 43 vestura, 34 VIBRAMYCIN, 10 VICKS VAPORUB, 65 VICTOZA, 31 VICTRELIS, 8 VIDEX PEDIATRIC, 6 VIGAMOX, 57 VIIBRYD, 25 VIMPAT, 23 vinblastine sulfate, 12 vincasar, 12 vincristine sulfate, 12 vinorelbine tartrate, 12 viorele, 34 VIRACEPT, 6 VIRAMUNE XR, 6 VIREAD, 6 VISINE-LR, 58 VITALETS, 56 VITA-MAG, 56 vitamin a, 56 VITAMIN A, 56 VITAMIN A PALMITATE, 56 VITAMIN B12/FOLIC ACID, 45 VITAMIN C, 56 VITAMIN D2, 56 VITAMIN D3, 56 VITAMIN D3 400, 56 vitamin e, 56 VITAMIN E, 56 VITAMIN K, 56 vitamin mixture, 56 vitamins a & d, 56 vitamins c & e, 56 VIVA DROPS, 60 VOLTAREN, 71 voriconazole, 5 VOTRIENT, 13 vyfemia 28 day, 34 warfarin sodium, 44 WELCHOL, 17 wheat dextrin, 41 wheat dextrin-calcium, 41 white petrolatum-mineral oil, 60 XALKORI, 13 XARELTO, 44 XENAZINE, 29 XGEVA, 36 XIFAXAN, 42 XOLAIR, 66 XOPENEX HFA, 61 XTANDI, 12 xulane, 34 XYREM, 29 YF-VAX, 48 zafirlukast, 66 zarah, 34 ZAVESCA, 35 zazole, 43 ZAZOLE, 43 ZELBORAF, 13 ZEMAIRA, 66 zenatane, 67 zenchent 28 day, 34 96

ZENPEP, 42 ZETIA TAB 10MG, 17 ZIAGEN, 6 zidovudine, 6 ZINC OXIDE, 71 zinc oxide (topical), 71 ziprasidone hcl, 27 ZMAX, 9 ZODRYL AC 25, 65 ZODRYL AC 30, 65 ZODRYL AC 35, 65 ZODRYL AC 40, 65 ZODRYL DAC 25, 65 ZODRYL DAC 30, 65 ZODRYL DAC 35, 65 ZODRYL DAC 40, 65 ZODRYL DEC 25, 65 ZODRYL DEC 30, 65 ZODRYL DEC 35, 65 ZODRYL DEC 40, 65 zoledronic inj 4mg/5ml, 32 ZOLINZA, 12 zolmitriptan, 29 zolmitriptan odt, 29 zolpidem tartrate, 28 ZOMETA, 32 zonatuss, 65 zonisamide, 23 ZOO FRIENDS COMPLETE, 56 ZORTRESS, 47 ZORTRESS TAB 0.5MG, 47 ZORTRESS TAB 0.75MG, 47 ZOSTAVAX, 48 Z-TUSS AC, 65 Z-TUSS E, 65 ZYKADIA, 13 ZYLET, 57 ZYTIGA, 12 ZYVOX, 5 97