non-asa jr tab 160mg 3 $0 NM; * non-aspirin chw 80mg 3 $0 NM; * pain relief dro 80/0.8ml 3 $0 NM; * pain relief liq 500/15ml 3 $0 NM; * pain relief su

NY_MMP_CY16_2T_STND eff 03/01/2016 藥物名稱 藥物層級您為藥物支 付的費用 止痛藥 - 治療疼痛和發炎的藥物 痛風藥 - 治療痛風的藥物 allopurinol tab 100 mg 1 $0 allopurinol tab 300 mg 1 $0 colchicine w/ probenecid tab 1 $0 0.5-500 mg COLCRYS TAB 0.6MG 2 $0 QL (120 tabs / 30 days) probenecid tab 500 mg 1 $0 ULORIC TAB 40MG 2 $0 ST ULORIC TAB 80MG 2 $0 ST 雜類 ACEPHEN SUP 120MG 3 $0 NM; * acephen sup 325mg 3 $0 NM; * acephen sup 650mg 3 $0 NM; * acetamin jr tab 160mg rt 3 $0 NM; * ACETAMINOPHE TAB 650MG 3 $0 NM; * acetaminophen soln 160 mg/5ml 3 $0 NM; * ADVIL JR ST TAB 100MG 3 $0 NM; * all day pain tab 220mg 3 $0 NM; * APAP 500 LIQ 500/5ML 3 $0 NM; * aspirin suppos 300 mg 3 $0 NM; * aspirin suppos 600 mg 3 $0 NM; * aspirin tab 81 mg 3 $0 NM; * aspirin tab 325 mg 3 $0 NM; * aspirin tab delayed release 325 mg 3 $0 NM; * aspirin tab delayed release 500 mg 3 $0 NM; * aspirin tab delayed release 650 mg 3 $0 NM; * child apap tab 80mg 3 $0 NM; * ed-apap liq 80mg/2.5 3 $0 NM; * FEBROL SOL 325/5ML 3 $0 NM; * FEVERALL INF SUP 80MG 3 $0 NM; * 8 hour pain tab 650mg 3 $0 NM; * ibuprofen cap 200 mg 3 $0 NM; * ibuprofen dro 50/1.25 3 $0 NM; * ibuprofen jr chw 100mg 3 $0 NM; * ibuprofen sus 100/5ml 3 $0 NM; * motrin ib tab 200mg 3 $0 NM; * NAPROXEN SODIUM CAP 220 MG 3 $0 NM; * 1

non-asa jr tab 160mg 3 $0 NM; * non-aspirin chw 80mg 3 $0 NM; * pain relief dro 80/0.8ml 3 $0 NM; * pain relief liq 500/15ml 3 $0 NM; * pain relief sus 160/5ml 3 $0 NM; * pain relief tab 500mg 3 $0 NM; * pain relievr tab 325mg 3 $0 NM; * q-pap infant dro 80/0.8ml 3 $0 NM; * tri-buff asa tab 325mg 3 $0 NM; * TRIAMINIC SYP INFANT 3 $0 NM; * 非甾體類消炎藥 - 治療疼痛和發炎的藥物 celecoxib cap 50 mg 1 $0 QL (60 caps / 30 days) celecoxib cap 100 mg 1 $0 QL (60 caps / 30 days) celecoxib cap 200 mg 1 $0 QL (60 caps / 30 days) celecoxib cap 400 mg 1 $0 QL (60 caps / 30 days) diclofenac potassium tab 50 mg 1 $0 diclofenac sodium tab delayed 1 $0 release 25 mg diclofenac sodium tab delayed 1 $0 release 50 mg diclofenac sodium tab delayed release 75 mg 1 $0 diclofenac sodium tab sr 24hr 100 1 $0 mg diflunisal tab 500 mg 1 $0 etodolac cap 200 mg 1 $0 etodolac cap 300 mg 1 $0 etodolac tab 400 mg 1 $0 etodolac tab 500 mg 1 $0 etodolac tab sr 24hr 400 mg 1 $0 etodolac tab sr 24hr 500 mg 1 $0 etodolac tab sr 24hr 600 mg 1 $0 flurbiprofen tab 50 mg 1 $0 flurbiprofen tab 100 mg 1 $0 ibuprofen susp 100 mg/5ml 1 $0 ibuprofen tab 400 mg 1 $0 ibuprofen tab 600 mg 1 $0 ibuprofen tab 800 mg 1 $0 ketoprofen cap 50 mg 1 $0 ketoprofen cap 75 mg 1 $0 MELOXICAM SUSP 7.5 MG/5ML 1 $0 meloxicam tab 7.5 mg 1 $0 2

meloxicam tab 15 mg 1 $0 nabumetone tab 500 mg 1 $0 nabumetone tab 750 mg 1 $0 naproxen dr tab 375mg 1 $0 naproxen dr tab 500mg 1 $0 naproxen sodium tab 275 mg 1 $0 naproxen sodium tab 550 mg 1 $0 naproxen susp 125 mg/5ml 1 $0 naproxen tab 250 mg 1 $0 naproxen tab 375 mg 1 $0 naproxen tab 500 mg 1 $0 piroxicam cap 10 mg 1 $0 piroxicam cap 20 mg 1 $0 sulindac tab 150 mg 1 $0 sulindac tab 200 mg 1 $0 麻醉性鎮痛劑 - 治療疼痛的藥物 acetaminophen w/ codeine soln 1 $0 QL (5000 ml / 30 days) 120-12 mg/5ml acetaminophen w/ codeine tab 1 $0 QL (400 tabs / 30 days) 300-15 mg acetaminophen w/ codeine tab 1 $0 QL (400 tabs / 30 days) 300-30 mg acetaminophen w/ codeine tab 1 $0 QL (400 tabs / 30 days) 300-60 mg butorphanol tartrate inj 1 mg/ml 1 $0 butorphanol tartrate inj 2 mg/ml 1 $0 nalbuphine hcl inj 10 mg/ml 1 $0 nalbuphine hcl inj 20 mg/ml 1 $0 tramadol hcl tab 50 mg 1 $0 QL (240 tabs / 30 days) tramadol-acetaminophen tab 37.5-325 mg 1 $0 QL (240 tabs / 30 days) 麻醉性鎮痛劑,CII - 治療疼痛的藥物 DURAMORPH INJ 0.5MG/ML 1 $0 B/D DURAMORPH INJ 1MG/ML 1 $0 B/D endocet tab 5-325mg 1 $0 QL (360 tabs / 30 days) endocet tab 7.5-325 1 $0 QL (360 tabs / 30 days) endocet tab 10-325mg 1 $0 QL (360 tabs / 30 days) fentanyl citrate lozenge on a handle 2 $0 QL (120 lozenges / 30 200 mcg days), PA fentanyl citrate lozenge on a handle 2 $0 QL (120 lozenges / 30 400 mcg days), PA fentanyl citrate lozenge on a handle 2 $0 QL (120 lozenges / 30 600 mcg days), PA 3

fentanyl citrate lozenge on a handle 2 $0 QL (120 lozenges / 30 800 mcg days), PA fentanyl citrate lozenge on a handle 2 $0 QL (120 lozenges / 30 1200 mcg days), PA fentanyl citrate lozenge on a handle 2 $0 QL (120 lozenges / 30 1600 mcg days), PA fentanyl td patch 72hr 12 mcg/hr 1 $0 QL (10 patches / 30 days) fentanyl td patch 72hr 25 mcg/hr 1 $0 QL (10 patches / 30 days) fentanyl td patch 72hr 50 mcg/hr 1 $0 QL (10 patches / 30 days), PA fentanyl td patch 72hr 75 mcg/hr 1 $0 QL (10 patches / 30 days), PA fentanyl td patch 72hr 100 mcg/hr 1 $0 QL (10 patches / 30 days), PA FENTORA TAB 100MCG 2 $0 QL (120 tabs / 30 days), PA FENTORA TAB 200MCG 2 $0 QL (120 tabs / 30 days), PA FENTORA TAB 400MCG 2 $0 QL (120 tabs / 30 days), PA FENTORA TAB 600MCG 2 $0 QL (120 tabs / 30 days), PA FENTORA TAB 800MCG 2 $0 QL (120 tabs / 30 days), PA hydrocodone-acetaminophen soln 1 $0 QL (5400 ml / 30 days) 7.5-325 mg/15ml hydrocodone-acetaminophen tab 1 $0 QL (360 tabs / 30 days) 5-325 mg hydrocodone-acetaminophen tab 1 $0 QL (360 tabs / 30 days) 7.5-325 mg hydrocodone-acetaminophen tab 10-325 mg 1 $0 QL (360 tabs / 30 days) hydrocodone-ibuprofen tab 7.5-2001 $0 QL (150 tabs / 30 days) mg hydromorphone hcl liqd 1 mg/ml 1 $0 hydromorphone hcl preservative 1 $0 B/D free (pf) inj 10 mg/ml hydromorphone hcl tab 2 mg 1 $0 QL (270 tabs / 30 days) hydromorphone hcl tab 4 mg 1 $0 QL (270 tabs / 30 days) hydromorphone hcl tab 8 mg 1 $0 QL (270 tabs / 30 days) methadone con 10mg/ml 1 $0 QL (120 ml / 30 days) methadone hcl soln 5 mg/5ml 1 $0 QL (600 ml / 30 days) methadone hcl soln 10 mg/5ml 1 $0 QL (600 ml / 30 days) 4

methadone hcl tab 5 mg 1 $0 QL (240 tabs / 30 days) methadone hcl tab 10 mg 1 $0 QL (240 tabs / 30 days) MORPHINE SUL INJ 2MG/ML 1 $0 B/D MORPHINE SUL INJ 4MG/ML 1 $0 B/D MORPHINE SUL INJ 8MG/ML 1 $0 B/D morphine sulfate beads cap sr 24hr 1 $0 QL (60 caps / 30 days) 30 mg morphine sulfate beads cap sr 24hr 1 $0 QL (60 caps / 30 days) 45 mg morphine sulfate beads cap sr 24hr 1 $0 QL (60 caps / 30 days) 60 mg morphine sulfate beads cap sr 24hr 1 $0 QL (60 caps / 30 days) 75 mg morphine sulfate beads cap sr 24hr 1 $0 QL (60 caps / 30 days) 90 mg morphine sulfate beads cap sr 24hr 1 $0 QL (60 caps / 30 days) 120 mg morphine sulfate cap sr 24hr 10 mg 1 $0 QL (60 caps / 30 days) morphine sulfate cap sr 24hr 20 mg 1 $0 QL (60 caps / 30 days) morphine sulfate cap sr 24hr 30 mg 1 $0 QL (60 caps / 30 days) morphine sulfate cap sr 24hr 50 mg 1 $0 QL (60 caps / 30 days) morphine sulfate cap sr 24hr 60 mg 1 $0 QL (60 caps / 30 days) morphine sulfate cap sr 24hr 80 mg 2 $0 QL (60 caps / 30 days) morphine sulfate cap sr 24hr 100 mg 2 $0 QL (60 caps / 30 days) morphine sulfate inj pf 0.5 mg/ml 1 $0 B/D morphine sulfate inj pf 1 mg/ml 1 $0 B/D MORPHINE SULFATE IV SOLN 1 MG/ML 1 $0 B/D morphine sulfate iv soln pf 4 mg/ml 1 $0 B/D morphine sulfate iv soln pf 8 mg/ml 1 $0 B/D MORPHINE SULFATE IV SOLN PF 101 $0 B/D MG/ML MORPHINE SULFATE IV SOLN PF 151 $0 B/D MG/ML MORPHINE SULFATE ORAL SOLN 101 $0 MG/5ML MORPHINE SULFATE ORAL SOLN 201 $0 MG/5ML MORPHINE SULFATE ORAL SOLN 1 $0 100 MG/5ML (20 MG/ML) MORPHINE SULFATE TAB 15 MG 1 $0 QL (180 tabs / 30 days) MORPHINE SULFATE TAB 30 MG 1 $0 QL (180 tabs / 30 days) morphine sulfate tab cr 15 mg 1 $0 QL (90 tabs / 30 days) 5

morphine sulfate tab cr 30 mg 1 $0 QL (90 tabs / 30 days) morphine sulfate tab cr 60 mg 1 $0 QL (90 tabs / 30 days) morphine sulfate tab cr 100 mg 1 $0 QL (90 tabs / 30 days) morphine sulfate tab cr 200 mg 1 $0 QL (60 tabs / 30 days) oxycodone hcl cap 5 mg 1 $0 QL (180 caps / 30 days) oxycodone hcl conc 100 mg/5ml (201 $0 mg/ml) OXYCODONE HCL SOLN 5 MG/5ML 1 $0 oxycodone hcl tab 5 mg 1 $0 QL (180 tabs / 30 days) oxycodone hcl tab 10 mg 1 $0 QL (180 tabs / 30 days) oxycodone hcl tab 15 mg 1 $0 QL (180 tabs / 30 days) oxycodone hcl tab 20 mg 1 $0 QL (180 tabs / 30 days) oxycodone hcl tab 30 mg 1 $0 QL (180 tabs / 30 days) oxycodone w/ acetaminophen tab 1 $0 QL (360 tabs / 30 days) 2.5-325 mg oxycodone w/ acetaminophen tab 1 $0 QL (360 tabs / 30 days) 5-325 mg oxycodone w/ acetaminophen tab 1 $0 QL (360 tabs / 30 days) 7.5-325 mg oxycodone w/ acetaminophen tab 1 $0 QL (360 tabs / 30 days) 10-325 mg roxicet sol 5-325/5 2 $0 QL (1800 ml / 30 days) 麻醉劑 - 麻痹藥物局部麻醉藥 lidocaine hcl local inj 0.5% 1 $0 B/D lidocaine hcl local inj 1% 1 $0 B/D lidocaine hcl local inj 1.5% 1 $0 B/D lidocaine hcl local inj 2% 1 $0 B/D lidocaine hcl local preservative free 1 $0 B/D (pf) inj 0.5% lidocaine hcl local preservative free 1 $0 B/D (pf) inj 1% 抗感染藥 - 治療感染的藥物抗菌藥 - 雜類 amikacin sulfate inj 1 gm/4ml (250 1 $0 mg/ml) amikacin sulfate inj 500 mg/2ml 1 $0 (250 mg/ml) gentam/nacl inj 0.9mg/ml 1 $0 gentam/nacl inj 1.4mg/ml 1 $0 gentamicin in saline inj 0.8 mg/ml 1 $0 gentamicin in saline inj 1 mg/ml 1 $0 gentamicin in saline inj 1.2 mg/ml 1 $0 6

gentamicin in saline inj 1.6 mg/ml 1 $0 gentamicin in saline inj 2 mg/ml 1 $0 gentamicin sulfate inj 10 mg/ml 1 $0 gentamicin sulfate inj 40 mg/ml 1 $0 gentamicin sulfate iv soln 10 mg/ml 1 $0 neomycin sulfate tab 500 mg 1 $0 paromomycin sulfate cap 250 mg 1 $0 streptomycin sulfate for inj 1 gm 1 $0 sulfadiazine tab 500mg 2 $0 tobra/nacl inj 80/0.9 2 $0 tobramycin nebu soln 300 mg/5ml 2 $0 B/D, NM tobramycin sulfate for inj 1.2 gm 1 $0 tobramycin sulfate inj 1.2 gm/30ml 1 $0 (40 mg/ml) tobramycin sulfate inj 2 gm/50ml 1 $0 (40 mg/ml) tobramycin sulfate inj 10 mg/ml 1 $0 tobramycin sulfate inj 80 mg/2ml 1 $0 (40 mg/ml) 抗感染藥 - 雜類 ALBENZA TAB 200MG 2 $0 ALINIA SUS 100/5ML 2 $0 ALINIA TAB 500MG 2 $0 atovaquone susp 750 mg/5ml 2 $0 AZACTAM/DEX INJ 1GM 2 $0 AZACTAM/DEX INJ 2GM 2 $0 aztreonam for inj 1 gm 1 $0 aztreonam for inj 2 gm 1 $0 BILTRICIDE TAB 600MG 2 $0 CAYSTON INH 75MG 2 $0 NM, LA, PA clindamycin hcl cap 75 mg 1 $0 clindamycin hcl cap 150 mg 1 $0 clindamycin hcl cap 300 mg 1 $0 clindamycin palmitate hcl for soln 1 $0 75 mg/5ml (base equiv) clindamycin phosphate in d5w iv 1 $0 soln 300 mg/50ml clindamycin phosphate in d5w iv 1 $0 soln 600 mg/50ml clindamycin phosphate in d5w iv 1 $0 soln 900 mg/50ml clindamycin phosphate inj 9 gm/60ml 1 $0 7

clindamycin phosphate inj 300 1 $0 mg/2ml clindamycin phosphate inj 600 1 $0 mg/4ml clindamycin phosphate inj 900 mg/6ml 1 $0 clindamycin phosphate iv soln 300 1 $0 mg/2ml clindamycin phosphate iv soln 600 1 $0 mg/4ml clindamycin phosphate iv soln 900 1 $0 mg/6ml colistimethate sodium for inj 150 1 $0 mg CUBICIN SOL 500MG 2 $0 dapsone tab 25 mg 1 $0 dapsone tab 100 mg 1 $0 DARAPRIM TAB 25MG 2 $0 imipenem-cilastatin intravenous for 1 $0 soln 250 mg imipenem-cilastatin intravenous for 1 $0 soln 500 mg INVANZ INJ 1GM 2 $0 ivermectin tab 3 mg 1 $0 LINEZOLID FOR SUSP 100 MG/5ML 2 $0 linezolid iv soln 2 mg/ml 2 $0 LINEZOLID TAB 600 MG 2 $0 meropenem iv for soln 1 gm 1 $0 meropenem iv for soln 500 mg 1 $0 methenamine hippurate tab 1 gm 1 $0 metronidazole in nacl 0.79% iv soln 1 $0 500 mg/100ml metronidazole tab 250 mg 1 $0 metronidazole tab 500 mg 1 $0 NEBUPENT INH 300MG 2 $0 B/D nitrofurantoin macrocrystalline cap 50 mg nitrofurantoin macrocrystalline cap 100 mg 2 $0 PA; PA applies if 65 years and after a 90 day supply in a calendar year 2 $0 PA; PA applies if 65 years and after a 90 day supply in a calendar year 8

nitrofurantoin monohydrate macrocrystalline cap 100 mg 藥物層級您為藥物支 付的費用 2 $0 PA; PA applies if 65 years and after a 90 day supply in a calendar year PENTAM 300 INJ 300MG 2 $0 SIVEXTRO INJ 200MG 2 $0 SIVEXTRO TAB 200MG 2 $0 sulfamethoxazole-trimethoprim iv 1 $0 soln 400-80 mg/5ml sulfamethoxazole-trimethoprim susp 200-40 mg/5ml 1 $0 sulfamethoxazole-trimethoprim tab 1 $0 400-80 mg sulfamethoxazole-trimethoprim tab 1 $0 800-160 mg SYNERCID INJ 500MG 2 $0 trimethoprim tab 100 mg 1 $0 TYGACIL INJ 50MG 2 $0 vancomycin hcl cap 125 mg 2 $0 vancomycin hcl cap 250 mg 2 $0 vancomycin hcl for inj 10 gm 1 $0 vancomycin hcl for inj 500 mg 1 $0 vancomycin hcl for inj 1000 mg 1 $0 vancomycin hcl for inj 5000 mg 1 $0 vancomycin inj 750mg 1 $0 ZYVOX SUS 100MG/5M 2 $0 ZYVOX TAB 600MG 2 $0 抗真菌藥 - 治療真菌感染的藥物 ABELCET INJ 5MG/ML 2 $0 B/D AMBISOME INJ 50MG 2 $0 B/D amphotericin b for inj 50 mg 1 $0 B/D CANCIDAS INJ 50MG 2 $0 CANCIDAS INJ 70MG 2 $0 fluconazole for susp 10 mg/ml 1 $0 fluconazole for susp 40 mg/ml 1 $0 fluconazole in dextrose inj 200 1 $0 mg/100ml fluconazole in dextrose inj 400 1 $0 mg/200ml fluconazole in nacl 0.9% inj 200 1 $0 mg/100ml fluconazole in nacl 0.9% inj 400 mg/200ml 1 $0 9

fluconazole tab 50 mg 1 $0 fluconazole tab 100 mg 1 $0 fluconazole tab 150 mg 1 $0 fluconazole tab 200 mg 1 $0 fluconazole/ inj nacl 100 1 $0 flucytosine cap 250 mg 2 $0 flucytosine cap 500 mg 2 $0 griseofulvin microsize susp 125 mg/5ml 1 $0 griseofulvin microsize tab 500 mg 1 $0 griseofulvin ultramicrosize tab 125 1 $0 mg griseofulvin ultramicrosize tab 250 1 $0 mg itraconazole cap 100 mg 1 $0 PA ketoconazole tab 200 mg 1 $0 PA MYCAMINE INJ 50MG 2 $0 MYCAMINE INJ 100MG 2 $0 NOXAFIL SUS 40MG/ML 2 $0 NOXAFIL TAB 100MG 2 $0 nystatin tab 500000 unit 1 $0 terbinafine hcl tab 250 mg 1 $0 QL (90 tabs / 365 days) voriconazole for inj 200 mg 1 $0 voriconazole for susp 40 mg/ml 2 $0 voriconazole tab 50 mg 2 $0 voriconazole tab 200 mg 2 $0 抗瘧藥 - 治療瘧疾的藥物 atovaquone-proguanil hcl tab 1 $0 62.5-25 mg atovaquone-proguanil hcl tab 250-100 mg 1 $0 chloroquine phosphate tab 250 mg 1 $0 chloroquine phosphate tab 500 mg 1 $0 COARTEM TAB 20-120MG 2 $0 mefloquine hcl tab 250 mg 1 $0 PRIMAQUINE TAB 26.3MG 2 $0 quinine sulfate cap 324 mg 1 $0 PA 抗逆轉錄病毒藥 - 抑制愛滋病感染的藥物 abacavir sulfate tab 300 mg (base 1 $0 equiv) APTIVUS CAP 250MG 2 $0 APTIVUS SOL 2 $0 10

CRIXIVAN CAP 200MG 2 $0 CRIXIVAN CAP 400MG 2 $0 didanosine delayed release capsule 1 $0 125 mg didanosine delayed release capsule 1 $0 200 mg didanosine delayed release capsule 1 $0 250 mg didanosine delayed release capsule 1 $0 400 mg EDURANT TAB 25MG 2 $0 EMTRIVA CAP 200MG 2 $0 EMTRIVA SOL 10MG/ML 2 $0 FUZEON INJ 90MG 2 $0 NM INTELENCE TAB 25MG 2 $0 INTELENCE TAB 100MG 2 $0 INTELENCE TAB 200MG 2 $0 INVIRASE CAP 200MG 2 $0 INVIRASE TAB 500MG 2 $0 ISENTRESS CHW 25MG 2 $0 ISENTRESS CHW 100MG 2 $0 ISENTRESS POW 100MG 2 $0 ISENTRESS TAB 400MG 2 $0 lamivudine oral soln 10 mg/ml 1 $0 lamivudine tab 150 mg 1 $0 lamivudine tab 300 mg 1 $0 LEXIVA SUS 50MG/ML 2 $0 LEXIVA TAB 700MG 2 $0 NEVIRAPINE SUSP 50 MG/5ML 1 $0 nevirapine tab 200 mg 1 $0 nevirapine tab sr 24hr 100 mg 1 $0 nevirapine tab sr 24hr 400 mg 1 $0 NORVIR CAP 100MG 2 $0 NORVIR SOL 80MG/ML 2 $0 NORVIR TAB 100MG 2 $0 PREZISTA SUS 100MG/ML 2 $0 PREZISTA TAB 75MG 2 $0 PREZISTA TAB 150MG 2 $0 PREZISTA TAB 600MG 2 $0 PREZISTA TAB 800MG 2 $0 RESCRIPTOR TAB 100 MG 2 $0 RESCRIPTOR TAB 200MG 2 $0 11

藥物層級您為藥物支 付的費用 RETROVIR INJ 10MG/ML 2 $0 REYATAZ CAP 150MG 2 $0 REYATAZ CAP 200MG 2 $0 REYATAZ CAP 300MG 2 $0 REYATAZ POW 50MG 2 $0 SELZENTRY TAB 150MG 2 $0 SELZENTRY TAB 300MG 2 $0 stavudine cap 15 mg 1 $0 stavudine cap 20 mg 1 $0 stavudine cap 30 mg 1 $0 stavudine cap 40 mg 1 $0 stavudine for oral soln 1 mg/ml 1 $0 SUSTIVA CAP 50MG 2 $0 SUSTIVA CAP 200MG 2 $0 SUSTIVA TAB 600MG 2 $0 TIVICAY TAB 50MG 2 $0 TYBOST TAB 150MG 2 $0 VIDEX SOL 2GM 2 $0 VIDEX SOL 4GM 2 $0 VIRACEPT TAB 250MG 2 $0 VIRACEPT TAB 625MG 2 $0 VIRAMUNE XR TAB 100MG 2 $0 VIREAD POW 40MG/GM 2 $0 VIREAD TAB 150MG 2 $0 VIREAD TAB 200MG 2 $0 VIREAD TAB 250MG 2 $0 VIREAD TAB 300MG 2 $0 VITEKTA TAB 85MG 2 $0 VITEKTA TAB 150MG 2 $0 ZIAGEN SOL 20MG/ML 2 $0 zidovudine cap 100 mg 1 $0 zidovudine syrup 10 mg/ml 1 $0 zidovudine tab 300 mg 1 $0 抗逆轉錄病毒組合藥 - 抑制愛滋病感染的藥物 abacavir 2 $0 sulfate-lamivudine-zidovudine tab 300-150-300 mg ATRIPLA TAB 2 $0 COMPLERA TAB 2 $0 EPZICOM TAB 600-300 2 $0 EVOTAZ TAB 300-150 2 $0 GENVOYA TAB 2 $0 12

KALETRA SOL 2 $0 KALETRA TAB 100-25MG 2 $0 KALETRA TAB 200-50MG 2 $0 lamivudine-zidovudine tab 150-3002 $0 mg PREZCOBIX TAB 800-150 2 $0 STRIBILD TAB 2 $0 TRIUMEQ TAB 2 $0 TRUVADA TAB 200-300 2 $0 QL (30 tabs / 30 days) 抗結核藥 - 治療肺結核的藥物 CAPASTAT SUL INJ 1GM 2 $0 cycloserine cap 250 mg 2 $0 ethambutol hcl tab 100 mg 1 $0 ethambutol hcl tab 400 mg 1 $0 isoniazid inj 100 mg/ml 1 $0 isoniazid syrup 50 mg/5ml 1 $0 isoniazid tab 100 mg 1 $0 isoniazid tab 300 mg 1 $0 paser gra 4gm 2 $0 PRIFTIN TAB 150MG 2 $0 pyrazinamide tab 500 mg 1 $0 rifabutin cap 150 mg 1 $0 rifampin cap 150 mg 1 $0 rifampin cap 300 mg 1 $0 rifampin for inj 600 mg 1 $0 RIFATER TAB 2 $0 SIRTURO TAB 100MG 2 $0 LA, PA TRECATOR TAB 250MG 2 $0 抗病毒藥 - 治療病毒感染的藥物 acyclovir cap 200 mg 1 $0 acyclovir sodium for inj 500 mg 1 $0 B/D acyclovir sodium iv soln 50 mg/ml 1 $0 B/D acyclovir susp 200 mg/5ml 1 $0 acyclovir tab 400 mg 1 $0 acyclovir tab 800 mg 1 $0 adefovir dipivoxil tab 10 mg 2 $0 BARACLUDE SOL.05MG/ML 2 $0 DAKLINZA TAB 30MG 2 $0 NM, PA DAKLINZA TAB 60MG 2 $0 NM, PA entecavir tab 0.5 mg 2 $0 entecavir tab 1 mg 2 $0 13

EPIVIR HBV SOL 5MG/ML 2 $0 famciclovir tab 125 mg 1 $0 famciclovir tab 250 mg 1 $0 famciclovir tab 500 mg 1 $0 ganciclovir sodium for inj 500 mg 1 $0 B/D HARVONI TAB 90-400MG 2 $0 NM, PA lamivudine tab 100 mg (hbv) 1 $0 moderiba pak 600/day 2 $0 NM moderiba pak 800/day 2 $0 NM moderiba pak 1000/day 2 $0 NM MODERIBA PAK 1200/DAY 2 $0 NM PEG-INTRON KIT 50MCG 2 $0 NM, PA PEG-INTRON KIT 50MCG RP 2 $0 NM, PA PEG-INTRON KIT 80MCG RP 2 $0 NM, PA PEG-INTRON KIT 120 RP 2 $0 NM, PA PEG-INTRON KIT 150 RP 2 $0 NM, PA PEGASYS INJ 2 $0 NM, PA PEGASYS INJ 180MCG/M 2 $0 NM, PA PEGASYS INJ PROCLICK 2 $0 NM, PA PEGINTRON KIT 80MCG 2 $0 NM, PA PEGINTRON KIT 120MCG 2 $0 NM, PA PEGINTRON KIT 150MCG 2 $0 NM, PA REBETOL SOL 40MG/ML 2 $0 NM RELENZA MIS DISKHALE 2 $0 ribapak pak 600/day 2 $0 NM ribapak pak 800/day 2 $0 NM ribapak pak 1000/day 2 $0 NM ribapak pak 1200/day 2 $0 NM ribasphere cap 200mg 1 $0 NM ribasphere tab 200mg 1 $0 NM ribasphere tab 400mg 1 $0 NM ribasphere tab 600mg 2 $0 NM ribavirin cap 200 mg 1 $0 NM ribavirin tab 200 mg 1 $0 NM rimantadine hydrochloride tab 100 1 $0 mg SOVALDI TAB 400MG 2 $0 NM, PA TAMIFLU CAP 30MG 2 $0 TAMIFLU CAP 45MG 2 $0 TAMIFLU CAP 75MG 2 $0 TAMIFLU SUS 6MG/ML 2 $0 TYZEKA TAB 600MG 2 $0 14

藥物層級您為藥物支 付的費用 valacyclovir hcl tab 1 gm 1 $0 valacyclovir hcl tab 500 mg 1 $0 VALCYTE SOL 50MG/ML 2 $0 valganciclovir hcl tab 450 mg (base 2 $0 equivalent) 頭孢菌素 - 治療感染的藥物 cefaclor cap 250 mg 1 $0 cefaclor cap 500 mg 1 $0 cefaclor er tab 500mg 2 $0 cefaclor for susp 125 mg/5ml 1 $0 cefaclor for susp 250 mg/5ml 1 $0 cefaclor for susp 375 mg/5ml 1 $0 cefadroxil cap 500 mg 1 $0 cefadroxil for susp 250 mg/5ml 1 $0 cefadroxil for susp 500 mg/5ml 1 $0 cefadroxil tab 1 gm 1 $0 cefazolin inj 1gm/50ml 2 $0 cefazolin sodium for inj 1 gm 1 $0 cefazolin sodium for inj 10 gm 1 $0 cefazolin sodium for inj 20 gm 1 $0 cefazolin sodium for inj 500 mg 1 $0 cefazolin sodium for iv soln 1 gm 1 $0 CEFAZOLIN SOL 2 $0 cefdinir cap 300 mg 1 $0 cefdinir for susp 125 mg/5ml 1 $0 cefdinir for susp 250 mg/5ml 1 $0 cefepime hcl for inj 1 gm 1 $0 cefepime hcl for inj 2 gm 1 $0 cefixime for susp 100 mg/5ml 1 $0 cefixime for susp 200 mg/5ml 1 $0 cefotaxime sodium for inj 1 gm 1 $0 cefotaxime sodium for inj 2 gm 1 $0 cefotaxime sodium for inj 500 mg 1 $0 cefoxitin sodium for inj 10 gm 1 $0 cefoxitin sodium for iv soln 1 gm 1 $0 cefoxitin sodium for iv soln 2 gm 1 $0 cefpodoxime proxetil for susp 50 1 $0 mg/5ml cefpodoxime proxetil for susp 100 1 $0 mg/5ml cefpodoxime proxetil tab 100 mg 1 $0 cefpodoxime proxetil tab 200 mg 1 $0 15

藥物層級您為藥物支 付的費用 cefprozil for susp 125 mg/5ml 1 $0 cefprozil for susp 250 mg/5ml 1 $0 cefprozil tab 250 mg 1 $0 cefprozil tab 500 mg 1 $0 ceftazidime for inj 1 gm 1 $0 ceftazidime for inj 2 gm 1 $0 ceftazidime for inj 6 gm 1 $0 CEFTAZIDIME/ SOL D5W 1GM 2 $0 CEFTAZIDIME/ SOL D5W 2GM 2 $0 ceftriaxone sodium for inj 1 gm 1 $0 ceftriaxone sodium for inj 2 gm 1 $0 ceftriaxone sodium for inj 10 gm 1 $0 ceftriaxone sodium for inj 250 mg 1 $0 ceftriaxone sodium for inj 500 mg 1 $0 ceftriaxone sodium for iv soln 1 gm 1 $0 ceftriaxone sodium for iv soln 2 gm 1 $0 cefuroxime axetil tab 250 mg 1 $0 cefuroxime axetil tab 500 mg 1 $0 cefuroxime inj 7.5gm 1 $0 cefuroxime sodium for inj 1.5 gm 1 $0 cefuroxime sodium for inj 7.5 gm 1 $0 cefuroxime sodium for inj 750 mg 1 $0 cefuroxime sodium for iv soln 1.5 1 $0 gm cephalexin cap 250 mg 1 $0 cephalexin cap 500 mg 1 $0 cephalexin for susp 125 mg/5ml 1 $0 cephalexin for susp 250 mg/5ml 1 $0 SUPRAX CAP 400MG 2 $0 suprax chw 100mg 2 $0 suprax chw 200mg 2 $0 SUPRAX SUS 500/5ML 2 $0 tazicef inj 1gm 1 $0 tazicef inj 2gm 1 $0 tazicef inj 6gm 1 $0 TEFLARO INJ 400MG 2 $0 TEFLARO INJ 600MG 2 $0 紅黴素 / 大環內酯 - 治療感染的藥物 azithromycin for susp 100 mg/5ml 1 $0 azithromycin for susp 200 mg/5ml 1 $0 azithromycin iv for soln 500 mg 1 $0 16

藥物層級您為藥物支 付的費用 AZITHROMYCIN POWD PACK FOR 1 $0 SUSP 1 GM azithromycin tab 250 mg 1 $0 azithromycin tab 500 mg 1 $0 azithromycin tab 600 mg 1 $0 clarithromycin for susp 125 mg/5ml 1 $0 clarithromycin for susp 250 mg/5ml 1 $0 clarithromycin tab 250 mg 1 $0 clarithromycin tab 500 mg 1 $0 clarithromycin tab sr 24hr 500 mg 1 $0 DIFICID TAB 200MG 2 $0 e.e.s. 400 tab 400mg 1 $0 ery-tab tab 250mg ec 1 $0 ery-tab tab 333mg ec 1 $0 ery-tab tab 500mg ec 1 $0 erythrocin inj 500mg 2 $0 erythrocin tab 250mg 1 $0 erythromycin ethylsuccinate tab 1 $0 400 mg erythromycin tab 250 mg 1 $0 erythromycin tab 500 mg 1 $0 erythromycin w/ delayed release 1 $0 particles cap 250 mg 氟喹諾酮 - 治療感染的藥物 ciprofloxacin 200 mg/100ml in d5w 1 $0 ciprofloxacin 400 mg/200ml in d5w 1 $0 ciprofloxacin for oral susp 250 1 $0 mg/5ml (5%) (5 gm/100ml) ciprofloxacin for oral susp 500 mg/5ml (10%) (10 gm/100ml) 1 $0 ciprofloxacin hcl tab 100 mg (base 1 $0 equiv) ciprofloxacin hcl tab 250 mg (base 1 $0 equiv) ciprofloxacin hcl tab 500 mg (base 1 $0 equiv) ciprofloxacin hcl tab 750 mg (base 1 $0 equiv) ciprofloxacin iv soln 200 mg/20ml 1 $0 (1%) ciprofloxacin iv soln 400 mg/40ml (1%) 1 $0 ciprofloxacin-ciprofloxacin hcl tab sr 1 $0 24hr 500 mg (base eq) 17

藥物層級您為藥物支 付的費用 ciprofloxacin-ciprofloxacin hcl tab sr 1 $0 24hr 1000 mg(base eq) levofloxacin in d5w iv soln 250 1 $0 mg/50ml levofloxacin in d5w iv soln 500 1 $0 mg/100ml levofloxacin in d5w iv soln 750 1 $0 mg/150ml levofloxacin iv soln 25 mg/ml 1 $0 levofloxacin oral soln 25 mg/ml 1 $0 levofloxacin tab 250 mg 1 $0 levofloxacin tab 500 mg 1 $0 levofloxacin tab 750 mg 1 $0 青黴素 - 治療感染的藥物 amoxicillin & k clavulanate chew tab 1 $0 200-28.5 mg amoxicillin & k clavulanate chew tab 1 $0 400-57 mg amoxicillin & k clavulanate for susp 1 $0 200-28.5 mg/5ml amoxicillin & k clavulanate for susp 1 $0 250-62.5 mg/5ml amoxicillin & k clavulanate for susp 1 $0 400-57 mg/5ml amoxicillin & k clavulanate for susp 1 $0 600-42.9 mg/5ml amoxicillin & k clavulanate tab 1 $0 250-125 mg amoxicillin & k clavulanate tab 1 $0 500-125 mg amoxicillin & k clavulanate tab 1 $0 875-125 mg amoxicillin & k clavulanate tab sr 12hr 1000-62.5 mg 1 $0 amoxicillin (trihydrate) cap 250 mg 1 $0 amoxicillin (trihydrate) cap 500 mg 1 $0 amoxicillin (trihydrate) chew tab 1 $0 125 mg amoxicillin (trihydrate) chew tab 250 mg 1 $0 amoxicillin (trihydrate) for susp 1251 $0 mg/5ml amoxicillin (trihydrate) for susp 2001 $0 mg/5ml 18

藥物層級您為藥物支 付的費用 amoxicillin (trihydrate) for susp 2501 $0 mg/5ml amoxicillin (trihydrate) for susp 4001 $0 mg/5ml amoxicillin (trihydrate) tab 500 mg 1 $0 amoxicillin (trihydrate) tab 875 mg 1 $0 ampicillin & sulbactam sodium for 1 $0 inj 1-0.5 gm ampicillin & sulbactam sodium for 1 $0 inj 2-1 gm ampicillin & sulbactam sodium for 1 $0 inj 10-5 gm ampicillin & sulbactam sodium for iv 1 $0 soln 1-0.5 gm ampicillin & sulbactam sodium for iv 1 $0 soln 2-1 gm ampicillin & sulbactam sodium for iv 1 $0 soln 10-5 gm ampicillin cap 250 mg 1 $0 ampicillin cap 500 mg 1 $0 ampicillin for susp 125 mg/5ml 1 $0 ampicillin for susp 250 mg/5ml 1 $0 ampicillin sodium for inj 1 gm 1 $0 ampicillin sodium for inj 2 gm 1 $0 ampicillin sodium for inj 125 mg 1 $0 ampicillin sodium for inj 250 mg 1 $0 ampicillin sodium for inj 500 mg 1 $0 ampicillin sodium for iv soln 1 gm 1 $0 ampicillin sodium for iv soln 2 gm 1 $0 ampicillin sodium for iv soln 10 gm 1 $0 BICILLIN L-A INJ 600000 2 $0 BICILLIN L-A INJ 1200000 2 $0 BICILLIN L-A INJ 2400000 2 $0 dicloxacillin sodium cap 250 mg 1 $0 dicloxacillin sodium cap 500 mg 1 $0 nafcillin sodium for inj 1 gm 1 $0 nafcillin sodium for inj 2 gm 2 $0 nafcillin sodium for inj 10 gm 2 $0 nafcillin sodium for iv soln 1 gm 1 $0 nafcillin sodium for iv soln 2 gm 2 $0 oxacillin sodium for inj 1 gm 1 $0 oxacillin sodium for inj 2 gm 1 $0 oxacillin sodium for inj 10 gm 2 $0 19

藥物層級您為藥物支 付的費用 pen g proc inj 600000 2 $0 PENICILL GK/ INJ DEX 2MU 2 $0 PENICILL GK/ INJ DEX 3MU 2 $0 penicillin g potassium for inj 1 $0 5000000 unit penicillin g potassium for inj 1 $0 20000000 unit penicillin g sodium for inj 5000000 1 $0 unit penicillin v potassium for soln 125 1 $0 mg/5ml penicillin v potassium for soln 250 1 $0 mg/5ml penicillin v potassium tab 250 mg 1 $0 penicillin v potassium tab 500 mg 1 $0 piperacillin sodium-tazobactam 1 $0 sodium for inj 2-0.25 gm piperacillin sodium-tazobactam 1 $0 sodium for inj 3-0.375 gm piperacillin sodium-tazobactam 1 $0 sodium for inj 4-0.5 gm piperacillin sodium-tazobactam 1 $0 sodium for inj 36-4.5 gm 四環素 - 治療感染的藥物 doxy 100 inj 100mg 1 $0 doxycycline hyclate cap 50 mg 1 $0 doxycycline hyclate cap 100 mg 1 $0 doxycycline hyclate for inj 100 mg 1 $0 doxycycline hyclate tab 20 mg 1 $0 doxycycline hyclate tab 100 mg 1 $0 doxycycline monohydrate cap 50 mg 1 $0 doxycycline monohydrate cap 100 1 $0 mg doxycycline monohydrate tab 50 1 $0 mg doxycycline monohydrate tab 75 1 $0 mg doxycycline monohydrate tab 100 1 $0 mg doxycycline monohydrate tab 150 1 $0 mg minocycline hcl cap 50 mg 1 $0 minocycline hcl cap 75 mg 1 $0 20

minocycline hcl cap 100 mg 1 $0 抗腫瘤藥 - 治療癌症的藥物烷基化藥 BICNU INJ 100MG 2 $0 B/D BUSULFEX INJ 6MG/ML 2 $0 B/D CYCLOPHOSPH CAP 25MG 2 $0 B/D CYCLOPHOSPH CAP 50MG 2 $0 B/D cyclophosphamide for inj 1 gm 2 $0 B/D cyclophosphamide for inj 2 gm 1 $0 B/D cyclophosphamide for inj 500 mg 2 $0 B/D dacarbazine for inj 100 mg 1 $0 B/D dacarbazine for inj 200 mg 1 $0 B/D EMCYT CAP 140MG 2 $0 GLEOSTINE CAP 5MG 2 $0 GLEOSTINE CAP 10MG 2 $0 GLEOSTINE CAP 40MG 2 $0 GLEOSTINE CAP 100MG 2 $0 HEXALEN CAP 50MG 2 $0 IFEX INJ 3GM 2 $0 B/D ifosfamide for inj 1 gm 1 $0 B/D IFOSFAMIDE INJ 3GM 2 $0 B/D ifosfamide iv inj 1 gm/20ml (50 1 $0 B/D mg/ml) ifosfamide iv inj 3 gm/60ml (50 1 $0 B/D mg/ml) LEUKERAN TAB 2MG 2 $0 LOMUSTINE CAP 10 MG 1 $0 LOMUSTINE CAP 40 MG 1 $0 LOMUSTINE CAP 100 MG 1 $0 melphalan hcl for inj 50 mg (base 2 $0 B/D equiv) MUSTARGEN INJ 10MG 2 $0 B/D TREANDA INJ 25MG 2 $0 B/D, NM TREANDA INJ 45/0.5ML 2 $0 B/D, NM TREANDA INJ 100MG 2 $0 B/D, NM TREANDA INJ 180/2ML 2 $0 B/D, NM 氨茴環黴素 daunorubicin hcl inj 5 mg/ml (base 1 $0 B/D equiv) doxorubicin hcl for inj 50 mg 1 $0 B/D doxorubicin hcl inj 2 mg/ml 1 $0 B/D 21

doxorubicin hcl liposomal inj (for iv 2 $0 B/D infusion) 2 mg/ml epirubicin hcl iv soln 50 mg/25ml (21 $0 B/D mg/ml) epirubicin hcl iv soln 200 mg/100ml 1 $0 B/D (2 mg/ml) idarubicin hcl iv inj 5 mg/5ml (1 mg/ml) 2 $0 B/D idarubicin hcl iv inj 10 mg/10ml (1 2 $0 B/D mg/ml) idarubicin hcl iv inj 20 mg/20ml (1 2 $0 B/D mg/ml) 抗生素 bleomycin sulfate for inj 15 unit 1 $0 B/D bleomycin sulfate for inj 30 unit 1 $0 B/D mitomycin for iv soln 5 mg 1 $0 B/D mitomycin for iv soln 20 mg 1 $0 B/D mitomycin for iv soln 40 mg 1 $0 B/D 抗代謝物 adrucil inj 2.5g/50m 1 $0 B/D adrucil inj 5gm/100m 1 $0 B/D adrucil inj 500/10ml 1 $0 B/D ALIMTA INJ 100MG 2 $0 B/D ALIMTA INJ 500MG 2 $0 B/D azacitidine for inj 100 mg 2 $0 B/D, NM cladribine inj 1 mg/ml 2 $0 B/D cytarabine inj 20 mg/ml 1 $0 B/D fludarabine phosphate for inj 50 mg 1 $0 B/D fludarabine phosphate inj 25 mg/ml 1 $0 B/D fluorouracil inj 1 gm/20ml (50 1 $0 B/D mg/ml) fluorouracil inj 2.5 gm/50ml (50 1 $0 B/D mg/ml) fluorouracil inj 5 gm/100ml (50 1 $0 B/D mg/ml) fluorouracil inj 500 mg/10ml (50 1 $0 B/D mg/ml) gemcitabine hcl for inj 1 gm 2 $0 B/D gemcitabine hcl for inj 2 gm 2 $0 B/D gemcitabine hcl for inj 200 mg 2 $0 B/D GEMCITABINE INJ 1GM 2 $0 B/D GEMCITABINE INJ 2GM 2 $0 B/D GEMCITABINE INJ 200MG 2 $0 B/D 22

mercaptopurine tab 50 mg 1 $0 methotrexate sodium for inj 1 gm 1 $0 B/D methotrexate sodium inj 25 mg/ml 1 $0 B/D methotrexate sodium inj pf 25 1 $0 B/D mg/ml NIPENT INJ 10MG 2 $0 B/D PURIXAN SUS 20MG/ML 2 $0 NM TABLOID TAB 40MG 2 $0 抗有絲分裂, 紫杉醇 ABRAXANE INJ 100MG 2 $0 B/D DOCETAXEL FOR INJ CONC 20 2 $0 B/D MG/ML DOCETAXEL FOR INJ CONC 80 2 $0 B/D MG/4ML (20 MG/ML) DOCETAXEL INJ 20MG/2ML 1 $0 B/D DOCETAXEL INJ 80MG/8ML 2 $0 B/D docetaxel inj 140/7ml 2 $0 B/D DOCETAXEL INJ 160/16ML 2 $0 B/D DOCETAXEL INJ 200MG/20 2 $0 B/D paclitaxel iv conc 30 mg/5ml (6 mg/ml) 1 $0 B/D paclitaxel iv conc 100 mg/16.7ml (61 $0 B/D mg/ml) paclitaxel iv conc 150 mg/25ml (6 1 $0 B/D mg/ml) paclitaxel iv conc 300 mg/50ml (6 1 $0 B/D mg/ml) 抗有絲分裂, 長春花鹼 vinblastine sulfate inj 1 mg/ml 2 $0 B/D vincasar pfs inj 1mg/ml 1 $0 B/D vincristine sulfate iv soln 1 mg/ml 1 $0 B/D vinorelbine tartrate inj 10 mg/ml (base equiv) 1 $0 B/D vinorelbine tartrate inj 50 mg/5ml 1 $0 B/D (10 mg/ml) (base equiv) 生物反應改性劑 AVASTIN INJ 2 $0 B/D, NM, LA AVASTIN INJ 400/16ML 2 $0 B/D, NM, LA BELEODAQ INJ 500MG 2 $0 NM, PA ERIVEDGE CAP 150MG 2 $0 NM, LA, PA FARYDAK CAP 10MG 2 $0 NM, LA, PA FARYDAK CAP 15MG 2 $0 NM, LA, PA FARYDAK CAP 20MG 2 $0 NM, LA, PA 23

HERCEPTIN INJ 440MG 2 $0 B/D, NM IBRANCE CAP 75MG 2 $0 NM, LA, PA IBRANCE CAP 100MG 2 $0 NM, LA, PA IBRANCE CAP 125MG 2 $0 NM, LA, PA ISTODAX INJ 10MG 2 $0 B/D, NM KADCYLA INJ 100MG 2 $0 B/D, NM KADCYLA INJ 160MG 2 $0 B/D, NM KEYTRUDA INJ 100MG/4M 2 $0 NM, PA KEYTRUDA SOL 50MG 2 $0 NM, PA LYNPARZA CAP 50MG 2 $0 NM, LA, PA NINLARO CAP 2.3MG 2 $0 NM, PA NINLARO CAP 3MG 2 $0 NM, PA NINLARO CAP 4MG 2 $0 NM, PA PROLEUKIN INJ 22MU 2 $0 B/D, NM RITUXAN INJ 100MG 2 $0 NM, LA, PA RITUXAN INJ 500MG 2 $0 NM, LA, PA VELCADE INJ 3.5MG 2 $0 B/D, NM YERVOY INJ 50MG 2 $0 NM, PA YERVOY INJ 200MG 2 $0 NM, PA ZOLINZA CAP 100MG 2 $0 NM, PA 激素類抗腫瘤藥 anastrozole tab 1 mg 1 $0 bicalutamide tab 50 mg 1 $0 DEPO-PROVERA INJ 400/ML 2 $0 B/D exemestane tab 25 mg 1 $0 FARESTON TAB 60MG 2 $0 FASLODEX INJ 250MG 2 $0 B/D flutamide cap 125 mg 1 $0 letrozole tab 2.5 mg 1 $0 leuprolide acetate inj kit 5 mg/ml 1 $0 NM, PA LUPR DEP-PED INJ 7.5MG 2 $0 NM, PA LUPR DEP-PED INJ 11.25MG 2 $0 NM, PA LUPR DEP-PED INJ 15MG 2 $0 NM, PA LUPR DEP-PED INJ 30MG 2 $0 NM, PA LUPRON DEPOT INJ 3.75MG 2 $0 NM, PA LUPRON DEPOT INJ 11.25MG 2 $0 NM, PA LYSODREN TAB 500MG 2 $0 MEGACE ES SUS 625/5ML 2 $0 PA megestrol acetate susp 40 mg/ml 2 $0 PA; PA if 65 years and MEGESTROL ACETATE SUSP 625 MG/5ML 2 $0 PA 24

megestrol acetate tab 20 mg 2 $0 PA; PA if 65 years and megestrol acetate tab 40 mg 2 $0 PA; PA if 65 years and NILANDRON TAB 150MG 2 $0 SOLTAMOX SOL 10MG/5ML 2 $0 tamoxifen citrate tab 10 mg (base 1 $0 equivalent) tamoxifen citrate tab 20 mg (base 1 $0 equivalent) TRELSTAR MIX INJ 3.75MG 2 $0 NM, PA TRELSTAR MIX INJ 11.25MG 2 $0 NM, PA XTANDI CAP 40MG 2 $0 NM, LA, PA ZYTIGA TAB 250MG 2 $0 NM, LA, PA 激酶抑制劑 AFINITOR DIS TAB 2MG 2 $0 NM, PA AFINITOR DIS TAB 3MG 2 $0 NM, PA AFINITOR DIS TAB 5MG 2 $0 NM, PA AFINITOR TAB 2.5MG 2 $0 NM, PA AFINITOR TAB 5MG 2 $0 NM, PA AFINITOR TAB 7.5MG 2 $0 NM, PA AFINITOR TAB 10MG 2 $0 NM, PA ALECENSA CAP 150MG 2 $0 NM, LA, PA BOSULIF TAB 100MG 2 $0 NM, PA BOSULIF TAB 500MG 2 $0 NM, PA CAPRELSA TAB 100MG 2 $0 NM, LA, PA CAPRELSA TAB 300MG 2 $0 NM, LA, PA COMETRIQ KIT 60MG 2 $0 NM, LA, PA COMETRIQ KIT 100MG 2 $0 NM, LA, PA COMETRIQ KIT 140MG 2 $0 NM, LA, PA COTELLIC TAB 20MG 2 $0 NM, LA, 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 TAB 100MG 2 $0 NM, PA GLEEVEC TAB 400MG 2 $0 NM, PA ICLUSIG TAB 15MG 2 $0 NM, LA, PA ICLUSIG TAB 45MG 2 $0 NM, LA, PA IMBRUVICA CAP 140MG 2 $0 NM, LA, PA INLYTA TAB 1MG 2 $0 NM, LA, PA INLYTA TAB 5MG 2 $0 NM, LA, PA IRESSA TAB 250MG 2 $0 NM, LA, PA 25

JAKAFI TAB 5MG 2 $0 NM, LA, PA JAKAFI TAB 10MG 2 $0 NM, LA, PA JAKAFI TAB 15MG 2 $0 NM, LA, PA JAKAFI TAB 20MG 2 $0 NM, LA, PA JAKAFI TAB 25MG 2 $0 NM, LA, PA LENVIMA CAP 10MG 2 $0 NM, LA, PA LENVIMA CAP 14MG 2 $0 NM, LA, PA LENVIMA CAP 20MG 2 $0 NM, LA, PA LENVIMA CAP 24MG 2 $0 NM, LA, PA MEKINIST TAB 0.5MG 2 $0 NM, LA, PA MEKINIST TAB 2MG 2 $0 NM, LA, PA NEXAVAR TAB 200MG 2 $0 NM, LA, PA SPRYCEL TAB 20MG 2 $0 NM, PA SPRYCEL TAB 50MG 2 $0 NM, PA SPRYCEL TAB 70MG 2 $0 NM, PA SPRYCEL TAB 80MG 2 $0 NM, PA SPRYCEL TAB 100MG 2 $0 NM, PA SPRYCEL TAB 140MG 2 $0 NM, PA STIVARGA TAB 40MG 2 $0 NM, LA, PA SUTENT CAP 12.5MG 2 $0 NM, PA SUTENT CAP 25MG 2 $0 NM, PA SUTENT CAP 37.5MG 2 $0 NM, PA SUTENT CAP 50MG 2 $0 NM, PA TAFINLAR CAP 50MG 2 $0 NM, LA, PA TAFINLAR CAP 75MG 2 $0 NM, LA, PA TAGRISSO TAB 40MG 2 $0 NM, LA, PA TAGRISSO TAB 80MG 2 $0 NM, LA, PA TARCEVA TAB 25MG 2 $0 NM, LA, PA TARCEVA TAB 100MG 2 $0 NM, LA, PA TARCEVA TAB 150MG 2 $0 NM, LA, PA TASIGNA CAP 150MG 2 $0 NM, PA TASIGNA CAP 200MG 2 $0 NM, PA TYKERB TAB 250MG 2 $0 NM, LA, PA VOTRIENT TAB 200MG 2 $0 NM, LA, PA XALKORI CAP 200MG 2 $0 NM, LA, PA XALKORI CAP 250MG 2 $0 NM, LA, PA ZELBORAF TAB 240MG 2 $0 NM, LA, PA ZYDELIG TAB 100MG 2 $0 NM, LA, PA ZYDELIG TAB 150MG 2 $0 NM, LA, PA ZYKADIA CAP 150MG 2 $0 NM, LA, PA 雜類 26

bexarotene cap 75 mg 2 $0 NM, PA DROXIA CAP 200MG 2 $0 DROXIA CAP 300MG 2 $0 DROXIA CAP 400MG 2 $0 hydroxyurea cap 500 mg 1 $0 LONSURF TAB 15-6.14 2 $0 NM, PA LONSURF TAB 20-8.19 2 $0 NM, PA MATULANE CAP 50MG 2 $0 LA mitoxantrone hcl inj conc 20 1 $0 B/D, NM mg/10ml (2 mg/ml) mitoxantrone hcl inj conc 25 1 $0 B/D, NM mg/12.5ml (2 mg/ml) mitoxantrone hcl inj conc 30 1 $0 B/D, NM mg/15ml (2 mg/ml) ODOMZO CAP 200MG 2 $0 NM, LA, PA 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 200MCG 2 $0 NM, PA SYLATRON KIT 300MCG 2 $0 NM, PA SYLATRON KIT 600MCG 2 $0 NM, PA SYNRIBO INJ 3.5MG 2 $0 NM, PA TARGRETIN CAP 75MG 2 $0 NM, PA tretinoin cap 10 mg 2 $0 TRISENOX SOL 10MG/10M 2 $0 B/D 鉑類藥物 carboplatin iv soln 50 mg/5ml 1 $0 B/D carboplatin iv soln 150 mg/15ml 1 $0 B/D carboplatin iv soln 450 mg/45ml 1 $0 B/D carboplatin iv soln 600 mg/60ml 1 $0 B/D cisplatin inj 50 mg/50ml (1 mg/ml) 1 $0 B/D cisplatin inj 100 mg/100ml (1 1 $0 B/D mg/ml) cisplatin inj 200 mg/200ml (1 1 $0 B/D mg/ml) oxaliplatin for iv inj 50 mg 2 $0 B/D oxaliplatin for iv inj 100 mg 2 $0 B/D oxaliplatin iv soln 50 mg/10ml 2 $0 B/D oxaliplatin iv soln 100 mg/20ml 2 $0 B/D 保護劑 amifostine crystalline for inj 500 mg 2 $0 B/D 27

dexrazoxane for inj 250 mg 2 $0 B/D ELITEK INJ 1.5MG 2 $0 B/D ELITEK INJ 7.5MG 2 $0 B/D FUSILEV INJ 50MG 2 $0 B/D, NM leucovorin calcium for inj 50 mg 1 $0 B/D leucovorin calcium for inj 100 mg 1 $0 B/D leucovorin calcium for inj 200 mg 1 $0 B/D leucovorin calcium for inj 350 mg 1 $0 B/D leucovorin calcium tab 5 mg 1 $0 leucovorin calcium tab 10 mg 1 $0 leucovorin calcium tab 15 mg 1 $0 leucovorin calcium tab 25 mg 1 $0 leucovorin inj calcium 1 $0 B/D levoleucovor inj 50mg 2 $0 B/D, NM levoleucovor sol 250mg/25 2 $0 B/D, NM mesna inj 100 mg/ml 1 $0 B/D MESNEX TAB 400MG 2 $0 拓撲異構酶抑制劑 etoposide inj 500 mg/25ml (20 1 $0 B/D mg/ml) irinotecan hcl inj 40 mg/2ml (20 1 $0 B/D mg/ml) irinotecan hcl inj 100 mg/5ml (20 mg/ml) 1 $0 B/D irinotecan hcl inj 500 mg/25ml (20 1 $0 B/D mg/ml) toposar inj 1gm/50ml 1 $0 B/D topotecan hcl for inj 4 mg 2 $0 B/D 心血管藥 - 治療心臟和循環疾病的藥物 血管緊張素轉化酶複方抑制劑 - 治療高血壓的藥物 amlodipine besylate-benazepril hcl 1 $0 QL (30 caps / 30 days) cap 2.5-10 mg amlodipine besylate-benazepril hcl 1 $0 QL (30 caps / 30 days) cap 5-10 mg amlodipine besylate-benazepril hcl 1 $0 QL (30 caps / 30 days) cap 5-20 mg amlodipine besylate-benazepril hcl 1 $0 QL (30 caps / 30 days) cap 5-40 mg amlodipine besylate-benazepril hcl 1 $0 QL (30 caps / 30 days) cap 10-20 mg amlodipine besylate-benazepril hcl 1 cap 10-40 mg $0 28

藥物層級您為藥物支 付的費用 benazepril & hydrochlorothiazide 1 $0 tab 5-6.25 mg benazepril & hydrochlorothiazide 1 $0 tab 10-12.5 mg benazepril & hydrochlorothiazide 1 $0 tab 20-12.5 mg benazepril & hydrochlorothiazide 1 $0 tab 20-25 mg captopril & hydrochlorothiazide tab 1 $0 25-15 mg captopril & hydrochlorothiazide tab 1 $0 25-25 mg captopril & hydrochlorothiazide tab 1 $0 50-15 mg captopril & hydrochlorothiazide tab 1 $0 50-25 mg enalapril maleate & 1 $0 hydrochlorothiazide tab 5-12.5 mg enalapril maleate & 1 $0 hydrochlorothiazide tab 10-25 mg fosinopril sodium & 1 $0 hydrochlorothiazide tab 10-12.5 mg fosinopril sodium & 1 $0 hydrochlorothiazide tab 20-12.5 mg lisinopril & hydrochlorothiazide tab 1 $0 10-12.5 mg lisinopril & hydrochlorothiazide tab 1 $0 20-12.5 mg lisinopril & hydrochlorothiazide tab 1 $0 20-25 mg moexipril-hydrochlorothiazide tab 1 $0 7.5-12.5 mg moexipril-hydrochlorothiazide tab 1 $0 15-12.5 mg moexipril-hydrochlorothiazide tab 1 $0 15-25 mg quinapril-hydrochlorothiazide tab 1 $0 10-12.5 mg quinapril-hydrochlorothiazide tab 1 $0 20-12.5 mg quinapril-hydrochlorothiazide tab 1 $0 20-25 mg 血管緊張素轉化酶抑制劑 - 治療高血壓的藥物 benazepril hcl tab 5 mg 1 $0 benazepril hcl tab 10 mg 1 $0 benazepril hcl tab 20 mg 1 $0 29

藥物層級您為藥物支 付的費用 benazepril hcl tab 40 mg 1 $0 captopril tab 12.5 mg 1 $0 captopril tab 25 mg 1 $0 captopril tab 50 mg 1 $0 captopril tab 100 mg 1 $0 enalapril maleate tab 2.5 mg 1 $0 enalapril maleate tab 5 mg 1 $0 enalapril maleate tab 10 mg 1 $0 enalapril maleate tab 20 mg 1 $0 fosinopril sodium tab 10 mg 1 $0 fosinopril sodium tab 20 mg 1 $0 fosinopril sodium tab 40 mg 1 $0 lisinopril tab 2.5 mg 1 $0 lisinopril tab 5 mg 1 $0 lisinopril tab 10 mg 1 $0 lisinopril tab 20 mg 1 $0 lisinopril tab 30 mg 1 $0 lisinopril tab 40 mg 1 $0 moexipril hcl tab 7.5 mg 1 $0 moexipril hcl tab 15 mg 1 $0 perindopril erbumine tab 2 mg 1 $0 perindopril erbumine tab 4 mg 1 $0 perindopril erbumine tab 8 mg 1 $0 quinapril hcl tab 5 mg 1 $0 quinapril hcl tab 10 mg 1 $0 quinapril hcl tab 20 mg 1 $0 quinapril hcl tab 40 mg 1 $0 ramipril cap 1.25 mg 1 $0 ramipril cap 2.5 mg 1 $0 ramipril cap 5 mg 1 $0 ramipril cap 10 mg 1 $0 trandolapril tab 1 mg 1 $0 trandolapril tab 2 mg 1 $0 trandolapril tab 4 mg 1 $0 醛固酮受體拮抗劑 - 治療高血壓的藥物 eplerenone tab 25 mg 1 $0 eplerenone tab 50 mg 1 $0 spironolactone tab 25 mg 1 $0 spironolactone tab 50 mg 1 $0 spironolactone tab 100 mg 1 $0 α 受體阻滯劑 - 治療高血壓的藥物 30

doxazosin mesylate tab 1 mg 1 $0 QL (30 tabs / 30 days) doxazosin mesylate tab 2 mg 1 $0 QL (30 tabs / 30 days) doxazosin mesylate tab 4 mg 1 $0 QL (30 tabs / 30 days) doxazosin mesylate tab 8 mg 1 $0 prazosin hcl cap 1 mg 1 $0 prazosin hcl cap 2 mg 1 $0 prazosin hcl cap 5 mg 1 $0 terazosin hcl cap 1 mg 1 $0 terazosin hcl cap 2 mg 1 $0 terazosin hcl cap 5 mg 1 $0 terazosin hcl cap 10 mg 1 $0 血管緊張素 Ⅱ 受體複方拮抗劑 - 治療高血壓的藥物 amlodipine besylate-valsartan tab 1 $0 QL (30 tabs / 30 days) 5-160 mg amlodipine besylate-valsartan tab 1 $0 QL (30 tabs / 30 days) 5-320 mg amlodipine besylate-valsartan tab 1 $0 QL (30 tabs / 30 days) 10-160 mg amlodipine besylate-valsartan tab 1 $0 10-320 mg amlodipine-valsartan-hydrochlorot 1 $0 QL (30 tabs / 30 days) hiazide tab 5-160-12.5 mg amlodipine-valsartan-hydrochlorot 1 $0 QL (60 tabs / 30 days) hiazide tab 5-160-25 mg amlodipine-valsartan-hydrochlorot 1 $0 QL (30 tabs / 30 days) hiazide tab 10-160-12.5 mg amlodipine-valsartan-hydrochlorot 1 $0 QL (30 tabs / 30 days) hiazide tab 10-160-25 mg amlodipine-valsartan-hydrochlorot 1 $0 hiazide tab 10-320-25 mg 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) AZOR TAB 10-40MG 2 $0 BENICAR HCT TAB 20-12.5 2 $0 BENICAR HCT TAB 40-12.5 2 $0 BENICAR HCT TAB 40-25MG 2 $0 ENTRESTO TAB 24-26MG 2 $0 PA ENTRESTO TAB 49-51MG 2 $0 PA ENTRESTO TAB 97-103MG 2 $0 PA irbesartan-hydrochlorothiazide tab 1 $0 150-12.5 mg irbesartan-hydrochlorothiazide tab 1 $0 300-12.5 mg 31

losartan potassium & 1 $0 hydrochlorothiazide tab 50-12.5 mg losartan potassium & 1 $0 hydrochlorothiazide tab 100-12.5 mg losartan potassium & 1 $0 hydrochlorothiazide tab 100-25 mg TRIBENZOR20- TAB 5-12.5MG 2 $0 QL (30 tabs / 30 days) TRIBENZOR40- TAB 5-12.5MG 2 $0 QL (30 tabs / 30 days) TRIBENZOR40- TAB 5-25MG 2 $0 QL (30 tabs / 30 days) TRIBENZOR40- TAB 10-12.5 2 $0 QL (30 tabs / 30 days) TRIBENZOR40- TAB 10-25MG 2 $0 valsartan-hydrochlorothiazide tab 1 $0 80-12.5 mg valsartan-hydrochlorothiazide tab 1 $0 160-12.5 mg valsartan-hydrochlorothiazide tab 1 $0 160-25 mg valsartan-hydrochlorothiazide tab 1 $0 320-12.5 mg valsartan-hydrochlorothiazide tab 320-25 mg 1 $0 血管緊張素 Ⅱ 受體拮抗劑 - 治療高血壓的藥物 BENICAR TAB 5MG 2 $0 BENICAR TAB 20MG 2 $0 BENICAR TAB 40MG 2 $0 irbesartan tab 75 mg 1 $0 irbesartan tab 150 mg 1 $0 irbesartan tab 300 mg 1 $0 losartan potassium tab 25 mg 1 $0 losartan potassium tab 50 mg 1 $0 losartan potassium tab 100 mg 1 $0 valsartan tab 40 mg 1 $0 valsartan tab 80 mg 1 $0 valsartan tab 160 mg 1 $0 valsartan tab 320 mg 1 $0 抗心律不齊藥 - 控制心律不齊的藥物 amiodarone hcl inj 150 mg/3ml (501 $0 mg/ml) amiodarone hcl inj 450 mg/9ml (501 $0 mg/ml) amiodarone hcl inj 900 mg/18ml 1 $0 (50 mg/ml) amiodarone hcl tab 100 mg 1 $0 32

amiodarone hcl tab 200 mg 1 $0 amiodarone hcl tab 400 mg 1 $0 disopyramide phosphate cap 100 mg 2 $0 PA; PA if 65 years and disopyramide phosphate cap 150 mg 2 $0 PA; PA if 65 years and flecainide acetate tab 50 mg 1 $0 flecainide acetate tab 100 mg 1 $0 flecainide acetate tab 150 mg 1 $0 mexiletine hcl cap 150 mg 1 $0 mexiletine hcl cap 200 mg 1 $0 mexiletine hcl cap 250 mg 1 $0 MULTAQ TAB 400MG 2 $0 NORPACE CAP 100MG CR 2 $0 PA; PA if 65 years and NORPACE CAP 150MG CR 2 $0 PA; PA if 65 years and pacerone tab 100mg 1 $0 pacerone tab 200mg 1 $0 pacerone tab 400mg 1 $0 propafenone hcl cap sr 12hr 225 mg 1 $0 propafenone hcl cap sr 12hr 325 mg 1 $0 propafenone hcl cap sr 12hr 425 mg 1 $0 propafenone hcl tab 150 mg 1 $0 propafenone hcl tab 225 mg 1 $0 propafenone hcl tab 300 mg 1 $0 quinidine gluconate tab cr 324 mg 1 $0 quinidine sulfate tab 200 mg 1 $0 quinidine sulfate tab 300 mg 1 $0 sorine tab 80mg 1 $0 sorine tab 120mg 1 $0 sorine tab 160mg 1 $0 sorine tab 240mg 1 $0 sotalol hcl (afib/afl) tab 80 mg 1 $0 sotalol hcl (afib/afl) tab 120 mg 1 $0 sotalol hcl (afib/afl) tab 160 mg 1 $0 sotalol hcl tab 80 mg 1 $0 sotalol hcl tab 120 mg 1 $0 sotalol hcl tab 160 mg 1 $0 sotalol hcl tab 240 mg 1 $0 TIKOSYN CAP 125MCG 2 $0 NM TIKOSYN CAP 250MCG 2 $0 NM 33

TIKOSYN CAP 500MCG 2 $0 NM 抗血脂藥,HMG-CoA 還原酶抑制劑 - 治療高膽固醇的藥物 atorvastatin calcium tab 10 mg 1 $0 QL (30 tabs / 30 days) (base equivalent) atorvastatin calcium tab 20 mg 1 $0 QL (30 tabs / 30 days) (base equivalent) atorvastatin calcium tab 40 mg 1 $0 QL (30 tabs / 30 days) (base equivalent) atorvastatin calcium tab 80 mg 1 $0 QL (30 tabs / 30 days) (base equivalent) CRESTOR TAB 5MG 2 $0 QL (30 tabs / 30 days) CRESTOR TAB 10MG 2 $0 QL (30 tabs / 30 days) CRESTOR TAB 20MG 2 $0 QL (30 tabs / 30 days) CRESTOR TAB 40MG 2 $0 QL (30 tabs / 30 days) lovastatin tab 10 mg 1 $0 QL (30 tabs / 30 days) lovastatin tab 20 mg 1 $0 QL (120 tabs / 30 days) lovastatin tab 40 mg 1 $0 QL (60 tabs / 30 days) pravastatin sodium tab 10 mg 1 $0 QL (30 tabs / 30 days) pravastatin sodium tab 20 mg 1 $0 QL (30 tabs / 30 days) pravastatin sodium tab 40 mg 1 $0 QL (30 tabs / 30 days) pravastatin sodium tab 80 mg 1 $0 QL (30 tabs / 30 days) simvastatin tab 5 mg 1 $0 QL (30 tabs / 30 days) simvastatin tab 10 mg 1 $0 QL (30 tabs / 30 days) simvastatin tab 20 mg 1 $0 QL (30 tabs / 30 days) simvastatin tab 40 mg 1 $0 QL (30 tabs / 30 days) simvastatin tab 80 mg 1 $0 QL (30 tabs / 30 days) 抗血脂藥, 雜類 - 治療高膽固醇的藥物 cholestyramine light powder packets 4 gm 1 $0 cholestyramine powder 4 gm/dose 1 $0 cholestyramine powder packets 4 1 $0 gm choline fenofibrate cap dr 45 mg 1 $0 (fenofibric acid equiv) choline fenofibrate cap dr 135 mg (fenofibric acid equiv) 1 $0 colestipol hcl granule packets 5 gm 1 $0 colestipol hcl granules 5 gm 1 $0 colestipol hcl tab 1 gm 1 $0 fenofibrate micronized cap 67 mg 1 $0 fenofibrate micronized cap 134 mg 1 $0 fenofibrate micronized cap 200 mg 1 $0 fenofibrate tab 48 mg 1 $0 34

fenofibrate tab 54 mg 1 $0 fenofibrate tab 145 mg 1 $0 fenofibrate tab 160 mg 1 $0 gemfibrozil tab 600 mg 1 $0 JUXTAPID CAP 5MG 2 $0 NM, LA, PA JUXTAPID CAP 10MG 2 $0 NM, LA, PA JUXTAPID CAP 20MG 2 $0 NM, LA, PA JUXTAPID CAP 30MG 2 $0 NM, LA, PA JUXTAPID CAP 40MG 2 $0 NM, LA, PA JUXTAPID CAP 60MG 2 $0 NM, LA, PA KYNAMRO INJ 200MG/ML 2 $0 NM, PA niacin tab cr 500 mg 1 $0 QL (90 tabs / 30 days) (antihyperlipidemic) niacin tab cr 750 mg 1 $0 (antihyperlipidemic) niacin tab cr 1000 mg 1 $0 (antihyperlipidemic) niacor tab 500mg 1 $0 omega-3-acid ethyl esters cap 1 gm 1 $0 prevalite pow 4gm 1 $0 prevalite pow 4gm pk 1 $0 VASCEPA CAP 1GM 2 $0 WELCHOL PAK 3.75GM 2 $0 WELCHOL TAB 625MG 2 $0 ZETIA TAB 10MG 2 $0 β- 受體阻滯劑 / 利尿複方製劑 - 治療高血壓和心臟疾病的藥物 atenolol & chlorthalidone tab 50-25 1 $0 mg atenolol & chlorthalidone tab 100-25 mg 1 $0 bisoprolol & hydrochlorothiazide tab 1 $0 2.5-6.25 mg bisoprolol & hydrochlorothiazide tab 1 $0 5-6.25 mg bisoprolol & hydrochlorothiazide tab 1 $0 10-6.25 mg metoprolol & hydrochlorothiazide 1 $0 tab 50-25 mg metoprolol & hydrochlorothiazide 1 $0 tab 100-25 mg metoprolol & hydrochlorothiazide 1 $0 tab 100-50 mg propranolol & hydrochlorothiazide tab 40-25 mg 1 $0 35

藥物層級您為藥物支 付的費用 propranolol & hydrochlorothiazide 1 $0 tab 80-25 mg β- 受體阻滯劑 - 治療高血壓和心臟疾病的藥物 acebutolol hcl cap 200 mg 1 $0 acebutolol hcl cap 400 mg 1 $0 atenolol tab 25 mg 1 $0 atenolol tab 50 mg 1 $0 atenolol tab 100 mg 1 $0 bisoprolol fumarate tab 5 mg 1 $0 bisoprolol fumarate tab 10 mg 1 $0 BYSTOLIC TAB 2.5MG 2 $0 BYSTOLIC TAB 5MG 2 $0 BYSTOLIC TAB 10MG 2 $0 BYSTOLIC TAB 20MG 2 $0 carvedilol tab 3.125 mg 1 $0 carvedilol tab 6.25 mg 1 $0 carvedilol tab 12.5 mg 1 $0 carvedilol tab 25 mg 1 $0 labetalol hcl tab 100 mg 1 $0 labetalol hcl tab 200 mg 1 $0 labetalol hcl tab 300 mg 1 $0 metoprolol succinate tab sr 24hr 251 $0 QL (60 tabs / 30 days) mg metoprolol succinate tab sr 24hr 501 $0 QL (60 tabs / 30 days) mg metoprolol succinate tab sr 24hr 1 $0 QL (45 tabs / 30 days) 100 mg metoprolol succinate tab sr 24hr 1 $0 200 mg metoprolol tartrate inj 1 mg/ml 1 $0 metoprolol tartrate tab 25 mg 1 $0 metoprolol tartrate tab 50 mg 1 $0 metoprolol tartrate tab 100 mg 1 $0 nadolol tab 20 mg 1 $0 nadolol tab 40 mg 1 $0 nadolol tab 80 mg 1 $0 pindolol tab 5 mg 1 $0 pindolol tab 10 mg 1 $0 propranolol hcl cap sr 24hr 60 mg 1 $0 propranolol hcl cap sr 24hr 80 mg 1 $0 propranolol hcl cap sr 24hr 120 mg 1 $0 propranolol hcl cap sr 24hr 160 mg 1 $0 36

藥物層級您為藥物支 付的費用 propranolol hcl inj 1 mg/ml 1 $0 propranolol hcl oral soln 20 mg/5ml 1 $0 propranolol hcl oral soln 40 mg/5ml 1 $0 propranolol hcl tab 10 mg 1 $0 propranolol hcl tab 20 mg 1 $0 propranolol hcl tab 40 mg 1 $0 propranolol hcl tab 60 mg 1 $0 propranolol hcl tab 80 mg 1 $0 timolol maleate tab 5 mg 1 $0 timolol maleate tab 10 mg 1 $0 timolol maleate tab 20 mg 1 $0 鈣通道阻滯劑 - 治療高血壓和心臟疾病的藥物 afeditab tab 30mg cr 1 $0 QL (60 tabs / 30 days) afeditab tab 60mg cr 1 $0 amlodipine besylate tab 2.5 mg 1 $0 QL (45 tabs / 30 days) amlodipine besylate tab 5 mg 1 $0 QL (45 tabs / 30 days) amlodipine besylate tab 10 mg 1 $0 diltiazem hcl cap sr 12hr 60 mg 1 $0 diltiazem hcl cap sr 12hr 90 mg 1 $0 diltiazem hcl cap sr 12hr 120 mg 1 $0 diltiazem hcl cap sr 24hr 120 mg 1 $0 diltiazem hcl cap sr 24hr 180 mg 1 $0 diltiazem hcl cap sr 24hr 240 mg 1 $0 diltiazem hcl coated beads cap sr 1 $0 24hr 120 mg diltiazem hcl coated beads cap sr 1 $0 24hr 180 mg diltiazem hcl coated beads cap sr 1 $0 24hr 240 mg diltiazem hcl coated beads cap sr 1 $0 24hr 300 mg diltiazem hcl coated beads cap sr 1 $0 24hr 360 mg diltiazem hcl extended release 1 $0 beads cap sr 24hr 120 mg diltiazem hcl extended release 1 $0 beads cap sr 24hr 180 mg diltiazem hcl extended release 1 $0 beads cap sr 24hr 240 mg diltiazem hcl extended release 1 $0 beads cap sr 24hr 300 mg diltiazem hcl extended release beads cap sr 24hr 360 mg 1 $0 37

diltiazem hcl extended release beads cap sr 24hr 420 mg 1 $0 diltiazem hcl iv soln 25 mg/5ml (5 1 $0 mg/ml) diltiazem hcl iv soln 50 mg/10ml (51 $0 mg/ml) diltiazem hcl iv soln 125 mg/25ml (51 $0 mg/ml) diltiazem hcl tab 30 mg 1 $0 diltiazem hcl tab 60 mg 1 $0 diltiazem hcl tab 90 mg 1 $0 diltiazem hcl tab 120 mg 1 $0 felodipine tab sr 24hr 2.5 mg 1 $0 QL (30 tabs / 30 days) felodipine tab sr 24hr 5 mg 1 $0 QL (60 tabs / 30 days) felodipine tab sr 24hr 10 mg 1 $0 isradipine cap 2.5 mg 1 $0 isradipine cap 5 mg 1 $0 nicardipine hcl cap 20 mg 1 $0 nicardipine hcl cap 30 mg 1 $0 nifedical xl tab 30mg 1 $0 QL (30 tabs / 30 days) nifedical xl tab 60mg 1 $0 nifedipine tab sr 24hr 30 mg 1 $0 QL (60 tabs / 30 days) nifedipine tab sr 24hr 60 mg 1 $0 nifedipine tab sr 24hr 90 mg 1 $0 nifedipine tab sr 24hr osmotic 1 $0 QL (30 tabs / 30 days) release 30 mg nifedipine tab sr 24hr osmotic 1 $0 release 60 mg nifedipine tab sr 24hr osmotic 1 $0 release 90 mg nimodipine cap 30 mg 2 $0 NYMALIZE SOL 60/20ML 2 $0 taztia xt cap 120mg/24 1 $0 taztia xt cap 180mg/24 1 $0 taztia xt cap 240mg/24 1 $0 taztia xt cap 300mg/24 1 $0 taztia xt cap 360mg/24 1 $0 verapamil hcl cap sr 24hr 100 mg 1 $0 verapamil hcl cap sr 24hr 120 mg 1 $0 verapamil hcl cap sr 24hr 180 mg 1 $0 verapamil hcl cap sr 24hr 200 mg 1 $0 verapamil hcl cap sr 24hr 240 mg 1 $0 verapamil hcl cap sr 24hr 300 mg 1 $0 38

藥物層級您為藥物支 付的費用 VERAPAMIL HCL CAP SR 24HR 360 1 $0 MG verapamil hcl iv soln 2.5 mg/ml 1 $0 verapamil hcl tab 40 mg 1 $0 verapamil hcl tab 80 mg 1 $0 verapamil hcl tab 120 mg 1 $0 verapamil hcl tab cr 120 mg 1 $0 verapamil hcl tab cr 180 mg 1 $0 verapamil hcl tab cr 240 mg 1 $0 毛地黃糖苷 - 治療心臟疾病的藥物 digitek tab 0.25mg 1 $0 PA; PA if 65 years and digitek tab 0.125mg 1 $0 QL (30 tabs / 30 days) digoxin inj 0.25 mg/ml 1 $0 DIGOXIN ORAL SOLN 0.05 MG/ML 1 $0 PA; PA if 65 years and digoxin tab 125 mcg (0.125 mg) 1 $0 QL (30 tabs / 30 days) digoxin tab 250 mcg (0.25 mg) 1 $0 PA; PA if 65 years and 直接腎素抑制劑 / 複方製劑 - 治療心臟疾病的藥物 TEKTURNA HCT TAB 150-12.5 2 $0 QL (30 tabs / 30 days) TEKTURNA HCT TAB 150-25MG 2 $0 QL (60 tabs / 30 days) TEKTURNA HCT TAB 300-12.5 2 $0 QL (30 tabs / 30 days) TEKTURNA HCT TAB 300-25MG 2 $0 TEKTURNA TAB 150MG 2 $0 QL (30 tabs / 30 days) TEKTURNA TAB 300MG 2 $0 利尿劑 - 治療心臟疾病的藥物 acetazolamide cap sr 12hr 500 mg 1 $0 acetazolamide tab 125 mg 1 $0 acetazolamide tab 250 mg 1 $0 amiloride & hydrochlorothiazide tab 1 $0 5-50 mg amiloride hcl tab 5 mg 1 $0 bumetanide inj 0.25 mg/ml 1 $0 bumetanide tab 0.5 mg 1 $0 bumetanide tab 1 mg 1 $0 bumetanide tab 2 mg 1 $0 chlorothiazide tab 250 mg 1 $0 chlorothiazide tab 500 mg 1 $0 chlorthalidone tab 25 mg 1 $0 chlorthalidone tab 50 mg 1 $0 furosemide inj 10 mg/ml 1 $0 39