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Santa Clara County, CA 2016 處方藥物清單 ( 藥物清單 ) Anthem Blue Cross Cal MediConnect Plan (Medicare-Medicaid Plan) 請查閱 : 包含本計劃所給付藥物的相關資訊, 請仔細閱讀 本處方藥物清單更新日期.. 07/28/2017 存在疑問嗎? 請撥打免費電話 1-855-817-5785 (TTY 711) 太平洋時間週一至週五上午 8 點至下午 8 點 或瀏覽網站 mss.anthem.com/cammp mss.anthem.com/cammp H6229_16_24684_T_007_CT CMS Approved 09/01/2015 處方藥物 : 16262 版本 : 13 發佈時間 08/01/2016

H6229_16_24684_T_007_CT CMS Approved 09/01/2015 Anthem Blue Cross Cal MediConnect Plan (Medicare-Medicaid Plan) 2016 給付藥物清單 ( 處方藥物清單 ) 這是會員可於 Anthem Blue Cross Cal MediConnect Plan (Medicare-Medicaid Plan) 取得的藥物清單 Anthem Blue Cross Cal MediConnect Plan 是一個同時與 Medicare 和 Medi-Cal 訂立合約的醫療保健計畫, 從而為參保人提供這兩個方案的福利 給付藥物清單和 / 或網路內藥房及醫療服務提供者在全年內可能發生變更 在我們執行影響您的變更前, 我們會向您寄送通知 福利和 / 或共付費用可能於每年 1 月 1 日進行變動 您可以隨時瀏覽網站 mss.anthem.com/cammp, 線上查看 Anthem Blue Cross Cal MediConnect Plan 的最新 給付藥物清單, 或致電 1-855-817-5785 (TTY 711) 您可以免費獲得其他格式的資料, 如大型字體版本或音訊版本 請撥打電話 1-855-817-5785 (TTY 711) 此為免付費電話 限額 共付費用和限制可能適用 有關更多資訊, 請致電 Anthem Blue Cross Cal MediConnect Plan 會員服務部, 或查閱 Anthem Blue Cross Cal MediConnect Plan 會員手冊 處方藥物的共付費用可能會根據您所領取的 Extra Help( 額外補助 ) 的等級而變動 請與計劃聯絡以了解詳情 You can get this information for free in other languages. Call 1-855-817-5785 (TTY 711). The call is free. Puede recibir esta información sin cargo en otros idiomas. Llame al 1-855-817-5785 (TTY 711). La llamada es gratuita. 您可免費獲得本資訊的其他語言版本 請致電免費電話 1-855-817-5785 (TTY 711) Quý vị có thể nhận thông tin này miễn phí bằng các ngôn ngữ khác. Hãy gọi 1-855-817-5785 (TTY 711). Cuộc gọi này được miễn phí. Maaari ninyong makuha nang libre ang impormasyon na ito sa ibang mga wika. Tawagan ang 1-855-817-5785 (TTY 711). Libre ang tawag. Anthem Blue Cross 是 Blue Cross of California 的商標名稱,Anthem Blue Cross Partnership Plan 是 Blue Cross of California Partnership Plan, Inc. 的商標名稱, 該公司屬 Blue Cross Association 的獨立持照組織 ANTHEM 是 Anthem Insurance Companies, Inc. 的註冊商標 Blue Cross 名稱和標誌均為 Blue Cross Association 的註冊商標? 如果您有任何疑問, 請於太平洋時間週一至週五上午 8 點至下午 8 點撥打電話 1-855-817-5785 (TTY 711), 聯絡 Anthem Blue Cross Cal MediConnect Plan 此為免付費電話 如需了解更多資訊, 請瀏覽網站 mss.anthem.com/cammp 1

常見問題 (FAQ) H6229_16_24684_T_007_CT CMS Approved 09/01/2015 如果您對本 給付藥物清單 有疑問, 您可以在此尋找解答 您可閱讀所有常見問題 (Frequently Asked Questions, FAQ) 以了解更多資訊, 或僅查詢某問題的解答 1. 給付藥物清單 中有哪些處方藥物?( 我們將 給付藥物清單 簡稱為 藥物清單 ) 藥物清單 中列出了 Anthem Blue Cross Cal MediConnect Plan 給付的藥物 您可在本計劃網路內的藥房取得這些藥物 本計劃網路內的藥房是與本計劃簽訂協議, 並與本計劃合作為您提供服務的藥房 我們稱這些藥房為 網路內藥房 Anthem Blue Cross Cal MediConnect Plan 在以下情況下給付 藥物清單 上的所有具有醫療必要性的藥物 : 您的醫師或其他處方醫師表示您需要這些藥物使病情好轉或保持健康, 以及 您可以到 Anthem Blue Cross Cal MediConnect Plan 網路內藥房領取藥物 在某些情況下, 您必須在領取藥物之前採取一些行動 ( 請參閱後面的問題 5) 您也可以瀏覽我們的網站 mss.anthem.com/cammp 或撥打會員服務部電話 1-855-817-5785 (TTY 711), 查看我們給付的最新藥物清單 2. 藥物清單 的內容會變更嗎? 是 Anthem Blue Cross Cal MediConnect Plan 可能會在年度內增加或刪除 藥物清單 上的某些藥物 一般而言, 藥物清單 的內容僅有在下列情況下才會變更 : 價格較低且功效與現在 藥物清單 中之藥物相當的藥物出現, 或 我們得知該藥物不安全 我們也可能會變更本計劃的藥物相關規定 例如, 我們可以 : 決定某藥物是否需要事先批准 ( 事先批准是在取得藥物前獲得 Anthem Blue Cross Cal MediConnect Plan 的許可 ) 增加或變更您可領取的藥量 ( 稱為 供藥量限制 ) 新增或變更某藥物的漸進式治療限制 ( 漸進式治療表示您必須先使用某種藥物, 然後我們才給付另外一種藥物 ) ( 如需了解關於這些藥物規定的更多資訊, 請參閱第 3 頁上的內容 ) 當我們將您正在服用的藥物自 藥物清單 中移除時, 我們將會告知您 當我們變更本計劃的藥物給付規定時, 我們亦會告知您 以下的問題 3 4 和 7 將會提供更多有關 藥物清單 變更事宜的資訊 您可以隨時瀏覽網站 mss.anthem.com/cammp, 線上查看 Anthem Blue Cross Cal MediConnect Plan 的最新 藥物清單 您還可以撥打會員服務部電話 1-855-817-5785 (TTY 711), 查看目前 藥物清單? 如果您有任何疑問, 請於太平洋時間週一至週五上午 8 點至下午 8 點撥打電話 1-855-817-5785 (TTY 711), 聯絡 Anthem Blue Cross Cal MediConnect Plan 此為免付費電話 如需了解更多資訊, 請瀏覽網站 mss.anthem.com/cammp 2

3. 當有價格較低且功效與現在 藥物清單 中之藥物相當的藥物出現時將會如何? 如您正在服用的藥物因出現價格較低且功效相當的藥物而被移除, 我們會告知您 我們會在將其從 藥物清單 中移除或重新領取藥物之前至少 60 天告知您 那麼您能在藥物被從藥物清單移除前獲得 60 天的供藥量 如果在年度內對藥物清單做出非例行變更, 我們將寄信告知您 我們將在網站上刊登通知信 4. 如果我們發現某項藥物並不安全將會如何? 如果 Food and Drug Administration (FDA) 表示您正在服用的藥物並不安全, 我們會立刻將該藥物自 藥物清單 中移除 我們亦會寄信給您告知您此事宜 如果您收到關於不安全藥物的通知, 請立即致電您的醫師 您的醫師可以幫助您尋找出最適合您的其他藥物 5. 藥物的給付範圍是否有任何限制或上限? 或者在領取某些藥物之前是否有任何必須採取的行動? 是, 部分藥物有給付規定或您可領取的藥量限制 在某些情況下, 您的醫師或其他處方醫師必須採取一些行動, 您才能領取藥物 例如 : 事先批准 ( 或事先授權 ): 某些藥物在領取處方藥之前, 您或您的醫師或者其他處方醫師必須取得 Anthem Blue Cross Cal MediConnect Plan 的批准 如果您未得到核准,Anthem Blue Cross Cal MediConnect Plan 可能不給付藥物 供藥量限制 : 有時候,Anthem Blue Cross Cal MediConnect Plan 設定了您可以領取的藥物限制 漸進式治療 : 有時候,Anthem Blue Cross Cal MediConnect Plan 會要求您接受漸進式治療 這表示您必須按一定的順序嘗試使用適用於您病況的藥物 您可能必須先試用某種藥物, 而後我們才會給付其他藥物 如果您的醫師認為第一種藥物對您沒有療效, 那麼我們將會給付第二種藥物 您可以查看第 8-123 頁上的表格, 查詢所需藥物是否有任何額外要求或限制 您也可以瀏覽我們的網站 mss.anthem.com/cammp 了解更多資訊 我們已在網站上發佈文件, 解釋我們的事先授權和漸進式治療限制 您亦可要求我們寄送一份副本給您 您可以要求對這些限制做出例外處理 請參閱問題 11 以了解更多有關例外處理的資訊 如果您住在療養院或其他長期照護機構且您需要不在 藥物清單 中的藥物, 或者您無法輕易取得您所需的藥物, 我們可協助您 不管您是否是 Anthem Blue Cross Cal MediConnect Plan 新會員, 我們將給付您所需要藥物的 31 天緊急供藥量 ( 除非您的處方規定更少天數的供藥量 ) 這將讓您有時間可以和您的醫師或其他處方開立者商量 其可協助您決定 藥物清單 中是否有類似的藥物可以取代您服用的藥物, 或者協助您決定是否應該申請例外處理 請參閱問題 11 以了解更多有關例外處理的資訊? 如果您有任何疑問, 請於太平洋時間週一至週五上午 8 點至下午 8 點撥打電話 1-855-817-5785 (TTY 711), 聯絡 Anthem Blue Cross Cal MediConnect Plan 此為免付費電話 如需了解更多資訊, 請瀏覽網站 mss.anthem.com/cammp 3

6. 您該如何知道您需要的藥物是否有限制或您是否需要在領取藥物之前採取任何行動? 第 7 頁的 給付藥物清單 中有一欄標為 必須採取的行動 限制, 或使用限制 7. 如果我們變更本計劃部分藥物的給付方式將會如何?( 例如, 我們新增了某項藥物的事先授權 ( 批准 ) 供藥量限制和 / 或漸進式治療限制 ) 如果我們新增了某項藥物的事先批准 供藥量限制和 / 或漸進式治療限制, 我們將會告知您 我們將會在新增限制前的至少 60 天內或在您下次要求藥房續配處方時告知您 而後, 您將可在給付規定變更之前獲得該藥物 60 天的供藥量 這將讓您有時間和您的醫師或其他處方開立者商量下一步該怎麼做 8. 您該如何在 藥物清單 中尋找藥物? 尋找藥物的方式有兩種 : 您可按字母順序搜尋 ( 如您知道藥物如何拼寫 ), 或 您可按醫療的病症搜尋 如按字母順序搜尋, 請前往按字母順序的名單部分 您可以使用藥物名稱的首字母查找 如按醫療病症搜尋, 請找到第 7 頁的 按醫療病症分類的藥物清單 部分內容 本部分中的藥物根據用於治療疾病的類型, 被分類到不同的類別 例如, 如果您患有心臟病, 您應該查看類別 心血管 高血壓 / 血脂藥治療物 您將可在該類別中找到治療心臟病症的藥物 9. 如果您欲服用的藥物不在 藥物清單 中該怎麼辦? 如果您在 藥物清單 上找不到您的藥物, 請撥打電話 1-855-817-5785 (TTY 711) 諮詢會員服務部 如果您發現到 Anthem Blue Cross Cal MediConnect Plan 不給付該藥物, 您可以執行以下操作之一 : 向會員服務部索取與您欲服用之藥物的類似藥物清單 然後將該清單交給您的醫師或其他處方開立者 其可開立 藥物清單 中與您欲服用之藥物類似的藥物 ; 或 您可要求保健計劃進行例外處理以給付您的藥物 請參閱問題 11 以了解更多有關例外處理的資訊 10. 如果您是 Anthem Blue Cross Cal MediConnect Plan 新會員, 而且在 藥物清單 上找不到您的藥物或在取得藥物方面存在問題, 您該怎麼辦? 我們會為您提供協助 我們在您成為 Anthem Blue Cross Cal MediConnect Plan 會員後前 90 天給付暫時性的 31 天供藥量 這將讓您有時間可以和您的醫師或其他處方開立者商量 其可協助您決定 藥物清單 中是否有類似的藥物可以取代您服用的藥物, 或者協助您決定是否應該申請例外處理? 如果您有任何疑問, 請於太平洋時間週一至週五上午 8 點至下午 8 點撥打電話 1-855-817-5785 (TTY 711), 聯絡 Anthem Blue Cross Cal MediConnect Plan 此為免付費電話 如需了解更多資訊, 請瀏覽網站 mss.anthem.com/cammp 4

我們在以下情況下為您給付 31 天的供藥量 : 您正在服用的藥物不在我們的 藥物清單 中, 或 保健計劃規定不允許您領取處方醫師指定的藥量, 或 該藥物需要 Anthem Blue Cross Cal MediConnect Plan 事先批准, 或 您正在服用的藥物是屬於漸進式治療限制中的藥物 如果您居住在療養院或其他長期照護機構, 您可以重新領取長達 91 至 98 天的處方藥物 在本計劃的前 90 天中, 您可以多次重新領取藥物 這將能夠讓您的處方醫師有時間將您的藥物變更為 藥物清單 上的藥物或者申請例外處理 如果您的照護級別發生變更, 需要您轉移機構或者治療中心, 您可能有資格領取一次性臨時處方藥物供應 例如, 如果您從醫院出院並且根據醫院處方獲得出院藥物清單, 您可以一次性領取藥物 您可以臨時一次性例外領取藥物, 不管您是否處於加入計劃的前 90 天 請讓您的處方醫師致電我們了解詳情 11. 您可以申請例外處理以使您的藥物獲得給付嗎? 是 您可以要求 Anthem Blue Cross Cal MediConnect Plan 例外給付不在 藥物清單 上的藥物 您也可要求本計劃變更您藥物的相關規定 例如,Anthem Blue Cross Cal MediConnect Plan 可能會限制我們給付藥物的藥量 假如您的藥物具有藥量限制, 您可以要求我們更改限制並給付更多的數量 其他範例 : 您可要求本計劃取消漸進式治療限制或事先批准規定 12. 例外處理申請需要多久時間? 首先, 我們必須收到支持您例外處理申請的醫師或其他處方醫師的聲明 在我們收到聲明後, 我們將會在 72 小時內告知您我們針對您例外處理申請所做的決定 如果您或您的處方開立者認為等待 72 小時將會使您的健康受損, 您可申請加速例外處理 這表示您將可更快的得到決定 如果您的處方開立者有為您的加速申請提供佐證, 我們將會在收到您處方開立者所提供之支持聲明後的 24 小時內告知您我們的決定 13. 您該如何提出例外處理申請? 如需提出例外處理申請, 請致電會員服務部 會員服務部將與您及您的醫療服務提供者合作, 幫助您申請例外處理 14. 什麼是一般藥物? 一般藥物的構成成份與原廠藥物一樣 一般藥物的價格通常比原廠藥物低, 且一般藥物的名稱通常較不廣為人知 一般藥物是經 Food and Drug Administration (FDA) 批准的藥物? 如果您有任何疑問, 請於太平洋時間週一至週五上午 8 點至下午 8 點撥打電話 1-855-817-5785 (TTY 711), 聯絡 Anthem Blue Cross Cal MediConnect Plan 此為免付費電話 如需了解更多資訊, 請瀏覽網站 mss.anthem.com/cammp 5

Anthem Blue Cross Cal MediConnect Plan 給付原廠藥物和一般藥物 15. 什麼是非處方藥物 (OTC)? OTC 全稱是 over-the-counter 當您的醫療服務提供者為您開具非處方藥物時,Anthem Blue Cross Cal MediConnect Plan 也給付這些藥物 您可以參閱 Anthem Blue Cross Cal MediConnect Plan 藥物清單, 了解所給付的 OTC 藥物 16. Anthem Blue Cross Cal MediConnect Plan 是否給付 OTC 非藥物產品? 當您的醫療服務提供者為您開具 OTC 非藥物產品時,Anthem Blue Cross Cal MediConnect Plan 也給付這些產品 您可以參閱 Anthem Blue Cross Cal MediConnect Plan 藥物清單, 了解所給付的 OTC 非藥物產品 17. 您需支付多少共付費用? 您可以參閱 Anthem Blue Cross Cal MediConnect Plan 藥物清單, 了解每種藥物的共付費用 住在療養院或其他長期照護機構的 Anthem Blue Cross Cal MediConnect Plan 會員無需支付共付費用 一些在社區中取得長期照護服務的會員也無需支付共付費用 共付費用按級別列出 同一級別的藥物群組具有相同的共付費用 第 1 級藥物為 Medicare D 部分的優先一般藥物及原廠藥物 共付費用為 $0 第 2 級藥物為 Medicare D 部分的優先與非優先一般藥物及原廠藥物 共付費用依您 Medi-Cal 資格等級不同, 將介於 $0 至 $7.40 之間 第 3 級藥物為非 D 部分的原廠藥物, 由 Medi-Cal 給付, 共付費用為 $0 第 4 級藥物為非處方 (OTC) 藥物, 由 Medi-Cal 給付 若您的醫療服務提供者提供開立處方, 其共付費用為 $0 給付藥物清單 以下給付藥物清單為您提供 Anthem Blue Cross Cal MediConnect Plan 給付的藥物資訊 假如您在清單中查尋藥物時有困難, 請翻到從第 124 頁開始的索引 表格第一欄所列的是藥物名稱 原廠藥物的名稱為大寫 ( 例如 AZOPT); 一般藥物則為小寫斜體字 ( 例如 amoxicillin) 透過 必須採取的行動 限制, 或使用限制 欄的資訊, 您將了解 Anthem Blue Cross Cal MediConnect Plan 對於給付您的藥物是否有任何規定 以下是我們使用的縮寫清單..? 如果您有任何疑問, 請於太平洋時間週一至週五上午 8 點至下午 8 點撥打電話 1-855-817-5785 (TTY 711), 聯絡 Anthem Blue Cross Cal MediConnect Plan 此為免付費電話 如需了解更多資訊, 請瀏覽網站 mss.anthem.com/cammp 6

縮寫 B/D HI LA PAR QLL ST 描述 B 部分與 D 部分決定 居家點滴 限制供應 郵購藥物 需要事先授權 供藥量限制 漸進式治療 解釋 根據實際狀況, 該處方藥物可由 Medicare B 部分或 D 部分給付 可能需要呈交藥物使用和設置的資訊, 以進行判定 我們的醫療福利給付本處方藥物 如需更多資訊, 請聯絡會員服務部, 電話 1-855-817-5785 (TTY 711) 本處方藥物僅在特定的藥房供應 如需更多資訊, 請聯絡會員服務部, 電話 1-855-817-5785 (TTY 711) 本處方藥物透過我們的郵購服務及網路內零售藥房供應 考慮郵購您的長期 ( 維持性 ) 藥物 ( 例如高血壓藥物 ) 網路內零售藥房可能更適合供應短期處方藥物 ( 例如抗生素 ) 此計劃要求您或您的醫師取得某些處方藥物的預先批准 這意味著您需要在配藥前先取得批准 如果您沒有取得批准, 我們可能不會給付此藥物 對于某些藥物, 此計劃會限制給付藥物的數量 在某些情況下, 計劃在給付另一種適用於您的病情的藥物前, 需要您先嘗試某些藥物來治療您的疾病 例如, 如果藥物 A 和 B 皆可治療您的病情, 若您沒有先嘗試使用藥物 A, 我們可能不會給付藥物 B 如果藥物 A 對您的治療無效, 我們將給付藥物 B 請注意 : 藥物旁邊的星號 (*) 表示該藥物並非 D 部分藥物 您不需要支付這些藥物的共付費用 這類藥物也有不同的上訴規定 上訴是在您認為我們有錯誤的情況下, 要求我們審查我們對您的給付福利做出之決定, 並要求我們做出變更的一種正式的方式 例如, 我們可能決定某項您欲取得的藥物不屬於或不再屬於 Medicare 或 Medi-Cal 的給付範圍 如果您或您的醫師不同意我們的決定, 您可以提出上訴 如果您有任何疑問, 請撥打會員服務部電話 1-855-817-5785 (TTY 711) 您也可參閱 會員手冊 以了解針對我們的決定提出上訴的方式? 如果您有任何疑問, 請於太平洋時間週一至週五上午 8 點至下午 8 點撥打電話 1-855-817-5785 (TTY 711), 聯絡 Anthem Blue Cross Cal MediConnect Plan 此為免付費電話 如需了解更多資訊, 請瀏覽網站 mss.anthem.com/cammp 7

按醫療病症分類的藥物清單 本部分中的藥物根據用於治療疾病的類型, 被分類到不同的類別 例如, 如果您患有心臟病, 您應該查看類別 心血管 高血壓 / 血脂藥治療藥物 您將可在該類別中找到治療心臟病症的藥物 藥物名稱 ANTI - INFECTIVES ANTIFUNGAL AGENTS ABELCET AMBISOME amphotericin b CANCIDAS clotrimazole mucous membrane ERAXIS(WATER DILUENT) fluconazole fluconazole in dextrose(iso-o) FLUCONAZOLE IN NACL (ISO-OSM) INTRAVENOUS PIGGYBACK 100 MG/50 ML fluconazole in nacl (iso-osm) intravenous piggyback 200 mg/100 ml fluconazole in nacl (iso-osm) intravenous piggyback 400 mg/200 ml flucytosine griseofulvin microsize oral suspension griseofulvin ultramicrosize itraconazole ketoconazole oral NOXAFIL ORAL SUSPENSION nystatin oral suspension nystatin oral tablet terbinafine hcl oral voriconazole intravenous voriconazole oral suspension for reconstitution voriconazole oral tablet 200 mg B/D PAR; B/D PAR; B/D PAR; B/D PAR; PAR; PAR; PAR; ; QLL (630 per 30 days) ; QLL (30 per 30 days) PAR; ; QLL (300 per 30 days) PAR; ; QLL (60 per 30 days) 有關本表格所含標誌與縮寫的含義, 可參見第 7 8

voriconazole oral tablet 50 mg ANTIVIRALS abacavir abacavir-lamivudine-zidovudine acyclovir oral capsule acyclovir oral suspension 200 mg/5 ml acyclovir oral tablet acyclovir sodium intravenous solution adefovir amantadine hcl oral capsule amantadine hcl oral tablet APTIVUS ORAL CAPSULE APTIVUS ORAL SOLUTION ATRIPLA BARACLUDE ORAL SOLUTION cidofovir COMPLERA CRIXIVAN ORAL CAPSULE 200 MG CRIXIVAN ORAL CAPSULE 400 MG DAKLINZA ORAL TABLET 30 MG, 60 MG DAKLINZA ORAL TABLET 90 MG DESCOVY didanosine oral capsule,delayed release(dr/ec) 125 mg didanosine oral capsule,delayed release(dr/ec) 200 mg didanosine oral capsule,delayed release(dr/ec) 250 mg, 400 mg EDURANT EMTRIVA ORAL CAPSULE EMTRIVA ORAL SOLUTION PAR; ; QLL (120 per 30 days) ; QLL (60 per 30 days) ; QLL (60 per 30 days) B/D PAR; ; QLL (120 per 30 days) QLL (380 per 30 days) ; QLL (30 per 30 days) PAR; B/D PAR; ; QLL (30 per 30 days) ; QLL (360 per 30 days) ; QLL (180 per 30 days) PAR; ; QLL (30 per 30 days) PAR; QLL (30 per 30 days) QLL (30 per 30 days) ; QLL (90 per 30 days) ; QLL (60 per 30 days) ; QLL (30 per 30 days) ; QLL (30 per 30 days) ; QLL (30 per 30 days) ; QLL (850 per 30 days) 有關本表格所含標誌與縮寫的含義, 可參見第 7 9

entecavir EPIVIR HBV ORAL SOLUTION EPIVIR ORAL SOLUTION EPZICOM EVOTAZ famciclovir oral tablet 125 mg, 250 mg famciclovir oral tablet 500 mg foscarnet FUZEON SUBCUTANEOUS RECON SOLN ganciclovir sodium GENVOYA HARVONI INTELENCE ORAL TABLET 100 MG INTELENCE ORAL TABLET 200 MG INTELENCE ORAL TABLET 25 MG INVIRASE ORAL CAPSULE INVIRASE ORAL TABLET ISENTRESS ORAL POWDER IN PACKET ISENTRESS ORAL TABLET ISENTRESS ORAL TABLET,CHEWABLE 100 MG ISENTRESS ORAL TABLET,CHEWABLE 25 MG KALETRA ORAL SOLUTION KALETRA ORAL TABLET 100-25 MG KALETRA ORAL TABLET 200-50 MG lamivudine oral solution lamivudine oral tablet 100 mg lamivudine oral tablet 150 mg lamivudine oral tablet 300 mg lamivudine-zidovudine PAR; ; QLL (900 per 30 days) ; QLL (30 per 30 days) ; QLL (30 per 30 days) ; QLL (60 per 30 days) ; QLL (21 per 7 days) B/D PAR ; QLL (60 per 30 days) ; QLL (30 per 30 days) PAR; ; QLL (28 per 28 days) ; QLL (120 per 30 days) ; QLL (60 per 30 days) ; QLL (480 per 30 days) ; QLL (300 per 30 days) ; QLL (120 per 30 days) ; QLL (120 per 30 days) ; QLL (180 per 30 days) ; QLL (720 per 30 days) ; QLL (480 per 30 days) ; QLL (300 per 30 days) ; QLL (120 per 30 days) ; QLL (900 per 30 days) ; QLL (60 per 30 days) ; QLL (30 per 30 days) ; QLL (60 per 30 days) 有關本表格所含標誌與縮寫的含義, 可參見第 7 10

LEXIVA ORAL SUSPENSION LEXIVA ORAL TABLET nevirapine oral suspension nevirapine oral tablet nevirapine oral tablet extended release 24 hr 100 mg nevirapine oral tablet extended release 24 hr 400 mg NORVIR ORAL CAPSULE NORVIR ORAL SOLUTION NORVIR ORAL TABLET ODEFSEY OLYSIO PREZCOBIX PREZISTA ORAL SUSPENSION PREZISTA ORAL TABLET 150 MG PREZISTA ORAL TABLET 600 MG, 800 MG PREZISTA ORAL TABLET 75 MG RELENZA DISKHALER RESCRIPTOR ORAL TABLET RESCRIPTOR ORAL TABLET, DISPERSIBLE RETROVIR INTRAVENOUS REYATAZ ORAL CAPSULE 150 MG, 200 MG REYATAZ ORAL CAPSULE 300 MG REYATAZ ORAL POWDER IN PACKET ribasphere oral capsule ribasphere oral tablet 200 mg ribavirin oral capsule ribavirin oral tablet 200 mg rimantadine SELZENTRY ; QLL (1800 per 30 days) ; QLL (120 per 30 days) ; QLL (1200 per 30 days) ; QLL (60 per 30 days) ; QLL (30 per 30 days) ; QLL (360 per 30 days) ; QLL (480 per 30 days) ; QLL (360 per 30 days) QLL (30 per 30 days) PAR; ; QLL (30 per 30 days) ; QLL (400 per 30 days) ; QLL (180 per 30 days) ; QLL (60 per 30 days) ; QLL (300 per 30 days) ; QLL (60 per 180 days) ; QLL (180 per 30 days) ; QLL (360 per 30 days) ; QLL (60 per 30 days) ; QLL (30 per 30 days) ; QLL (240 per 30 days) PAR; PAR; PAR; PAR; ; QLL (120 per 30 days) 有關本表格所含標誌與縮寫的含義, 可參見第 7 11

SOVALDI stavudine oral capsule 15 mg, 20 mg stavudine oral capsule 30 mg, 40 mg stavudine oral recon soln STRIBILD SUSTIVA ORAL CAPSULE 200 MG SUSTIVA ORAL CAPSULE 50 MG SUSTIVA ORAL TABLET SYNAGIS TAMIFLU TECHNIVIE TIVICAY ORAL TABLET 10 MG, 25 MG TIVICAY ORAL TABLET 50 MG TRIUMEQ TRUVADA ORAL TABLET 100-150 MG, 133-200 MG, 167-250 MG TRUVADA ORAL TABLET 200-300 MG TYBOST TYZEKA valacyclovir valganciclovir VIDEX 2 GRAM PEDIATRIC VIDEX 4 GRAM PEDIATRIC VIEKIRA PAK VIRACEPT ORAL TABLET 250 MG VIRACEPT ORAL TABLET 625 MG VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 HR 100 MG VIRAZOLE VIREAD ORAL POWDER VIREAD ORAL TABLET PAR; ; QLL (120 per 30 days) ; QLL (60 per 30 days) ; QLL (2400 per 30 days) ; QLL (30 per 30 days) ; QLL (120 per 30 days) ; QLL (360 per 30 days) ; QLL (30 per 30 days) PAR; ; LA PAR; ; QLL (56 per 28 days) QLL (60 per 30 days) ; QLL (60 per 30 days) ; QLL (30 per 30 days) QLL (30 per 30 days) ; QLL (30 per 30 days) ; QLL (30 per 30 days) PAR; ; QLL (30 per 2 days) ; QLL (1200 per 30 days) ; QLL (1200 per 30 days) PAR; ; QLL (300 per 30 days) ; QLL (120 per 30 days) PAR; ; QLL (240 per 30 days) ; QLL (30 per 30 days) 有關本表格所含標誌與縮寫的含義, 可參見第 7 12

VITEKTA ZEPATIER ZIAGEN ORAL SOLUTION zidovudine oral capsule zidovudine oral syrup zidovudine oral tablet CEPHALOSPORINS cefaclor oral capsule cefaclor oral suspension for reconstitution 125 mg/ 5 ml cefaclor oral suspension for reconstitution 250 mg/ 5 ml, 375 mg/5 ml cefaclor oral tablet extended release 12 hr cefadroxil oral capsule cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml cefadroxil oral tablet cefazolin in dextrose (iso-os) intravenous piggyback 1 gram/50 ml CEFAZOLIN IN DEXTROSE (ISO-OS) INTRAVENOUS PIGGYBACK 2 GRAM/50 ML cefazolin injection recon soln 1 gram, 500 mg cefazolin injection recon soln 10 gram, 20 gram CEFAZOLIN INJECTION RECON SOLN 100 GRAM, 300 G cefazolin intravenous cefdinir cefepime cefoxitin in dextrose, iso-osm cefoxitin intravenous recon soln 1 gram cefoxitin intravenous recon soln 10 gram, 2 gram cefpodoxime ; QLL (30 per 30 days) PAR; ; QLL (30 per 30 days) ; QLL (960 per 30 days) ; QLL (180 per 30 days) ; QLL (1920 per 30 days) ; QLL (60 per 30 days) 有關本表格所含標誌與縮寫的含義, 可參見第 7 13

cefprozil ceftazidime injection recon soln 1 gram, 2 gram ceftazidime injection recon soln 6 gram ceftriaxone in dextrose,iso-os ceftriaxone injection recon soln 1 gram, 2 gram, 250 mg, 500 mg ceftriaxone injection recon soln 10 gram CEFTRIAXONE INJECTION RECON SOLN 100 GRAM ceftriaxone intravenous cefuroxime axetil oral tablet cefuroxime sodium intravenous vial injection recon soln 1.5 gram, 750 mg cefuroxime sodium intravenous vial intravenous recon soln 7.5 gram cephalexin oral capsule 250 mg, 500 mg cephalexin oral suspension for reconstitution cephalexin oral tablet TEFLARO ERYTHROMYCINS / OTHER MACROLIDES azithromycin intravenous recon soln 500 mg azithromycin intravenous recon soln 500 mg (2 mg/ ml) azithromycin oral clarithromycin oral suspension for reconstitution clarithromycin oral tablet clarithromycin oral tablet extended release 24 hr e.e.s. 400 oral tablet ery-tab erythrocin (as stearate) oral tablet 250 mg ERYTHROCIN INTRAVENOUS RECON SOLN 500 MG ; QLL (28 per 2 days) 有關本表格所含標誌與縮寫的含義, 可參見第 7 14

erythromycin ethylsuccinate oral tablet erythromycin oral tablet MISCELLANEOUS ANTIINFECTIVES ALBENZA ALINIA ORAL SUSPENSION FOR RECONSTITUTION ALINIA ORAL TABLET AMIKACIN INJECTION SOLUTION 1,000 MG/ 4 ML amikacin injection solution 500 mg/2 ml atovaquone atovaquone-proguanil AZACTAM IN DEXTROSE (ISO-OSM) aztreonam baciim BILTRICIDE CAPASTAT CAYSTON chloramphenicol sod succinate chloroquine phosphate oral clindamycin hcl clindamycin phosphate injection CLINDAMYCIN PHOSPHATE INTRAVENOUS SOLUTION 300 MG/2 ML clindamycin phosphate intravenous solution 600 mg/4 ml clindamycin phosphate intravenous solution 900 mg/6 ml colistin (colistimethate na) DAPSONE DARAPRIM ethambutol ; QLL (180 per 3 days) PAR; PAR; ; LA 有關本表格所含標誌與縮寫的含義, 可參見第 7 15

gentamicin injection GENTAMICIN SULFATE (PED) (PF) GENTAMICIN SULFATE (PF) INTRAVENOUS SOLUTION 100 MG/10 ML GENTAMICIN SULFATE (PF) INTRAVENOUS SOLUTION 60 MG/6 ML gentamicin sulfate (pf) intravenous solution 80 mg/ 8 ml hydroxychloroquine oral imipenem-cilastatin INVANZ INJECTION isoniazid oral ivermectin oral linezolid intravenous linezolid oral suspension for reconstitution linezolid oral tablet LINEZOLID-0.9% SODIUM CHLORIDE mefloquine meropenem METRO I.V. metronidazole in nacl (iso-os) metronidazole oral NEBUPENT neomycin paromomycin PASER PENTAM PRIFTIN PRIMAQUINE pyrazinamide rifabutin PAR; ; QLL (1800 per 2 days) PAR; ; QLL (28 per 2 days) B/D PAR; 有關本表格所含標誌與縮寫的含義, 可參見第 7 16

rifampin RIFATER SIRTURO STREPTOMYCIN INTRAMUSCULAR SYNERCID tobramycin in 0.225 % nacl tobramycin sulfate injection recon soln tobramycin sulfate injection solution TRECATOR TYGACIL ZYVOX INTRAVENOUS PARENTERAL SOLUTION 200 MG/100 ML ZYVOX INTRAVENOUS PARENTERAL SOLUTION 600 MG/300 ML ZYVOX ORAL SUSPENSION FOR RECONSTITUTION PENICILLINS amoxicillin oral capsule amoxicillin oral suspension for reconstitution amoxicillin oral tablet amoxicillin oral tablet,chewable 125 mg, 250 mg amoxicillin-pot clavulanate ampicillin ampicillin sodium injection ampicillin sodium intravenous ampicillin-sulbactam injection recon soln 1.5 gram, 3 gram ampicillin-sulbactam injection recon soln 15 gram ampicillin-sulbactam intravenous recon soln 1.5 gram ampicillin-sulbactam intravenous recon soln 3 gram BICILLIN C-R PAR; ; LA B/D PAR; ; QLL (280 per 28 days) PAR; ; QLL (1800 per 2 days) 有關本表格所含標誌與縮寫的含義, 可參見第 7 17

BICILLIN L-A dicloxacillin nafcillin injection nafcillin intravenous recon soln 2 gram oxacillin injection oxacillin intravenous PENICILLIN G POT IN DEXTROSE penicillin g potassium penicillin g procaine intramuscular syringe 1.2 million unit/2 ml penicillin g procaine intramuscular syringe 600,000 unit/ml penicillin g sodium penicillin v potassium piperacillin-tazobactam QUINOLONES ciprofloxacin ciprofloxacin er oral tablet, er multiphase 24 hr 1, 000 mg ciprofloxacin er oral tablet, er multiphase 24 hr 500 mg ciprofloxacin hcl oral ciprofloxacin lactate intravenous solution 200 mg/ 20 ml ciprofloxacin lactate intravenous solution 400 mg/ 40 ml levofloxacin intravenous levofloxacin oral tablet moxifloxacin ofloxacin oral tablet 400 mg SULFA'S / RELATED AGENTS sulfadiazine oral ; QLL (14 per 2 days) ; QLL (3 per 2 days) ; QLL (14 per 2 days) ; QLL (21 per 2 days) 有關本表格所含標誌與縮寫的含義, 可參見第 7 18

sulfamethoxazole-trimethoprim TETRACYCLINES demeclocycline DOXY-100 doxycycline hyclate intravenous doxycycline hyclate oral capsule doxycycline hyclate oral tablet doxycycline hyclate oral tablet,delayed release (dr/ ec) 100 mg, 150 mg, 75 mg doxycycline monohydrate oral capsule doxycycline monohydrate oral tablet minocycline oral capsule minocycline oral tablet tetracycline URINARY TRACT AGENTS methenamine hippurate nitrofurantoin macrocrystal oral capsule 50 mg trimethoprim VANCOMYCIN VANCOMYCIN IN 0.9% SODIUM CL INTRAVENOUS PIGGYBACK 500 MG/100 ML, 750 MG/150 ML vancomycin in dextrose 5 % intravenous piggyback 1 gram/200 ml vancomycin in dextrose 5 % intravenous piggyback 500 mg/100 ml VANCOMYCIN IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK 750 MG/150 ML vancomycin intravenous VANCOMYCIN INTRAVENOUS vancomycin oral capsule 125 mg vancomycin oral capsule 250 mg PAR; PAR; ; QLL (40 per 2 days) PAR; ; QLL (80 per 2 days) 有關本表格所含標誌與縮寫的含義, 可參見第 7 19

ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ADJUNCTIVE AGENTS amifostine crystalline dexrazoxane hcl intravenous recon soln 250 mg dexrazoxane hcl intravenous recon soln 500 mg ELITEK FUSILEV KEPIVANCE leucovorin calcium injection recon soln 100 mg, 350 mg, 50 mg LEUCOVORIN CALCIUM INJECTION RECON SOLN 200 MG LEUCOVORIN CALCIUM INJECTION RECON SOLN 500 MG leucovorin calcium oral mesna MESNEX ORAL XGEVA ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ABRAXANE AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION 2 MG, 5 MG AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION 3 MG AFINITOR ORAL TABLET 10 MG AFINITOR ORAL TABLET 2.5 MG AFINITOR ORAL TABLET 5 MG AFINITOR ORAL TABLET 7.5 MG ALECENSA ALIMTA anastrozole ARRANON PAR; PAR; PAR; ; QLL (1.7 per 28 days) PAR; ; QLL (60 per 30 days) PAR; ; QLL (90 per 30 days) PAR; ; QLL (30 per 30 days) PAR; ; QLL (120 per 30 days) PAR; ; QLL (60 per 30 days) PAR; ; QLL (40 per 30 days) PAR; ; QLL (30 per 30 days) 有關本表格所含標誌與縮寫的含義, 可參見第 7 20

ARZERRA AVASTIN azacitidine azathioprine azathioprine sodium BELEODAQ BENDEKA bexarotene bicalutamide BICNU bleomycin BLINCYTO BOSULIF ORAL TABLET 100 MG BOSULIF ORAL TABLET 500 MG BUSULFEX CABOMETYX ORAL TABLET 20 MG CABOMETYX ORAL TABLET 40 MG, 60 MG CAPRELSA ORAL TABLET 100 MG CAPRELSA ORAL TABLET 300 MG carboplatin intravenous solution CELLCEPT INTRAVENOUS cisplatin cladribine CLOLAR COMETRIQ ORAL CAPSULE 100 MG/DAY(80 MG X1-20 MG X1) COMETRIQ ORAL CAPSULE 140 MG/DAY(80 MG X1-20 MG X3) COMETRIQ ORAL CAPSULE 60 MG/DAY (20 MG X 3/DAY) COTELLIC PAR; PAR; PAR; B/D PAR; B/D PAR PAR; PAR; PAR; PAR; ; QLL (120 per 30 days) PAR; ; QLL (30 per 30 days) PAR; LA; QLL (90 per 30 days) PAR; LA; QLL (30 per 30 days) PAR; ; LA; QLL (90 per 30 days) PAR; ; LA; QLL (30 per 30 days) B/D PAR; PAR; ; QLL (56 per 28 days) PAR; ; QLL (112 per 28 days) PAR; ; QLL (84 per 28 days) PAR; ; LA; QLL (90 per 30 days) 有關本表格所含標誌與縮寫的含義, 可參見第 7 21

cyclophosphamide oral capsule cyclosporine intravenous cyclosporine modified cyclosporine oral capsule CYRAMZA cytarabine CYTARABINE (PF) INJECTION SOLUTION 100 MG/5 ML (20 MG/ML) cytarabine (pf) injection solution 2 gram/20 ml (100 mg/ml) CYTARABINE (PF) INJECTION SOLUTION 20 MG/ML dacarbazine DARZALEX daunorubicin intravenous solution decitabine DOCEFREZ INTRAVENOUS RECON SOLN 20 MG DOCETAXEL INTRAVENOUS SOLUTION 10 MG/ML, 160 MG/16 ML (10 MG/ML), 160 MG/ 8 ML (20 MG/ML), 20 MG/2 ML (10 MG/ML) docetaxel intravenous solution 20 mg/ml (1 ml), 80 mg/4 ml (20 mg/ml), 80 mg/8 ml (10 mg/ml) doxorubicin intravenous recon soln doxorubicin intravenous solution DROXIA EMCYT EMPLICITI ENVARSUS XR epirubicin intravenous solution 200 mg/100 ml epirubicin intravenous solution 50 mg/25 ml ERBITUX ERIVEDGE B/D PAR; B/D PAR B/D PAR; B/D PAR; PAR; ; LA B/D PAR; B/D PAR; PAR; PAR; ; QLL (30 per 30 days) 有關本表格所含標誌與縮寫的含義, 可參見第 7 22

ERWINAZE ETOPOPHOS etoposide intravenous EVOMELA exemestane FARESTON FARYDAK ORAL CAPSULE 10 MG FARYDAK ORAL CAPSULE 15 MG, 20 MG FASLODEX FIRMAGON KIT W DILUENT SYRINGE fludarabine intravenous recon soln FLUDARABINE INTRAVENOUS SOLUTION fluorouracil intravenous FLUOROURACIL INTRAVENOUS flutamide FOLOTYN GAZYVA gemcitabine intravenous recon soln 1 gram, 200 mg GEMCITABINE INTRAVENOUS RECON SOLN 2 GRAM GEMCITABINE INTRAVENOUS SOLUTION 1 GRAM/26.3 ML (38 MG/ML), 200 MG/5.26 ML (38 MG/ML) GEMCITABINE INTRAVENOUS SOLUTION 2 GRAM/52.6 ML (38 MG/ML) gengraf oral capsule 100 mg, 25 mg gengraf oral solution GILOTRIF GLEEVEC ORAL TABLET 100 MG GLEEVEC ORAL TABLET 400 MG GLEOSTINE PAR; ; QLL (60 per 30 days) ; QLL (30 per 30 days) PAR; ; QLL (60 per 30 days) PAR; ; QLL (30 per 30 days) PAR; PAR; PAR; B/D PAR; B/D PAR; PAR; ; QLL (30 per 30 days) PAR; ; QLL (240 per 30 days) PAR; ; QLL (60 per 30 days) 有關本表格所含標誌與縮寫的含義, 可參見第 7 23

HALAVEN HERCEPTIN HEXALEN hydroxyurea IBRANCE ICLUSIG ORAL TABLET 15 MG ICLUSIG ORAL TABLET 45 MG idarubicin ifosfamide intravenous recon soln IFOSFAMIDE INTRAVENOUS SOLUTION imatinib oral tablet 100 mg imatinib oral tablet 400 mg IMBRUVICA INLYTA ORAL TABLET 1 MG INLYTA ORAL TABLET 5 MG IRESSA irinotecan intravenous solution 100 mg/5 ml, 40 mg/2 ml IRINOTECAN INTRAVENOUS SOLUTION 500 MG/25 ML ISTODAX IXEMPRA JAKAFI ORAL TABLET 10 MG JAKAFI ORAL TABLET 15 MG JAKAFI ORAL TABLET 20 MG JAKAFI ORAL TABLET 25 MG JAKAFI ORAL TABLET 5 MG JEVTANA KADCYLA KEYTRUDA PAR; PAR; PAR; ; QLL (30 per 30 days) PAR; ; QLL (60 per 30 days) PAR; ; QLL (30 per 30 days) PAR; ; QLL (240 per 30 days) PAR; ; QLL (60 per 30 days) PAR; ; QLL (120 per 30 days) PAR; ; QLL (240 per 30 days) PAR; ; QLL (120 per 30 days) PAR; PAR; ; QLL (150 per 30 days) PAR; ; QLL (100 per 30 days) PAR; ; QLL (75 per 30 days) PAR; ; QLL (60 per 30 days) PAR; ; QLL (300 per 30 days) PAR; PAR; 有關本表格所含標誌與縮寫的含義, 可參見第 7 24

LENVIMA ORAL CAPSULE 10 MG/DAY (10 MG X 1/DAY) LENVIMA ORAL CAPSULE 14 MG/DAY(10 MG X 1-4 MG X 1), 20 MG/DAY (10 MG X 2) LENVIMA ORAL CAPSULE 18 MG/DAY (10 MG X 1-4 MG X2) LENVIMA ORAL CAPSULE 24 MG/DAY(10 MG X 2-4 MG X 1) LENVIMA ORAL CAPSULE 8 MG/DAY (4 MG X 2) letrozole LEUKERAN leuprolide subcutaneous kit LONSURF LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 3.75 MG LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 7.5 MG LUPRON DEPOT-PED INTRAMUSCULAR KIT 7.5 MG (PED) LYNPARZA LYSODREN MATULANE MEGESTROL ORAL SUSPENSION 400 MG/10 ML (10 ML), 800 MG/20 ML (20 ML) megestrol oral suspension 400 mg/10 ml (40 mg/ ml) megestrol oral tablet MEKINIST ORAL TABLET 0.5 MG MEKINIST ORAL TABLET 2 MG melphalan hcl mercaptopurine methotrexate sodium methotrexate sodium (pf) injection recon soln PAR; ; QLL (30 per 30 days) PAR; ; QLL (60 per 30 days) PAR; QLL (90 per 30 days) PAR; ; QLL (90 per 30 days) PAR; QLL (60 per 30 days) ; QLL (30 per 30 days) PAR; PAR; PAR; ; QLL (1 per 28 days) PAR; PAR; ; QLL (1 per 28 days) PAR; ; QLL (480 per 30 days) PAR PAR; PAR; PAR; QLL (90 per 30 days) PAR; QLL (30 per 30 days) 有關本表格所含標誌與縮寫的含義, 可參見第 7 25

methotrexate sodium (pf) injection solution mitomycin mitoxantrone MUSTARGEN mycophenolate mofetil mycophenolate sodium NEXAVAR NILANDRON NINLARO NIPENT NULOJIX octreotide acetate ODOMZO ONCASPAR OPDIVO oxaliplatin intravenous recon soln 100 mg oxaliplatin intravenous recon soln 50 mg oxaliplatin intravenous solution paclitaxel PERJETA POMALYST ORAL CAPSULE 1 MG POMALYST ORAL CAPSULE 2 MG POMALYST ORAL CAPSULE 3 MG, 4 MG PORTRAZZA PROGRAF INTRAVENOUS PURIXAN RAPAMUNE ORAL SOLUTION REVLIMID ORAL CAPSULE 10 MG REVLIMID ORAL CAPSULE 15 MG, 2.5 MG, 20 MG, 25 MG REVLIMID ORAL CAPSULE 5 MG B/D PAR; B/D PAR; PAR; ; LA; QLL (120 per 30 days) ; QLL (30 per 30 days) PAR; ; QLL (3 per 28 days) PAR; PAR; PAR; ; LA; QLL (30 per 30 days) PAR; PAR; PAR; PAR; ; QLL (120 per 30 days) PAR; ; QLL (60 per 30 days) PAR; ; QLL (30 per 30 days) B/D PAR; PAR; B/D PAR; PAR; ; LA; QLL (60 per 30 days) PAR; ; LA; QLL (30 per 30 days) PAR; ; LA; QLL (150 per 30 days) 有關本表格所含標誌與縮寫的含義, 可參見第 7 26

RITUXAN SIGNIFOR SIMULECT INTRAVENOUS RECON SOLN 10 MG SIMULECT INTRAVENOUS RECON SOLN 20 MG sirolimus SOLTAX SOMATULINE DEPOT SPRYCEL STIVARGA SUTENT ORAL CAPSULE 12.5 MG SUTENT ORAL CAPSULE 25 MG, 37.5 MG, 50 MG SYNRIBO TABLOID tacrolimus oral TAFINLAR ORAL CAPSULE 50 MG TAFINLAR ORAL CAPSULE 75 MG TAGRISSO ORAL TABLET 40 MG TAGRISSO ORAL TABLET 80 MG tamoxifen TARCEVA ORAL TABLET 100 MG, 150 MG TARCEVA ORAL TABLET 25 MG TARGRETIN ORAL TARGRETIN TOPICAL TASIGNA TECENTRIQ THALOMID ORAL CAPSULE 100 MG, 50 MG THALOMID ORAL CAPSULE 150 MG, 200 MG thiotepa PAR; B/D PAR B/D PAR; B/D PAR; PAR; PAR; ; QLL (30 per 30 days) PAR; ; QLL (120 per 30 days) PAR; ; QLL (90 per 30 days) PAR; ; QLL (30 per 30 days) PAR; B/D PAR; PAR; ; QLL (120 per 30 days) PAR; QLL (120 per 30 days) PAR; ; LA; QLL (60 per 30 days) PAR; ; LA; QLL (30 per 30 days) PAR; ; QLL (30 per 30 days) PAR; ; QLL (90 per 30 days) PAR; ; QLL (300 per 30 days) PAR; PAR; ; QLL (120 per 30 days) LA; QLL (20 per 21 days) PAR; ; QLL (30 per 30 days) PAR; ; QLL (60 per 30 days) 有關本表格所含標誌與縮寫的含義, 可參見第 7 27

toposar topotecan intravenous recon soln TOPOTECAN INTRAVENOUS SOLUTION TORISEL TREANDA INTRAVENOUS RECON SOLN TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION TRELSTAR INTRAMUSCULAR SYRINGE 11.25 MG/2 ML, 3.75 MG/2 ML TRELSTAR INTRAMUSCULAR SYRINGE 22.5 MG/2 ML tretinoin (chemotherapy) TREXALL TRISENOX TYKERB UNITUXIN VECTIBIX VELCADE VENCLEXTA ORAL TABLET 10 MG VENCLEXTA ORAL TABLET 100 MG VENCLEXTA ORAL TABLET 50 MG VENCLEXTA STARTING PACK vinblastine intravenous solution VINCASAR PFS INTRAVENOUS SOLUTION 1 MG/ML VINCASAR PFS INTRAVENOUS SOLUTION 2 MG/2 ML vincristine vinorelbine VOTRIENT XALKORI XTANDI ; QLL (1 per 168 days) ; QLL (1 per 168 days) PAR; ; LA; QLL (180 per 30 days) PAR; PAR; PAR; LA; QLL (60 per 30 days) PAR; LA; QLL (120 per 30 days) PAR; LA; QLL (30 per 30 days) PAR; LA; QLL (42 per 365 days) PAR; ; QLL (120 per 30 days) PAR; ; QLL (60 per 30 days) PAR; ; QLL (120 per 30 days) 有關本表格所含標誌與縮寫的含義, 可參見第 7 28

YERVOY YONDELIS ZALTRAP ZANOSAR ZELBORAF ZOLINZA ZORTRESS ZYDELIG ZYKADIA ZYTIGA AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH ANTICONVULSANTS APTIOM BANZEL ORAL SUSPENSION BANZEL ORAL TABLET 200 MG BANZEL ORAL TABLET 400 MG BRIVIACT INTRAVENOUS BRIVIACT ORAL SOLUTION BRIVIACT ORAL TABLET 10 MG BRIVIACT ORAL TABLET 100 MG, 75 MG BRIVIACT ORAL TABLET 25 MG BRIVIACT ORAL TABLET 50 MG carbamazepine oral capsule, er multiphase 12 hr carbamazepine oral suspension 100 mg/5 ml carbamazepine oral suspension 200 mg/10 ml carbamazepine oral tablet carbamazepine oral tablet extended release 12 hr 100 mg carbamazepine oral tablet extended release 12 hr 200 mg, 400 mg carbamazepine oral tablet,chewable PAR; PAR; PAR; ; QLL (240 per 30 days) PAR; ; QLL (120 per 30 days) B/D PAR; PAR; ; QLL (60 per 30 days) PAR; ; QLL (150 per 30 days) PAR; ; QLL (120 per 30 days) ST; PAR; ; QLL (2400 per 30 days) PAR; ; QLL (480 per 30 days) PAR; ; QLL (240 per 30 days) PAR PAR; QLL (600 per 30 days) PAR; QLL (600 per 30 days) PAR; QLL (60 per 30 days) PAR; QLL (240 per 30 days) PAR; QLL (120 per 30 days) 有關本表格所含標誌與縮寫的含義, 可參見第 7 29

CELONTIN ORAL CAPSULE 300 MG clonazepam oral tablet 0.5 mg clonazepam oral tablet 1 mg clonazepam oral tablet 2 mg clonazepam oral tablet,disintegrating 0.125 mg clonazepam oral tablet,disintegrating 0.25 mg clonazepam oral tablet,disintegrating 0.5 mg clonazepam oral tablet,disintegrating 1 mg clonazepam oral tablet,disintegrating 2 mg diazepam rectal kit 12.5-15-17.5-20 mg diazepam rectal kit 2.5 mg, 5-7.5-10 mg DILANTIN DILANTIN EXTENDED ORAL CAPSULES 100 MG DILANTIN INFATABS divalproex epitol EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 100 MG EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 200 MG EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 300 MG ethosuximide felbamate fosphenytoin FYCOMPA ORAL SUSPENSION FYCOMPA ORAL TABLET 10 MG, 12 MG FYCOMPA ORAL TABLET 2 MG FYCOMPA ORAL TABLET 4 MG FYCOMPA ORAL TABLET 6 MG FYCOMPA ORAL TABLET 8 MG PAR; ; QLL (1200 per 30 days) PAR; ; QLL (600 per 30 days) PAR; ; QLL (300 per 30 days) PAR; ; QLL (4800 per 30 days) PAR; ; QLL (2400 per 30 days) PAR; ; QLL (1200 per 30 days) PAR; ; QLL (600 per 30 days) PAR; ; QLL (300 per 30 days) ; QLL (2 per 2 days) ; QLL (480 per 30 days) ; QLL (240 per 30 days) ; QLL (180 per 30 days) QLL (720 per 30 days) ; QLL (30 per 30 days) ; QLL (180 per 30 days) ; QLL (90 per 30 days) ; QLL (60 per 30 days) ; QLL (45 per 30 days) 有關本表格所含標誌與縮寫的含義, 可參見第 7 30

gabapentin oral capsule 100 mg gabapentin oral capsule 300 mg gabapentin oral capsule 400 mg gabapentin oral solution 250 mg/5 ml GABAPENTIN ORAL SOLUTION 250 MG/5 ML (5 ML), 300 MG/6 ML (6 ML) gabapentin oral tablet 600 mg gabapentin oral tablet 800 mg GABITRIL ORAL TABLET 12 MG, 16 MG lamotrigine oral tablet lamotrigine oral tablet, chewable dispersible levetiracetam in nacl (iso-os) intravenous piggyback 1,000 mg/100 ml, 1,500 mg/100 ml levetiracetam in nacl (iso-os) intravenous piggyback 500 mg/100 ml levetiracetam intravenous levetiracetam oral solution 100 mg/ml LEVETIRACETAM ORAL SOLUTION 500 MG/ 5 ML (5 ML) levetiracetam oral tablet levetiracetam oral tablet extended release 24 hr 500 mg levetiracetam oral tablet extended release 24 hr 750 mg LYRICA ORAL CAPSULE 100 MG LYRICA ORAL CAPSULE 150 MG LYRICA ORAL CAPSULE 200 MG LYRICA ORAL CAPSULE 225 MG, 300 MG LYRICA ORAL CAPSULE 25 MG LYRICA ORAL CAPSULE 50 MG LYRICA ORAL CAPSULE 75 MG LYRICA ORAL SOLUTION ; QLL (1080 per 30 days) ; QLL (360 per 30 days) ; QLL (270 per 30 days) ; QLL (2160 per 30 days) QLL (2160 per 30 days) ; QLL (180 per 30 days) ; QLL (135 per 30 days) ; QLL (180 per 30 days) ; QLL (120 per 30 days) PAR; ; QLL (180 per 30 days) PAR; ; QLL (120 per 30 days) PAR; ; QLL (90 per 30 days) PAR; ; QLL (60 per 30 days) PAR; ; QLL (720 per 30 days) PAR; ; QLL (360 per 30 days) PAR; ; QLL (240 per 30 days) PAR; ; QLL (900 per 30 days) 有關本表格所含標誌與縮寫的含義, 可參見第 7 31

ONFI ORAL SUSPENSION ONFI ORAL TABLET 10 MG ONFI ORAL TABLET 20 MG oxcarbazepine OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR 150 MG OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR 300 MG OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR 600 MG PEGANONE phenobarbital oral elixir phenobarbital oral tablet 100 mg phenobarbital oral tablet 15 mg phenobarbital oral tablet 16.2 mg phenobarbital oral tablet 30 mg phenobarbital oral tablet 32.4 mg phenobarbital oral tablet 60 mg phenobarbital oral tablet 64.8 mg phenobarbital oral tablet 97.2 mg PHENYTEK PHENYTOIN ORAL SUSPENSION 100 MG/4 ML phenytoin oral suspension 125 mg/5 ml phenytoin oral tablet,chewable phenytoin sodium extended phenytoin sodium intravenous solution phenytoin sodium intravenous syringe POTIGA ORAL TABLET 200 MG, 300 MG, 400 MG POTIGA ORAL TABLET 50 MG primidone PAR; ; QLL (480 per 30 days) PAR; ; QLL (120 per 30 days) PAR; ; QLL (60 per 30 days) ; QLL (480 per 30 days) ; QLL (240 per 30 days) ; QLL (120 per 30 days) PAR; ; QLL (3000 per 30 days) PAR; ; QLL (120 per 30 days) PAR; ; QLL (800 per 30 days) PAR; ; QLL (741 per 30 days) PAR; ; QLL (400 per 30 days) PAR; ; QLL (370 per 30 days) PAR; ; QLL (200 per 30 days) PAR; ; QLL (185 per 30 days) PAR; ; QLL (123 per 30 days) ; QLL (90 per 30 days) ; QLL (270 per 30 days) 有關本表格所含標誌與縮寫的含義, 可參見第 7 32

roweepra SABRIL SPRITAM ORAL TABLET FOR SUSPENSION 1,000 MG, 250 MG, 500 MG SPRITAM ORAL TABLET FOR SUSPENSION 750 MG tiagabine topiramate oral capsule, sprinkle topiramate oral tablet 100 mg topiramate oral tablet 200 mg topiramate oral tablet 25 mg topiramate oral tablet 50 mg valproate sodium valproic acid valproic acid (as sodium salt) oral solution 250 mg/ 5 ml VALPROIC ACID (AS SODIUM SALT) ORAL SOLUTION 250 MG/5 ML (5 ML), 500 MG/10 ML (10 ML) VIMPAT INTRAVENOUS VIMPAT ORAL SOLUTION VIMPAT ORAL TABLET 100 MG VIMPAT ORAL TABLET 150 MG VIMPAT ORAL TABLET 200 MG VIMPAT ORAL TABLET 50 MG zonisamide ANTIPARKINSONISM AGENTS APOKYN AZILECT benztropine oral bromocriptine carbidopa-levodopa PAR; ; LA; QLL (180 per 30 days) PAR; QLL (60 per 30 days) PAR; QLL (120 per 30 days) PAR; PAR; ; QLL (480 per 30 days) PAR; ; QLL (240 per 30 days) PAR; ; QLL (1920 per 30 days) PAR; ; QLL (960 per 30 days) QLL (1200 per 30 days) ; QLL (1200 per 30 days) ; QLL (120 per 30 days) ; QLL (80 per 30 days) ; QLL (60 per 30 days) ; QLL (240 per 30 days) PAR; ; LA PAR; 有關本表格所含標誌與縮寫的含義, 可參見第 7 33

entacapone NEUPRO pramipexole oral tablet ropinirole oral tablet selegiline hcl tolcapone MIGRAINE / CLUSTER HEADACHE THERAPY dihydroergotamine injection ERGOMAR rizatriptan sumatriptan succinate oral sumatriptan succinate subcutaneous cartridge sumatriptan succinate subcutaneous pen injector sumatriptan succinate subcutaneous solution SUMATRIPTAN SUCCINATE SUBCUTANEOUS SYRINGE 6 MG/0.5 ML zolmitriptan ZOMIG NASAL MISCELLANEOUS NEUROLOGICAL THERAPY AMPYRA COPAXONE SUBCUTANEOUS SYRINGE 20 MG/ML COPAXONE SUBCUTANEOUS SYRINGE 40 MG/ML donepezil oral tablet 10 mg, 5 mg donepezil oral tablet,disintegrating galantamine oral capsule,ext rel. pellets 24 hr galantamine oral solution galantamine oral tablet GILENYA GLATOPA PAR; ; QLL (30 per 30 days) PAR; ; QLL (12 per 30 days) ; QLL (9 per 30 days) ; QLL (4 per 30 days) ; QLL (4 per 30 days) ; QLL (4 per 30 days) QLL (4 per 30 days) ; QLL (9 per 30 days) ; QLL (6 per 30 days) PAR; ; LA; QLL (60 per 30 days) PAR; ; QLL (30 per 30 days) PAR; ; QLL (12 per 28 days) ; QLL (30 per 30 days) ; QLL (30 per 30 days) ; QLL (30 per 30 days) ; QLL (180 per 30 days) ; QLL (60 per 30 days) PAR; ; QLL (30 per 30 days) PAR; ; QLL (30 per 30 days) 有關本表格所含標誌與縮寫的含義, 可參見第 7 34

memantine oral solution memantine oral tablet 10 mg memantine oral tablet 5 mg NAMENDA ORAL SOLUTION NAMENDA XR ORAL CAP,SPRINKLE,ER 24HR DOSE PACK NAMENDA XR ORAL CAPSULE,SPRINKLE, ER 24HR NAMZARIC NUEDEXTA rivastigmine rivastigmine tartrate TECFIDERA tetrabenazine oral tablet 12.5 mg tetrabenazine oral tablet 25 mg TYSABRI XENAZINE ORAL TABLET 12.5 MG XENAZINE ORAL TABLET 25 MG MUSCLE RELAXANTS / ANTISPASDIC THERAPY baclofen cyclobenzaprine oral tablet dantrolene MESTINON ORAL SYRUP MESTINON TIMESPAN pyridostigmine bromide tizanidine oral tablet NARCOTIC ANALGESICS acetaminophen-codeine oral solution 120 mg-12 mg /5 ml (5 ml), 300 mg-30 mg /12.5 ml acetaminophen-codeine oral solution 120-12 mg/5 ml ; QLL (300 per 30 days) ; QLL (60 per 30 days) ; QLL (90 per 30 days) ; QLL (300 per 30 days) ; QLL (56 per 365 days) ; QLL (30 per 30 days) ; QLL (60 per 30 days) ; QLL (30 per 30 days) ; QLL (60 per 30 days) PAR; PAR; ; QLL (240 per 30 days) PAR; ; QLL (120 per 30 days) PAR; ; LA PAR; ; LA; QLL (240 per 30 days) PAR; ; LA; QLL (120 per 30 days) PAR; QLL (4500 per 30 days) ; QLL (4500 per 30 days) 有關本表格所含標誌與縮寫的含義, 可參見第 7 35

ACETAMINOPHEN-CODEINE ORAL SOLUTION 240 MG-24 MG /10 ML (10 ML) acetaminophen-codeine oral tablet 300-15 mg acetaminophen-codeine oral tablet 300-30 mg acetaminophen-codeine oral tablet 300-60 mg buprenorphine hcl injection solution buprenorphine hcl injection syringe buprenorphine hcl sublingual tablet 2 mg buprenorphine hcl sublingual tablet 8 mg BUTALBITAL COMPOUND W/CODEINE duramorph (pf) injection solution 0.5 mg/ml duramorph (pf) injection solution 1 mg/ml endocet oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg fentanyl citrate fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr HYDROCODONE-ACETAMINOPHEN ORAL SOLUTION 2.5-167 MG/5 ML hydrocodone-acetaminophen oral solution 7.5-325 mg/15 ml hydrocodone-acetaminophen oral tablet 10-300 mg, 5-300 mg, 7.5-300 mg hydrocodone-acetaminophen oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg hydrocodone-ibuprofen oral tablet 10-200 mg, 5-200 mg, 7.5-200 mg hydromorphone oral tablet 2 mg, 4 mg hydromorphone oral tablet 8 mg levorphanol tartrate methadone injection METHADONE INTENSOL methadone oral concentrate QLL (4500 per 30 days) ; QLL (390 per 30 days) ; QLL (360 per 30 days) ; QLL (180 per 30 days) ; QLL (150 per 30 days) QLL (150 per 30 days) PAR; ; QLL (240 per 30 days) PAR; ; QLL (60 per 30 days) PAR; ; QLL (180 per 30 days) ; QLL (180 per 30 days) QLL (180 per 30 days) ; QLL (360 per 30 days) PAR; ; QLL (120 per 30 days) ST; ; QLL (15 per 30 days) QLL (2700 per 30 days) ; QLL (2700 per 30 days) ; QLL (390 per 30 days) ; QLL (360 per 30 days) ; QLL (480 per 30 days) ; QLL (360 per 30 days) ; QLL (180 per 30 days) ; QLL (180 per 30 days) QLL (150 per 30 days) ; QLL (180 per 30 days) ; QLL (180 per 30 days) 有關本表格所含標誌與縮寫的含義, 可參見第 7 36

methadone oral solution 10 mg/5 ml methadone oral solution 5 mg/5 ml methadone oral tablet 10 mg methadone oral tablet 5 mg METHADOSE ORAL CONCENTRATE morphine (pf) injection solution 0.5 mg/ml morphine (pf) injection solution 1 mg/ml RPHINE (PF) INTRAVENOUS PATIENT CONTROL.ANALGESIA SOLN 150 MG/30 ML RPHINE (PF) INTRAVENOUS PATIENT CONTROL.ANALGESIA SOLN 30 MG/30 ML morphine concentrate oral solution RPHINE INTRAVENOUS CARTRIDGE RPHINE INTRAVENOUS SOLUTION 10 MG/ML, 50 MG/ML RPHINE INTRAVENOUS SOLUTION 100 MG/4 ML, 25 MG/ML, 250 MG/10 ML RPHINE INTRAVENOUS SOLUTION 4 MG/ ML, 8 MG/ML morphine intravenous syringe 2 mg/ml, 4 mg/ml morphine oral capsule, er multiphase 24 hr 120 mg, 75 mg, 90 mg morphine oral capsule, er multiphase 24 hr 30 mg, 45 mg, 60 mg morphine oral capsule,extend.release pellets 100 mg, 20 mg, 30 mg, 50 mg, 60 mg, 80 mg morphine oral solution 20 mg/5 ml (4 mg/ml) morphine oral tablet 15 mg morphine oral tablet 30 mg morphine oral tablet extended release 100 mg, 15 mg, 30 mg, 60 mg morphine oral tablet extended release 200 mg oxycodone oral capsule ; QLL (900 per 30 days) ; QLL (1800 per 30 days) ; QLL (180 per 30 days) ; QLL (360 per 30 days) ; QLL (180 per 30 days) ; QLL (180 per 30 days) ; QLL (120 per 30 days) QLL (180 per 30 days) ; QLL (270 per 30 days) QLL (120 per 30 days) ; QLL (120 per 30 days) QLL (120 per 30 days) ; QLL (180 per 30 days) QLL (120 per 30 days) ; QLL (60 per 30 days) ; QLL (30 per 30 days) ; QLL (60 per 30 days) ; QLL (1350 per 30 days) ; QLL (360 per 30 days) ; QLL (180 per 30 days) ; QLL (90 per 30 days) ; QLL (60 per 30 days) ; QLL (360 per 30 days) 有關本表格所含標誌與縮寫的含義, 可參見第 7 37

oxycodone oral concentrate oxycodone oral tablet 10 mg, 5 mg oxycodone oral tablet 15 mg oxycodone oral tablet 20 mg, 30 mg oxycodone-acetaminophen oral solution oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg oxycodone-aspirin NON-NARCOTIC ANALGESICS ACEPHEN RECTAL SUPPOSITORY 650 MG ACETAMINOPHEN EXTRA STRENGTH ORAL CAPSULE 500 MG ACETAMINOPHEN EXTRA STRENGTH ORAL LIQUID 500 MG/15 ML ACETAMINOPHEN EXTRA STRENGTH ORAL SUSPENSION 160 MG/5 ML ACETAMINOPHEN LIQUID acetaminophen oral suspension 160 mg/5 ml acetaminophen oral tablet 500 mg ACETAMINOPHEN PAIN RELIEF acetaminophen rectal suppository 650 mg ADULT LOW DOSE ASPIRIN ALL DAY RELIEF ASPIR-LOW ASPIRIN CHILDRENS ASPIRIN LOW DOSE aspirin oral tablet aspirin oral tablet,chewable aspirin oral tablet,delayed release (dr/ec) 325 mg, 81 mg BAYER ADVANCED BAYER ASPIRIN ; QLL (360 per 30 days) ; QLL (360 per 30 days) ; QLL (540 per 30 days) ; QLL (180 per 30 days) QLL (1800 per 30 days) ; QLL (360 per 30 days) ; QLL (360 per 30 days) ; ; ; ; ; ; ; ; ; ; ; 有關本表格所含標誌與縮寫的含義, 可參見第 7 38

BETATEMP buprenorphine-naloxone sublingual tablet 2-0.5 mg buprenorphine-naloxone sublingual tablet 8-2 mg butorphanol tartrate injection solution 1 mg/ml butorphanol tartrate injection solution 2 mg/ml butorphanol tartrate nasal CHILD ASPIRIN CHILDREN'S ACETAMINOPHEN ORAL SUSPENSION 160 MG/5 ML, 160 MG/5 ML (5 ML) CHILDREN'S ASPIRIN CHILDREN'S NON-ASPIRIN ORAL SUSPENSION CHILDREN'S PAIN RELIEF ORAL SUSPENSION CHILDREN'S PAIN RELIEVER ORAL SUSPENSION CHILDREN'S PAIN-FEVER RELIEF ORAL SUSPENSION CHILDREN'S Q-PAP diclofenac potassium diclofenac sodium oral diclofenac sodium topical gel 1 % diflunisal ECOTRIN LOW STRENGTH ENTERIC COATED ASPIRIN etodolac oral capsule 200 mg etodolac oral tablet etodolac oral tablet extended release 24 hr EXTRA STRENGTH BAYER fenoprofen oral tablet FEVER REDUCER AN PAIN RELIEVER ORAL SUSPENSION PAR; ; QLL (360 per 30 days) PAR; ; QLL (90 per 30 days) ; QLL (240 per 30 days) ; QLL (120 per 30 days) ; QLL (5 per 28 days) ; ; ; QLL (1000 per 30 days) ; 有關本表格所含標誌與縮寫的含義, 可參見第 7 39

FEVERALL RECTAL SUPPOSITORY 650 MG FLANAX (NAPROXEN) flurbiprofen HEADACHE RELIEF (ASA-ACET-CAF) I-PRIN IBUPROFEN IB ORAL TABLET ibuprofen oral capsule ibuprofen oral suspension ibuprofen oral tablet 200 mg ibuprofen oral tablet 400 mg, 600 mg, 800 mg INFANT FEVER REDUCER-PAIN RELF INFANT PAIN RELIEVER INFANT'S PAIN RELIEF ORAL SUSPENSION INFANTS' PAIN AND FEVER INFANTS' PAIN RELIEF LITTLE REMEDIES FEVER AND PAIN MAPAP EXTRA STRENGTH MASOPHEN ORAL TABLET 500 MG meclofenamate oral MEDIPROXEN meloxicam oral suspension meloxicam oral tablet MENSTRUAL RELIEF MIGRAINE FORMULA MIGRAINE RELIEF nabumetone nalbuphine injection solution 10 mg/ml nalbuphine injection solution 20 mg/ml naloxone naltrexone ; ; ; QLL (300 per 30 days) ; QLL (30 per 30 days) ; QLL (180 per 30 days) ; QLL (90 per 30 days) 有關本表格所含標誌與縮寫的含義, 可參見第 7 40

naproxen naproxen sodium oral capsule naproxen sodium oral tablet 220 mg naproxen sodium oral tablet 275 mg, 550 mg NON-ASPIRIN ORAL SUSPENSION NON-ASPIRIN PAIN RELIEF ORAL TABLET 500 MG oxaprozin PAIN AND FEVER ORAL TABLET 500 MG PAIN RELIEF (ACETAMIN-ASP-CAF) PAIN RELIEF EXTRA STRENGTH PAIN RELIEF ORAL TABLET PAIN RELIEVER (ACETAM-ASPIRIN) PAIN RELIEVER EXTRA STRENGTH PAIN RELIEVER ORAL CAPSULE PAIN RELIEVER ORAL TABLET 500 MG PAIN RELIEVER PLUS PAIN-OFF PAMPRIN MAX PEDIACARE FEVER REDUCER PHARBETOL ORAL TABLET 500 MG piroxicam PROVIL Q-PAP EXTRA STRENGTH Q-PAP ORAL TABLET 500 MG SHAKE THAT ACHE SUBOXONE SUBLINGUAL FILM 12-3 MG SUBOXONE SUBLINGUAL FILM 2-0.5 MG SUBOXONE SUBLINGUAL FILM 4-1 MG SUBOXONE SUBLINGUAL FILM 8-2 MG sulindac oral ; ; ; ; ; PAR; ; QLL (60 per 30 days) PAR; ; QLL (360 per 30 days) PAR; ; QLL (180 per 30 days) PAR; ; QLL (90 per 30 days) 有關本表格所含標誌與縮寫的含義, 可參見第 7 41

SUPER PAIN RELIEF tolmetin tramadol oral tablet tramadol-acetaminophen VOLTAREN GEL TOPICAL GEL 1 % WAL-PROFEN WAL-PROXEN PSYCHOTHERAPEUTIC DRUGS ABILIFY MAINTENA ADASUVE alprazolam oral tablet amitriptyline amoxapine aripiprazole oral solution aripiprazole oral tablet 10 mg aripiprazole oral tablet 15 mg aripiprazole oral tablet 2 mg aripiprazole oral tablet 20 mg, 30 mg aripiprazole oral tablet 5 mg aripiprazole oral tablet,disintegrating 10 mg aripiprazole oral tablet,disintegrating 15 mg ARISTADA INTRAMUSCULAR SUSPENSION, EXTENDED REL SYRING 441 MG/1.6 ML ARISTADA INTRAMUSCULAR SUSPENSION, EXTENDED REL SYRING 662 MG/2.4 ML ARISTADA INTRAMUSCULAR SUSPENSION, EXTENDED REL SYRING 882 MG/3.2 ML bupropion hcl oral tablet 100 mg bupropion hcl oral tablet 75 mg bupropion hcl oral tablet extended release 100 mg bupropion hcl oral tablet extended release 150 mg, 200 mg ; QLL (240 per 30 days) ; QLL (240 per 30 days) ; QLL (1000 per 30 days) ; QLL (1 per 28 days) ; QLL (90 per 30 days) PAR; PAR; ; QLL (900 per 30 days) PAR; ; QLL (90 per 30 days) PAR; ; QLL (60 per 30 days) PAR; ; QLL (450 per 30 days) PAR; ; QLL (30 per 30 days) PAR; ; QLL (180 per 30 days) PAR; ; QLL (90 per 30 days) PAR; ; QLL (60 per 30 days) PAR; ; QLL (1.6 per 30 days) PAR; ; QLL (2.4 per 30 days) PAR; ; QLL (3.2 per 30 days) ; QLL (135 per 30 days) ; QLL (180 per 30 days) ; QLL (120 per 30 days) ; QLL (60 per 30 days) 有關本表格所含標誌與縮寫的含義, 可參見第 7 42

bupropion hcl oral tablet extended release 24 hr 150 mg bupropion hcl oral tablet extended release 24 hr 300 mg buspirone chlorpromazine citalopram oral solution citalopram oral tablet 10 mg citalopram oral tablet 20 mg citalopram oral tablet 40 mg clomipramine clorazepate dipotassium clozapine oral tablet 100 mg clozapine oral tablet 200 mg clozapine oral tablet 25 mg clozapine oral tablet 50 mg clozapine oral tablet,disintegrating 100 mg clozapine oral tablet,disintegrating 12.5 mg clozapine oral tablet,disintegrating 150 mg clozapine oral tablet,disintegrating 200 mg clozapine oral tablet,disintegrating 25 mg desipramine oral DESVENLAFAXINE FUMARATE ORAL TABLET EXTENDED RELEASE 24HR 100 MG DESVENLAFAXINE FUMARATE ORAL TABLET EXTENDED RELEASE 24HR 50 MG DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE 24 HR 100 MG DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE 24 HR 50 MG desvenlafaxine oral tablet extended release 24hr 100 mg ; QLL (90 per 30 days) ; QLL (45 per 30 days) PAR; ; QLL (600 per 30 days) ; QLL (120 per 30 days) ; QLL (60 per 30 days) ; QLL (30 per 30 days) PAR; ; QLL (120 per 30 days) ; QLL (270 per 30 days) ; QLL (135 per 30 days) ; QLL (1080 per 30 days) ; QLL (540 per 30 days) QLL (270 per 30 days) QLL (2160 per 30 days) QLL (180 per 30 days) QLL (135 per 30 days) QLL (1080 per 30 days) ; QLL (120 per 30 days) ; QLL (240 per 30 days) ; QLL (120 per 30 days) ; QLL (240 per 30 days) QLL (120 per 30 days) 有關本表格所含標誌與縮寫的含義, 可參見第 7 43

desvenlafaxine oral tablet extended release 24hr 50 mg dextroamphetamine oral capsule, extended release 10 mg, 5 mg dextroamphetamine oral capsule, extended release 15 mg dextroamphetamine oral tablet 10 mg dextroamphetamine oral tablet 5 mg dextroamphetamine-amphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 5 mg, 7.5 mg dextroamphetamine-amphetamine oral tablet 30 mg diazepam injection solution diazepam injection syringe diazepam intensol diazepam oral concentrate diazepam oral solution 5 mg/5 ml (1 mg/ml) DIAZEPAM ORAL SOLUTION 5 MG/5 ML (1 MG/ML, 5 ML) diazepam oral tablet 10 mg diazepam oral tablet 2 mg diazepam oral tablet 5 mg doxepin oral duloxetine oral capsule,delayed release(dr/ec) 20 mg duloxetine oral capsule,delayed release(dr/ec) 30 mg duloxetine oral capsule,delayed release(dr/ec) 40 mg duloxetine oral capsule,delayed release(dr/ec) 60 mg EMSAM ergoloid escitalopram oxalate oral solution QLL (240 per 30 days) ; QLL (60 per 30 days) ; QLL (120 per 30 days) ; QLL (180 per 30 days) ; QLL (90 per 30 days) PAR; ; QLL (90 per 30 days) PAR; ; QLL (60 per 30 days) PAR; ; QLL (240 per 30 days) PAR; ; QLL (240 per 30 days) PAR; ; QLL (1200 per 30 days) PAR; QLL (1200 per 30 days) PAR; ; QLL (120 per 30 days) PAR; ; QLL (600 per 30 days) PAR; ; QLL (240 per 30 days) PAR; ; QLL (180 per 30 days) ; QLL (120 per 30 days) ; QLL (90 per 30 days) ; QLL (60 per 30 days) PAR; ; QLL (30 per 30 days) PAR; ; QLL (600 per 30 days) 有關本表格所含標誌與縮寫的含義, 可參見第 7 44