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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

escitalopram oxalate oral tablet 10 mg escitalopram oxalate oral tablet 20 mg escitalopram oxalate oral tablet 5 mg FANAPT ORAL TABLET 1 MG FANAPT ORAL TABLET 10 MG FANAPT ORAL TABLET 12 MG FANAPT ORAL TABLET 2 MG FANAPT ORAL TABLET 4 MG FANAPT ORAL TABLET 6 MG FANAPT ORAL TABLET 8 MG FANAPT ORAL TABLETS,DOSE PACK FETZIMA ORAL CAPSULE,EXT REL 24HR DOSE PACK FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR 120 MG, 80 MG FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR 20 MG FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR 40 MG fluoxetine oral capsule 10 mg fluoxetine oral capsule 20 mg fluoxetine oral capsule 40 mg fluoxetine oral solution fluoxetine oral tablet 10 mg fluoxetine oral tablet 20 mg fluphenazine decanoate fluphenazine hcl fluvoxamine oral tablet 100 mg fluvoxamine oral tablet 25 mg fluvoxamine oral tablet 50 mg GEODON INTRAMUSCULAR guanfacine oral tablet extended release 24 hr ; QLL (60 per 30 days) ; QLL (30 per 30 days) ; QLL (120 per 30 days) ST; ; QLL (720 per 30 days) ST; QLL (72 per 30 days) ST; ; QLL (60 per 30 days) ST; ; QLL (360 per 30 days) ST; ; QLL (180 per 30 days) ST; ; QLL (120 per 30 days) ST; ; QLL (90 per 30 days) ST; ; QLL (16 per 365 days) PAR; ; QLL (56 per 365 days) PAR; ; QLL (30 per 30 days) PAR; ; QLL (180 per 30 days) PAR; ; QLL (90 per 30 days) ; QLL (240 per 30 days) ; QLL (120 per 30 days) ; QLL (60 per 30 days) ; QLL (600 per 30 days) ; QLL (240 per 30 days) ; QLL (120 per 30 days) ; QLL (90 per 30 days) ; QLL (360 per 30 days) ; QLL (180 per 30 days) 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 45

guanidine haloperidol haloperidol decanoate haloperidol lactate HETLIOZ imipramine hcl INVEGA ORAL TABLET EXTENDED RELEASE 24HR 1.5 MG INVEGA ORAL TABLET EXTENDED RELEASE 24HR 3 MG INVEGA ORAL TABLET EXTENDED RELEASE 24HR 6 MG INVEGA ORAL TABLET EXTENDED RELEASE 24HR 9 MG INVEGA SUSTENNA INVEGA TRINZA INTRAMUSCULAR SYRINGE 273 MG/0.875 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 410 MG/1.315 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 546 MG/1.75 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 819 MG/2.625 ML KHEDEZLA ORAL TABLET EXTENDED RELEASE 24HR 100 MG KHEDEZLA ORAL TABLET EXTENDED RELEASE 24HR 50 MG LATUDA ORAL TABLET 120 MG LATUDA ORAL TABLET 20 MG LATUDA ORAL TABLET 40 MG LATUDA ORAL TABLET 60 MG LATUDA ORAL TABLET 80 MG lithium carbonate lithium citrate oral solution 8 meq/5 ml PAR; ; QLL (30 per 30 days) PAR; PAR; ; QLL (240 per 30 days) PAR; ; QLL (120 per 30 days) PAR; ; QLL (60 per 30 days) PAR; ; QLL (30 per 30 days) ; QLL (2 per 28 days) ; QLL (0.875 per 90 days) ; QLL (1.315 per 90 days) ; QLL (1.75 per 90 days) ; QLL (2.625 per 90 days) ; QLL (120 per 30 days) ; QLL (240 per 30 days) PAR; ; QLL (30 per 30 days) PAR; ; QLL (240 per 30 days) PAR; ; QLL (120 per 30 days) PAR; ; QLL (75 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 46

lorazepam oral tablet loxapine succinate maprotiline oral tablet 25 mg maprotiline oral tablet 50 mg maprotiline oral tablet 75 mg MARPLAN methylphenidate oral tablet mirtazapine oral tablet 15 mg mirtazapine oral tablet 30 mg mirtazapine oral tablet 45 mg mirtazapine oral tablet 7.5 mg mirtazapine oral tablet,disintegrating 15 mg mirtazapine oral tablet,disintegrating 30 mg mirtazapine oral tablet,disintegrating 45 mg modafinil oral tablet 100 mg modafinil oral tablet 200 mg molindone nefazodone oral tablet 100 mg nefazodone oral tablet 150 mg nefazodone oral tablet 200 mg nefazodone oral tablet 250 mg nefazodone oral tablet 50 mg nortriptyline NUPLAZID olanzapine intramuscular olanzapine oral tablet 10 mg olanzapine oral tablet 15 mg olanzapine oral tablet 2.5 mg olanzapine oral tablet 20 mg olanzapine oral tablet 5 mg ; QLL (90 per 30 days) ; QLL (270 per 30 days) ; QLL (135 per 30 days) ; QLL (90 per 30 days) ; QLL (90 per 30 days) ; QLL (45 per 30 days) ; QLL (30 per 30 days) ; QLL (180 per 30 days) ; QLL (90 per 30 days) ; QLL (45 per 30 days) ; QLL (30 per 30 days) PAR; ; QLL (30 per 30 days) PAR; ; QLL (60 per 30 days) ; QLL (180 per 30 days) ; QLL (120 per 30 days) ; QLL (90 per 30 days) ; QLL (72 per 30 days) ; QLL (360 per 30 days) PAR; LA; QLL (60 per 30 days) ; QLL (60 per 30 days) ; QLL (60 per 30 days) ; QLL (40 per 30 days) ; QLL (240 per 30 days) ; QLL (30 per 30 days) ; QLL (120 per 30 days) 有關本表格所含標誌與縮寫的含義, 可參見第 7 47

olanzapine oral tablet 7.5 mg olanzapine oral tablet,disintegrating 10 mg olanzapine oral tablet,disintegrating 15 mg olanzapine oral tablet,disintegrating 20 mg olanzapine oral tablet,disintegrating 5 mg ORAP paliperidone oral tablet extended release 24hr 1.5 mg paliperidone oral tablet extended release 24hr 3 mg paliperidone oral tablet extended release 24hr 6 mg paliperidone oral tablet extended release 24hr 9 mg paroxetine hcl oral tablet 10 mg paroxetine hcl oral tablet 20 mg paroxetine hcl oral tablet 30 mg paroxetine hcl oral tablet 40 mg paroxetine hcl oral tablet extended release 24 hr 12.5 mg paroxetine hcl oral tablet extended release 24 hr 25 mg paroxetine hcl oral tablet extended release 24 hr 37.5 mg PAXIL ORAL SUSPENSION perphenazine phenelzine pimozide protriptyline quetiapine oral tablet 100 mg quetiapine oral tablet 200 mg quetiapine oral tablet 25 mg quetiapine oral tablet 300 mg ; QLL (80 per 30 days) ; QLL (60 per 30 days) ; QLL (40 per 30 days) ; QLL (30 per 30 days) ; QLL (120 per 30 days) PAR; ; QLL (240 per 30 days) PAR; ; QLL (120 per 30 days) PAR; ; QLL (60 per 30 days) PAR; ; QLL (30 per 30 days) ; QLL (180 per 30 days) ; QLL (90 per 30 days) ; QLL (60 per 30 days) ; QLL (45 per 30 days) ; QLL (180 per 30 days) ; QLL (90 per 30 days) ; QLL (60 per 30 days) ; QLL (900 per 30 days) ; QLL (240 per 30 days) ; QLL (120 per 30 days) ; QLL (960 per 30 days) ; QLL (80 per 30 days) 有關本表格所含標誌與縮寫的含義, 可參見第 7 48

quetiapine oral tablet 400 mg quetiapine oral tablet 50 mg REXULTI ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG REXULTI ORAL TABLET 3 MG, 4 MG RISPERDAL CONSTA INTRAMUSCULAR SYRINGE 12.5 MG/2 ML, 25 MG/2 ML, 37.5 MG/ 2 ML RISPERDAL CONSTA INTRAMUSCULAR SYRINGE 50 MG/2 ML risperidone oral solution risperidone oral tablet 0.25 mg risperidone oral tablet 0.5 mg risperidone oral tablet 1 mg risperidone oral tablet 2 mg risperidone oral tablet 3 mg risperidone oral tablet 4 mg risperidone oral tablet,disintegrating 0.25 mg risperidone oral tablet,disintegrating 0.5 mg risperidone oral tablet,disintegrating 1 mg risperidone oral tablet,disintegrating 2 mg risperidone oral tablet,disintegrating 3 mg risperidone oral tablet,disintegrating 4 mg ROZEREM SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 10 MG SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 2.5 MG SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 5 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 150 MG ; QLL (60 per 30 days) ; QLL (480 per 30 days) PAR; ; QLL (60 per 30 days) PAR; ; QLL (30 per 30 days) ; QLL (2 per 28 days) ; QLL (480 per 30 days) ; QLL (1920 per 30 days) ; QLL (960 per 30 days) ; QLL (480 per 30 days) ; QLL (240 per 30 days) ; QLL (150 per 30 days) ; QLL (120 per 30 days) ; QLL (1920 per 30 days) ; QLL (960 per 30 days) ; QLL (480 per 30 days) ; QLL (240 per 30 days) ; QLL (150 per 30 days) ; QLL (120 per 30 days) ; QLL (30 per 30 days) PAR; ; QLL (60 per 30 days) PAR; ; QLL (240 per 30 days) PAR; ; QLL (120 per 30 days) PAR; ; 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 49

SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 200 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 300 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 400 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 50 MG sertraline oral concentrate sertraline oral tablet 100 mg sertraline oral tablet 25 mg sertraline oral tablet 50 mg SLEEP AID (DOXYLAMINE) STRATTERA ORAL CAPSULE 10 MG, 18 MG, 25 MG, 40 MG STRATTERA ORAL CAPSULE 100 MG, 60 MG, 80 MG SURNTIL temazepam oral capsule 15 mg, 22.5 mg, 30 mg thioridazine thiothixene tranylcypromine trazodone trifluoperazine TRINTELLIX ORAL TABLET 10 MG TRINTELLIX ORAL TABLET 20 MG TRINTELLIX ORAL TABLET 5 MG ULTRA SLEEP (DOXYLAMINE SUCC) venlafaxine oral capsule,extended release 24hr 150 mg venlafaxine oral capsule,extended release 24hr 37.5 mg PAR; ; QLL (120 per 30 days) PAR; ; QLL (80 per 30 days) PAR; ; QLL (60 per 30 days) PAR; ; QLL (480 per 30 days) ; QLL (300 per 30 days) ; QLL (60 per 30 days) ; QLL (240 per 30 days) ; QLL (120 per 30 days) PAR; ; QLL (60 per 30 days) PAR; ; QLL (30 per 30 days) PAR; ; QLL (30 per 30 days) PAR; ST; QLL (60 per 30 days) ST; QLL (30 per 30 days) ST; QLL (120 per 30 days) ; QLL (60 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 50

venlafaxine oral capsule,extended release 24hr 75 mg venlafaxine oral tablet 100 mg venlafaxine oral tablet 25 mg venlafaxine oral tablet 37.5 mg venlafaxine oral tablet 50 mg venlafaxine oral tablet 75 mg venlafaxine oral tablet extended release 24hr 150 mg venlafaxine oral tablet extended release 24hr 37.5 mg venlafaxine oral tablet extended release 24hr 75 mg VERSACLOZ VIIBRYD ORAL TABLET 10 MG VIIBRYD ORAL TABLET 20 MG VIIBRYD ORAL TABLET 40 MG VIIBRYD ORAL TABLETS,DOSE PACK 10 MG (7)- 20 MG (23) VRAYLAR ORAL CAPSULE VRAYLAR ORAL CAPSULE,DOSE PACK WAL-SOM (DOXYLAMINE) XYREM zaleplon oral capsule 10 mg zaleplon oral capsule 5 mg zenzedi oral tablet 10 mg zenzedi oral tablet 5 mg ziprasidone hcl oral capsule 20 mg ziprasidone hcl oral capsule 40 mg ziprasidone hcl oral capsule 60 mg, 80 mg zolpidem oral tablet ; QLL (90 per 30 days) ; QLL (113 per 30 days) ; QLL (450 per 30 days) ; QLL (300 per 30 days) ; QLL (225 per 30 days) ; QLL (150 per 30 days) ; QLL (60 per 30 days) ; QLL (180 per 30 days) ; QLL (90 per 30 days) QLL (600 per 30 days) ST; ; QLL (120 per 30 days) ST; ; QLL (60 per 30 days) ST; ; QLL (30 per 30 days) ST; ; QLL (30 per 30 days) PAR; QLL (30 per 30 days) PAR; QLL (7 per 365 days) PAR; ; LA; QLL (540 per 30 days) PAR; ; QLL (60 per 30 days) PAR; ; QLL (30 per 30 days) PAR; ; QLL (180 per 30 days) PAR; ; QLL (90 per 30 days) ; QLL (240 per 30 days) ; QLL (120 per 30 days) ; QLL (60 per 30 days) 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 51

ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 210 MG, 405 MG ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 300 MG CARDIOVASCULAR, HYPERTENSION / LIPIDS ANTIARRHYTHMIC AGENTS amiodarone intravenous solution AMIODARONE INTRAVENOUS SYRINGE amiodarone oral dofetilide flecainide lidocaine (pf) intravenous solution LIDOCAINE (PF) INTRAVENOUS SYRINGE mexiletine MULTAQ pacerone oral tablet 100 mg, 200 mg, 400 mg procainamide injection solution 100 mg/ml procainamide injection solution 500 mg/ml propafenone oral tablet quinidine sulfate oral tablet 200 mg, 300 mg sorine oral tablet 120 mg, 160 mg, 80 mg sorine oral tablet 240 mg sotalol af oral tablet 120 mg SOTALOL AF ORAL TABLET 160 MG, 80 MG sotalol oral tablet 120 mg sotalol oral tablet 160 mg, 240 mg, 80 mg TIKOSYN ANTIHYPERTENSIVE THERAPY acebutolol afeditab cr PAR; QLL (2 per 28 days) PAR; ; QLL (2 per 28 days) B/D PAR; B/D 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 52

amiloride amiloride-hydrochlorothiazide amlodipine besylate oral tablet 10 mg, 2.5 mg amlodipine besylate oral tablet 5 mg amlodipine-benazepril amlodipine-valsartan amlodipine-valsartan-hcthiazid atenolol atenolol-chlorthalidone AZOR benazepril benazepril-hydrochlorothiazide betaxolol oral bisoprolol fumarate bisoprolol-hydrochlorothiazide bumetanide BYSTOLIC candesartan oral tablet 16 mg, 4 mg, 8 mg candesartan oral tablet 32 mg candesartan-hydrochlorothiazid oral tablet 16-12.5 mg candesartan-hydrochlorothiazid oral tablet 32-12.5 mg, 32-25 mg captopril captopril-hydrochlorothiazide cartia xt carvedilol chlorothiazide chlorothiazide sodium chlorthalidone oral tablet 25 mg, 50 mg clonidine hcl oral tablet ; QLL (30 per 30 days) ; QLL (45 per 30 days) ; QLL (30 per 30 days) ; QLL (30 per 30 days) ; QLL (30 per 30 days) ; QLL (60 per 30 days) ; QLL (30 per 30 days) ; QLL (60 per 30 days) ; QLL (30 per 30 days) 有關本表格所含標誌與縮寫的含義, 可參見第 7 53

clonidine transdermal patches COREG CR DEMSER dilt-xr diltiazem hcl intravenous diltiazem hcl oral capsule, extended release 120 mg, 240 mg, 300 mg diltiazem hcl oral capsule, extended release 180 mg, 360 mg, 420 mg diltiazem hcl oral capsule,ext release degradable diltiazem hcl oral capsule,extended release 12 hr diltiazem hcl oral capsule,extended release 24hr 120 mg, 240 mg, 300 mg diltiazem hcl oral capsule,extended release 24hr 180 mg, 360 mg diltiazem hcl oral tablet diltiazem hcl oral tablet extended release 24 hr doxazosin enalapril maleate enalapril-hydrochlorothiazide eplerenone eprosartan felodipine oral er fosinopril fosinopril-hydrochlorothiazide furosemide injection furosemide oral solution 10 mg/ml, 40 mg/5 ml (8 mg/ml) furosemide oral tablet hydralazine hydrochlorothiazide indapamide ; QLL (4 per 28 days) ST; ; 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 54

irbesartan irbesartan-hydrochlorothiazide oral tablet 150-12.5 mg irbesartan-hydrochlorothiazide oral tablet 300-12.5 mg isradipine labetalol intravenous solution labetalol oral lisinopril lisinopril-hydrochlorothiazide losartan oral tablet 100 mg losartan oral tablet 25 mg, 50 mg losartan-hydrochlorothiazide methyclothiazide metolazone metoprolol succinate metoprolol ta-hydrochlorothiaz metoprolol tartrate intravenous solution metoprolol tartrate intravenous syringe metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg metoprolol tartrate oral tablet 37.5 mg, 75 mg minoxidil oral moexipril moexipril-hydrochlorothiazide nadolol nadolol-bendroflumethiazide nicardipine intravenous solution nicardipine oral nifedical xl nifedipine oral tablet extended release ; QLL (30 per 30 days) ; QLL (60 per 30 days) ; QLL (30 per 30 days) ; QLL (30 per 30 days) ; QLL (60 per 30 days) ; QLL (30 per 30 days) 有關本表格所含標誌與縮寫的含義, 可參見第 7 55

nifedipine oral tablet extended release 24hr nimodipine perindopril erbumine pindolol prazosin oral propranolol intravenous propranolol oral propranolol-hydrochlorothiazid quinapril quinapril-hydrochlorothiazide ramipril spironolacton-hydrochlorothiaz spironolactone taztia xt TEKTURNA TEKTURNA HCT telmisartan oral tablet 20 mg, 40 mg telmisartan oral tablet 80 mg telmisartan-amlodipine telmisartan-hydrochlorothiazid oral tablet 40-12.5 mg, 80-25 mg telmisartan-hydrochlorothiazid oral tablet 80-12.5 mg terazosin timolol maleate oral torsemide oral trandolapril triamterene-hydrochlorothiazid oral capsule 37.5-25 mg triamterene-hydrochlorothiazid oral tablet TRIBENZOR ; QLL (30 per 30 days) ; QLL (30 per 30 days) ; QLL (30 per 30 days) ; QLL (60 per 30 days) ; QLL (30 per 30 days) ; QLL (30 per 30 days) ; QLL (60 per 30 days) ; QLL (30 per 30 days) 有關本表格所含標誌與縮寫的含義, 可參見第 7 56

valsartan oral tablet 160 mg valsartan oral tablet 320 mg valsartan oral tablet 40 mg, 80 mg valsartan-hydrochlorothiazide verapamil intravenous solution verapamil intravenous syringe verapamil oral capsule, 24 hr er pellet ct verapamil oral capsule,ext rel. pellets 24 hr verapamil oral tablet verapamil oral tablet extended release 120 mg (24 hours) verapamil oral tablet extended release 120 mg, 180 mg, 240 mg CARDIAC GLYCOSIDES DIGITEK ORAL TABLET 125 MCG DIGOX ORAL TABLET 125 MCG digoxin oral solution 50 mcg/ml digoxin oral tablet 125 mcg LANOXIN ORAL TABLET 125 MCG, 62.5 MCG COAGULATION THERAPY AGGRENOX aspirin-dipyridamole BRILINTA cilostazol clopidogrel oral tablet 300 mg clopidogrel oral tablet 75 mg COUMADIN ORAL EFFIENT ELIQUIS ORAL TABLET 2.5 MG ELIQUIS ORAL TABLET 5 MG enoxaparin subcutaneous solution ; QLL (60 per 30 days) ; QLL (30 per 30 days) ; QLL (90 per 30 days) ; QLL (30 per 30 days) ST; ; QLL (60 per 30 days) ST; ; QLL (60 per 30 days) ; QLL (60 per 30 days) ; QLL (1 per 30 days) ; QLL (30 per 30 days) ; QLL (30 per 30 days) ; QLL (60 per 30 days) ; QLL (74 per 30 days) ; QLL (84 per 30 days) 有關本表格所含標誌與縮寫的含義, 可參見第 7 57

enoxaparin subcutaneous syringe 100 mg/ml, 150 mg/ml enoxaparin subcutaneous syringe 120 mg/0.8 ml, 80 mg/0.8 ml enoxaparin subcutaneous syringe 30 mg/0.3 ml enoxaparin subcutaneous syringe 40 mg/0.4 ml enoxaparin subcutaneous syringe 60 mg/0.6 ml fondaparinux subcutaneous syringe 10 mg/0.8 ml fondaparinux subcutaneous syringe 2.5 mg/0.5 ml fondaparinux subcutaneous syringe 5 mg/0.4 ml fondaparinux subcutaneous syringe 7.5 mg/0.6 ml HEPARIN (PORCINE) IN 5 % DEX INTRAVENOUS PARENTERAL SOLUTION 12, 500 UNIT/250 ML heparin (porcine) in 5 % dex intravenous parenteral solution 25,000 unit/250 ml(100 unit/ml), 25,000 unit/500 ml (50 unit/ml) HEPARIN (PORCINE) IN NACL (PF) INTRAVENOUS PARENTERAL SOLUTION 1, 000 UNIT/500 ML, 2,000 UNIT/1,000 ML HEPARIN (PORCINE) INJECTION CARTRIDGE heparin (porcine) injection solution HEPARIN FLUSH heparin lock flush intravenous kit 100 unit/ml heparin lock flush intravenous solution 10 unit/ml, 100 unit/ml heparin lock flush intravenous syringe 10 unit/ml HEPARIN LOCK FLUSH INTRAVENOUS SYRINGE 100 UNIT/ML HEPARIN LOCKFLUSH(PORCINE)(PF) HEPARIN(PORCINE) IN 0.45% NACL INTRAVENOUS PARENTERAL SOLUTION 12, 500 UNIT/250 ML $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) ; QLL (28 per 30 days) ; QLL (22.4 per 30 days) ; QLL (8.4 per 30 days) ; QLL (11.2 per 30 days) ; QLL (16.8 per 30 days) ; QLL (24 per 30 days) ; QLL (15 per 30 days) ; QLL (12 per 30 days) ; QLL (18 per 30 days) B/D PAR B/D PAR B/D PAR; B/D PAR; ; ; ; ; B/D PAR 有關本表格所含標誌與縮寫的含義, 可參見第 7 58

HEPARIN(PORCINE) IN 0.45% NACL INTRAVENOUS PARENTERAL SOLUTION 25, 000 UNIT/250 ML HEPARIN(PORCINE) IN 0.45% NACL INTRAVENOUS PARENTERAL SOLUTION 25, 000 UNIT/500 ML HEPARIN, PORCINE (PF) INJECTION SOLUTION heparin, porcine (pf) intravenous solution 100 unit/ ml (1 ml) HEPARIN, PORCINE (PF) INTRAVENOUS SYRINGE 1 UNIT/ML heparin, porcine (pf) intravenous syringe 10 unit/ ml, 100 unit/ml jantoven MEPHYTON NOJECT PREFILL (PF) NOJECT PREFILL ADVANCED (PF) pentoxifylline PRADAXA PROMACTA ORAL TABLET 12.5 MG, 25 MG, 75 MG PROMACTA ORAL TABLET 50 MG tranexamic acid intravenous warfarin XARELTO ORAL TABLET 10 MG, 20 MG XARELTO ORAL TABLET 15 MG XARELTO ORAL TABLETS,DOSE PACK LIPID/CHOLESTEROL LOWERING AGENTS ALTOPREV amlodipine-atorvastatin atorvastatin cholestyramine (with sugar) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) B/D PAR; ; ; ; ; QLL (60 per 30 days) PAR; ; LA; QLL (30 per 30 days) PAR; ; LA; QLL (60 per 30 days) ; QLL (30 per 30 days) ; QLL (42 per 30 days) ; QLL (102 per 365 days) PAR; ; QLL (30 per 30 days) ; QLL (30 per 30 days) ; QLL (30 per 30 days) 有關本表格所含標誌與縮寫的含義, 可參見第 7 59

cholestyramine light colestipol CRESTOR fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg fenofibrate nanocrystallized 48 mg, 145 mg fenofibrate oral tablet 160 mg, 54 mg gemfibrozil oral JUXTAPID lovastatin oral tablet 10 mg, 20 mg lovastatin oral tablet 40 mg niacin oral capsule, extended release 250 mg, 500 mg niacin oral tablet NIACIN ORAL TABLET niacin oral tablet extended release 24 hr 1,000 mg, 750 mg niacin oral tablet extended release 24 hr 500 mg niacin oral tablet extended release 250 mg, 750 mg NIACOR omega-3 acid ethyl esters PRALUENT PEN PRALUENT SYRINGE pravastatin prevalite REPATHA SURECLICK REPATHA SYRINGE rosuvastatin simvastatin VASCEPA WELCHOL ; QLL (30 per 30 days) ; QLL (30 per 30 days) ; QLL (30 per 30 days) PAR; ; LA ; QLL (30 per 30 days) ; QLL (60 per 30 days) ; ; ; ; QLL (60 per 30 days) ; QLL (30 per 30 days) ; PAR; PAR; ; QLL (2 per 28 days) PAR; ; QLL (2 per 28 days) ; QLL (30 per 30 days) PAR; ; QLL (3 per 28 days) PAR; ; QLL (3 per 28 days) QLL (30 per 30 days) ; QLL (30 per 30 days) 有關本表格所含標誌與縮寫的含義, 可參見第 7 60

ZETIA MISCELLANEOUS CARDIOVASCULAR AGENTS RANEXA VECAMYL NITRATES isosorbide dinitrate oral isosorbide mononitrate nitro-bid nitroglycerin intravenous nitroglycerin transdermal patch 24 hour NITROSTAT DERMATOLOGICALS/TOPICAL THERAPY ANTIPSORIATIC / ANTISEBORRHEIC acitretin calcipotriene scalp calcipotriene topical selenium sulfide topical lotion BURN THERAPY silver sulfadiazine ssd KERATOLYTICS SALICYLIC ACID TOPICAL LIQUID 3 % SCALP RELIEF HYDROCORTISONE SOLUTION TOPICAL LIQUID 3 % MISCELLANEOUS DERMATOLOGICALS AMLACTIN TOPICAL LOTION ammonium lactate AMNIUM LACTATE TOPICAL LOTION 12 % AMNIUM LACTATE TOPICAL LOTION 5 % ; QLL (30 per 30 days) B/D PAR ; QLL (60 per 30 days) ; QLL (120 per 30 days) ; ; 有關本表格所含標誌與縮寫的含義, 可參見第 7 61

AQUA CARE calamine CALAMINE-ZINC OXIDE TOPICAL LOTION 8-8 % ELIDEL fluorouracil topical cream 5 % fluorouracil topical solution imiquimod methoxsalen rapid OXSORALEN PANRETIN PICATO podofilox SKIN TREATMENT tacrolimus topical urea topical cream 10 %, 20 % UREA TOPICAL CREAM 20% urea topical lotion 10 % UREACIN-20 UVADEX VALCHLOR THERAPY FOR ACNE ACNE MEDICATION TOPICAL GEL 10 % ACNE TREATMENT (BENZOYL PEROX) TOPICAL GEL ACNE-CLEAR adapalene topical gel 0.3 % adapalene topical gel with pump benzoyl peroxide topical gel 10 %, 5 % BP clindamycin phosphate topical ; ; PAR; ; QLL (100 per 90 days) PAR; PAR; ; QLL (100 per 90 days) ; ; ; ; ; 有關本表格所含標誌與縮寫的含義, 可參見第 7 62

ery pads erythromycin with ethanol erythromycin-benzoyl peroxide metronidazole topical cream metronidazole topical gel 0.75 % metronidazole topical lotion PERSA-GEL ROSADAN TOPICAL CREAM TAZORAC tretinoin topical cream tretinoin topical gel 0.01 %, 0.025 % TOPICAL ANESTHETICS LIDOCAINE (PF) INJECTION SOLUTION 15 MG/ML (1.5 %) lidocaine (pf) injection solution 20 mg/ml (2 %), 40 mg/ml (4 %), 5 mg/ml (0.5 %) lidocaine hcl injection solution 20 mg/ml (2 %), 5 mg/ml (0.5 %) lidocaine hcl laryngotracheal lidocaine hcl mucous membrane lidocaine hcl urethral lidocaine topical adhesive patch,medicated lidocaine topical ointment LIDOCAINE VISCOUS lidocaine-prilocaine topical cream TOPICAL ANTIBACTERIALS ANTIBIOTIC (NEOMY-BACIT-POLYM) ANTIBIOTIC-PAIN RELIEF (BACIT) bacitracin topical ointment BACITRACIN TOPICAL PACKET BACITRACIN ZINC TOPICAL PACKET PAR; ; QLL (45 per 30 days) ; QLL (45 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 63

bacitracin-polymyxin b topical ointment bacitracin-polymyxin b topical packet BACITRAYCIN PLUS TOPICAL OINTMENT 500 UNIT/GRAM DOUBLE ANTIBIOTIC gentamicin topical mupirocin calcium mupirocin topical ointment NEOSPORIN PLUS PAINRELIEF(BAC) POLY BACITRACIN sulfacetamide sodium (acne) SULFAMYLON TOPICAL CREAM TRI-BIOZENE TRIPLE ANTIBIOTIC (PRAM) EXTRA TRIPLE ANTIBIOTIC PLUS TRIPLE ANTIBIOTIC TOPICAL OINTMENT TRIPLE ANTIBIOTIC TOPICAL OINTMENT IN PACKET TRIPLE ANTIBIOTIC-PAIN RELIEF TOPICAL ANTIFUNGALS AF ANTI-FUNGAL MICONAZOLE POWDER TOPICAL POWDER 2 % antifungal (clotrimazole) ANTIFUNGAL (TOLNAFTATE) TOPICAL AEROSOL,SPRAY ANTIFUNGAL (TOLNAFTATE) TOPICAL CREAM ANTIFUNGAL MICONAZOLE CREAM ANTIFUNGAL SPRAY athlete's foot (clotrimazole) ATHLETE'S FOOT (TERBINAFINE) ; ; ; 有關本表格所含標誌與縮寫的含義, 可參見第 7 64

ATHLETE'S FOOT (TOLNAFTATE) ATHLETE'S FOOT AF ATHLETE'S FOOT TOPICAL POWDER BAZA ANTIFUNGAL CICLODAN TOPICAL SOLUTION ciclopirox topical cream ciclopirox topical gel ciclopirox topical shampoo ciclopirox topical solution ciclopirox topical suspension CLOTRIMAZOLE AF CLOTRIMAZOLE ANTIFUNGAL clotrimazole topical clotrimazole-betamethasone DESENEX TOPICAL POWDER econazole topical FOOT AND SNEAKER FUNGOID-D INZO ANTIFUNGAL ITCH RELIEF (CLOTRIMAZOLE) JOCK ITCH jock itch (clotrimazole) JOCK ITCH (TERBINAFINE) ketoconazole topical LAMISIL AF TOPICAL AEROSOL POWDER LAMISIL AT TOPICAL CREAM lotrimin af topical cream LOTRIMIN AF TOPICAL POWDER MICATIN miconazole nitrate topical cream ; PAR; PAR; ; ; ; ; ; ; 有關本表格所含標誌與縮寫的含義, 可參見第 7 65

MICONAZORB AF MICRO-GUARD nystatin topical nystatin-triamcinolone nystop ODOR CONTROL FOOT-SNEAKER REMEDY PHYTOPLEX ANTIFUNGAL TOPICAL POWDER RINGWORM SECURA ANTIFUNGAL SECURA ANTIFUNGAL EXTRA THICK terbinafine hcl topical TINACTIN TOPICAL AEROSOL POWDER tolnaftate topical aerosol powder tolnaftate topical cream ZEASORB (MICONAZOLE) TOPICAL ANTIVIRALS acyclovir topical DENAVIR TOPICAL CORTICOSTEROIDS ala-cort topical cream alclometasone amcinonide anti-itch (hc) topical cream anti-itch (hc) topical ointment AVEENO ANTI-ITCH (HYDROCORTSN) BETA-HC betamethasone dipropionate betamethasone valerate topical cream betamethasone valerate topical lotion betamethasone valerate topical ointment ; ; ; ; ; ; QLL (30 per 30 days) ; QLL (5 per 2 days) ; 有關本表格所含標誌與縮寫的含義, 可參見第 7 66

betamethasone, augmented CAPEX clobetasol scalp clobetasol topical cream clobetasol topical foam clobetasol topical gel clobetasol topical ointment clobetasol-emollient topical cream cormax scalp cortisone (hydrocortisone) topical cream CORTIZONE-10 PLUS CORTIZONE-10 TOPICAL CREAM cortizone-10 topical ointment DERMAREST ECZEMA (HYDROCORT) DERMATOP TOPICAL OINTMENT desonide desoximetasone diflorasone ECZEMA ANTI-ITCH fluocinolone fluocinolone and shower cap fluocinonide topical cream 0.05 % fluocinonide topical gel fluocinonide topical ointment fluocinonide topical solution fluocinonide-e fluticasone topical halobetasol propionate HALOG hydrocortisone acetate topical ; 有關本表格所含標誌與縮寫的含義, 可參見第 7 67

hydrocortisone plus hydrocortisone topical cream 0.5 % hydrocortisone topical cream 1 %, 2.5 % hydrocortisone topical lotion 1 % hydrocortisone topical lotion 2.5 % hydrocortisone topical ointment 0.5 % hydrocortisone topical ointment 1 %, 2.5 % hydrocortisone valerate HYDROCORTISONE-MIN OIL-WHT PET HYDROCREAM HYDROSKIN TOPICAL LOTION mometasone topical NEOSPORIN ANTI-ITCH NOBLE FORMULA HC TOPICAL CREAM RECORT PLUS SCALP RELIEF HYDROCORTISONE SOLUTION TOPICAL SOLUTION 1 % SCALPICIN ANTI-ITCH SOOTHING CARE (HYDROCORTISONE) triamcinolone acetonide topical cream triamcinolone acetonide topical lotion triamcinolone acetonide topical ointment 0.025 %, 0.1 %, 0.5 % trianex triderm topical cream TOPICAL ENZYMES SANTYL TOPICAL SCABICIDES / PEDICULICIDES COMPLETE LICE TREATMENT LICE BEDDING SPRAY LICE COMPLETE KIT 1-2-3 ; ; ; ; ; 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 68

LICE KILLING LICE KILLING (PERMETHRIN) LICE PYRINYL SHAMPOO LICE SOLUTION LICE TREATMENT (PERMETHRIN) LICE TREATMENT TOPICAL LIQUID 1 % LICE TREATMENT TOPICAL SHAMPOO lindane topical shampoo permethrin topical cream permethrin topical liquid RID COMPLETE LICE ELIM KIT TOPICAL STOP LICE DIAGNOSTICS / MISCELLANEOUS AGENTS ANOREXIANTS benzphetamine oral tablet 50 mg phentermine ANTIDOTES acetylcysteine intravenous IRRIGATING SOLUTIONS lactated ringers irrigation neomycin-polymyxin b gu ringers irrigation MISCELLANEOUS AGENTS acamprosate ADAGEN alendronate oral tablet 40 mg anagrelide ARALAST NP BUPHENYL ORAL TABLET CARBAGLU $0 (Tier 3) $0 (Tier 3) ; PAR; ; PAR; ; ; QLL (30 per 30 days) PAR; ; LA PAR; PAR; ; LA 有關本表格所含標誌與縮寫的含義, 可參見第 7 69

CLINIMIX 4.25%/D5W SULFIT FREE CLINIMIX E 2.75%/D10W SUL FREE CLINIMIX E 2.75%/D5W SULF FREE d10 %-0.45 % sodium chloride d2.5 %-0.45 % sodium chloride d5 % and 0.9 % sodium chloride d5 %-0.45 % sodium chloride DEX4 GLUCOSE ORAL GEL DEX4 GLUCOSE ORAL TABLET,CHEWABLE DEX4 GLUCOSE POUCH PACK DEX4 GLUCOSE QUICK DISSOLVE dextrose 10 % and 0.2 % nacl dextrose 10 % in water (d10w) dextrose 25 % in water (d25w) DEXTROSE 30 % IN WATER (D30W) DEXTROSE 40 % IN WATER (D40W) dextrose 5 % in water (d5w) dextrose 5 %-lactated ringers dextrose 5%-0.2 % sod chloride dextrose 5%-0.3 % sod.chloride DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS PARENTERAL SOLUTION DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE dextrose 70 % in water (d70w) dextrose oral gel dextrose with sodium chloride disulfiram EXJADE GLUCO BURST GLUCOSE GEL B/D PAR B/D PAR B/D PAR ; ; PAR; ; LA 有關本表格所含標誌與縮寫的含義, 可參見第 7 70

glucose oral tablet,chewable 4 gram GLUTOSE 15 GLUTOSE 45 INCRELEX kionex levocarnitine (with sugar) levocarnitine oral tablet midodrine ORFADIN ORAL CAPSULE pilocarpine hcl oral PROLASTIN-C RAVICTI RENAGEL RENVELA ORAL POWDER IN PACKET 0.8 GRAM RENVELA ORAL POWDER IN PACKET 2.4 GRAM RENVELA ORAL TABLET riluzole sodium chloride 0.9 % intravenous SODIUM CHLORIDE 0.9 % INTRAVENOUS sodium chloride irrigation sodium polystyrene (sorb free) sodium polystyrene sulfonate oral powder sodium polystyrene sulfonate oral suspension sodium polystyrene sulfonate rectal SODIUM POLYSTYRENE SULFONATE RECTAL SPS ORAL SPS RECTAL SYPRINE ; ; ; PAR; ; LA B/D PAR; LA PAR; LA PAR; ; QLL (525 per 30 days) ST; ; QLL (180 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 71

water for irrigation, sterile SKING DETERRENTS buproban CHANTIX CHANTIX CONTINUING NTH BOX CHANTIX STARTING NTH BOX NICORELIEF nicorette buccal lozenge nicotine (polacrilex) buccal gum nicotine (polacrilex) buccal lozenge NICOTINE TRANSDERMAL nicotine transdermal system transdermal patch 24 hour 14 mg/24 hr, 21 mg/24 hr, 7 mg/24 hr nicotine transdermal system transdermal patch, td daily, sequential 21-14-7 mg/24 hr NICOTROL NS QUIT 2 BUCCAL GUM quit 2 buccal lozenge QUIT 4 BUCCAL GUM quit 4 buccal lozenge stop smoking aid EAR, NOSE / THROAT MEDICATIONS MISCELLANEOUS AGENTS azelastine nasal chlorhexidine gluconate mucous membrane ipratropium bromide nasal NASAL MIST PAROEX ORAL RINSE periogard STERILE SALINE NASAL triamcinolone acetonide dental QLL (60 per 30 days) PAR; ; QLL (60 per 30 days) PAR; ; QLL (56 per 28 days) PAR; ; QLL (106 per 365 days) ; ; ; QLL (20 per 1 day) ; ; ; QLL (20 per 1 day) ; QLL (30 per 30 days) ; ; QLL (30 per 30 days) ; ; QLL (30 per 30 days) ; QLL (120 per 30 days) ; QLL (20 per 1 day) ; QLL (20 per 1 day) ; QLL (20 per 1 day) ; QLL (30 per 25 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 72

TYZINE NASAL DROPS 0.05 % MISCELLANEOUS OTIC PREPARATIONS acetic acid otic acetic acid-aluminum acetate fluocinolone acetonide oil hydrocortisone-acetic acid ofloxacin otic OTIC STEROID / ANTIBIOTIC CIPRODEX COLY-MYCIN S neomycin-polymyxin-hc otic ENDOCRINE/DIABETES ADRENAL HORNES ACTHAR H.P. cortisone dexamethasone DEXAMETHASONE SODIUM PHOS (PF) dexamethasone sodium phosphate injection fludrocortisone hydrocortisone oral methylprednisolone acetate methylprednisolone oral tablets methylprednisolone sodium succ injection recon soln 125 mg, 40 mg methylprednisolone sodium succ intravenous prednisolone oral solution 15 mg/5 ml prednisolone sodium phosphate oral solution 15 mg/5 ml (3 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml) prednisolone sodium phosphate oral tablet, disintegrating prednisone intensol PAR; 有關本表格所含標誌與縮寫的含義, 可參見第 7 73

prednisone oral triamcinolone acetonide injection suspension 10 mg/ml triamcinolone acetonide injection suspension 40 mg/ml ANTITHYROID AGENTS methimazole oral tablet 10 mg, 5 mg propylthiouracil DIABETES THERAPY acarbose oral tablet 100 mg acarbose oral tablet 25 mg acarbose oral tablet 50 mg ACCU-CHEK AVIVA ACCU-CHEK AVIVA PLUS TEST STRP ACCU-CHEK COMPACT PLUS TEST ACCU-CHEK COMPACT TEST ACCU-CHEK MULTICLIX LANCET ACCU-CHEK SMARTVIEW TEST STRIP ACCU-CHEK SOFTCLIX LANCETS alcohol pads BYDUREON BYETTA SUBCUTANEOUS PEN INJECTOR 10 MCG/DOSE(250 MCG/ML) 2.4 ML BYETTA SUBCUTANEOUS PEN INJECTOR 5 MCG/DOSE (250 MCG/ML) 1.2 ML CONDOMS-PREM LUBRICATED CYCLOSET E-Z JECT LANCETS 30 GAUGE E-Z JECT LANCETS 32 GAUGE FANTASY GAUZE PADS 2 X 2 glimepiride oral tablet 1 mg ; QLL (90 per 30 days) ; QLL (360 per 30 days) ; QLL (180 per 30 days) ; ; ; ; ; ; ; QLL (4 per 28 days) ; QLL (2.4 per 30 days) ; QLL (1.2 per 30 days) ; ST; ; QLL (180 per 30 days) ; ; QLL (200 per 30 days) ; QLL (240 per 30 days) 有關本表格所含標誌與縮寫的含義, 可參見第 7 74

glimepiride oral tablet 2 mg glimepiride oral tablet 4 mg glipizide oral tablet 10 mg glipizide oral tablet 5 mg glipizide oral tablet extended release 24hr 10 mg glipizide oral tablet extended release 24hr 2.5 mg glipizide oral tablet extended release 24hr 5 mg glipizide-metformin oral tablet 2.5-250 mg glipizide-metformin oral tablet 2.5-500 mg, 5-500 mg GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT (HUMAN) HUMALOG HUMALOG KWIKPEN HUMALOG MIX 50-50 HUMALOG MIX 50-50 KWIKPEN HUMALOG MIX 75-25 HUMALOG MIX 75-25 KWIKPEN HUMAPEN LUXURA HD HUMULIN 70/30 HUMULIN 70/30 KWIKPEN HUMULIN N HUMULIN N KWIKPEN HUMULIN R HUMULIN R U-500 (CONC) KWIKPEN HUMULIN R U-500 (CONCENTRATED) INSTA-GLUCOSE insulin pen needle INSULIN SYRINGE (DISP) U-100 0.3 ML, 1 ML, 1/2 ML JANUMET ; QLL (120 per 30 days) ; QLL (60 per 30 days) ; QLL (120 per 30 days) ; QLL (240 per 30 days) ; QLL (60 per 30 days) ; QLL (240 per 30 days) ; QLL (120 per 30 days) ; QLL (240 per 30 days) ; QLL (120 per 30 days) ; QLL (200 per 30 days) ; ; QLL (200 per 30 days) ; QLL (200 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 75

JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 100-1,000 MG JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 50-1,000 MG, 50-500 MG JANUVIA ORAL TABLET 100 MG JANUVIA ORAL TABLET 25 MG JANUVIA ORAL TABLET 50 MG JARDIANCE JENTADUETO KINO MICROTHIN LARGE CONDOMS KINO TEXTURED CONDOMS lancets, 30 gauge LANCETS,ULTRA THIN 26 GAUGE LANTUS LANTUS SOLOSTAR LEVEMIR LEVEMIR FLEXTOUCH metformin oral tablet 1,000 mg metformin oral tablet 500 mg metformin oral tablet 850 mg metformin oral tablet extended release 24 hr 500 mg metformin oral tablet extended release 24 hr 750 mg metformin oral tablet extended release 24hr 1,000 mg metformin oral tablet extended release 24hr 500 mg nateglinide oral tablet 120 mg nateglinide oral tablet 60 mg needles, insulin disp.,safety NOVOPEN ECHO ; QLL (30 per 30 days) ; QLL (60 per 30 days) ; QLL (30 per 30 days) ; QLL (120 per 30 days) ; QLL (60 per 30 days) PAR; ; QLL (30 per 30 days) ; QLL (60 per 30 days) ; ; ; QLL (76 per 30 days) ; QLL (153 per 30 days) ; QLL (90 per 30 days) ; QLL (120 per 30 days) ; QLL (80 per 30 days) ; QLL (75 per 30 days) ; QLL (150 per 30 days) ; QLL (90 per 30 days) ; QLL (180 per 30 days) ; QLL (200 per 30 days) ; QLL (200 per 30 days) 有關本表格所含標誌與縮寫的含義, 可參見第 7 76

ONETOUCH DELICA LANCETS ONETOUCH ULTRA TEST ONETOUCH VERIO pioglitazone oral tablet 15 mg pioglitazone oral tablet 30 mg pioglitazone oral tablet 45 mg pioglitazone-glimepiride pioglitazone-metformin PRODIGY LANCETS 28 GAUGE PRODIGY TWIST TOP LANCET PROGLYCEM repaglinide-metformin SYMLINPEN 120 SYMLINPEN 60 SYNJARDY TANZEUM tolazamide oral tablet 250 mg tolazamide oral tablet 500 mg tolbutamide TOUJEO SOLOSTAR TRADJENTA TRULICITY TRUSTEX LATEX CONDOM TRUSTEX LUBRICATED CONDOMS TRUSTEX-RIA LUBRICATED CONDOMS ULTRA THIN LANCETS ULTRA THIN LANCETS 28 GAUGE, 33 GAUGE UNILET COMFORTOUCH LANCET UNILET COMFORTOUCH LANCET 26 GAUGE UNILET EXCELITE II LANCET ; ; ; ; QLL (90 per 30 days) ; QLL (45 per 30 days) ; QLL (30 per 30 days) ; QLL (30 per 30 days) ; QLL (90 per 30 days) ; ; QLL (150 per 30 days) PAR; ; QLL (11 per 30 days) PAR; ; QLL (6 per 30 days) PAR; ; QLL (60 per 30 days) ; QLL (4 per 28 days) ; QLL (120 per 30 days) ; QLL (60 per 30 days) ; QLL (180 per 30 days) ; QLL (30 per 30 days) ; QLL (2 per 28 days) ; ; ; 有關本表格所含標誌與縮寫的含義, 可參見第 7 77

UNILET GP LANCET UNISTIK 3 COMFORT LANCET UNISTIK 3 EXTRA LANCET UNISTIK 3 LANCETS UNISTIK 3 NORMAL LANCET UNISTIK CZT LANCET 23 GAUGE UNISTIK CZT LANCET 28 GAUGE VICTOZA 2-PAK VICTOZA 3-PAK MISCELLANEOUS HORNES ALDURAZYME ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP 20.25 MG/1.25 GRAM (1.62 %) ANDROGEL TRANSDERMAL GEL IN PACKET 1.62 % (20.25 MG/1.25 GRAM) ANDROGEL TRANSDERMAL GEL IN PACKET 1.62 % (40.5 MG/2.5 GRAM) ANDROXY cabergoline calcitonin (salmon) calcitriol intravenous solution 1 mcg/ml calcitriol oral CEREZYME INTRAVENOUS RECON SOLN 400 UNIT danazol oral desmopressin injection desmopressin nasal desmopressin oral doxercalciferol intravenous doxercalciferol oral ELAPRASE ; ; ; ; ; QLL (9 per 30 days) ; QLL (9 per 30 days) PAR; PAR; ; QLL (150 per 30 days) PAR; ; QLL (112.5 per 30 days) PAR; ; QLL (150 per 30 days) PAR; ; QLL (4 per 30 days) B/D PAR; PAR; B/D PAR B/D PAR; PAR; 有關本表格所含標誌與縮寫的含義, 可參見第 7 78

FABRAZYME KORLYM KUVAN ORAL TABLET,SOLUBLE MIACALCIN INJECTION MYOZYME NAGLAZYME NATPARA oxandrolone oral tablet 10 mg oxandrolone oral tablet 2.5 mg pamidronate intravenous recon soln pamidronate intravenous solution 30 mg/10 ml (3 mg/ml), 90 mg/10 ml (9 mg/ml) pamidronate intravenous solution 60 mg/10 ml (6 mg/ml) paricalcitol oral SENSIPAR ORAL TABLET 30 MG, 60 MG SENSIPAR ORAL TABLET 90 MG SOMAVERT STIMATE SYNAREL testosterone cypionate testosterone enanthate testosterone transdermal gel testosterone transdermal gel in metered-dose pump 1.25 gram/ actuation (1 %) testosterone transdermal gel in metered-dose pump 10 mg/0.5 gram /actuation testosterone transdermal gel in packet 1 % (25 mg/ 2.5gram) testosterone transdermal gel in packet 1 % (50 mg/ 5 gram) VPRIV PAR; PAR; PAR; B/D PAR; PAR; PAR; ; LA PAR; ; LA; QLL (2 per 28 days) PAR; ; QLL (60 per 30 days) PAR; ; QLL (120 per 30 days) B/D PAR; B/D PAR; ; QLL (60 per 30 days) ; QLL (120 per 30 days) PAR; PAR; PAR; ; QLL (300 per 30 days) PAR; ; QLL (300 per 30 days) PAR; ; QLL (120 per 30 days) PAR; ; QLL (225 per 30 days) PAR; ; QLL (300 per 30 days) PAR; 有關本表格所含標誌與縮寫的含義, 可參見第 7 79

ZAVESCA ZEMPLAR INTRAVENOUS zoledronic acid intravenous recon soln 4 mg zoledronic acid intravenous solution 4 mg/5 ml ZOMETA INTRAVENOUS SOLUTION 4 MG/ 100 ML THYROID HORNES levothyroxine oral levoxyl oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg liothyronine oral SYNTHROID UNITHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG GASTROENTEROLOGY ANTIDIARRHEALS / ANTISPASDICS ANTI-DIARRHEAL ANTI-DIARRHEAL (LOPERAMIDE) ORAL LIQUID 1 MG/5 ML atropine injection syringe 0.05 mg/ml, 0.1 mg/ml BISMATROL ORAL SUSPENSION 262 MG/15 ML BISMATROL ORAL SUSPENSION 525 MG/15 ML BISMATROL ORAL TABLET,CHEWABLE BISMUTH BISMUTH MAXIMUM STRENGTH bismuth subsalicylate oral tablet,chewable DIARRHEA RELIEF (BISMUTH SUBS) dicyclomine oral capsule dicyclomine oral solution PAR; ; LA B/D PAR; PAR PAR; PAR; ; 有關本表格所含標誌與縮寫的含義, 可參見第 7 80

dicyclomine oral tablet DIOTAME diphenoxylate-atropine GERI-PECTATE glycopyrrolate oral K-PEC ANTIDIARRHEAL (BISM SUB) KAO-TIN (BISMUTH SUBSALICYLAT) KAOPECTATE (BISMUTH SUBSALICY) KAOPECTATE EX STR (BISMUTH SS) loperamide oral capsule loperamide oral liquid 1 mg/5 ml OPIUM TINCTURE PEPTIC RELIEF PEPTO-BISL ORAL TABLET,CHEWABLE PEPTO-BISL TO-GO PINK BISMUTH MAXIMUM STRENGTH PINK BISMUTH ORAL SUSPENSION PINK BISMUTH ORAL TABLET PINK BISMUTH ORAL TABLET,CHEWABLE SOOTHE (BISMUTH SUBSALICYLATE) SOOTHE REGULAR STRENGTH STOMACH RELIEF STOMACH RELIEF MAX STRENGTH STOMACH RELIEF ORIGINAL MISCELLANEOUS GASTROINTESTINAL AGENTS ACID GONE ANTACID E.STRENGTH ADVANCED ANTACID-ANTIGAS ALOPHEN alosetron ALUMINA AND MAGNESIUM ANTACID ORAL SUSPENSION 95-358 MG/15 ML ; ; ; ; 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 81

ALUMINA AND MAGNESIUM ANTACID ORAL TABLET,CHEWABLE 80-20 MG ALUMINA, MAGNESIA, SIMETHICONE SUSPENSION ORAL SUSPENSION 200-200-20 MG/5 ML, 400-400-40 MG/5 ML aluminum hydroxide gel oral suspension 320 mg/5 ml aluminum hydroxide gel oral suspension 600 mg/5 ml AMITIZA ANTACID ANTACID ANTI-GAS ANTACID ANTI-GAS DOUBLE STR ANTACID EXST (MAG CARB-AL HYD) ANTACID EXTRA-STRENGTH ORAL SUSPENSION 200-200-20 MG/5 ML ANTACID LIQUID ANTACID M ANTACID MAXIMUM STRENGTH ANTACID PLUS ANTI-GAS ANTACID REGULAR STRENGTH ANTACID WITH SIMETHICONE ANTACID-ANTIGAS ANTACID-SIMETHICONE APRISO ASACOL HD balsalazide BISA-LAX BISAC-EVAC bisacodyl oral bisacodyl rectal BISCOLAX ; ; ; ; ; 有關本表格所含標誌與縮寫的含義, 可參見第 7 82

budesonide oral CALCIUM CARBONATE AND MAGNESIA ANTACID ORAL SUSPENSION 200-200-20 MG/ 5 ML, 400-400-40 MG/5 ML CALCIUM CARBONATE AND MAGNESIA ANTACID ORAL TABLET,CHEWABLE 700-300 MG CANASA CIMZIA CIMZIA POWDER FOR RECONST CIMZIA STARTER KIT CITRATE OF MAGNESIA CITROMA clearlax col-rite colocort COMFORT GEL COMFORT GEL EXTRA STRENGTH compro constulose CREON CYSTADANE DELZICOL ORAL CAPSULE,DELAYED RELEASE(DR/EC) DIOCTO ORAL LIQUID DIOCTO ORAL SYRUP DIOCTYL DIPENTUM doc-q-lace DOCU DOCUPRENE docusate calcium ; PAR; ; QLL (6 per 28 days) PAR; ; QLL (6 per 28 days) PAR; ; QLL (6 per 28 days) PAR; ; ; ; ; 有關本表格所含標誌與縮寫的含義, 可參見第 7 83

docusate sodium oral capsule 100 mg docusate sodium oral capsule 250 mg docusate sodium oral liquid docusate sodium oral tablet docusil dok oral capsule 100 mg DOK ORAL CAPSULE 250 MG DOK ORAL TABLET dramamine less drowsy dronabinol DSS DUCODYL dulcolax stool softener (dss) EMEND ORAL CAPSULE 125 MG EMEND ORAL CAPSULE 40 MG EMEND ORAL CAPSULE 80 MG EMEND ORAL CAPSULE,DOSE PACK enulose FLANAX ANTACID FLEET GLYCERIN (ADULT) FLEET LAXATIVE GAS RELIEF 80 GAS RELIEF ULTRA STRENGTH GAS-X ULTRA-STRENGTH GATTEX 30-VIAL GATTEX ONE-VIAL GAVILAX ORAL POWDER gavilyte-c gavilyte-g gavilyte-n ; ; ; ; ; B/D PAR; ; QLL (120 per 30 days) ; B/D PAR; ; QLL (5 per 30 days) B/D PAR; ; QLL (1 per 2 days) B/D PAR; ; QLL (10 per 30 days) B/D PAR; ; QLL (15 per 30 days) ; 有關本表格所含標誌與縮寫的含義, 可參見第 7 84

generlac GENTLE LAXATIVE gentlelax GERI-LANTA GERI-X ANTACID-ANTIGAS glycerin (adult) GLYCOLAX ORAL POWDER HEALTHYLAX HEARTBURN ANTACID HEARTBURN RELIEF hydrocortisone rectal cream 2.5 % hydrocortisone rectal enema KAO-TIN (DOCUSATE CALCIUM) lactulose laxa clear LAXATIVE (BISACODYL) ORAL TABLET, DELAYED RELEASE (DR/EC) LAXATIVE (BISACODYL) RECTAL LAXATIVE PEG 3350 ORAL POWDER LIALDA LINZESS LIQUID ANTACID MAALOX MAXIMUM STRENGTH MAG-AL PLUS MAG-AL PLUS EXTRA STRENGTH magnesium citrate oral solution MASANTI DOUBLE STRENGTH meclizine oral tablet 12.5 mg, 25 mg meclizine oral tablet,chewable medi-meclizine mesalamine rectal ; ; 有關本表格所含標誌與縮寫的含義, 可參見第 7 85

mesalamine with cleansing wipe metoclopramide hcl injection solution METOCLOPRAMIDE HCL INJECTION SYRINGE metoclopramide hcl oral solution metoclopramide hcl oral tablet MI-ACID GAS RELIEF MILK OF MAGNESIA MILK OF MAGNESIA CONCENTRATED MINERAL OIL EXTRA HEAVY MINERAL OIL HEAVY ORAL MINERAL OIL LAXATIVE mineral oil oral mineral oil rectal MINTOX MINTOX MAXIMUM STRENGTH MINTOX PLUS MIRALAX ORAL POWDER IN PACKET motion relief (meclizine) motion sickness (meclizine) motion sickness relief(mecliz) TION-TIME VE IT ALONG VIPREP MYTAB GAS MYTAB GAS MAXIMUM STRENGTH ondansetron hcl (pf) injection solution ondansetron hcl (pf) injection syringe ondansetron hcl intravenous ondansetron hcl oral solution ondansetron hcl oral tablet 24 mg ; ; ; ; ; ; ; ; ; B/D PAR; ; QLL (450 per 30 days) B/D 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 86

ondansetron hcl oral tablet 4 mg, 8 mg ondansetron odt ORAL SALINE LAXATIVE ORAL LIQUID peg 3350-electrolytes oral recon soln 236-22.74-6.74-5.86 gram peg 3350-electrolytes oral recon soln 240-22.72-6.72-5.84 gram peg-electrolyte soln PEG3350 PENTASA PHAZYME ORAL CAPSULE 180 MG PHOSPHATE LAXATIVE ORAL LIQUID polyethylene glycol 3350 oral powder polyethylene glycol 3350 oral powder in packet POWDERLAX prochlorperazine edisylate injection solution 10 mg/2 ml (5 mg/ml) prochlorperazine maleate oral prochlorperazine maleate rectal procto-pak proctosol hc proctozone-hc PROLAXIN PURELAX READY-TO-USE ENEMA (MIN OIL) RELISTOR SUBCUTANEOUS SOLUTION RELISTOR SUBCUTANEOUS SYRINGE REMICADE RI-GEL RI-GEL II RI-X B/D PAR; ; QLL (90 per 30 days) B/D PAR; ; QLL (90 per 30 days) ; ; PAR; PAR; PAR; PAR; PAR; PAR; 有關本表格所含標誌與縮寫的含義, 可參見第 7 87

SANI-SUPP (ADULT) SILACE ORAL LIQUID SILACE ORAL SYRUP simethicone oral capsule simethicone oral tablet,chewable smoothlax sof-lax stool softener oral capsule 100 mg STOOL SOFTENER ORAL CAPSULE 240 MG, 250 MG STOOL SOFTENER ORAL CAPSULE 50 MG STOOL SOFTENER ORAL LIQUID STOOL SOFTENER ORAL SYRUP STOOL SOFTENER ORAL TABLET sulfasalazine SUPPOSITORY ADULT SURFAK THE MAGIC BULLET TRAVEL SICKNESS (MECLIZINE) ursodiol WOMAN'S LAXATIVE ORAL TABLET, DELAYED RELEASE (DR/EC) WOMEN'S GENTLE LAXATIVE(BISAC) WOMEN'S LAXATIVE (BISACODYL) ORAL TABLET,DELAYED RELEASE (DR/EC) ZENPEP ULCER THERAPY acid control (ranitidine) oral tablet 150 mg acid reducer (famotidine) acid reducer (ranitidine) DEXILANT ; ; ; ; ; ; ; ST; ; 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 88

famotidine (pf) famotidine (pf)-nacl (iso-os) famotidine intravenous famotidine oral suspension famotidine oral tablet 10 mg famotidine oral tablet 20 mg, 40 mg heartburn prevention HEARTBURN RELIEF (FATIDINE) heartburn relief (ranitidine) lansoprazole oral capsule,delayed release(dr/ec) misoprostol omeprazole oral capsule,delayed release(dr/ec) OMEPRAZOLE ORAL TABLET,DELAYED RELEASE (DR/EC) pantoprazole intravenous pantoprazole oral pepcid ac oral tablet 20 mg PROTONIX INTRAVENOUS ranitidine hcl injection ranitidine hcl oral syrup ranitidine hcl oral tablet 150 mg, 300 mg ranitidine hcl oral tablet 75 mg sucralfate oral tablet wal-zan 150 WAL-ZAN 75 ZANTAC MAXIMUM STRENGTH ZANTAC ORAL TABLET 150 MG IMMUNOLOGY, VACCINES / BIOTECHNOLOGY BIOTECHNOLOGY DRUGS ACTIMMUNE ; ; QLL (30 per 30 days) ; QLL (30 per 30 days) ; ; QLL (30 per 30 days) ; ; ; ; PAR; 有關本表格所含標誌與縮寫的含義, 可參見第 7 89

ARANESP (IN POLYSORBATE) INJECTION SOLUTION 100 MCG/ML, 200 MCG/ML, 25 MCG/ML, 300 MCG/ML, 40 MCG/ML, 60 MCG/ ML ARANESP (IN POLYSORBATE) INJECTION SYRINGE ARCALYST AVONEX (WITH ALBUMIN) AVONEX INTRAMUSCULAR PEN INJECTOR KIT AVONEX INTRAMUSCULAR SYRINGE AVONEX INTRAMUSCULAR SYRINGE KIT EXTAVIA SUBCUTANEOUS KIT EXTAVIA SUBCUTANEOUS RECON SOLN ILARIS (PF) INTRON A INJECTION NEUPOGEN NORDITROPIN FLEXPRO OMNITROPE PEGASYS PEGASYS PROCLICK PEGINTRON PEGINTRON REDIPEN PROCRIT PROLEUKIN REBIF (WITH ALBUMIN) REBIF REBIDOSE REBIF TITRATION PACK SYLATRON VACCINES / MISCELLANEOUS IMMUNOLOGICALS ACTHIB (PF) ADACEL(TDAP ADOLESN/ADULT)(PF) PAR; PAR; PAR; PAR; ; QLL (4 per 28 days) PAR; ; QLL (4 per 28 days) PAR; ; QLL (4 per 28 days) PAR; ; QLL (4 per 28 days) PAR; PAR PAR; ; LA PAR; PAR; PAR; PAR; PAR; PAR; PAR; PAR; PAR; ; QLL (12 per 28 days) PAR; PAR; PAR; PAR; 有關本表格所含標誌與縮寫的含義, 可參見第 7 90

ATGAM BCG VACCINE, LIVE (PF) BEXSERO (PF) BOOSTRIX TDAP CARIMUNE NF NANOFILTERED INTRAVENOUS RECON SOLN 12 GRAM, 6 GRAM CERVARIX VACCINE (PF) DAPTACEL (DTAP PEDIATRIC) (PF) ENGERIX-B (PF) ENGERIX-B PEDIATRIC (PF) GAMASTAN S/D GAMMAGARD LIQUID GAMMAGARD S-D (IGA < 1 MCG/ML) GAMMAPLEX GAMUNEX-C GARDASIL (PF) GARDASIL 9 (PF) HAVRIX (PF) INTRAMUSCULAR SUSPENSION HAVRIX (PF) INTRAMUSCULAR SYRINGE 1, 440 ELISA UNIT/ML HAVRIX (PF) INTRAMUSCULAR SYRINGE 720 ELISA UNIT/0.5 ML HIBERIX (PF) IVAX RABIES VACCINE (PF) INFANRIX (DTAP) (PF) IPOL INJECTION SUSPENSION IXIARO (PF) M-M-R II (PF) MENACTRA (PF) INTRAMUSCULAR SOLUTION MENOMUNE - A/C/Y/W-135 B/D PAR PAR; B/D PAR; B/D PAR; PAR; PAR; PAR; PAR; PAR; 有關本表格所含標誌與縮寫的含義, 可參見第 7 91

MENOMUNE - A/C/Y/W-135 (PF) MENVEO A-C-Y-W-135-DIP (PF) OCTAGAM PEDVAX HIB (PF) PRIVIGEN PROQUAD (PF) QUADRACEL (PF) RABAVERT (PF) RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 10 MCG/ML RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 5 MCG/0.5 ML ROTARIX ROTATEQ VACCINE tetanus,diphtheria tox ped(pf) TETANUS-DIPHTHERIA TOXOIDS-TD THYGLOBULIN TICE BCG TRUMENBA TWINRIX (PF) TYPHIM VI INTRAMUSCULAR SOLUTION TYPHIM VI INTRAMUSCULAR SYRINGE VAQTA (PF) INTRAMUSCULAR SUSPENSION VAQTA (PF) INTRAMUSCULAR SYRINGE VARIVAX (PF) VARIZIG YF-VAX (PF) ZOSTAVAX (PF) PAR; PAR; B/D PAR; B/D PAR 有關本表格所含標誌與縮寫的含義, 可參見第 7 92

MUSCULOSKELETAL / RHEUMATOLOGY GOUT THERAPY allopurinol colchicine-probenecid COLCRYS probenecid ULORIC OSTEOPOROSIS THERAPY alendronate oral solution alendronate oral tablet 10 mg, 5 mg alendronate oral tablet 35 mg, 70 mg BONIVA INTRAVENOUS FORTEO ibandronate intravenous solution ibandronate intravenous syringe ibandronate oral PROLIA raloxifene OTHER RHEUMATOLOGICALS ACTEMRA INTRAVENOUS ACTEMRA INTRAVENOUS VIAL BENLYSTA DEPEN TITRATABS ENBREL SUBCUTANEOUS RECON SOLN ENBREL SUBCUTANEOUS SYRINGE 25 MG/ 0.5ML (0.51) ENBREL SUBCUTANEOUS SYRINGE 50 MG/ ML (0.98 ML) ENBREL SURECLICK HUMIRA PEDIATRIC CROHN'S START HUMIRA PEN ST; ; QLL (300 per 28 days) ; QLL (30 per 30 days) ; QLL (4 per 28 days) B/D PAR; PAR; ; QLL (3 per 28 days) B/D PAR; ; QLL (1 per 28 days) PAR; ; QLL (2 per 365 days) ; QLL (30 per 30 days) PAR; PAR; PAR; PAR; ; QLL (8 per 28 days) PAR; ; QLL (4.08 per 28 days) PAR; ; QLL (8 per 28 days) PAR; ; QLL (8 per 28 days) PAR; ; QLL (4.8 per 365 days) PAR; ; QLL (3.2 per 28 days) 有關本表格所含標誌與縮寫的含義, 可參見第 7 93

HUMIRA PEN CROHN'S-UC-HS START HUMIRA PEN PSORIASIS STARTER HUMIRA SUBCUTANEOUS SYRINGE KIT 10 MG/0.2 ML, 20 MG/0.4 ML HUMIRA SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML KINERET leflunomide ORENCIA ORENCIA (WITH MALTOSE) RIDAURA SAVELLA ORAL TABLET 100 MG SAVELLA ORAL TABLET 12.5 MG SAVELLA ORAL TABLET 25 MG SAVELLA ORAL TABLET 50 MG SAVELLA ORAL TABLETS,DOSE PACK SIMPONI OBSTETRICS / GYNECOLOGY ESTROGENS / PROGESTINS camila DEPO-PROVERA INTRAMUSCULAR SOLUTION errin ESTRACE VAGINAL estradiol oral estradiol transdermal patch weekly ESTRING FEMRING lyza medroxyprogesterone MENEST PAR; ; QLL (9.6 per 365 days) PAR; ; QLL (3.2 per 28 days) PAR; ; QLL (2 per 28 days) PAR; ; QLL (3.2 per 28 days) PAR; ; QLL (28 per 28 days) PAR; ; QLL (4 per 28 days) PAR; ; QLL (60 per 30 days) ; QLL (480 per 30 days) ; QLL (240 per 30 days) ; QLL (120 per 30 days) ; QLL (110 per 365 days) PAR; ; QLL (1 per 28 days) PAR; PAR; ; QLL (4 per 28 days) ; QLL (1 per 90 days) ; QLL (1 per 90 days) PAR; 有關本表格所含標誌與縮寫的含義, 可參見第 7 94

nora-be norethindrone (contraceptive) norethindrone acetate ORTHO MICRONOR PREMARIN ORAL PREMARIN VAGINAL PREMPRO progesterone micronized MISCELLANEOUS OB/GYN 3-DAY VAGINAL clindamycin phosphate vaginal CLOTRIMAZOLE 3 DAY clotrimazole vaginal cream CLOTRIMAZOLE-3 CLOTRIMAZOLE-7 metronidazole vaginal MICONAZOLE 3 DAY VAGINAL CREAM MICONAZOLE 7 miconazole nitrate vaginal comb pack,prefill appl, cream miconazole nitrate vaginal cream miconazole nitrate vaginal suppository MICONAZOLE-3 VAGINAL KIT miconazole-3 vaginal suppository NUVARING terconazole tranexamic acid oral VAGINAL CONTRACEPTIVE FOAM VAGISTAT-3 XULANE PAR; PAR; ST; ; ; ; ; ; QLL (6 per 30 days) 有關本表格所含標誌與縮寫的含義, 可參見第 7 95

ORAL CONTRACEPTIVES / RELATED AGENTS AFTERA ALTAVERA (28) ALYACEN 1/35 (28) ALYACEN 7/7/7 (28) apri aranelle (28) aviane AZURETTE (28) blisovi fe 1.5/30 (28) CAZIANT (28) cryselle (28) cyclafem 1/35 (28) cyclafem 7/7/7 (28) drospirenone-ethinyl estradiol oral tablet 3-0.03 mg ECONTRA EZ ELINEST ELLA enpresse FALLBACK SOLO falmina (28) gildagia GILDESS FE 1.5/30 (28) GILDESS FE 1/20 (28) junel 1.5/30 (21) junel 1/20 (21) junel fe 1.5/30 (28) junel fe 1/20 (28) kariva (28) kelnor 1/35 (28) 有關本表格所含標誌與縮寫的含義, 可參見第 7 96

LARIN 1/20 (21) LARIN FE 1.5/30 (28) LARIN FE 1/20 (28) lessina levonest (28) levonorg-eth estrad triphasic levonorgestrel-ethinyl estrad oral tablet 0.15-0.03 mg levonorgestrel-ethinyl estrad oral tablets,dose pack, 3 month LOW-OGESTREL (28) lutera (28) marlissa MICROGESTIN 1.5/30 (21) MICROGESTIN 1/20 (21) MICROGESTIN FE 1.5/30 (28) MICROGESTIN FE 1/20 (28) NO-LINYAH mononessa (28) MY WAY MYZILRA necon 0.5/35 (28) necon 1/35 (28) necon 1/50 (28) necon 10/11 (28) necon 7/7/7 (28) NEXT CHOICE ONE DOSE norgestimate-ethinyl estradiol oral tablet 0.18/ 0.215/0.25 mg-35 mcg (28), 0.25-35 mg-mcg nortrel 0.5/35 (28) nortrel 1/35 (21) 有關本表格所含標誌與縮寫的含義, 可參見第 7 97

nortrel 1/35 (28) nortrel 7/7/7 (28) ocella ogestrel (28) OPCICON ONE-STEP PLAN B ONE-STEP portia previfem reclipsen (28) sprintec (28) SYEDA TAKE ACTION tri-previfem (28) tri-sprintec (28) trivora (28) velivet triphasic regimen (28) VIORELE (28) ZARAH zenchent (28) zovia 1/35e (28) zovia 1/50e (28) OXYTOCICS methylergonovine oral OPHTHALLOGY ANTIBIOTICS bacitracin ophthalmic bacitracin-polymyxin b ophthalmic BESIVANCE ciprofloxacin hcl ophthalmic erythromycin ophthalmic ; 有關本表格所含標誌與縮寫的含義, 可參見第 7 98

gentak ophthalmic ointment gentamicin ophthalmic NEO-POLYCIN neomycin-bacitracin-polymyxin neomycin-polymyxin-gramicidin ofloxacin ophthalmic POLYCIN polymyxin b sulf-trimethoprim tobramycin VIGAX ANTIVIRALS trifluridine ZIRGAN BETA-BLOCKERS betaxolol ophthalmic BETIL BETOPTIC S carteolol levobunolol ophthalmic drops 0.5 % metipranolol timolol maleate ophthalmic TIPTIC OCUDOSE (PF) CHOLINESTERASE INHIBITOR MIOTICS PHOSPHOLINE IODIDE DIRECT ACTING MIOTICS PILOCARPINE HCL OPHTHALMIC DROPS 1 %, 2 %, 4 % MISCELLANEOUS OPHTHALLOGICS ADVANCED EYE RELIEF AKWA TEARS (POLYVINYL ALCOHOL) ALAWAY ; ; ; 有關本表格所含標誌與縮寫的含義, 可參見第 7 99

ALLERGY EYE (KETOTIFEN) ARTIFICIAL TEARS (PF) OPHTHALMIC DROPPERETTE 0.1-0.3 % ARTIFICIAL TEARS (POLYVIN ALC) ARTIFICIAL TEARS OPHTHALMIC DROPS 0.5-0.6 %, 1-0.2-0.2 % ARTIFICIAL TEARS(GLYCERIN-PEG) azelastine ophthalmic BION TEARS (PF) CHILDREN'S ALAWAY COLLYRIUM cromolyn ophthalmic DRY EYE RELIEF EYE DROP TEARS EYE IRRIGATING SOLUTION EYE ITCH RELIEF EYE STREAM EYE WASH EYE WASH STERILE ITCHY EYE DROPS ketotifen fumarate LIQUITEARS LUBRICANT EYE (PG-PEG 400) LUBRICANT EYE DROPS LUBRICANT EYE DROPS (GLYC-PG) LUBRICATING PLUS MEDIWASH MEDIWASH EYE IRRIGANT ISTURE DROPS NATURAL TEARS (PF) OCUSOFT IRRIGATING OPHTH SOLN ; ; ; ; ; ; ; ; ; 有關本表格所含標誌與縮寫的含義, 可參見第 7 100

PATADAY PAZEO polyvinyl alcohol RESTASIS RETAINE CMC REVIVE PLUS STERILE EYE WASH TEARS AGAIN (PVA) TEARS NATURALE FREE (PF) ULTRA FRESH WAL-ZYR (KETOTIFEN) NON-STEROIDAL ANTI-INFLAMMATORY AGENTS flurbiprofen ophthalmic drops ILEVRO ketorolac ophthalmic NEVANAC ORAL DRUGS FOR GLAUCOMA acetazolamide acetazolamide sodium methazolamide oral OTHER GLAUCOMA DRUGS AZOPT bimatoprost COMBIGAN dorzolamide dorzolamide-timolol latanoprost LUMIGAN OPHTHALMIC DROPS 0.01 % TRAVATAN Z ; ; ; QLL (5 per 30 days) 有關本表格所含標誌與縮寫的含義, 可參見第 7 101

STEROID-ANTIBIOTIC COMBINATIONS NEO-POLYCIN HC neomycin-bacitracin-poly-hc neomycin-polymyxin b-dexameth neomycin-polymyxin-hc ophthalmic tobramycin-dexamethasone opthalmic suspension STEROID-SULFONAMIDE COMBINATIONS BLEPHAMIDE S.O.P. sulfacetamide-prednisolone STEROIDS dexamethasone sodium phosphate ophthalmic fluorometholone prednisolone acetate prednisolone sodium phosphate ophthalmic SULFONAMIDES sulfacetamide sodium ophthalmic drops SYMPATHOMIMETICS ALPHAGAN P OPHTHALMIC DROPS 0.1 % apraclonidine brimonidine VASOCONSTRICTOR DECONGESTANTS LUBRICANT REDNESS RELIEVER OPHTHALMIC DROPS 0.03-0.5 % MAXIMUM REDNESS RELIEF naphazoline REDNESS RELIEVER LUBRICANT STERILE EYE DROPS OPHTHALMIC DROPS 0.012-0.2 %, 0.03-0.5 % RESPIRATORY AND ALLERGY ANTIHISTAMINE / ANTIALLERGENIC AGENTS 12 HOUR COLD RELIEF 有關本表格所含標誌與縮寫的含義, 可參見第 7 102

ACTA-TABS PE ADULT ROBITUSSIN PEAK COLD DM ADULT TUSSIN CHEST CONGESTION ADULT TUSSIN COUGH CONGEST DM ADULT WAL-TUSSIN ALA-HIST DM ALAVERT ALKA-SELTZER PLUS ALLERGY all day allergy (cetirizine) oral tablet all day allergy relief(cetir) ALLER-G-TIME aller-tec ALLERGY (DIPHENHYDRAMINE) ALLERGY AND SINUS RELIEF ALLERGY MEDICATION ALLERGY MEDICINE allergy relief (cetirizine) oral tablet ALLERGY RELIEF (CLEMASTINE) allergy relief (loratadine) oral tablet allergy relief (loratadine) oral tablet,disintegrating ALLERGY RELIEF(DIPHENHYDRAMIN) AMBI 10PEH-4CPM AMBI 60PSE-4CPM AP-HIST DM APRODINE arbinoxa BANOPHEN ALLERGY BANOPHEN ORAL CAPSULE 25 MG BANOPHEN ORAL CAPSULE 50 MG BANOPHEN ORAL LIQUID ; ; ; ; QLL (30 per 30 days) ; QLL (30 per 30 days) ; QLL (30 per 30 days) ; QLL (30 per 30 days) ; QLL (30 per 30 days) ; ; ; QLL (30 per 30 days) ; QLL (30 per 30 days) ; PAR; ; ; ; 有關本表格所含標誌與縮寫的含義, 可參見第 7 103

BANOPHEN ORAL TABLET benzonatate oral capsule 100 mg, 200 mg BIOCOTRON brompheniramin-phenylephrin-dm oral liquid 2-5- 10 mg/5 ml cetirizine oral tablet CHERATUSSIN AC CHILD MUCINEX CHEST CONGESTION CHILD MUCUS RELIEF EXPECTORANT CHILDREN'S CHEST CONGESTION CHILDREN'S SILFEDRINE CHILDREN'S WAL-DRYL ALLERGY ORAL LIQUID clemastine oral tablet 1.34 mg clemastine oral tablet 2.68 mg codeine-guaifenesin COLD AND ALLERGY COLD AND ALLERGY PE COMPLETE ALLERGY COMPLETE ALLERGY MEDICINE COUGH CONTROL (GUAIFENESIN) COUGH CONTROL DM ORAL LIQUID COUGH SYRUP DAYHIST ALLERGY DIABETIC SILTUSSIN DAS-NA DIABETIC SILTUSSIN-DM DIABETIC TUSSIN DM ORAL LIQUID 10-100 MG/5 ML DIABETIC TUSSIN EX DIPHEDRYL ALLERGY DIPHEDRYL ORAL CAPSULE $0 (Tier 3) ; ; ; QLL (30 per 30 days) ; ; PAR; ; ; ; 有關本表格所含標誌與縮寫的含義, 可參見第 7 104

DIPHEDRYL ORAL TABLET DIPHENHIST ORAL CAPSULE DIPHENHIST ORAL LIQUID DIPHENHIST ORAL TABLET 25 MG diphenhydramine hcl injection solution 50 mg/ml diphenhydramine hcl injection syringe diphenhydramine hcl oral capsule 25 mg diphenhydramine hcl oral capsule 50 mg diphenhydramine hcl oral elixir diphenhydramine hcl oral liquid diphenhydramine hcl oral syrup diphenhydramine hcl oral tablet 25 mg DIPHENHYDRAMINE ORAL CAPSULE 25 MG, 50 MG diphenhydramine oral elixir 12.5 mg/5 ml DIPHENHYDRAMINE ORAL LIQUID 12.5 MG/ 5 ML DIPHENHYDRAMINE ORAL SYRUP 12.5 MG/ 5 ML ED A-HIST ORAL TABLET ED A-HIST PSE ENTRE-HIST PSE epinephrine injection syringe 0.1 mg/ml EPIPEN 2-PAK EPIPEN JR 2-PAK EXPECTORANT COUGH SYRUP EXPECTORANT ORAL LIQUID G-TRON GERI-DRYL GERI-TUSSIN GUAIASORB DM $0 (Tier 3) ; ; ; PAR; PAR; ; PAR; ; PAR; PAR; ; ; QLL (2 per 2 days) ; QLL (2 per 2 days) 有關本表格所含標誌與縮寫的含義, 可參見第 7 105

GUAIFENESIN AC guaifenesin oral liquid GUAIFENESIN-DM hydrocodone-chlorpheniramine hydrocodone-homatropine oral syrup 5-1.5 mg/5 ml HYDROCODONE-HOMATROPINE ORAL SYRUP 5-1.5 MG/5 ML (5 ML) hydrocodone-homatropine oral tablet HYDROMET IOPHEN C-NR IOPHEN DM-NR IOPHEN-NR levocetirizine oral tablet LOHIST-DM LORADAMED loratadine oral tablet loratadine oral tablet,disintegrating M-CLEAR WC NASAL DECONGESTANT (PSEUDOEPH) NIGHTIME SLEEP NIGHTTIME ALLERGY RELIEF NIGHTTIME SLEEP AID (DIPHEN) ORAL CAPSULE 50 MG NIGHTTIME SLEEP AID (DIPHEN) ORAL TABLET NIVA-HIST DM non-drowsy allergy promethazine injection solution promethazine oral tablet 12.5 mg, 25 mg PROMETHAZINE VC-CODEINE promethazine-codeine $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) ; ; ; ; ; ; ; ; QLL (30 per 30 days) ; ; ; QLL (30 per 30 days) ; ; QLL (30 per 30 days) ; ; QLL (30 per 30 days) ; ; ; QLL (30 per 30 days) PAR; PAR; ; ; 有關本表格所含標誌與縮寫的含義, 可參見第 7 106

promethazine-dm promethazine-phenyleph-codeine PROMETHEGAN RECTAL SUPPOSITORY 12.5 MG PSEUDOEPHEDRINE 120 MG ER pseudoephedrine hcl oral liquid pseudoephedrine hcl oral tablet 30 mg pseudoephedrine hcl oral tablet 60 mg pseudoephedrine hcl oral tablet extended release Q-DRYL ORAL CAPSULE Q-DRYL ORAL LIQUID Q-TUSSIN QUENALIN RELCOF C REST SIMPLY NIGHTTIME SLEEP RESTFULLY SLEEP RI-TUSSIN ROBAFEN ROBAFEN DM COUGH RYDEX SCOT-TUSSIN EXPECTORANT SILADRYL SA SILTUSSIN DM DAS SILTUSSIN SA SINUS 12 HOUR SINUS AND ALLERGY PE SINUS-ALLERGY (PHENYLEPHRINE) SLEEP SLEEP AID (DIPHENHYDRAMINE) ORAL CAPSULE 50 MG $0 (Tier 3) $0 (Tier 3) ; ; PAR; ; ; ; ; ; ; 有關本表格所含標誌與縮寫的含義, 可參見第 7 107

SLEEP AID (DIPHENHYDRAMINE) ORAL TABLET SLEEP AID MAX STR (DIPHENHYDR) SLEEP II SLEEP TABLET (DIPHENHYDRAMINE) SLEEP-TABS SORBUGEN NR SUDOGEST SUDOGEST 12-HOUR SUDOGEST COLD AND ALLERGY SUDOGEST SINUS AND ALLERGY SUPHEDRIN SUPHEDRIN 12 HOUR SUPHEDRINE SUPHEDRINE 12 HOUR SUPHEDRINE PE COLD AND ALLERGY SUPHEDRINE PE SINUS ANDALLERGY TOTAL ALLERGY MEDICINE TUSNEL DIABETIC TUSSI PRES-B ORAL LIQUID 4-10-20 MG/5 ML TUSSIGON TUSSIN CHEST CONGESTION TUSSIN COUGH-CHEST CONGESTION TUSSIN DM COUGH AND CHEST ORAL LIQUID 10-100 MG/5 ML TUSSIN DM ORAL LIQUID TUSSIN EXPECTORANT TUSSIN HONEY TUSSIN ORAL LIQUID UNISOM SLEEPGELS VALU-DRYL ALLERGY ORAL CAPSULE $0 (Tier 3) ; ; ; 有關本表格所含標誌與縮寫的含義, 可參見第 7 108

VICKS QLEARQUIL ALLERGY VICKS QLEARQUIL NIGHTTIME RLF VIRTUSSIN AC WAL-ACT D COLD AND ALLERGY WAL-DRYL ALLERGY WAL-DRYL-D ALLERGY AND SINUS WAL-FINATE-D wal-itin oral tablet wal-itin oral tablet,disintegrating WAL-PHED WAL-PHED 12 HOUR WAL-PHED PE SINUS AND ALLERGY WAL-SOM (DIPHENHYDRAMINE) ORAL CAPSULE wal-zyr (cetirizine) oral tablet PULNARY AGENTS acetylcysteine ADEMPAS ADVAIR DISKUS ADVAIR HFA AEROSPAN albuterol sulfate inhalation solution for nebulization 0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 mg /3 ml (0.083 %) ALBUTEROL SULFATE INHALATION SOLUTION FOR NEBULIZATION 2.5 MG/0.5 ML albuterol sulfate inhalation solution for nebulization 5 mg/ml albuterol sulfate oral ANORO ELLIPTA ARNUITY ELLIPTA ASMANEX HFA ; QLL (30 per 30 days) ; ; QLL (30 per 30 days) ; QLL (30 per 30 days) ; QLL (30 per 30 days) B/D PAR; PAR; ; LA ; QLL (60 per 30 days) ; QLL (12 per 30 days) QLL (18 per 30 days) B/D PAR; ; QLL (360 per 30 days) B/D PAR; ; QLL (60 per 30 days) B/D PAR; ; QLL (60 per 30 days) ; QLL (60 per 30 days) ; QLL (30 per 30 days) ; QLL (13 per 30 days) 有關本表格所含標誌與縮寫的含義, 可參見第 7 109

ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG (30 DOSES) ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG (7 DOSES), 220 MCG (14 DOSES) ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 220 MCG (120 DOSES), 220 MCG (30 DOSES), 220 MCG (60 DOSES) ATROVENT HFA BREO ELLIPTA CINRYZE COMBIVENT RESPIMAT cromolyn inhalation DALIRESP DULERA ESBRIET FIRAZYR FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 250 MCG/ACTUATION, 50 MCG/ ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 220 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 44 MCG/ACTUATION flunisolide nasal spray,non-aerosol 25 mcg (0.025 %) fluticasone nasal FORADIL AEROLIZER ipratropium bromide inhalation ; QLL (0.14 per 30 days) ; QLL (0.24 per 30 days) ; QLL (26 per 30 days) ; QLL (60 per 30 days) PAR; ; QLL (8 per 30 days) B/D PAR; ; QLL (240 per 30 days) PAR; ; QLL (30 per 30 days) ; QLL (13 per 30 days) PAR; QLL (270 per 30 days) PAR; ; QLL (60 per 30 days) ; QLL (240 per 30 days) ; QLL (12 per 30 days) ; QLL (24 per 30 days) ; QLL (11 per 30 days) ; QLL (75 per 30 days) ; QLL (16 per 30 days) ; QLL (60 per 30 days) B/D PAR; 有關本表格所含標誌與縮寫的含義, 可參見第 7 110

ipratropium-albuterol KALYDECO ORAL TABLET LETAIRIS levalbuterol hcl inhalation solution for nebulization 0.31 mg/3 ml, 1.25 mg/0.5 ml, 1.25 mg/3 ml levalbuterol hcl inhalation solution for nebulization 0.63 mg/3 ml metaproterenol mometasone nasal montelukast NASONEX OFEV ORAL CAPSULE 150 MG PERFOROMIST PROAIR HFA PROAIR RESPICLICK PULZYME QVAR INHALATION AEROSOL 40 MCG/ ACTUATION QVAR INHALATION AEROSOL 80 MCG/ ACTUATION SEREVENT DISKUS sildenafil oral sodium chloride inhalation solution for nebulization 3 % SPIRIVA RESPIMAT SPIRIVA WITH HANDIHALER STIOLTO RESPIMAT terbutaline oral terbutaline subcutaneous theophylline oral tablet extended release theophylline oral tablet extended release 12 hr TRACLEER $0 (Tier 3) B/D PAR; ; QLL (540 per 30 days) PAR; ; QLL (60 per 30 days) PAR; ; LA; QLL (30 per 30 days) B/D PAR; ; QLL (270 per 30 days) B/D PAR; ; QLL (540 per 30 days) QLL (17 per 30 days) ; QLL (30 per 30 days) ; QLL (17 per 30 days) PAR; ; QLL (60 per 30 days) B/D PAR; ; QLL (120 per 30 days) ; QLL (18 per 30 days) ; QLL (2 per 30 days) B/D PAR; ; QLL (9 per 30 days) ; QLL (18 per 30 days) ; QLL (60 per 30 days) PAR; ; QLL (90 per 30 days) ; ; QLL (4 per 30 days) ; QLL (30 per 30 days) ; QLL (4 per 30 days) PAR; ; LA; QLL (60 per 30 days) 有關本表格所含標誌與縮寫的含義, 可參見第 7 111

VENTAVIS VENTOLIN HFA XOLAIR XOPENEX HFA zafirlukast UROLOGICALS ANTICHOLINERGICS / ANTISPASDICS MYRBETRIQ oxybutynin chloride oral syrup oxybutynin chloride oral tablet oxybutynin chloride oral tablet extended release 24hr 10 mg, 15 mg oxybutynin chloride oral tablet extended release 24hr 5 mg tolterodine oral capsule,extended release 24hr tolterodine oral tablet TOVIAZ trospium oral tablet VESICARE BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPY alfuzosin finasteride oral tablet 5 mg tamsulosin CHOLINERGIC STIMULANTS bethanechol chloride MISCELLANEOUS UROLOGICALS CIALIS ORAL TABLET 2.5 MG, 5 MG CYSTAGON potassium citrate oral tablet extended release 10 meq (1,080 mg), 5 meq (540 mg) PAR; ; QLL (36 per 30 days) PAR; ; LA; QLL (6 per 28 days) ; QLL (45 per 30 days) ; QLL (60 per 30 days) ; QLL (30 per 30 days) ; QLL (600 per 30 days) ; QLL (120 per 30 days) ; QLL (60 per 30 days) ; QLL (30 per 30 days) ; QLL (30 per 30 days) ; QLL (60 per 30 days) ; QLL (30 per 30 days) ; QLL (60 per 30 days) ; QLL (30 per 30 days) PAR; ; QLL (30 per 30 days) ; LA 有關本表格所含標誌與縮寫的含義, 可參見第 7 112

URINARY ANESTHETICS URINARY PAIN RELIEF ORAL TABLET 95 MG URINARY TRACT VITAMINS, HEMATINICS / ELECTROLYTES ELECTROLYTES ALCALAK ANTACID (CALCIUM CARBONATE) ANTACID EXT STR (CALCIUM CARB) ANTACID EXTRA-STRENGTH ORAL TABLET, CHEWABLE 168 MG (420 MG), 300 MG (750 MG) CAL-GEST ANTACID CALCI-CHEW CALCIONATE CALCITRATE CALCIUM 500 + D (D3) CALCIUM 500 + D ORAL TABLET 500 MG(1, 250MG) -200 UNIT CALCIUM 500 + D ORAL TABLET 500 MG(1, 250MG) -400 UNIT CALCIUM 500 + D ORAL TABLET,CHEWABLE CALCIUM 500 ORAL TABLET,CHEWABLE CALCIUM 500 WITH D CALCIUM 600 CALCIUM 600 + D(3) ORAL TABLET 600 MG (1,500MG) -200 UNIT, 600 MG(1,500MG) -400 UNIT CALCIUM 600 WITH VITAMIN D3 ORAL TABLET calcium acetate oral capsule CALCIUM ANTACID ORAL TABLET, CHEWABLE 200 MG CALCIUM (500 MG) ; ; ; ; ; ; ; ; ; 有關本表格所含標誌與縮寫的含義, 可參見第 7 113

CALCIUM ANTACID ORAL TABLET, CHEWABLE 300 MG (750 MG), 400 MG (1,000 MG) CALCIUM ANTACID TROPICAL CALCIUM ANTACID ULTRA MAX ST calcium carbonate - d3 oral tablet 500 mg(1,250mg) -125 unit, 500 mg(1,250mg) -200 unit, 500 mg(1, 250mg) -400 unit, 500mg (1,250mg) -600 unit calcium carbonate - d3 oral tablet 600 mg(1,500mg) -200 unit, 600 mg(1,500mg) -400 unit, 600 mg(1, 500mg) -800 unit calcium carbonate - d3 oral tablet,chewable 500 mg(1,250mg) -400 unit CALCIUM CARBONATE - D3 ORAL TABLET, CHEWABLE 500-100 MG-UNIT CALCIUM CARBONATE ANTACID ORAL TABLET,CHEWABLE 400 MG (1,000 MG) CALCIUM CARBONATE ORAL SUSPENSION calcium carbonate oral tablet 500 mg calcium (1, 250 mg), 600 mg (1,500 mg) calcium carbonate oral tablet,chewable 200 mg calcium (500 mg), 300 mg (750 mg), 400 mg (1,000 mg), 500 mg calcium (1,250 mg) CALCIUM CITRATE + D calcium citrate oral tablet 200 mg (950 mg) CALCIUM CITRATE ORAL TABLET 250 MG CALCIUM calcium citrate-vitamin d3 oral tablet 200 mg calcium -250 unit, 250 mg calcium- 200 unit calcium citrate-vitamin d3 oral tablet 315-200 mgunit, 315-250 mg-unit CALCIUM GLUCONATE ORAL TABLET 45 MG (500 MG) CALCIUM GLUCONATE ORAL TABLET 60 MG (650 MG) ; ; ; ; ; ; ; ; 有關本表格所含標誌與縮寫的含義, 可參見第 7 114

CALCIUM LACTATE ORAL TABLET 84 MG (648 MG) CALCIUM WITH VITAMIN D calcium-magnesium-zinc oral tablet CALCIUM-MAGNESIUM-ZINC ORAL TABLET 333-133-5 MG CALTRATE WITH VITAMIN D3 CERASPORT ORAL LIQUID CITRUS CALCIUM ORAL TABLET 200 MG CALCIUM -250 UNIT CITRUS CALCIUM ORAL TABLET 315-250 MG-UNIT dextrose-kcl-nacl FLAVOR CHEWS ANTACID HI-CAL PLUS VIT D K-TAB ORAL TABLET EXTENDED RELEASE 8 MEQ KLOR-CON 10 KLOR-CON 8 KLOR-CON M10 KLOR-CON M15 KLOR-CON M20 lactated ringers intravenous MAGNESIUM OXIDE ORAL CAPSULE 500 MG MAGNESIUM SULFATE IN WATER INTRAVENOUS PARENTERAL SOLUTION MAGNESIUM SULFATE IN WATER INTRAVENOUS PIGGYBACK 2 GRAM/50 ML (4 %), 4 GRAM/50 ML (8 %) MAGNESIUM SULFATE IN WATER INTRAVENOUS PIGGYBACK 4 GRAM/100 ML (4 %) magnesium sulfate injection solution magnesium sulfate injection syringe ; ; ; ; 有關本表格所含標誌與縮寫的含義, 可參見第 7 115

NORSOL-R NORSOL-R IN 5 % DEXTROSE OYSCO 500/D ORAL TABLET OYSCO D OYSCO-500 OYST-CAL-500 OYSTER SHELL + D3 OYSTER SHELL CALCIUM OYSTER SHELL CALCIUM 500 OYSTER SHELL CALCIUM-VIT D3 OYSTERCAL-D potassium chlorid-d5-0.45%nacl intravenous parenteral solution 10 meq/l, 30 meq/l, 40 meq/l potassium chlorid-d5-0.45%nacl intravenous parenteral solution 20 meq/l potassium chloride in 0.9%nacl intravenous parenteral solution 20 meq/l potassium chloride in 5 % dex intravenous parenteral solution 20 meq/l, 30 meq/l, 40 meq/l potassium chloride in lr-d5 intravenous parenteral solution 20 meq/l potassium chloride in lr-d5 intravenous parenteral solution 40 meq/l potassium chloride intravenous piggyback 10 meq/ 100 ml, 20 meq/100 ml, 40 meq/100 ml POTASSIUM CHLORIDE INTRAVENOUS PIGGYBACK 10 MEQ/50 ML POTASSIUM CHLORIDE INTRAVENOUS PIGGYBACK 20 MEQ/50 ML, 30 MEQ/100 ML potassium chloride intravenous solution potassium chloride oral capsule, extended release potassium chloride oral tablet extended release potassium chloride oral tablet,er particles/crystals ; ; ; ; ; ; 有關本表格所含標誌與縮寫的含義, 可參見第 7 116

potassium chloride-0.45 % nacl potassium chloride-d5-0.2%nacl intravenous parenteral solution 20 meq/l potassium chloride-d5-0.2%nacl intravenous parenteral solution 30 meq/l, 40 meq/l potassium chloride-d5-0.3%nacl intravenous parenteral solution 20 meq/l potassium chloride-d5-0.9%nacl intravenous parenteral solution 20 meq/l potassium chloride-d5-0.9%nacl intravenous parenteral solution 40 meq/l ringers intravenous SOTH ANTACID sodium chloride 0.45 % intravenous parenteral solution SODIUM CHLORIDE 0.45 % INTRAVENOUS PIGGYBACK sodium chloride 3 % sodium chloride 5 % sodium chloride intravenous SUPER CALCIUM TUMS ULTRA ORAL TABLET,CHEWABLE 400 MG (1,000 MG) ULTRA STRENGTH ANTACID ULTRA STRENGTH CALCIUM ANTACID MISCELLANEOUS NUTRITION PRODUCTS AMINOSYN 8.5 % AMINOSYN 8.5 %-ELECTROLYTES AMINOSYN II 10 % AMINOSYN II 7 % AMINOSYN II 8.5 % AMINOSYN II 8.5 %-ELECTROLYTES AMINOSYN M 3.5 % ; B/D PAR B/D PAR B/D PAR B/D PAR B/D PAR B/D PAR B/D PAR 有關本表格所含標誌與縮寫的含義, 可參見第 7 117

AMINOSYN-HBC 7% AMINOSYN-PF 10 % AMINOSYN-PF 7 % (SULFITE-FREE) CLINIMIX 5%/D15W SULFITE FREE CLINIMIX 5%/D25W SULFITE-FREE CLINIMIX 2.75%/D5W SULFIT FREE CLINIMIX 4.25%-D20W SULF-FREE CLINIMIX 4.25%-D25W SULF-FREE CLINIMIX 4.25%/D10W SULF FREE CLINIMIX 5%-D20W(SULFITE-FREE) CLINIMIX E 4.25%/D10W SUL FREE CLINIMIX E 4.25%/D25W SUL FREE CLINIMIX E 4.25%/D5W SULF FREE CLINIMIX E 5%/D15W SULFIT FREE CLINIMIX E 5%/D20W SULFIT FREE CLINIMIX E 5%/D25W SULFIT FREE FREAMINE III 10 % HEPATAMINE 8% intralipid intravenous emulsion 20 % ISOLYTE-P IN 5 % DEXTROSE NORSOL-M IN 5 % DEXTROSE NORSOL-R PH 7.4 PLASMA-LYTE 148 PLASMA-LYTE-56 IN 5 % DEXTROSE travasol 10 % TROPHAMINE 10 % TROPHAMINE 6% VITAMINS / HEMATINICS ascorbic acid (vitamin c) oral capsule, extended release ascorbic acid (vitamin c) oral tablet B/D PAR B/D PAR B/D PAR B/D PAR B/D PAR B/D PAR B/D PAR B/D PAR B/D PAR B/D PAR B/D PAR B/D PAR B/D PAR B/D PAR B/D PAR B/D PAR B/D PAR B/D PAR B/D PAR; B/D PAR; B/D PAR; B/D PAR ; 有關本表格所含標誌與縮寫的含義, 可參見第 7 118

ASCORBIC ACID WITH ROSE HIPS B-12 DOTS C-1000 ORAL TABLET C-1000 WITH ROSE HIPS C-500 ORAL TABLET C-500 ORAL TABLET,CHEWABLE CALCIUM 600 + MINERALS calcium carbonate-vit d3-min oral tablet CALCIUM CARBONATE-VIT D3-MIN ORAL TABLET,CHEWABLE 600 MG (1,500 MG)-400 UNIT CALCIUM FOR WOMEN CALCIUM SOFT CHEW ORAL TABLET, CHEWABLE 500-100-40 MG-UNIT-MCG, 500-200-40 MG-UNIT-MCG calcium-vitamin d3-vitamin k oral tablet,chewable 500-200-40 mg-unit-mcg cholecalciferol (vitamin d3) oral capsule 1,000 unit, 5,000 unit cholecalciferol (vitamin d3) oral capsule 2,000 unit, 400 unit cholecalciferol (vitamin d3) oral drops 400 unit/ml cholecalciferol (vitamin d3) oral tablet 1,000 unit, 2,000 unit, 5,000 unit cholecalciferol (vitamin d3) oral tablet 400 unit CLASSIC PRENATAL cyanocobalamin (vitamin b-12) injection cyanocobalamin (vitamin b-12) oral tablet 1,000 mcg, 100 mcg, 500 mcg cyanocobalamin (vitamin b-12) oral tablet extended release cyanocobalamin (vitamin b-12) sublingual tablet 1,000 mcg $0 (Tier 3) ; ; ; ; ; ; ; 有關本表格所含標誌與縮寫的含義, 可參見第 7 119

cyanocobalamin (vitamin b-12) sublingual tablet 2,500 mcg D-VI-SOL D-VITA D3-2000 DAILY PRENATAL DELTA D3 DIALYVITE 800 DIALYVITE VITAMIN D ergocalciferol (vitamin d2) oral capsule ergocalciferol (vitamin d2) oral tablet 400 unit EZFE 200 FEOSOL ORAL TABLET 325 MG (65 MG IRON) FERATE ORAL TABLET 240 MG (27 MG IRON) FEROSUL ORAL TABLET FERRETTS FERREX 150 FERRIC X-150 FERRO-TIME ferrous gluconate oral tablet 240 mg (27 mg iron) ferrous gluconate oral tablet 256 mg (28 mg iron) FERROUS GLUCONATE ORAL TABLET 324 MG (36 MG IRON), 324 MG (37.5 MG IRON), 324 MG (38 MG IRON), 325 MG (36 MG IRON) ferrous sulfate oral tablet 325 mg (65 mg iron) ferrous sulfate oral tablet,delayed release (dr/ec) FERROUS SULFATE ORAL TABLET,DELAYED RELEASE (DR/EC) FERROUSUL FLUORITAB ORAL TABLET,CHEWABLE 1 MG FLUORIDE (2.2 MG) folic acid oral tablet 1 mg $0 (Tier 3) $0 (Tier 3) ; ; ; ; ; ; ; ; ; ; ; ; ; ; ; ; ; ; ; ; 有關本表格所含標誌與縮寫的含義, 可參見第 7 120

folic acid oral tablet 400 mcg, 800 mcg FRUIT C-500 FULL SPECTRUM B-VITAMIN C HIGH POTENCY IRON IFEREX 150 IRON (DRIED) IRON (FERROUS SULFATE) IRON HIGH POTENCY IRON ORAL TABLET 325 MG (65 MG IRON) KPN LUDENT FLUORIDE ORAL TABLET, CHEWABLE 1 MG FLUORIDE (2.2 MG) MYFERON 150 ONE DAILY PRENATAL ORAL COMBO PACK 28-800-440 MG-MCG-MG OYSTER SHELL CALCIUM WITH D POLY-IRON POLY-VITA POLY-VITAMIN polysaccharide iron complex PRENATAL FORMULA ORAL TABLET 28 MG IRON- 800 MCG PRENATAL ONE DAILY PRENATAL TABLET PRENATAL VITAMIN ORAL CAPSULE 13.5-0.4 MG prenatal vitamin oral tablet PRENATAL VITAMIN ORAL TABLET, 27-0.8 MG PRENATAL VITAMIN ORAL TABLET 27 MG IRON- 800 MCG prenatal vitamin oral tablet 28 mg iron- 800 mcg ; ; ; ; ; ; ; 有關本表格所含標誌與縮寫的含義, 可參見第 7 121

pyridoxine (vitamin b6) oral tablet 100 mg, 25 mg, 50 mg RENA-VITE riboflavin (vitamin b2) oral tablet 100 mg, 50 mg RISACAL-D SLOW RELEASE IRON ORAL TABLET EXTENDED RELEASE 160 MG (50 MG IRON), 47.5 MG IRON sodium fluoride oral tablet sodium fluoride oral tablet,chewable 1 mg fluoride (2.2 mg) SOOTHING PUREWAY-C STRAWBERRY C THERA-D thiamine hcl (vitamin b1) oral tablet 100 mg, 250 mg, 50 mg thiamine mononitrate (vit b1) vitamin a palmitate oral VITAMIN A PALMITATE ORAL VITAMIN B-1 VITAMIN B-1 (NONITRATE) VITAMIN B-12 ORAL TABLET 1,000 MCG, 100 MCG, 250 MCG, 500 MCG VITAMIN B-12 ORAL TABLET EXTENDED RELEASE 1,000 MCG VITAMIN B-12 ORAL TABLET EXTENDED RELEASE 2,000 MCG VITAMIN B-12 SUBLINGUAL TABLET 2,500 MCG VITAMIN B-2 VITAMIN B-6 ORAL TABLET 100 MG, 25 MG, 50 MG VITAMIN C ORAL CAPSULE, EXTENDED RELEASE ; ; ; ; ; ; ; ; ; 有關本表格所含標誌與縮寫的含義, 可參見第 7 122

VITAMIN C ORAL TABLET 1,000 MG, 250 MG, 500 MG VITAMIN C ORAL TABLET,CHEWABLE 250 MG, 500 MG VITAMIN C WITH ROSE HIPS ORAL TABLET VITAMIN D2 VITAMIN D3 ORAL CAPSULE 1,000 UNIT, 2, 000 UNIT, 400 UNIT VITAMIN D3 ORAL TABLET 1,000 UNIT, 400 UNIT VITAMIN D3 ORAL TABLET 2,000 UNIT, 5,000 UNIT VITAMIN E (DL, ACETATE) ORAL CAPSULE 100 UNIT vitamin e oral capsule 1,000 unit, 200 unit, 400 unit vitamin e oral capsule 100 unit $0 (Tier 3) ; ; ; ; ; ; ; ; 有關本表格所含標誌與縮寫的含義, 可參見第 7 123

Index of Drugs 1 12 HOUR COLD RELIEF... 102 3 3-DAY VAGINAL... 95 A abacavir... 9 abacavir-lamivudinezidovudine... 9 ABELCET... 8 ABILIFY MAINTENA... 42 ABRAXANE... 20 acamprosate... 69 acarbose oral tablet 100 mg... 74 acarbose oral tablet 25 mg... 74 acarbose oral tablet 50 mg... 74 ACCU-CHEK AVIVA... 74 ACCU-CHEK AVIVA PLUS TEST STRP... 74 ACCU-CHEK COMPACT PLUS TEST... 74 ACCU-CHEK COMPACT TEST... 74 ACCU-CHEK MULTICLIX LANCET... 74 ACCU-CHEK SMARTVIEW TEST STRIP... 74 ACCU-CHEK SOFTCLIX LANCETS... 74 acebutolol... 52 ACEPHEN RECTAL SUPPOSITORY 650 MG... 38 ACETAMINOPHEN EXTRA STRENGTH ORAL CAPSULE 500 MG... 38 ACETAMINOPHEN EXTRA STRENGTH ORAL LIQUID 500 MG/15 ML... 38 ACETAMINOPHEN EXTRA STRENGTH ORAL SUSPENSION 160 MG/5 ML... 38 ACETAMINOPHEN LIQUID... 38 acetaminophen oral suspension 160 mg/5 ml... 38 acetaminophen oral tablet 500 mg... 38 ACETAMINOPHEN PAIN RELIEF... 38 acetaminophen rectal suppository 650 mg... 38 acetaminophen-codeine oral solution 120 mg-12 mg /5 ml (5 ml), 300 mg-30 mg /12.5 ml... 35 acetaminophen-codeine oral solution 120-12 mg/5 ml... 35 ACETAMINOPHEN- CODEINE ORAL SOLUTION 240 MG-24 MG /10 ML (10 ML)... 36 acetaminophen-codeine oral tablet 300-15 mg... 36 acetaminophen-codeine oral tablet 300-30 mg... 36 acetaminophen-codeine oral tablet 300-60 mg... 36 acetazolamide... 101 acetazolamide sodium... 101 acetic acid otic... 73 acetic acid-aluminum acetate... 73 acetylcysteine... 109 acetylcysteine intravenous... 69 acid control (ranitidine) oral tablet 150 mg... 88 ACID GONE ANTACID E.STRENGTH... 81 acid reducer (famotidine)... 88 acid reducer (ranitidine)... 88 acitretin... 61 ACNE MEDICATION TOPICAL GEL 10 %... 62 ACNE TREATMENT (BENZOYL PEROX) TOPICAL GEL... 62 ACNE-CLEAR... 62 ACTA-TABS PE... 103 ACTEMRA INTRAVENOUS... 93 ACTEMRA INTRAVENOUS VIAL... 93 ACTHAR H.P.... 73 ACTHIB (PF)... 90 ACTIMMUNE... 89 acyclovir oral capsule... 9 acyclovir oral suspension 200 mg/5 ml... 9 acyclovir oral tablet... 9 acyclovir sodium intravenous solution... 9 acyclovir topical... 66 ADACEL(TDAP ADOLESN/ ADULT)(PF)... 90 ADAGEN... 69 adapalene topical gel 0.3 %... 62 adapalene topical gel with pump... 62 ADASUVE... 42 adefovir... 9 ADEMPAS... 109 ADULT LOW DOSE ASPIRIN... 38 ADULT ROBITUSSIN PEAK COLD DM... 103 ADULT TUSSIN CHEST CONGESTION... 103 ADULT TUSSIN COUGH CONGEST DM... 103 ADULT WAL-TUSSIN... 103 ADVAIR DISKUS... 109 ADVAIR HFA... 109 ADVANCED ANTACID- ANTIGAS... 81? 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 124

ADVANCED EYE RELIEF... 99 AEROSPAN... 109 AF... 64 afeditab cr... 52 AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION 2 MG, 5 MG... 20 AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION 3 MG... 20 AFINITOR ORAL TABLET 10 MG... 20 AFINITOR ORAL TABLET 2.5 MG... 20 AFINITOR ORAL TABLET 5 MG... 20 AFINITOR ORAL TABLET 7.5 MG... 20 AFTERA... 96 AGGRENOX... 57 AKWA TEARS (POLYVINYL ALCOHOL)... 99 ala-cort topical cream... 66 ALA-HIST DM... 103 ALAVERT... 103 ALAWAY... 99 ALBENZA... 15 albuterol sulfate inhalation solution for nebulization 0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 mg /3 ml (0.083 %)... 109 ALBUTEROL SULFATE INHALATION SOLUTION FOR NEBULIZATION 2.5 MG/0.5 ML... 109 albuterol sulfate inhalation solution for nebulization 5 mg/ ml... 109 albuterol sulfate oral... 109 ALCALAK... 113 alclometasone... 66 alcohol pads... 74 ALDURAZYME... 78 ALECENSA... 20 alendronate oral solution... 93 alendronate oral tablet 10 mg, 5 mg... 93 alendronate oral tablet 35 mg, 70 mg... 93 alendronate oral tablet 40 mg... 69 alfuzosin... 112 ALIMTA... 20 ALINIA ORAL SUSPENSION FOR RECONSTITUTION... 15 ALINIA ORAL TABLET... 15 ALKA-SELTZER PLUS ALLERGY... 103 all day allergy relief (cetir)... 103 all day allergy (cetirizine) oral tablet... 103 ALL DAY RELIEF... 38 ALLER-G-TIME... 103 aller-tec... 103 ALLERGY AND SINUS RELIEF... 103 ALLERGY EYE (KETOTIFEN)... 100 ALLERGY MEDICATION... 103 ALLERGY MEDICINE... 103 allergy relief (cetirizine) oral tablet... 103 ALLERGY RELIEF (CLEMASTINE)... 103 allergy relief (loratadine) oral tablet... 103 allergy relief (loratadine) oral tablet,disintegrating... 103 ALLERGY RELIEF (DIPHENHYDRAMIN)... 103 ALLERGY (DIPHENHYDRAMINE)... 103 allopurinol... 93 ALOPHEN... 81 alosetron... 81 ALPHAGAN P OPHTHALMIC DROPS 0.1 %... 102 alprazolam oral tablet... 42 ALTAVERA (28)... 96 ALTOPREV... 59 ALUMINA AND MAGNESIUM ANTACID ORAL SUSPENSION 95-358 MG/15 ML... 81 ALUMINA AND MAGNESIUM ANTACID ORAL TABLET,CHEWABLE 80-20 MG... 82 ALUMINA, MAGNESIA, SIMETHICONE SUSPENSION ORAL SUSPENSION 200-200-20 MG/5 ML, 400-400-40 MG/5 ML... 82 aluminum hydroxide gel oral suspension 320 mg/5 ml... 82 aluminum hydroxide gel oral suspension 600 mg/5 ml... 82 ALYACEN 1/35 (28)... 96 ALYACEN 7/7/7 (28)... 96 amantadine hcl oral capsule... 9 amantadine hcl oral tablet... 9 AMBI 10PEH-4CPM... 103 AMBI 60PSE-4CPM... 103 AMBISOME... 8 amcinonide... 66 amifostine crystalline... 20 AMIKACIN INJECTION SOLUTION 1,000 MG/4 ML... 15 amikacin injection solution 500 mg/2 ml... 15 amiloride... 53 amiloridehydrochlorothiazide... 53 AMINOSYN 8.5 %... 117 AMINOSYN 8.5 %- ELECTROLYTES... 117 AMINOSYN II 10 %... 117 AMINOSYN II 7 %... 117 AMINOSYN II 8.5 %... 117 AMINOSYN II 8.5 %- ELECTROLYTES... 117 AMINOSYN M 3.5 %... 117? 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 125

AMINOSYN-HBC 7%... 118 AMINOSYN-PF 10 %... 118 AMINOSYN-PF 7 % (SULFITE-FREE)... 118 amiodarone intravenous solution... 52 AMIODARONE INTRAVENOUS SYRINGE... 52 amiodarone oral... 52 AMITIZA... 82 amitriptyline... 42 AMLACTIN TOPICAL LOTION... 61 amlodipine besylate oral tablet 10 mg, 2.5 mg... 53 amlodipine besylate oral tablet 5 mg... 53 amlodipine-atorvastatin... 59 amlodipine-benazepril... 53 amlodipine-valsartan... 53 amlodipine-valsartanhcthiazid... 53 ammonium lactate... 61 AMNIUM LACTATE TOPICAL LOTION 12 %... 61 AMNIUM LACTATE TOPICAL LOTION 5 %... 61 amoxapine... 42 amoxicillin oral capsule... 17 amoxicillin oral suspension for reconstitution... 17 amoxicillin oral tablet... 17 amoxicillin oral tablet, chewable 125 mg, 250 mg... 17 amoxicillin-pot clavulanate... 17 amphotericin b... 8 ampicillin... 17 ampicillin sodium injection... 17 ampicillin sodium intravenous... 17 ampicillin-sulbactam injection recon soln 1.5 gram, 3 gram... 17 ampicillin-sulbactam injection recon soln 15 gram... 17 ampicillin-sulbactam intravenous recon soln 1.5 gram... 17 ampicillin-sulbactam intravenous recon soln 3 gram... 17 AMPYRA... 34 anagrelide... 69 anastrozole... 20 ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP 20.25 MG/1.25 GRAM (1.62 %)... 78 ANDROGEL TRANSDERMAL GEL IN PACKET 1.62 % (20.25 MG/ 1.25 GRAM)... 78 ANDROGEL TRANSDERMAL GEL IN PACKET 1.62 % (40.5 MG/ 2.5 GRAM)... 78 ANDROXY... 78 ANORO ELLIPTA... 109 ANTACID... 82 ANTACID ANTI-GAS... 82 ANTACID ANTI-GAS DOUBLE STR... 82 ANTACID EXST (MAG CARB-AL HYD)... 82 ANTACID EXT STR (CALCIUM CARB)... 113 ANTACID EXTRA- STRENGTH ORAL SUSPENSION 200-200-20 MG/5 ML... 82 ANTACID EXTRA- STRENGTH ORAL TABLET, CHEWABLE 168 MG (420 MG), 300 MG (750 MG)... 113 ANTACID LIQUID... 82 ANTACID M... 82 ANTACID MAXIMUM STRENGTH... 82 ANTACID PLUS ANTI- GAS... 82 ANTACID REGULAR STRENGTH... 82 ANTACID WITH SIMETHICONE... 82 ANTACID (CALCIUM CARBONATE)... 113 ANTACID-ANTIGAS... 82 ANTACID- SIMETHICONE... 82 ANTI-DIARRHEAL... 80 ANTI-DIARRHEAL (LOPERAMIDE) ORAL LIQUID 1 MG/5 ML... 80 ANTI-FUNGAL MICONAZOLE POWDER TOPICAL POWDER 2 %... 64 anti-itch (hc) topical cream... 66 anti-itch (hc) topical ointment... 66 ANTIBIOTIC (NEOMY- BACIT-POLYM)... 63 ANTIBIOTIC-PAIN RELIEF (BACIT)... 63 ANTIFUNGAL MICONAZOLE CREAM... 64 ANTIFUNGAL SPRAY... 64 antifungal (clotrimazole)... 64 ANTIFUNGAL (TOLNAFTATE) TOPICAL AEROSOL,SPRAY... 64 ANTIFUNGAL (TOLNAFTATE) TOPICAL CREAM... 64 AP-HIST DM... 103 APOKYN... 33 apraclonidine... 102 apri... 96 APRISO... 82 APRODINE... 103 APTIOM... 29 APTIVUS ORAL CAPSULE... 9? 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 126

APTIVUS ORAL SOLUTION... 9 AQUA CARE... 62 ARALAST NP... 69 aranelle (28)... 96 ARANESP (IN POLYSORBATE) INJECTION SOLUTION 100 MCG/ML, 200 MCG/ML, 25 MCG/ML, 300 MCG/ML, 40 MCG/ML, 60 MCG/ML... 90 ARANESP (IN POLYSORBATE) INJECTION SYRINGE... 90 arbinoxa... 103 ARCALYST... 90 aripiprazole oral solution... 42 aripiprazole oral tablet 10 mg... 42 aripiprazole oral tablet 15 mg... 42 aripiprazole oral tablet 2 mg... 42 aripiprazole oral tablet 20 mg, 30 mg... 42 aripiprazole oral tablet 5 mg... 42 aripiprazole oral tablet, disintegrating 10 mg... 42 aripiprazole oral tablet, disintegrating 15 mg... 42 ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 441 MG/1.6 ML... 42 ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 662 MG/2.4 ML... 42 ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 882 MG/3.2 ML... 42 ARNUITY ELLIPTA... 109 ARRANON... 20 ARTIFICIAL TEARS OPHTHALMIC DROPS 0.5-0.6 %, 1-0.2-0.2 %... 100 ARTIFICIAL TEARS (PF) OPHTHALMIC DROPPERETTE 0.1-0.3 %... 100 ARTIFICIAL TEARS (POLYVIN ALC)... 100 ARTIFICIAL TEARS (GLYCERIN-PEG)... 100 ARZERRA... 21 ASACOL HD... 82 ASCORBIC ACID WITH ROSE HIPS... 119 ascorbic acid (vitamin c) oral capsule, extended release... 118 ascorbic acid (vitamin c) oral tablet... 118 ASMANEX HFA... 109 ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG (30 DOSES)... 110 ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG (7 DOSES), 220 MCG (14 DOSES)... 110 ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 220 MCG (120 DOSES), 220 MCG (30 DOSES), 220 MCG (60 DOSES)... 110 ASPIR-LOW... 38 ASPIRIN CHILDRENS... 38 ASPIRIN LOW DOSE... 38 aspirin oral tablet... 38 aspirin oral tablet, chewable... 38 aspirin oral tablet,delayed release (dr/ec) 325 mg, 81 mg... 38 aspirin-dipyridamole... 57 atenolol... 53 atenolol-chlorthalidone... 53 ATGAM... 91 ATHLETE'S FOOT AF... 65 ATHLETE'S FOOT TOPICAL POWDER... 65 athlete's foot (clotrimazole)... 64 ATHLETE'S FOOT (TERBINAFINE)... 64 ATHLETE'S FOOT (TOLNAFTATE)... 65 atorvastatin... 59 atovaquone... 15 atovaquone-proguanil... 15 ATRIPLA... 9 atropine injection syringe 0.05 mg/ml, 0.1 mg/ml... 80 ATROVENT HFA... 110 AVASTIN... 21 AVEENO ANTI-ITCH (HYDROCORTSN)... 66 aviane... 96 AVONEX INTRAMUSCULAR PEN INJECTOR KIT... 90 AVONEX INTRAMUSCULAR SYRINGE... 90 AVONEX INTRAMUSCULAR SYRINGE KIT... 90 AVONEX (WITH ALBUMIN)... 90 azacitidine... 21 AZACTAM IN DEXTROSE (ISO-OSM)... 15 azathioprine... 21 azathioprine sodium... 21 azelastine nasal... 72 azelastine ophthalmic... 100 AZILECT... 33 azithromycin intravenous recon soln 500 mg... 14? 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 127

azithromycin intravenous recon soln 500 mg (2 mg/ ml)... 14 azithromycin oral... 14 AZOPT... 101 AZOR... 53 aztreonam... 15 AZURETTE (28)... 96 B B-12 DOTS... 119 baciim... 15 bacitracin ophthalmic... 98 bacitracin topical ointment... 63 BACITRACIN TOPICAL PACKET... 63 BACITRACIN ZINC TOPICAL PACKET... 63 bacitracin-polymyxin b ophthalmic... 98 bacitracin-polymyxin b topical ointment... 64 bacitracin-polymyxin b topical packet... 64 BACITRAYCIN PLUS TOPICAL OINTMENT 500 UNIT/GRAM... 64 baclofen... 35 balsalazide... 82 BANOPHEN ALLERGY... 103 BANOPHEN ORAL CAPSULE 25 MG... 103 BANOPHEN ORAL CAPSULE 50 MG... 103 BANOPHEN ORAL LIQUID... 103 BANOPHEN ORAL TABLET... 104 BANZEL ORAL SUSPENSION... 29 BANZEL ORAL TABLET 200 MG... 29 BANZEL ORAL TABLET 400 MG... 29 BARACLUDE ORAL SOLUTION... 9 BAYER ADVANCED... 38 BAYER ASPIRIN... 38 BAZA ANTIFUNGAL... 65 BCG VACCINE, LIVE (PF)... 91 BELEODAQ... 21 benazepril... 53 benazeprilhydrochlorothiazide... 53 BENDEKA... 21 BENLYSTA... 93 benzonatate oral capsule 100 mg, 200 mg... 104 benzoyl peroxide topical gel 10 %, 5 %... 62 benzphetamine oral tablet 50 mg... 69 benztropine oral... 33 BESIVANCE... 98 BETA-HC... 66 betamethasone dipropionate... 66 betamethasone valerate topical cream... 66 betamethasone valerate topical lotion... 66 betamethasone valerate topical ointment... 66 betamethasone, augmented... 67 BETATEMP... 39 betaxolol ophthalmic... 99 betaxolol oral... 53 bethanechol chloride... 112 BETIL... 99 BETOPTIC S... 99 bexarotene... 21 BEXSERO (PF)... 91 bicalutamide... 21 BICILLIN C-R... 17 BICILLIN L-A... 18 BICNU... 21 BILTRICIDE... 15 bimatoprost... 101 BIOCOTRON... 104 BION TEARS (PF)... 100 BISA-LAX... 82 BISAC-EVAC... 82 bisacodyl oral... 82 bisacodyl rectal... 82 BISCOLAX... 82 BISMATROL ORAL SUSPENSION 262 MG/15 ML... 80 BISMATROL ORAL SUSPENSION 525 MG/15 ML... 80 BISMATROL ORAL TABLET,CHEWABLE... 80 BISMUTH... 80 BISMUTH MAXIMUM STRENGTH... 80 bismuth subsalicylate oral tablet,chewable... 80 bisoprolol fumarate... 53 bisoprololhydrochlorothiazide... 53 bleomycin... 21 BLEPHAMIDE S.O.P.... 102 BLINCYTO... 21 blisovi fe 1.5/30 (28)... 96 BONIVA INTRAVENOUS... 93 BOOSTRIX TDAP... 91 BOSULIF ORAL TABLET 100 MG... 21 BOSULIF ORAL TABLET 500 MG... 21 BP... 62 BREO ELLIPTA... 110 BRILINTA... 57 brimonidine... 102 BRIVIACT INTRAVENOUS... 29 BRIVIACT ORAL SOLUTION... 29 BRIVIACT ORAL TABLET 10 MG... 29 BRIVIACT ORAL TABLET 100 MG, 75 MG... 29 BRIVIACT ORAL TABLET 25 MG... 29 BRIVIACT ORAL TABLET 50 MG... 29 bromocriptine... 33? 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 128

brompheniraminphenylephrin-dm oral liquid 2-5-10 mg/5 ml... 104 budesonide oral... 83 bumetanide... 53 BUPHENYL ORAL TABLET... 69 buprenorphine hcl injection solution... 36 buprenorphine hcl injection syringe... 36 buprenorphine hcl sublingual tablet 2 mg... 36 buprenorphine hcl sublingual tablet 8 mg... 36 buprenorphine-naloxone sublingual tablet 2-0.5 mg... 39 buprenorphine-naloxone sublingual tablet 8-2 mg... 39 buproban... 72 bupropion hcl oral tablet 100 mg... 42 bupropion hcl oral tablet 75 mg... 42 bupropion hcl oral tablet extended release 100 mg... 42 bupropion hcl oral tablet extended release 150 mg, 200 mg... 42 bupropion hcl oral tablet extended release 24 hr 150 mg... 43 bupropion hcl oral tablet extended release 24 hr 300 mg... 43 buspirone... 43 BUSULFEX... 21 BUTALBITAL COMPOUND W/CODEINE... 36 butorphanol tartrate injection solution 1 mg/ml... 39 butorphanol tartrate injection solution 2 mg/ml... 39 butorphanol tartrate nasal... 39 BYDUREON... 74 BYETTA SUBCUTANEOUS PEN INJECTOR 10 MCG/ DOSE(250 MCG/ML) 2.4 ML... 74 BYETTA SUBCUTANEOUS PEN INJECTOR 5 MCG/ DOSE (250 MCG/ML) 1.2 ML... 74 BYSTOLIC... 53 C C-1000 ORAL TABLET... 119 C-1000 WITH ROSE HIPS... 119 C-500 ORAL TABLET... 119 C-500 ORAL TABLET, CHEWABLE... 119 cabergoline... 78 CABOMETYX ORAL TABLET 20 MG... 21 CABOMETYX ORAL TABLET 40 MG, 60 MG... 21 CAL-GEST ANTACID... 113 calamine... 62 CALAMINE-ZINC OXIDE TOPICAL LOTION 8-8 %... 62 CALCI-CHEW... 113 CALCIONATE... 113 calcipotriene scalp... 61 calcipotriene topical... 61 calcitonin (salmon)... 78 CALCITRATE... 113 calcitriol intravenous solution 1 mcg/ml... 78 calcitriol oral... 78 CALCIUM 500 + D ORAL TABLET 500 MG(1,250MG) -200 UNIT... 113 CALCIUM 500 + D ORAL TABLET 500 MG(1,250MG) -400 UNIT... 113 CALCIUM 500 + D ORAL TABLET,CHEWABLE... 113 CALCIUM 500 + D (D3)... 113 CALCIUM 500 ORAL TABLET,CHEWABLE... 113 CALCIUM 500 WITH D... 113 CALCIUM 600... 113 CALCIUM 600 + D(3) ORAL TABLET 600 MG(1,500MG) -200 UNIT, 600 MG(1, 500MG) -400 UNIT... 113 CALCIUM 600 + MINERALS... 119 CALCIUM 600 WITH VITAMIN D3 ORAL TABLET... 113 calcium acetate oral capsule... 113 CALCIUM ANTACID ORAL TABLET,CHEWABLE 200 MG CALCIUM (500 MG)... 113 CALCIUM ANTACID ORAL TABLET,CHEWABLE 300 MG (750 MG), 400 MG (1,000 MG)... 114 CALCIUM ANTACID TROPICAL... 114 CALCIUM ANTACID ULTRA MAX ST... 114 calcium carbonate - d3 oral tablet 500 mg(1,250mg) -125 unit, 500 mg(1,250mg) -200 unit, 500 mg(1,250mg) -400 unit, 500mg (1,250mg) -600 unit... 114 calcium carbonate - d3 oral tablet 600 mg(1,500mg) -200 unit, 600 mg(1,500mg) -400 unit, 600 mg(1,500mg) -800 unit... 114 calcium carbonate - d3 oral tablet,chewable 500 mg(1, 250mg) -400 unit... 114 CALCIUM CARBONATE - D3 ORAL TABLET, CHEWABLE 500-100 MG- UNIT... 114 CALCIUM CARBONATE AND MAGNESIA ANTACID? 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 129

ORAL SUSPENSION 200-200-20 MG/5 ML, 400-400-40 MG/5 ML... 83 CALCIUM CARBONATE AND MAGNESIA ANTACID ORAL TABLET,CHEWABLE 700-300 MG... 83 CALCIUM CARBONATE ANTACID ORAL TABLET, CHEWABLE 400 MG (1,000 MG)... 114 CALCIUM CARBONATE ORAL SUSPENSION... 114 calcium carbonate oral tablet 500 mg calcium (1,250 mg), 600 mg (1,500 mg)... 114 calcium carbonate oral tablet, chewable 200 mg calcium (500 mg), 300 mg (750 mg), 400 mg (1,000 mg), 500 mg calcium (1,250 mg)... 114 calcium carbonate-vit d3-min oral tablet... 119 CALCIUM CARBONATE- VIT D3-MIN ORAL TABLET,CHEWABLE 600 MG (1,500 MG)-400 UNIT... 119 CALCIUM CITRATE + D... 114 calcium citrate oral tablet 200 mg (950 mg)... 114 CALCIUM CITRATE ORAL TABLET 250 MG CALCIUM... 114 calcium citrate-vitamin d3 oral tablet 200 mg calcium -250 unit, 250 mg calcium- 200 unit... 114 calcium citrate-vitamin d3 oral tablet 315-200 mg-unit, 315-250 mg-unit... 114 CALCIUM FOR WOMEN... 119 CALCIUM GLUCONATE ORAL TABLET 45 MG (500 MG)... 114 CALCIUM GLUCONATE ORAL TABLET 60 MG (650 MG)... 114 CALCIUM LACTATE ORAL TABLET 84 MG (648 MG)... 115 CALCIUM SOFT CHEW ORAL TABLET,CHEWABLE 500-100-40 MG-UNIT-MCG, 500-200-40 MG-UNIT- MCG... 119 CALCIUM WITH VITAMIN D... 115 calcium-magnesium-zinc oral tablet... 115 CALCIUM-MAGNESIUM- ZINC ORAL TABLET 333-133-5 MG... 115 calcium-vitamin d3-vitamin k oral tablet,chewable 500-200- 40 mg-unit-mcg... 119 CALTRATE WITH VITAMIN D3... 115 camila... 94 CANASA... 83 CANCIDAS... 8 candesartan oral tablet 16 mg, 4 mg, 8 mg... 53 candesartan oral tablet 32 mg... 53 candesartanhydrochlorothiazid oral tablet 16-12.5 mg... 53 candesartanhydrochlorothiazid oral tablet 32-12.5 mg, 32-25 mg... 53 CAPASTAT... 15 CAPEX... 67 CAPRELSA ORAL TABLET 100 MG... 21 CAPRELSA ORAL TABLET 300 MG... 21 captopril... 53 captoprilhydrochlorothiazide... 53 CARBAGLU... 69 carbamazepine oral capsule, er multiphase 12 hr... 29 carbamazepine oral suspension 100 mg/5 ml... 29 carbamazepine oral suspension 200 mg/10 ml... 29 carbamazepine oral tablet... 29 carbamazepine oral tablet extended release 12 hr 100 mg... 29 carbamazepine oral tablet extended release 12 hr 200 mg, 400 mg... 29 carbamazepine oral tablet, chewable... 29 carbidopa-levodopa... 33 carboplatin intravenous solution... 21 CARIMUNE NF NANOFILTERED INTRAVENOUS RECON SOLN 12 GRAM, 6 GRAM... 91 carteolol... 99 cartia xt... 53 carvedilol... 53 CAYSTON... 15 CAZIANT (28)... 96 cefaclor oral capsule... 13 cefaclor oral suspension for reconstitution 125 mg/5 ml... 13 cefaclor oral suspension for reconstitution 250 mg/5 ml, 375 mg/5 ml... 13 cefaclor oral tablet extended release 12 hr... 13 cefadroxil oral capsule... 13 cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml... 13 cefadroxil oral tablet... 13 cefazolin in dextrose (iso-os) intravenous piggyback 1 gram/ 50 ml... 13 CEFAZOLIN IN DEXTROSE (ISO-OS) INTRAVENOUS PIGGYBACK 2 GRAM/50 ML... 13? 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 130

cefazolin injection recon soln 1 gram, 500 mg... 13 cefazolin injection recon soln 10 gram, 20 gram... 13 CEFAZOLIN INJECTION RECON SOLN 100 GRAM, 300 G... 13 cefazolin intravenous... 13 cefdinir... 13 cefepime... 13 cefoxitin in dextrose, isoosm... 13 cefoxitin intravenous recon soln 1 gram... 13 cefoxitin intravenous recon soln 10 gram, 2 gram... 13 cefpodoxime... 13 cefprozil... 14 ceftazidime injection recon soln 1 gram, 2 gram... 14 ceftazidime injection recon soln 6 gram... 14 ceftriaxone in dextrose,isoos... 14 ceftriaxone injection recon soln 1 gram, 2 gram, 250 mg, 500 mg... 14 ceftriaxone injection recon soln 10 gram... 14 CEFTRIAXONE INJECTION RECON SOLN 100 GRAM... 14 ceftriaxone intravenous... 14 cefuroxime axetil oral tablet... 14 cefuroxime sodium intravenous vial injection recon soln 1.5 gram, 750 mg... 14 cefuroxime sodium intravenous vial intravenous recon soln 7.5 gram... 14 CELLCEPT INTRAVENOUS... 21 CELONTIN ORAL CAPSULE 300 MG... 30 cephalexin oral capsule 250 mg, 500 mg... 14 cephalexin oral suspension for reconstitution... 14 cephalexin oral tablet... 14 CERASPORT ORAL LIQUID... 115 CEREZYME INTRAVENOUS RECON SOLN 400 UNIT... 78 CERVARIX VACCINE (PF)... 91 cetirizine oral tablet... 104 CHANTIX... 72 CHANTIX CONTINUING NTH BOX... 72 CHANTIX STARTING NTH BOX... 72 CHERATUSSIN AC... 104 CHILD ASPIRIN... 39 CHILD MUCINEX CHEST CONGESTION... 104 CHILD MUCUS RELIEF EXPECTORANT... 104 CHILDREN'S ACETAMINOPHEN ORAL SUSPENSION 160 MG/5 ML, 160 MG/5 ML (5 ML)... 39 CHILDREN'S ALAWAY... 100 CHILDREN'S ASPIRIN... 39 CHILDREN'S CHEST CONGESTION... 104 CHILDREN'S NON-ASPIRIN ORAL SUSPENSION... 39 CHILDREN'S PAIN RELIEF ORAL SUSPENSION... 39 CHILDREN'S PAIN RELIEVER ORAL SUSPENSION... 39 CHILDREN'S PAIN-FEVER RELIEF ORAL SUSPENSION... 39 CHILDREN'S Q-PAP... 39 CHILDREN'S SILFEDRINE... 104 CHILDREN'S WAL-DRYL ALLERGY ORAL LIQUID... 104 chloramphenicol sod succinate... 15 chlorhexidine gluconate mucous membrane... 72 chloroquine phosphate oral... 15 chlorothiazide... 53 chlorothiazide sodium... 53 chlorpromazine... 43 chlorthalidone oral tablet 25 mg, 50 mg... 53 cholecalciferol (vitamin d3) oral capsule 1,000 unit, 5,000 unit... 119 cholecalciferol (vitamin d3) oral capsule 2,000 unit, 400 unit... 119 cholecalciferol (vitamin d3) oral drops 400 unit/ml... 119 cholecalciferol (vitamin d3) oral tablet 1,000 unit, 2,000 unit, 5,000 unit... 119 cholecalciferol (vitamin d3) oral tablet 400 unit... 119 cholestyramine light... 60 cholestyramine (with sugar)... 59 CIALIS ORAL TABLET 2.5 MG, 5 MG... 112 CICLODAN TOPICAL SOLUTION... 65 ciclopirox topical cream... 65 ciclopirox topical gel... 65 ciclopirox topical shampoo... 65 ciclopirox topical solution... 65 ciclopirox topical suspension... 65 cidofovir... 9 cilostazol... 57 CIMZIA... 83 CIMZIA POWDER FOR RECONST... 83 CIMZIA STARTER KIT... 83 CINRYZE... 110 CIPRODEX... 73 ciprofloxacin... 18? 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 131

ciprofloxacin er oral tablet, er multiphase 24 hr 1,000 mg... 18 ciprofloxacin er oral tablet, er multiphase 24 hr 500 mg... 18 ciprofloxacin hcl ophthalmic... 98 ciprofloxacin hcl oral... 18 ciprofloxacin lactate intravenous solution 200 mg/ 20 ml... 18 ciprofloxacin lactate intravenous solution 400 mg/ 40 ml... 18 cisplatin... 21 citalopram oral solution... 43 citalopram oral tablet 10 mg... 43 citalopram oral tablet 20 mg... 43 citalopram oral tablet 40 mg... 43 CITRATE OF MAGNESIA... 83 CITROMA... 83 CITRUS CALCIUM ORAL TABLET 200 MG CALCIUM -250 UNIT... 115 CITRUS CALCIUM ORAL TABLET 315-250 MG- UNIT... 115 cladribine... 21 clarithromycin oral suspension for reconstitution... 14 clarithromycin oral tablet... 14 clarithromycin oral tablet extended release 24 hr... 14 CLASSIC PRENATAL... 119 clearlax... 83 clemastine oral tablet 1.34 mg... 104 clemastine oral tablet 2.68 mg... 104 clindamycin hcl... 15 clindamycin phosphate injection... 15 CLINDAMYCIN PHOSPHATE INTRAVENOUS SOLUTION 300 MG/2 ML... 15 clindamycin phosphate intravenous solution 600 mg/4 ml... 15 clindamycin phosphate intravenous solution 900 mg/6 ml... 15 clindamycin phosphate topical... 62 clindamycin phosphate vaginal... 95 CLINIMIX 2.75%/D5W SULFIT FREE... 118 CLINIMIX 4.25%-D20W SULF-FREE... 118 CLINIMIX 4.25%-D25W SULF-FREE... 118 CLINIMIX 4.25%/D10W SULF FREE... 118 CLINIMIX 4.25%/D5W SULFIT FREE... 70 CLINIMIX 5%-D20W (SULFITE-FREE)... 118 CLINIMIX 5%/D15W SULFITE FREE... 118 CLINIMIX 5%/D25W SULFITE-FREE... 118 CLINIMIX E 2.75%/D10W SUL FREE... 70 CLINIMIX E 2.75%/D5W SULF FREE... 70 CLINIMIX E 4.25%/D10W SUL FREE... 118 CLINIMIX E 4.25%/D25W SUL FREE... 118 CLINIMIX E 4.25%/D5W SULF FREE... 118 CLINIMIX E 5%/D15W SULFIT FREE... 118 CLINIMIX E 5%/D20W SULFIT FREE... 118 CLINIMIX E 5%/D25W SULFIT FREE... 118 clobetasol scalp... 67 clobetasol topical cream... 67 clobetasol topical foam... 67 clobetasol topical gel... 67 clobetasol topical ointment... 67 clobetasol-emollient topical cream... 67 CLOLAR... 21 clomipramine... 43 clonazepam oral tablet 0.5 mg... 30 clonazepam oral tablet 1 mg... 30 clonazepam oral tablet 2 mg... 30 clonazepam oral tablet, disintegrating 0.125 mg... 30 clonazepam oral tablet, disintegrating 0.25 mg... 30 clonazepam oral tablet, disintegrating 0.5 mg... 30 clonazepam oral tablet, disintegrating 1 mg... 30 clonazepam oral tablet, disintegrating 2 mg... 30 clonidine hcl oral tablet... 53 clonidine transdermal patches... 54 clopidogrel oral tablet 300 mg... 57 clopidogrel oral tablet 75 mg... 57 clorazepate dipotassium... 43 CLOTRIMAZOLE 3 DAY... 95 CLOTRIMAZOLE AF... 65 CLOTRIMAZOLE ANTIFUNGAL... 65 clotrimazole mucous membrane... 8 clotrimazole topical... 65 clotrimazole vaginal cream... 95 CLOTRIMAZOLE-3... 95 CLOTRIMAZOLE-7... 95 clotrimazolebetamethasone... 65 clozapine oral tablet 100 mg... 43? 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 132

clozapine oral tablet 200 mg... 43 clozapine oral tablet 25 mg... 43 clozapine oral tablet 50 mg... 43 clozapine oral tablet, disintegrating 100 mg... 43 clozapine oral tablet, disintegrating 12.5 mg... 43 clozapine oral tablet, disintegrating 150 mg... 43 clozapine oral tablet, disintegrating 200 mg... 43 clozapine oral tablet, disintegrating 25 mg... 43 codeine-guaifenesin... 104 col-rite... 83 colchicine-probenecid... 93 COLCRYS... 93 COLD AND ALLERGY... 104 COLD AND ALLERGY PE... 104 colestipol... 60 colistin (colistimethate na)... 15 COLLYRIUM... 100 colocort... 83 COLY-MYCIN S... 73 COMBIGAN... 101 COMBIVENT RESPIMAT... 110 COMETRIQ ORAL CAPSULE 100 MG/DAY(80 MG X1-20 MG X1)... 21 COMETRIQ ORAL CAPSULE 140 MG/DAY(80 MG X1-20 MG X3)... 21 COMETRIQ ORAL CAPSULE 60 MG/DAY (20 MG X 3/DAY)... 21 COMFORT GEL... 83 COMFORT GEL EXTRA STRENGTH... 83 COMPLERA... 9 COMPLETE ALLERGY... 104 COMPLETE ALLERGY MEDICINE... 104 COMPLETE LICE TREATMENT... 68 compro... 83 CONDOMS-PREM LUBRICATED... 74 constulose... 83 COPAXONE SUBCUTANEOUS SYRINGE 20 MG/ML... 34 COPAXONE SUBCUTANEOUS SYRINGE 40 MG/ML... 34 COREG CR... 54 cormax scalp... 67 cortisone... 73 cortisone (hydrocortisone) topical cream... 67 CORTIZONE-10 PLUS... 67 CORTIZONE-10 TOPICAL CREAM... 67 cortizone-10 topical ointment... 67 COTELLIC... 21 COUGH CONTROL DM ORAL LIQUID... 104 COUGH CONTROL (GUAIFENESIN)... 104 COUGH SYRUP... 104 COUMADIN ORAL... 57 CREON... 83 CRESTOR... 60 CRIXIVAN ORAL CAPSULE 200 MG... 9 CRIXIVAN ORAL CAPSULE 400 MG... 9 cromolyn inhalation... 110 cromolyn ophthalmic... 100 cryselle (28)... 96 cyanocobalamin (vitamin b-12) injection... 119 cyanocobalamin (vitamin b-12) oral tablet 1,000 mcg, 100 mcg, 500 mcg... 119 cyanocobalamin (vitamin b-12) oral tablet extended release... 119 cyanocobalamin (vitamin b-12) sublingual tablet 1,000 mcg... 119 cyanocobalamin (vitamin b-12) sublingual tablet 2,500 mcg... 120 cyclafem 1/35 (28)... 96 cyclafem 7/7/7 (28)... 96 cyclobenzaprine oral tablet... 35 cyclophosphamide oral capsule... 22 CYCLOSET... 74 cyclosporine intravenous... 22 cyclosporine modified... 22 cyclosporine oral capsule... 22 CYRAMZA... 22 CYSTADANE... 83 CYSTAGON... 112 cytarabine... 22 CYTARABINE (PF) INJECTION SOLUTION 100 MG/5 ML (20 MG/ML)... 22 cytarabine (pf) injection solution 2 gram/20 ml (100 mg/ml)... 22 CYTARABINE (PF) INJECTION SOLUTION 20 MG/ML... 22 D D-VI-SOL... 120 D-VITA... 120 d10 %-0.45 % sodium chloride... 70 d2.5 %-0.45 % sodium chloride... 70 D3-2000... 120 d5 % and 0.9 % sodium chloride... 70 d5 %-0.45 % sodium chloride... 70 dacarbazine... 22 DAILY PRENATAL... 120 DAKLINZA ORAL TABLET 30 MG, 60 MG... 9 DAKLINZA ORAL TABLET 90 MG... 9? 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 133

DALIRESP... 110 danazol oral... 78 dantrolene... 35 DAPSONE... 15 DAPTACEL (DTAP PEDIATRIC) (PF)... 91 DARAPRIM... 15 DARZALEX... 22 daunorubicin intravenous solution... 22 DAYHIST ALLERGY... 104 decitabine... 22 DELTA D3... 120 DELZICOL ORAL CAPSULE,DELAYED RELEASE(DR/EC)... 83 demeclocycline... 19 DEMSER... 54 DENAVIR... 66 DEPEN TITRATABS... 93 DEPO-PROVERA INTRAMUSCULAR SOLUTION... 94 DERMAREST ECZEMA (HYDROCORT)... 67 DERMATOP TOPICAL OINTMENT... 67 DESCOVY... 9 DESENEX TOPICAL POWDER... 65 desipramine oral... 43 desmopressin injection... 78 desmopressin nasal... 78 desmopressin oral... 78 desonide... 67 desoximetasone... 67 DESVENLAFAXINE FUMARATE ORAL TABLET EXTENDED RELEASE 24HR 100 MG... 43 DESVENLAFAXINE FUMARATE ORAL TABLET EXTENDED RELEASE 24HR 50 MG... 43 DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE 24 HR 100 MG... 43 DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE 24 HR 50 MG... 43 desvenlafaxine oral tablet extended release 24hr 100 mg... 43 desvenlafaxine oral tablet extended release 24hr 50 mg... 44 DEX4 GLUCOSE ORAL GEL... 70 DEX4 GLUCOSE ORAL TABLET,CHEWABLE... 70 DEX4 GLUCOSE POUCH PACK... 70 DEX4 GLUCOSE QUICK DISSOLVE... 70 dexamethasone... 73 DEXAMETHASONE SODIUM PHOS (PF)... 73 dexamethasone sodium phosphate injection... 73 dexamethasone sodium phosphate ophthalmic... 102 DEXILANT... 88 dexrazoxane hcl intravenous recon soln 250 mg... 20 dexrazoxane hcl intravenous recon soln 500 mg... 20 dextroamphetamine oral capsule, extended release 10 mg, 5 mg... 44 dextroamphetamine oral capsule, extended release 15 mg... 44 dextroamphetamine oral tablet 10 mg... 44 dextroamphetamine oral tablet 5 mg... 44 dextroamphetamineamphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 5 mg, 7.5 mg... 44 dextroamphetamineamphetamine oral tablet 30 mg... 44 dextrose 10 % and 0.2 % nacl... 70 dextrose 10 % in water (d10w)... 70 dextrose 25 % in water (d25w)... 70 DEXTROSE 30 % IN WATER (D30W)... 70 DEXTROSE 40 % IN WATER (D40W)... 70 dextrose 5 % in water (d5w)... 70 dextrose 5 %-lactated ringers... 70 dextrose 5%-0.2 % sod chloride... 70 dextrose 5%-0.3 % sod.chloride... 70 DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS PARENTERAL SOLUTION... 70 DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE... 70 dextrose 70 % in water (d70w)... 70 dextrose oral gel... 70 dextrose with sodium chloride... 70 dextrose-kcl-nacl... 115 DIABETIC SILTUSSIN DAS- NA... 104 DIABETIC SILTUSSIN- DM... 104 DIABETIC TUSSIN DM ORAL LIQUID 10-100 MG/5 ML... 104 DIABETIC TUSSIN EX... 104 DIALYVITE 800... 120 DIALYVITE VITAMIN D... 120 DIARRHEA RELIEF (BISMUTH SUBS)... 80? 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 134

diazepam injection solution... 44 diazepam injection syringe... 44 diazepam intensol... 44 diazepam oral concentrate... 44 diazepam oral solution 5 mg/5 ml (1 mg/ml)... 44 DIAZEPAM ORAL SOLUTION 5 MG/5 ML (1 MG/ML, 5 ML)... 44 diazepam oral tablet 10 mg... 44 diazepam oral tablet 2 mg... 44 diazepam oral tablet 5 mg... 44 diazepam rectal kit 12.5-15- 17.5-20 mg... 30 diazepam rectal kit 2.5 mg, 5-7.5-10 mg... 30 diclofenac potassium... 39 diclofenac sodium oral... 39 diclofenac sodium topical gel 1 %... 39 dicloxacillin... 18 dicyclomine oral capsule... 80 dicyclomine oral solution... 80 dicyclomine oral tablet... 81 didanosine oral capsule, delayed release(dr/ec) 125 mg... 9 didanosine oral capsule, delayed release(dr/ec) 200 mg... 9 didanosine oral capsule, delayed release(dr/ec) 250 mg, 400 mg... 9 diflorasone... 67 diflunisal... 39 DIGITEK ORAL TABLET 125 MCG... 57 DIGOX ORAL TABLET 125 MCG... 57 digoxin oral solution 50 mcg/ ml... 57 digoxin oral tablet 125 mcg... 57 dihydroergotamine injection... 34 DILANTIN... 30 DILANTIN EXTENDED ORAL CAPSULES 100 MG... 30 DILANTIN INFATABS... 30 dilt-xr... 54 diltiazem hcl intravenous... 54 diltiazem hcl oral capsule, extended release 120 mg, 240 mg, 300 mg... 54 diltiazem hcl oral capsule, extended release 180 mg, 360 mg, 420 mg... 54 diltiazem hcl oral capsule,ext release degradable... 54 diltiazem hcl oral capsule, extended release 12 hr... 54 diltiazem hcl oral capsule, extended release 24hr 120 mg, 240 mg, 300 mg... 54 diltiazem hcl oral capsule, extended release 24hr 180 mg, 360 mg... 54 diltiazem hcl oral tablet... 54 diltiazem hcl oral tablet extended release 24 hr... 54 DIOCTO ORAL LIQUID... 83 DIOCTO ORAL SYRUP... 83 DIOCTYL... 83 DIOTAME... 81 DIPENTUM... 83 DIPHEDRYL ALLERGY... 104 DIPHEDRYL ORAL CAPSULE... 104 DIPHEDRYL ORAL TABLET... 105 DIPHENHIST ORAL CAPSULE... 105 DIPHENHIST ORAL LIQUID... 105 DIPHENHIST ORAL TABLET 25 MG... 105 diphenhydramine hcl injection solution 50 mg/ml... 105 diphenhydramine hcl injection syringe... 105 diphenhydramine hcl oral capsule 25 mg... 105 diphenhydramine hcl oral capsule 50 mg... 105 diphenhydramine hcl oral elixir... 105 diphenhydramine hcl oral liquid... 105 diphenhydramine hcl oral syrup... 105 diphenhydramine hcl oral tablet 25 mg... 105 DIPHENHYDRAMINE ORAL CAPSULE 25 MG, 50 MG... 105 diphenhydramine oral elixir 12.5 mg/5 ml... 105 DIPHENHYDRAMINE ORAL LIQUID 12.5 MG/5 ML... 105 DIPHENHYDRAMINE ORAL SYRUP 12.5 MG/5 ML... 105 diphenoxylate-atropine... 81 disulfiram... 70 divalproex... 30 doc-q-lace... 83 DOCEFREZ INTRAVENOUS RECON SOLN 20 MG... 22 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)... 22 docetaxel intravenous solution 20 mg/ml (1 ml), 80 mg/4 ml (20 mg/ml), 80 mg/8 ml (10 mg/ml)... 22 DOCU... 83 DOCUPRENE... 83 docusate calcium... 83 docusate sodium oral capsule 100 mg... 84? 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 135

docusate sodium oral capsule 250 mg... 84 docusate sodium oral liquid... 84 docusate sodium oral tablet... 84 docusil... 84 dofetilide... 52 dok oral capsule 100 mg... 84 DOK ORAL CAPSULE 250 MG... 84 DOK ORAL TABLET... 84 donepezil oral tablet 10 mg, 5 mg... 34 donepezil oral tablet, disintegrating... 34 dorzolamide... 101 dorzolamide-timolol... 101 DOUBLE ANTIBIOTIC... 64 doxazosin... 54 doxepin oral... 44 doxercalciferol intravenous... 78 doxercalciferol oral... 78 doxorubicin intravenous recon soln... 22 doxorubicin intravenous solution... 22 DOXY-100... 19 doxycycline hyclate intravenous... 19 doxycycline hyclate oral capsule... 19 doxycycline hyclate oral tablet... 19 doxycycline hyclate oral tablet, delayed release (dr/ec) 100 mg, 150 mg, 75 mg... 19 doxycycline monohydrate oral capsule... 19 doxycycline monohydrate oral tablet... 19 dramamine less drowsy... 84 dronabinol... 84 drospirenone-ethinyl estradiol oral tablet 3-0.03 mg... 96 DROXIA... 22 DRY EYE RELIEF... 100 DSS... 84 DUCODYL... 84 dulcolax stool softener (dss)... 84 DULERA... 110 duloxetine oral capsule, delayed release(dr/ec) 20 mg... 44 duloxetine oral capsule, delayed release(dr/ec) 30 mg... 44 duloxetine oral capsule, delayed release(dr/ec) 40 mg... 44 duloxetine oral capsule, delayed release(dr/ec) 60 mg... 44 duramorph (pf) injection solution 0.5 mg/ml... 36 duramorph (pf) injection solution 1 mg/ml... 36 E E-Z JECT LANCETS 30 GAUGE... 74 E-Z JECT LANCETS 32 GAUGE... 74 e.e.s. 400 oral tablet... 14 econazole topical... 65 ECONTRA EZ... 96 ECOTRIN LOW STRENGTH... 39 ECZEMA ANTI-ITCH... 67 ED A-HIST ORAL TABLET... 105 ED A-HIST PSE... 105 EDURANT... 9 EFFIENT... 57 ELAPRASE... 78 ELIDEL... 62 ELINEST... 96 ELIQUIS ORAL TABLET 2.5 MG... 57 ELIQUIS ORAL TABLET 5 MG... 57 ELITEK... 20 ELLA... 96 EMCYT... 22 EMEND ORAL CAPSULE 125 MG... 84 EMEND ORAL CAPSULE 40 MG... 84 EMEND ORAL CAPSULE 80 MG... 84 EMEND ORAL CAPSULE, DOSE PACK... 84 EMPLICITI... 22 EMSAM... 44 EMTRIVA ORAL CAPSULE... 9 EMTRIVA ORAL SOLUTION... 9 enalapril maleate... 54 enalaprilhydrochlorothiazide... 54 ENBREL SUBCUTANEOUS RECON SOLN... 93 ENBREL SUBCUTANEOUS SYRINGE 25 MG/0.5ML (0.51)... 93 ENBREL SUBCUTANEOUS SYRINGE 50 MG/ML (0.98 ML)... 93 ENBREL SURECLICK... 93 endocet oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg... 36 ENGERIX-B PEDIATRIC (PF)... 91 ENGERIX-B (PF)... 91 enoxaparin subcutaneous solution... 57 enoxaparin subcutaneous syringe 100 mg/ml, 150 mg/ ml... 58 enoxaparin subcutaneous syringe 120 mg/0.8 ml, 80 mg/ 0.8 ml... 58 enoxaparin subcutaneous syringe 30 mg/0.3 ml... 58 enoxaparin subcutaneous syringe 40 mg/0.4 ml... 58 enoxaparin subcutaneous syringe 60 mg/0.6 ml... 58 enpresse... 96 entacapone... 34 entecavir... 10? 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 136

ENTERIC COATED ASPIRIN... 39 ENTRE-HIST PSE... 105 enulose... 84 ENVARSUS XR... 22 epinephrine injection syringe 0.1 mg/ml... 105 EPIPEN 2-PAK... 105 EPIPEN JR 2-PAK... 105 epirubicin intravenous solution 200 mg/100 ml... 22 epirubicin intravenous solution 50 mg/25 ml... 22 epitol... 30 EPIVIR HBV ORAL SOLUTION... 10 EPIVIR ORAL SOLUTION... 10 eplerenone... 54 eprosartan... 54 EPZICOM... 10 EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 100 MG... 30 EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 200 MG... 30 EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 300 MG... 30 ERAXIS(WATER DILUENT)... 8 ERBITUX... 22 ergocalciferol (vitamin d2) oral capsule... 120 ergocalciferol (vitamin d2) oral tablet 400 unit... 120 ergoloid... 44 ERGOMAR... 34 ERIVEDGE... 22 errin... 94 ERWINAZE... 23 ery pads... 63 ery-tab... 14 ERYTHROCIN INTRAVENOUS RECON SOLN 500 MG... 14 erythrocin (as stearate) oral tablet 250 mg... 14 erythromycin ethylsuccinate oral tablet... 15 erythromycin ophthalmic... 98 erythromycin oral tablet... 15 erythromycin with ethanol... 63 erythromycin-benzoyl peroxide... 63 ESBRIET... 110 escitalopram oxalate oral solution... 44 escitalopram oxalate oral tablet 10 mg... 45 escitalopram oxalate oral tablet 20 mg... 45 escitalopram oxalate oral tablet 5 mg... 45 ESTRACE VAGINAL... 94 estradiol oral... 94 estradiol transdermal patch weekly... 94 ESTRING... 94 ethambutol... 15 ethosuximide... 30 etodolac oral capsule 200 mg... 39 etodolac oral tablet... 39 etodolac oral tablet extended release 24 hr... 39 ETOPOPHOS... 23 etoposide intravenous... 23 EVOMELA... 23 EVOTAZ... 10 exemestane... 23 EXJADE... 70 EXPECTORANT COUGH SYRUP... 105 EXPECTORANT ORAL LIQUID... 105 EXTAVIA SUBCUTANEOUS KIT... 90 EXTAVIA SUBCUTANEOUS RECON SOLN... 90 EXTRA STRENGTH BAYER... 39 EYE DROP TEARS... 100 EYE IRRIGATING SOLUTION... 100 EYE ITCH RELIEF... 100 EYE STREAM... 100 EYE WASH... 100 EYE WASH STERILE... 100 EZFE 200... 120 F FABRAZYME... 79 FALLBACK SOLO... 96 falmina (28)... 96 famciclovir oral tablet 125 mg, 250 mg... 10 famciclovir oral tablet 500 mg... 10 famotidine intravenous... 89 famotidine oral suspension... 89 famotidine oral tablet 10 mg... 89 famotidine oral tablet 20 mg, 40 mg... 89 famotidine (pf)... 89 famotidine (pf)-nacl (isoos)... 89 FANAPT ORAL TABLET 1 MG... 45 FANAPT ORAL TABLET 10 MG... 45 FANAPT ORAL TABLET 12 MG... 45 FANAPT ORAL TABLET 2 MG... 45 FANAPT ORAL TABLET 4 MG... 45 FANAPT ORAL TABLET 6 MG... 45 FANAPT ORAL TABLET 8 MG... 45 FANAPT ORAL TABLETS, DOSE PACK... 45 FANTASY... 74 FARESTON... 23 FARYDAK ORAL CAPSULE 10 MG... 23 FARYDAK ORAL CAPSULE 15 MG, 20 MG... 23? 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 137

FASLODEX... 23 felbamate... 30 felodipine oral er... 54 FEMRING... 94 fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg... 60 fenofibrate nanocrystallized 48 mg, 145 mg... 60 fenofibrate oral tablet 160 mg, 54 mg... 60 fenoprofen oral tablet... 39 fentanyl citrate... 36 fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/ hr... 36 FEOSOL ORAL TABLET 325 MG (65 MG IRON)... 120 FERATE ORAL TABLET 240 MG (27 MG IRON)... 120 FEROSUL ORAL TABLET... 120 FERRETTS... 120 FERREX 150... 120 FERRIC X-150... 120 FERRO-TIME... 120 ferrous gluconate oral tablet 240 mg (27 mg iron)... 120 ferrous gluconate oral tablet 256 mg (28 mg iron)... 120 FERROUS GLUCONATE ORAL TABLET 324 MG (36 MG IRON), 324 MG (37.5 MG IRON), 324 MG (38 MG IRON), 325 MG (36 MG IRON)... 120 ferrous sulfate oral tablet 325 mg (65 mg iron)... 120 ferrous sulfate oral tablet, delayed release (dr/ec)... 120 FERROUS SULFATE ORAL TABLET,DELAYED RELEASE (DR/EC)... 120 FERROUSUL... 120 FETZIMA ORAL CAPSULE, EXT REL 24HR DOSE PACK... 45 FETZIMA ORAL CAPSULE, EXTENDED RELEASE 24 HR 120 MG, 80 MG... 45 FETZIMA ORAL CAPSULE, EXTENDED RELEASE 24 HR 20 MG... 45 FETZIMA ORAL CAPSULE, EXTENDED RELEASE 24 HR 40 MG... 45 FEVER REDUCER AN PAIN RELIEVER ORAL SUSPENSION... 39 FEVERALL RECTAL SUPPOSITORY 650 MG... 40 finasteride oral tablet 5 mg... 112 FIRAZYR... 110 FIRMAGON KIT W DILUENT SYRINGE... 23 FLANAX ANTACID... 84 FLANAX (NAPROXEN)... 40 FLAVOR CHEWS ANTACID... 115 flecainide... 52 FLEET GLYCERIN (ADULT)... 84 FLEET LAXATIVE... 84 FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCG/ ACTUATION... 110 FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 250 MCG/ ACTUATION, 50 MCG/ ACTUATION... 110 FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCG/ACTUATION... 110 FLOVENT HFA INHALATION HFA AEROSOL INHALER 220 MCG/ACTUATION... 110 FLOVENT HFA INHALATION HFA AEROSOL INHALER 44 MCG/ACTUATION... 110 fluconazole... 8 fluconazole in dextrose(isoo)... 8 FLUCONAZOLE IN NACL (ISO-OSM) INTRAVENOUS PIGGYBACK 100 MG/50 ML... 8 fluconazole in nacl (iso-osm) intravenous piggyback 200 mg/ 100 ml... 8 fluconazole in nacl (iso-osm) intravenous piggyback 400 mg/ 200 ml... 8 flucytosine... 8 fludarabine intravenous recon soln... 23 FLUDARABINE INTRAVENOUS SOLUTION... 23 fludrocortisone... 73 flunisolide nasal spray,nonaerosol 25 mcg (0.025 %)... 110 fluocinolone... 67 fluocinolone acetonide oil... 73 fluocinolone and shower cap... 67 fluocinonide topical cream 0.05 %... 67 fluocinonide topical gel... 67 fluocinonide topical ointment... 67 fluocinonide topical solution... 67 fluocinonide-e... 67 FLUORITAB ORAL TABLET,CHEWABLE 1 MG FLUORIDE (2.2 MG)... 120 fluorometholone... 102 fluorouracil intravenous... 23 FLUOROURACIL INTRAVENOUS... 23 fluorouracil topical cream 5 %... 62? 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 138

fluorouracil topical solution... 62 fluoxetine oral capsule 10 mg... 45 fluoxetine oral capsule 20 mg... 45 fluoxetine oral capsule 40 mg... 45 fluoxetine oral solution... 45 fluoxetine oral tablet 10 mg... 45 fluoxetine oral tablet 20 mg... 45 fluphenazine decanoate... 45 fluphenazine hcl... 45 flurbiprofen... 40 flurbiprofen ophthalmic drops... 101 flutamide... 23 fluticasone nasal... 110 fluticasone topical... 67 fluvoxamine oral tablet 100 mg... 45 fluvoxamine oral tablet 25 mg... 45 fluvoxamine oral tablet 50 mg... 45 folic acid oral tablet 1 mg... 120 folic acid oral tablet 400 mcg, 800 mcg... 121 FOLOTYN... 23 fondaparinux subcutaneous syringe 10 mg/0.8 ml... 58 fondaparinux subcutaneous syringe 2.5 mg/0.5 ml... 58 fondaparinux subcutaneous syringe 5 mg/0.4 ml... 58 fondaparinux subcutaneous syringe 7.5 mg/0.6 ml... 58 FOOT AND SNEAKER... 65 FORADIL AEROLIZER... 110 FORTEO... 93 foscarnet... 10 fosinopril... 54 fosinoprilhydrochlorothiazide... 54 fosphenytoin... 30 FREAMINE III 10 %... 118 FRUIT C-500... 121 FULL SPECTRUM B- VITAMIN C... 121 FUNGOID-D... 65 furosemide injection... 54 furosemide oral solution 10 mg/ml, 40 mg/5 ml (8 mg/ ml)... 54 furosemide oral tablet... 54 FUSILEV... 20 FUZEON SUBCUTANEOUS RECON SOLN... 10 FYCOMPA ORAL SUSPENSION... 30 FYCOMPA ORAL TABLET 10 MG, 12 MG... 30 FYCOMPA ORAL TABLET 2 MG... 30 FYCOMPA ORAL TABLET 4 MG... 30 FYCOMPA ORAL TABLET 6 MG... 30 FYCOMPA ORAL TABLET 8 MG... 30 G G-TRON... 105 gabapentin oral capsule 100 mg... 31 gabapentin oral capsule 300 mg... 31 gabapentin oral capsule 400 mg... 31 gabapentin oral solution 250 mg/5 ml... 31 GABAPENTIN ORAL SOLUTION 250 MG/5 ML (5 ML), 300 MG/6 ML (6 ML)... 31 gabapentin oral tablet 600 mg... 31 gabapentin oral tablet 800 mg... 31 GABITRIL ORAL TABLET 12 MG, 16 MG... 31 galantamine oral capsule,ext rel. pellets 24 hr... 34 galantamine oral solution... 34 galantamine oral tablet... 34 GAMASTAN S/D... 91 GAMMAGARD LIQUID... 91 GAMMAGARD S-D (IGA < 1 MCG/ML)... 91 GAMMAPLEX... 91 GAMUNEX-C... 91 ganciclovir sodium... 10 GARDASIL 9 (PF)... 91 GARDASIL (PF)... 91 GAS RELIEF 80... 84 GAS RELIEF ULTRA STRENGTH... 84 GAS-X ULTRA- STRENGTH... 84 GATTEX 30-VIAL... 84 GATTEX ONE-VIAL... 84 GAUZE PADS 2 X 2... 74 GAVILAX ORAL POWDER... 84 gavilyte-c... 84 gavilyte-g... 84 gavilyte-n... 84 GAZYVA... 23 gemcitabine intravenous recon soln 1 gram, 200 mg... 23 GEMCITABINE INTRAVENOUS RECON SOLN 2 GRAM... 23 GEMCITABINE INTRAVENOUS SOLUTION 1 GRAM/26.3 ML (38 MG/ ML), 200 MG/5.26 ML (38 MG/ML)... 23 GEMCITABINE INTRAVENOUS SOLUTION 2 GRAM/52.6 ML (38 MG/ ML)... 23 gemfibrozil oral... 60 generlac... 85 gengraf oral capsule 100 mg, 25 mg... 23 gengraf oral solution... 23 gentak ophthalmic ointment... 99? 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 139

gentamicin injection... 16 gentamicin ophthalmic... 99 GENTAMICIN SULFATE (PED) (PF)... 16 GENTAMICIN SULFATE (PF) INTRAVENOUS SOLUTION 100 MG/10 ML... 16 GENTAMICIN SULFATE (PF) INTRAVENOUS SOLUTION 60 MG/6 ML... 16 gentamicin sulfate (pf) intravenous solution 80 mg/8 ml... 16 gentamicin topical... 64 GENTLE LAXATIVE... 85 gentlelax... 85 GENVOYA... 10 GEODON INTRAMUSCULAR... 45 GERI-DRYL... 105 GERI-LANTA... 85 GERI-X ANTACID- ANTIGAS... 85 GERI-PECTATE... 81 GERI-TUSSIN... 105 gildagia... 96 GILDESS FE 1.5/30 (28)... 96 GILDESS FE 1/20 (28)... 96 GILENYA... 34 GILOTRIF... 23 GLATOPA... 34 GLEEVEC ORAL TABLET 100 MG... 23 GLEEVEC ORAL TABLET 400 MG... 23 GLEOSTINE... 23 glimepiride oral tablet 1 mg... 74 glimepiride oral tablet 2 mg... 75 glimepiride oral tablet 4 mg... 75 glipizide oral tablet 10 mg... 75 glipizide oral tablet 5 mg... 75 glipizide oral tablet extended release 24hr 10 mg... 75 glipizide oral tablet extended release 24hr 2.5 mg... 75 glipizide oral tablet extended release 24hr 5 mg... 75 glipizide-metformin oral tablet 2.5-250 mg... 75 glipizide-metformin oral tablet 2.5-500 mg, 5-500 mg... 75 GLUCAGEN HYPOKIT... 75 GLUCAGON EMERGENCY KIT (HUMAN)... 75 GLUCO BURST... 70 GLUCOSE GEL... 70 glucose oral tablet,chewable 4 gram... 71 GLUTOSE 15... 71 GLUTOSE 45... 71 glycerin (adult)... 85 GLYCOLAX ORAL POWDER... 85 glycopyrrolate oral... 81 griseofulvin microsize oral suspension... 8 griseofulvin ultramicrosize... 8 GUAIASORB DM... 105 GUAIFENESIN AC... 106 guaifenesin oral liquid... 106 GUAIFENESIN-DM... 106 guanfacine oral tablet extended release 24 hr... 45 guanidine... 46 H HALAVEN... 24 halobetasol propionate... 67 HALOG... 67 haloperidol... 46 haloperidol decanoate... 46 haloperidol lactate... 46 HARVONI... 10 HAVRIX (PF) INTRAMUSCULAR SUSPENSION... 91 HAVRIX (PF) INTRAMUSCULAR SYRINGE 1,440 ELISA UNIT/ML... 91 HAVRIX (PF) INTRAMUSCULAR SYRINGE 720 ELISA UNIT/ 0.5 ML... 91 HEADACHE RELIEF (ASA- ACET-CAF)... 40 HEALTHYLAX... 85 HEARTBURN ANTACID... 85 heartburn prevention... 89 HEARTBURN RELIEF... 85 HEARTBURN RELIEF (FATIDINE)... 89 heartburn relief (ranitidine)... 89 HEPARIN FLUSH... 58 heparin lock flush intravenous kit 100 unit/ml... 58 heparin lock flush intravenous solution 10 unit/ml, 100 unit/ ml... 58 heparin lock flush intravenous syringe 10 unit/ml... 58 HEPARIN LOCK FLUSH INTRAVENOUS SYRINGE 100 UNIT/ML... 58 HEPARIN LOCKFLUSH (PORCINE)(PF)... 58 HEPARIN (PORCINE) IN 5 % DEX INTRAVENOUS PARENTERAL SOLUTION 12,500 UNIT/250 ML... 58 heparin (porcine) in 5 % dex intravenous parenteral solution 25,000 unit/250 ml (100 unit/ml), 25,000 unit/500 ml (50 unit/ml)... 58 HEPARIN (PORCINE) IN NACL (PF) INTRAVENOUS PARENTERAL SOLUTION 1,000 UNIT/500 ML, 2,000 UNIT/1,000 ML... 58 HEPARIN (PORCINE) INJECTION CARTRIDGE... 58? 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 140

heparin (porcine) injection solution... 58 HEPARIN, PORCINE (PF) INJECTION SOLUTION... 59 heparin, porcine (pf) intravenous solution 100 unit/ ml (1 ml)... 59 HEPARIN, PORCINE (PF) INTRAVENOUS SYRINGE 1 UNIT/ML... 59 heparin, porcine (pf) intravenous syringe 10 unit/ml, 100 unit/ml... 59 HEPARIN(PORCINE) IN 0.45% NACL INTRAVENOUS PARENTERAL SOLUTION 12,500 UNIT/250 ML... 58 HEPARIN(PORCINE) IN 0.45% NACL INTRAVENOUS PARENTERAL SOLUTION 25,000 UNIT/250 ML... 59 HEPARIN(PORCINE) IN 0.45% NACL INTRAVENOUS PARENTERAL SOLUTION 25,000 UNIT/500 ML... 59 HEPATAMINE 8%... 118 HERCEPTIN... 24 HETLIOZ... 46 HEXALEN... 24 HI-CAL PLUS VIT D... 115 HIBERIX (PF)... 91 HIGH POTENCY IRON... 121 HUMALOG... 75 HUMALOG KWIKPEN... 75 HUMALOG MIX 50-50... 75 HUMALOG MIX 50-50 KWIKPEN... 75 HUMALOG MIX 75-25... 75 HUMALOG MIX 75-25 KWIKPEN... 75 HUMAPEN LUXURA HD... 75 HUMIRA PEDIATRIC CROHN'S START... 93 HUMIRA PEN... 93 HUMIRA PEN CROHN'S- UC-HS START... 94 HUMIRA PEN PSORIASIS STARTER... 94 HUMIRA SUBCUTANEOUS SYRINGE KIT 10 MG/0.2 ML, 20 MG/0.4 ML... 94 HUMIRA SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML... 94 HUMULIN 70/30... 75 HUMULIN 70/30 KWIKPEN... 75 HUMULIN N... 75 HUMULIN N KWIKPEN... 75 HUMULIN R... 75 HUMULIN R U-500 (CONC) KWIKPEN... 75 HUMULIN R U-500 (CONCENTRATED)... 75 hydralazine... 54 hydrochlorothiazide... 54 HYDROCODONE- ACETAMINOPHEN ORAL SOLUTION 2.5-167 MG/5 ML... 36 hydrocodone-acetaminophen oral solution 7.5-325 mg/15 ml... 36 hydrocodone-acetaminophen oral tablet 10-300 mg, 5-300 mg, 7.5-300 mg... 36 hydrocodone-acetaminophen oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg... 36 hydrocodonechlorpheniramine... 106 hydrocodone-homatropine oral syrup 5-1.5 mg/5 ml... 106 HYDROCODONE- HOMATROPINE ORAL SYRUP 5-1.5 MG/5 ML (5 ML)... 106 hydrocodone-homatropine oral tablet... 106 hydrocodone-ibuprofen oral tablet 10-200 mg, 5-200 mg, 7.5-200 mg... 36 hydrocortisone acetate topical... 67 hydrocortisone oral... 73 hydrocortisone plus... 68 hydrocortisone rectal cream 2.5 %... 85 hydrocortisone rectal enema... 85 hydrocortisone topical cream 0.5 %... 68 hydrocortisone topical cream 1 %, 2.5 %... 68 hydrocortisone topical lotion 1 %... 68 hydrocortisone topical lotion 2.5 %... 68 hydrocortisone topical ointment 0.5 %... 68 hydrocortisone topical ointment 1 %, 2.5 %... 68 hydrocortisone valerate... 68 hydrocortisone-acetic acid... 73 HYDROCORTISONE-MIN OIL-WHT PET... 68 HYDROCREAM... 68 HYDROMET... 106 hydromorphone oral tablet 2 mg, 4 mg... 36 hydromorphone oral tablet 8 mg... 36 HYDROSKIN TOPICAL LOTION... 68 hydroxychloroquine oral... 16 hydroxyurea... 24 I I-PRIN... 40 ibandronate intravenous solution... 93 ibandronate intravenous syringe... 93 ibandronate oral... 93 IBRANCE... 24? 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 141

IBUPROFEN IB ORAL TABLET... 40 ibuprofen oral capsule... 40 ibuprofen oral suspension... 40 ibuprofen oral tablet 200 mg... 40 ibuprofen oral tablet 400 mg, 600 mg, 800 mg... 40 ICLUSIG ORAL TABLET 15 MG... 24 ICLUSIG ORAL TABLET 45 MG... 24 idarubicin... 24 IFEREX 150... 121 ifosfamide intravenous recon soln... 24 IFOSFAMIDE INTRAVENOUS SOLUTION... 24 ILARIS (PF)... 90 ILEVRO... 101 imatinib oral tablet 100 mg... 24 imatinib oral tablet 400 mg... 24 IMBRUVICA... 24 imipenem-cilastatin... 16 imipramine hcl... 46 imiquimod... 62 IVAX RABIES VACCINE (PF)... 91 INCRELEX... 71 indapamide... 54 INFANRIX (DTAP) (PF)... 91 INFANT FEVER REDUCER- PAIN RELF... 40 INFANT PAIN RELIEVER... 40 INFANT'S PAIN RELIEF ORAL SUSPENSION... 40 INFANTS' PAIN AND FEVER... 40 INFANTS' PAIN RELIEF... 40 INLYTA ORAL TABLET 1 MG... 24 INLYTA ORAL TABLET 5 MG... 24 INSTA-GLUCOSE... 75 insulin pen needle... 75 INSULIN SYRINGE (DISP) U-100 0.3 ML, 1 ML, 1/2 ML... 75 INTELENCE ORAL TABLET 100 MG... 10 INTELENCE ORAL TABLET 200 MG... 10 INTELENCE ORAL TABLET 25 MG... 10 intralipid intravenous emulsion 20 %... 118 INTRON A INJECTION... 90 INVANZ INJECTION... 16 INVEGA ORAL TABLET EXTENDED RELEASE 24HR 1.5 MG... 46 INVEGA ORAL TABLET EXTENDED RELEASE 24HR 3 MG... 46 INVEGA ORAL TABLET EXTENDED RELEASE 24HR 6 MG... 46 INVEGA ORAL TABLET EXTENDED RELEASE 24HR 9 MG... 46 INVEGA SUSTENNA... 46 INVEGA TRINZA INTRAMUSCULAR SYRINGE 273 MG/0.875 ML... 46 INVEGA TRINZA INTRAMUSCULAR SYRINGE 410 MG/1.315 ML... 46 INVEGA TRINZA INTRAMUSCULAR SYRINGE 546 MG/1.75 ML... 46 INVEGA TRINZA INTRAMUSCULAR SYRINGE 819 MG/2.625 ML... 46 INVIRASE ORAL CAPSULE... 10 INVIRASE ORAL TABLET... 10 INZO ANTIFUNGAL... 65 IOPHEN C-NR... 106 IOPHEN DM-NR... 106 IOPHEN-NR... 106 IPOL INJECTION SUSPENSION... 91 ipratropium bromide inhalation... 110 ipratropium bromide nasal... 72 ipratropium-albuterol... 111 irbesartan... 55 irbesartan-hydrochlorothiazide oral tablet 150-12.5 mg... 55 irbesartan-hydrochlorothiazide oral tablet 300-12.5 mg... 55 IRESSA... 24 irinotecan intravenous solution 100 mg/5 ml, 40 mg/2 ml... 24 IRINOTECAN INTRAVENOUS SOLUTION 500 MG/25 ML... 24 IRON HIGH POTENCY... 121 IRON ORAL TABLET 325 MG (65 MG IRON)... 121 IRON (DRIED)... 121 IRON (FERROUS SULFATE)... 121 ISENTRESS ORAL POWDER IN PACKET... 10 ISENTRESS ORAL TABLET... 10 ISENTRESS ORAL TABLET, CHEWABLE 100 MG... 10 ISENTRESS ORAL TABLET, CHEWABLE 25 MG... 10 ISOLYTE-P IN 5 % DEXTROSE... 118 isoniazid oral... 16 isosorbide dinitrate oral... 61 isosorbide mononitrate... 61 isradipine... 55 ISTODAX... 24 ITCH RELIEF (CLOTRIMAZOLE)... 65? 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 142

ITCHY EYE DROPS... 100 itraconazole... 8 ivermectin oral... 16 IXEMPRA... 24 IXIARO (PF)... 91 J JAKAFI ORAL TABLET 10 MG... 24 JAKAFI ORAL TABLET 15 MG... 24 JAKAFI ORAL TABLET 20 MG... 24 JAKAFI ORAL TABLET 25 MG... 24 JAKAFI ORAL TABLET 5 MG... 24 jantoven... 59 JANUMET... 75 JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 100-1,000 MG... 76 JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 50-1,000 MG, 50-500 MG... 76 JANUVIA ORAL TABLET 100 MG... 76 JANUVIA ORAL TABLET 25 MG... 76 JANUVIA ORAL TABLET 50 MG... 76 JARDIANCE... 76 JENTADUETO... 76 JEVTANA... 24 JOCK ITCH... 65 jock itch (clotrimazole)... 65 JOCK ITCH (TERBINAFINE)... 65 junel 1.5/30 (21)... 96 junel 1/20 (21)... 96 junel fe 1.5/30 (28)... 96 junel fe 1/20 (28)... 96 JUXTAPID... 60 K K-PEC ANTIDIARRHEAL (BISM SUB)... 81 K-TAB ORAL TABLET EXTENDED RELEASE 8 MEQ... 115 KADCYLA... 24 KALETRA ORAL SOLUTION... 10 KALETRA ORAL TABLET 100-25 MG... 10 KALETRA ORAL TABLET 200-50 MG... 10 KALYDECO ORAL TABLET... 111 KAO-TIN (BISMUTH SUBSALICYLAT)... 81 KAO-TIN (DOCUSATE CALCIUM)... 85 KAOPECTATE EX STR (BISMUTH SS)... 81 KAOPECTATE (BISMUTH SUBSALICY)... 81 kariva (28)... 96 kelnor 1/35 (28)... 96 KEPIVANCE... 20 ketoconazole oral... 8 ketoconazole topical... 65 ketorolac ophthalmic... 101 ketotifen fumarate... 100 KEYTRUDA... 24 KHEDEZLA ORAL TABLET EXTENDED RELEASE 24HR 100 MG... 46 KHEDEZLA ORAL TABLET EXTENDED RELEASE 24HR 50 MG... 46 KINO MICROTHIN LARGE CONDOMS... 76 KINO TEXTURED CONDOMS... 76 KINERET... 94 kionex... 71 KLOR-CON 10... 115 KLOR-CON 8... 115 KLOR-CON M10... 115 KLOR-CON M15... 115 KLOR-CON M20... 115 KORLYM... 79 KPN... 121 KUVAN ORAL TABLET, SOLUBLE... 79 L labetalol intravenous solution... 55 labetalol oral... 55 lactated ringers intravenous... 115 lactated ringers irrigation... 69 lactulose... 85 LAMISIL AF TOPICAL AEROSOL POWDER... 65 LAMISIL AT TOPICAL CREAM... 65 lamivudine oral solution... 10 lamivudine oral tablet 100 mg... 10 lamivudine oral tablet 150 mg... 10 lamivudine oral tablet 300 mg... 10 lamivudine-zidovudine... 10 lamotrigine oral tablet... 31 lamotrigine oral tablet, chewable dispersible... 31 lancets, 30 gauge... 76 LANCETS,ULTRA THIN 26 GAUGE... 76 LANOXIN ORAL TABLET 125 MCG, 62.5 MCG... 57 lansoprazole oral capsule, delayed release(dr/ec)... 89 LANTUS... 76 LANTUS SOLOSTAR... 76 LARIN 1/20 (21)... 97 LARIN FE 1.5/30 (28)... 97 LARIN FE 1/20 (28)... 97 latanoprost... 101 LATUDA ORAL TABLET 120 MG... 46 LATUDA ORAL TABLET 20 MG... 46 LATUDA ORAL TABLET 40 MG... 46 LATUDA ORAL TABLET 60 MG... 46? 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 143

LATUDA ORAL TABLET 80 MG... 46 laxa clear... 85 LAXATIVE PEG 3350 ORAL POWDER... 85 LAXATIVE (BISACODYL) ORAL TABLET,DELAYED RELEASE (DR/EC)... 85 LAXATIVE (BISACODYL) RECTAL... 85 leflunomide... 94 LENVIMA ORAL CAPSULE 10 MG/DAY (10 MG X 1/ DAY)... 25 LENVIMA ORAL CAPSULE 14 MG/DAY(10 MG X 1-4 MG X 1), 20 MG/DAY (10 MG X 2)... 25 LENVIMA ORAL CAPSULE 18 MG/DAY (10 MG X 1-4 MG X2)... 25 LENVIMA ORAL CAPSULE 24 MG/DAY(10 MG X 2-4 MG X 1)... 25 LENVIMA ORAL CAPSULE 8 MG/DAY (4 MG X 2)... 25 lessina... 97 LETAIRIS... 111 letrozole... 25 leucovorin calcium injection recon soln 100 mg, 350 mg, 50 mg... 20 LEUCOVORIN CALCIUM INJECTION RECON SOLN 200 MG... 20 LEUCOVORIN CALCIUM INJECTION RECON SOLN 500 MG... 20 leucovorin calcium oral... 20 LEUKERAN... 25 leuprolide subcutaneous kit... 25 levalbuterol hcl inhalation solution for nebulization 0.31 mg/3 ml, 1.25 mg/0.5 ml, 1.25 mg/3 ml... 111 levalbuterol hcl inhalation solution for nebulization 0.63 mg/3 ml... 111 LEVEMIR... 76 LEVEMIR FLEXTOUCH... 76 levetiracetam in nacl (iso-os) intravenous piggyback 1,000 mg/100 ml, 1,500 mg/100 ml... 31 levetiracetam in nacl (iso-os) intravenous piggyback 500 mg/ 100 ml... 31 levetiracetam intravenous... 31 levetiracetam oral solution 100 mg/ml... 31 LEVETIRACETAM ORAL SOLUTION 500 MG/5 ML (5 ML)... 31 levetiracetam oral tablet... 31 levetiracetam oral tablet extended release 24 hr 500 mg... 31 levetiracetam oral tablet extended release 24 hr 750 mg... 31 levobunolol ophthalmic drops 0.5 %... 99 levocarnitine oral tablet... 71 levocarnitine (with sugar)... 71 levocetirizine oral tablet... 106 levofloxacin intravenous... 18 levofloxacin oral tablet... 18 levonest (28)... 97 levonorg-eth estrad triphasic... 97 levonorgestrel-ethinyl estrad oral tablet 0.15-0.03 mg... 97 levonorgestrel-ethinyl estrad oral tablets,dose pack,3 month... 97 levorphanol tartrate... 36 levothyroxine oral... 80 levoxyl oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg... 80 LEXIVA ORAL SUSPENSION... 11 LEXIVA ORAL TABLET... 11 LIALDA... 85 LICE BEDDING SPRAY... 68 LICE COMPLETE KIT 1-2- 3... 68 LICE KILLING... 69 LICE KILLING (PERMETHRIN)... 69 LICE PYRINYL SHAMPOO... 69 LICE SOLUTION... 69 LICE TREATMENT TOPICAL LIQUID 1 %... 69 LICE TREATMENT TOPICAL SHAMPOO... 69 LICE TREATMENT (PERMETHRIN)... 69 lidocaine hcl injection solution 20 mg/ml (2 %), 5 mg/ml (0.5 %)... 63 lidocaine hcl laryngotracheal... 63 lidocaine hcl mucous membrane... 63 lidocaine hcl urethral... 63 lidocaine topical adhesive patch,medicated... 63 lidocaine topical ointment... 63 LIDOCAINE VISCOUS... 63 LIDOCAINE (PF) INJECTION SOLUTION 15 MG/ML (1.5 %)... 63 lidocaine (pf) injection solution 20 mg/ml (2 %), 40 mg/ml (4 %), 5 mg/ml (0.5 %)... 63 lidocaine (pf) intravenous solution... 52? 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 144

LIDOCAINE (PF) INTRAVENOUS SYRINGE... 52 lidocaine-prilocaine topical cream... 63 lindane topical shampoo... 69 linezolid intravenous... 16 linezolid oral suspension for reconstitution... 16 linezolid oral tablet... 16 LINEZOLID-0.9% SODIUM CHLORIDE... 16 LINZESS... 85 liothyronine oral... 80 LIQUID ANTACID... 85 LIQUITEARS... 100 lisinopril... 55 lisinoprilhydrochlorothiazide... 55 lithium carbonate... 46 lithium citrate oral solution 8 meq/5 ml... 46 LITTLE REMEDIES FEVER AND PAIN... 40 LOHIST-DM... 106 LONSURF... 25 loperamide oral capsule... 81 loperamide oral liquid 1 mg/5 ml... 81 LORADAMED... 106 loratadine oral tablet... 106 loratadine oral tablet, disintegrating... 106 lorazepam oral tablet... 47 losartan oral tablet 100 mg... 55 losartan oral tablet 25 mg, 50 mg... 55 losartanhydrochlorothiazide... 55 lotrimin af topical cream... 65 LOTRIMIN AF TOPICAL POWDER... 65 lovastatin oral tablet 10 mg, 20 mg... 60 lovastatin oral tablet 40 mg... 60 LOW-OGESTREL (28)... 97 loxapine succinate... 47 LUBRICANT EYE DROPS... 100 LUBRICANT EYE DROPS (GLYC-PG)... 100 LUBRICANT EYE (PG-PEG 400)... 100 LUBRICANT REDNESS RELIEVER OPHTHALMIC DROPS 0.03-0.5 %... 102 LUBRICATING PLUS... 100 LUDENT FLUORIDE ORAL TABLET,CHEWABLE 1 MG FLUORIDE (2.2 MG)... 121 LUMIGAN OPHTHALMIC DROPS 0.01 %... 101 LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 3.75 MG... 25 LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 7.5 MG... 25 LUPRON DEPOT-PED INTRAMUSCULAR KIT 7.5 MG (PED)... 25 lutera (28)... 97 LYNPARZA... 25 LYRICA ORAL CAPSULE 100 MG... 31 LYRICA ORAL CAPSULE 150 MG... 31 LYRICA ORAL CAPSULE 200 MG... 31 LYRICA ORAL CAPSULE 225 MG, 300 MG... 31 LYRICA ORAL CAPSULE 25 MG... 31 LYRICA ORAL CAPSULE 50 MG... 31 LYRICA ORAL CAPSULE 75 MG... 31 LYRICA ORAL SOLUTION... 31 LYSODREN... 25 lyza... 94 M M-CLEAR WC... 106 M-M-R II (PF)... 91 MAALOX MAXIMUM STRENGTH... 85 MAG-AL PLUS... 85 MAG-AL PLUS EXTRA STRENGTH... 85 magnesium citrate oral solution... 85 MAGNESIUM OXIDE ORAL CAPSULE 500 MG... 115 MAGNESIUM SULFATE IN WATER INTRAVENOUS PARENTERAL SOLUTION... 115 MAGNESIUM SULFATE IN WATER INTRAVENOUS PIGGYBACK 2 GRAM/50 ML (4 %), 4 GRAM/50 ML (8 %)... 115 MAGNESIUM SULFATE IN WATER INTRAVENOUS PIGGYBACK 4 GRAM/100 ML (4 %)... 115 magnesium sulfate injection solution... 115 magnesium sulfate injection syringe... 115 MAPAP EXTRA STRENGTH... 40 maprotiline oral tablet 25 mg... 47 maprotiline oral tablet 50 mg... 47 maprotiline oral tablet 75 mg... 47 marlissa... 97 MARPLAN... 47 MASANTI DOUBLE STRENGTH... 85 MASOPHEN ORAL TABLET 500 MG... 40 MATULANE... 25 MAXIMUM REDNESS RELIEF... 102 meclizine oral tablet 12.5 mg, 25 mg... 85 meclizine oral tablet, chewable... 85 meclofenamate oral... 40? 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 145

medi-meclizine... 85 MEDIPROXEN... 40 MEDIWASH... 100 MEDIWASH EYE IRRIGANT... 100 medroxyprogesterone... 94 mefloquine... 16 MEGESTROL ORAL SUSPENSION 400 MG/10 ML (10 ML), 800 MG/20 ML (20 ML)... 25 megestrol oral suspension 400 mg/10 ml (40 mg/ml)... 25 megestrol oral tablet... 25 MEKINIST ORAL TABLET 0.5 MG... 25 MEKINIST ORAL TABLET 2 MG... 25 meloxicam oral suspension... 40 meloxicam oral tablet... 40 melphalan hcl... 25 memantine oral solution... 35 memantine oral tablet 10 mg... 35 memantine oral tablet 5 mg... 35 MENACTRA (PF) INTRAMUSCULAR SOLUTION... 91 MENEST... 94 MENOMUNE - A/C/Y/W- 135... 91 MENOMUNE - A/C/Y/W-135 (PF)... 92 MENSTRUAL RELIEF... 40 MENVEO A-C-Y-W-135-DIP (PF)... 92 MEPHYTON... 59 mercaptopurine... 25 meropenem... 16 mesalamine rectal... 85 mesalamine with cleansing wipe... 86 mesna... 20 MESNEX ORAL... 20 MESTINON ORAL SYRUP... 35 MESTINON TIMESPAN... 35 metaproterenol... 111 metformin oral tablet 1,000 mg... 76 metformin oral tablet 500 mg... 76 metformin oral tablet 850 mg... 76 metformin oral tablet extended release 24 hr 500 mg... 76 metformin oral tablet extended release 24 hr 750 mg... 76 metformin oral tablet extended release 24hr 1,000 mg... 76 metformin oral tablet extended release 24hr 500 mg... 76 methadone injection... 36 METHADONE INTENSOL... 36 methadone oral concentrate... 36 methadone oral solution 10 mg/5 ml... 37 methadone oral solution 5 mg/ 5 ml... 37 methadone oral tablet 10 mg... 37 methadone oral tablet 5 mg... 37 METHADOSE ORAL CONCENTRATE... 37 methazolamide oral... 101 methenamine hippurate... 19 methimazole oral tablet 10 mg, 5 mg... 74 methotrexate sodium... 25 methotrexate sodium (pf) injection recon soln... 25 methotrexate sodium (pf) injection solution... 26 methoxsalen rapid... 62 methyclothiazide... 55 methylergonovine oral... 98 methylphenidate oral tablet... 47 methylprednisolone acetate... 73 methylprednisolone oral tablets... 73 methylprednisolone sodium succ injection recon soln 125 mg, 40 mg... 73 methylprednisolone sodium succ intravenous... 73 metipranolol... 99 metoclopramide hcl injection solution... 86 METOCLOPRAMIDE HCL INJECTION SYRINGE... 86 metoclopramide hcl oral solution... 86 metoclopramide hcl oral tablet... 86 metolazone... 55 metoprolol succinate... 55 metoprolol tahydrochlorothiaz... 55 metoprolol tartrate intravenous solution... 55 metoprolol tartrate intravenous syringe... 55 metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg... 55 metoprolol tartrate oral tablet 37.5 mg, 75 mg... 55 METRO I.V.... 16 metronidazole in nacl (isoos)... 16 metronidazole oral... 16 metronidazole topical cream... 63 metronidazole topical gel 0.75 %... 63 metronidazole topical lotion... 63 metronidazole vaginal... 95 mexiletine... 52 MI-ACID GAS RELIEF... 86 MIACALCIN INJECTION... 79 MICATIN... 65 MICONAZOLE 3 DAY VAGINAL CREAM... 95 MICONAZOLE 7... 95? 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 146

miconazole nitrate topical cream... 65 miconazole nitrate vaginal comb pack,prefill appl, cream... 95 miconazole nitrate vaginal cream... 95 miconazole nitrate vaginal suppository... 95 MICONAZOLE-3 VAGINAL KIT... 95 miconazole-3 vaginal suppository... 95 MICONAZORB AF... 66 MICRO-GUARD... 66 MICROGESTIN 1.5/30 (21)... 97 MICROGESTIN 1/20 (21)... 97 MICROGESTIN FE 1.5/30 (28)... 97 MICROGESTIN FE 1/20 (28)... 97 midodrine... 71 MIGRAINE FORMULA... 40 MIGRAINE RELIEF... 40 MILK OF MAGNESIA... 86 MILK OF MAGNESIA CONCENTRATED... 86 MINERAL OIL EXTRA HEAVY... 86 MINERAL OIL HEAVY ORAL... 86 MINERAL OIL LAXATIVE... 86 mineral oil oral... 86 mineral oil rectal... 86 minocycline oral capsule... 19 minocycline oral tablet... 19 minoxidil oral... 55 MINTOX... 86 MINTOX MAXIMUM STRENGTH... 86 MINTOX PLUS... 86 MIRALAX ORAL POWDER IN PACKET... 86 mirtazapine oral tablet 15 mg... 47 mirtazapine oral tablet 30 mg... 47 mirtazapine oral tablet 45 mg... 47 mirtazapine oral tablet 7.5 mg... 47 mirtazapine oral tablet, disintegrating 15 mg... 47 mirtazapine oral tablet, disintegrating 30 mg... 47 mirtazapine oral tablet, disintegrating 45 mg... 47 misoprostol... 89 mitomycin... 26 mitoxantrone... 26 modafinil oral tablet 100 mg... 47 modafinil oral tablet 200 mg... 47 moexipril... 55 moexiprilhydrochlorothiazide... 55 ISTURE DROPS... 100 molindone... 47 mometasone nasal... 111 mometasone topical... 68 NO-LINYAH... 97 NOJECT PREFILL ADVANCED (PF)... 59 NOJECT PREFILL (PF)... 59 mononessa (28)... 97 montelukast... 111 morphine concentrate oral solution... 37 RPHINE INTRAVENOUS CARTRIDGE... 37 RPHINE INTRAVENOUS SOLUTION 10 MG/ML, 50 MG/ML... 37 RPHINE INTRAVENOUS SOLUTION 100 MG/4 ML, 25 MG/ML, 250 MG/10 ML... 37 RPHINE INTRAVENOUS SOLUTION 4 MG/ML, 8 MG/ ML... 37 morphine intravenous syringe 2 mg/ml, 4 mg/ml... 37 morphine oral capsule, er multiphase 24 hr 120 mg, 75 mg, 90 mg... 37 morphine oral capsule, er multiphase 24 hr 30 mg, 45 mg, 60 mg... 37 morphine oral capsule, extend.release pellets 100 mg, 20 mg, 30 mg, 50 mg, 60 mg, 80 mg... 37 morphine oral solution 20 mg/ 5 ml (4 mg/ml)... 37 morphine oral tablet 15 mg... 37 morphine oral tablet 30 mg... 37 morphine oral tablet extended release 100 mg, 15 mg, 30 mg, 60 mg... 37 morphine oral tablet extended release 200 mg... 37 morphine (pf) injection solution 0.5 mg/ml... 37 morphine (pf) injection solution 1 mg/ml... 37 RPHINE (PF) INTRAVENOUS PATIENT CONTROL.ANALGESIA SOLN 150 MG/30 ML... 37 RPHINE (PF) INTRAVENOUS PATIENT CONTROL.ANALGESIA SOLN 30 MG/30 ML... 37 motion relief (meclizine)... 86 motion sickness relief (mecliz)... 86 motion sickness (meclizine)... 86 TION-TIME... 86 VE IT ALONG... 86 VIPREP... 86 moxifloxacin... 18 MULTAQ... 52 mupirocin calcium... 64 mupirocin topical ointment... 64? 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 147

MUSTARGEN... 26 MY WAY... 97 mycophenolate mofetil... 26 mycophenolate sodium... 26 MYFERON 150... 121 MYOZYME... 79 MYRBETRIQ... 112 MYTAB GAS... 86 MYTAB GAS MAXIMUM STRENGTH... 86 MYZILRA... 97 N nabumetone... 40 nadolol... 55 nadololbendroflumethiazide... 55 nafcillin injection... 18 nafcillin intravenous recon soln 2 gram... 18 NAGLAZYME... 79 nalbuphine injection solution 10 mg/ml... 40 nalbuphine injection solution 20 mg/ml... 40 naloxone... 40 naltrexone... 40 NAMENDA ORAL SOLUTION... 35 NAMENDA XR ORAL CAP, SPRINKLE,ER 24HR DOSE PACK... 35 NAMENDA XR ORAL CAPSULE,SPRINKLE,ER 24HR... 35 NAMZARIC... 35 naphazoline... 102 naproxen... 41 naproxen sodium oral capsule... 41 naproxen sodium oral tablet 220 mg... 41 naproxen sodium oral tablet 275 mg, 550 mg... 41 NASAL DECONGESTANT (PSEUDOEPH)... 106 NASAL MIST... 72 NASONEX... 111 nateglinide oral tablet 120 mg... 76 nateglinide oral tablet 60 mg... 76 NATPARA... 79 NATURAL TEARS (PF)... 100 NEBUPENT... 16 necon 0.5/35 (28)... 97 necon 1/35 (28)... 97 necon 1/50 (28)... 97 necon 10/11 (28)... 97 necon 7/7/7 (28)... 97 needles, insulin disp., safety... 76 nefazodone oral tablet 100 mg... 47 nefazodone oral tablet 150 mg... 47 nefazodone oral tablet 200 mg... 47 nefazodone oral tablet 250 mg... 47 nefazodone oral tablet 50 mg... 47 NEO-POLYCIN... 99 NEO-POLYCIN HC... 102 neomycin... 16 neomycin-bacitracin-polyhc... 102 neomycin-bacitracinpolymyxin... 99 neomycin-polymyxin b gu... 69 neomycin-polymyxin b- dexameth... 102 neomycin-polymyxingramicidin... 99 neomycin-polymyxin-hc ophthalmic... 102 neomycin-polymyxin-hc otic... 73 NEOSPORIN ANTI- ITCH... 68 NEOSPORIN PLUS PAINRELIEF(BAC)... 64 NEUPOGEN... 90 NEUPRO... 34 NEVANAC... 101 nevirapine oral suspension... 11 nevirapine oral tablet... 11 nevirapine oral tablet extended release 24 hr 100 mg... 11 nevirapine oral tablet extended release 24 hr 400 mg... 11 NEXAVAR... 26 NEXT CHOICE ONE DOSE... 97 niacin oral capsule, extended release 250 mg, 500 mg... 60 niacin oral tablet... 60 NIACIN ORAL TABLET... 60 niacin oral tablet extended release 24 hr 1,000 mg, 750 mg... 60 niacin oral tablet extended release 24 hr 500 mg... 60 niacin oral tablet extended release 250 mg, 750 mg... 60 NIACOR... 60 nicardipine intravenous solution... 55 nicardipine oral... 55 NICORELIEF... 72 nicorette buccal lozenge... 72 NICOTINE TRANSDERMAL... 72 nicotine transdermal system transdermal patch 24 hour 14 mg/24 hr, 21 mg/24 hr, 7 mg/ 24 hr... 72 nicotine transdermal system transdermal patch, td daily, sequential 21-14-7 mg/24 hr... 72 nicotine (polacrilex) buccal gum... 72 nicotine (polacrilex) buccal lozenge... 72 NICOTROL NS... 72 nifedical xl... 55 nifedipine oral tablet extended release... 55? 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 148

nifedipine oral tablet extended release 24hr... 56 NIGHTIME SLEEP... 106 NIGHTTIME ALLERGY RELIEF... 106 NIGHTTIME SLEEP AID (DIPHEN) ORAL CAPSULE 50 MG... 106 NIGHTTIME SLEEP AID (DIPHEN) ORAL TABLET... 106 NILANDRON... 26 nimodipine... 56 NINLARO... 26 NIPENT... 26 nitro-bid... 61 nitrofurantoin macrocrystal oral capsule 50 mg... 19 nitroglycerin intravenous... 61 nitroglycerin transdermal patch 24 hour... 61 NITROSTAT... 61 NIVA-HIST DM... 106 NOBLE FORMULA HC TOPICAL CREAM... 68 NON-ASPIRIN ORAL SUSPENSION... 41 NON-ASPIRIN PAIN RELIEF ORAL TABLET 500 MG... 41 non-drowsy allergy... 106 nora-be... 95 NORDITROPIN FLEXPRO... 90 norethindrone acetate... 95 norethindrone (contraceptive)... 95 norgestimate-ethinyl estradiol oral tablet 0.18/0.215/0.25 mg- 35 mcg (28), 0.25-35 mgmcg... 97 NORSOL-M IN 5 % DEXTROSE... 118 NORSOL-R... 116 NORSOL-R IN 5 % DEXTROSE... 116 NORSOL-R PH 7.4... 118 nortrel 0.5/35 (28)... 97 nortrel 1/35 (21)... 97 nortrel 1/35 (28)... 98 nortrel 7/7/7 (28)... 98 nortriptyline... 47 NORVIR ORAL CAPSULE... 11 NORVIR ORAL SOLUTION... 11 NORVIR ORAL TABLET... 11 NOVOPEN ECHO... 76 NOXAFIL ORAL SUSPENSION... 8 NUEDEXTA... 35 NULOJIX... 26 NUPLAZID... 47 NUVARING... 95 nystatin oral suspension... 8 nystatin oral tablet... 8 nystatin topical... 66 nystatin-triamcinolone... 66 nystop... 66 O ocella... 98 OCTAGAM... 92 octreotide acetate... 26 OCUSOFT IRRIGATING OPHTH SOLN... 100 ODEFSEY... 11 ODOMZO... 26 ODOR CONTROL FOOT- SNEAKER... 66 OFEV ORAL CAPSULE 150 MG... 111 ofloxacin ophthalmic... 99 ofloxacin oral tablet 400 mg... 18 ofloxacin otic... 73 ogestrel (28)... 98 olanzapine intramuscular... 47 olanzapine oral tablet 10 mg... 47 olanzapine oral tablet 15 mg... 47 olanzapine oral tablet 2.5 mg... 47 olanzapine oral tablet 20 mg... 47 olanzapine oral tablet 5 mg... 47 olanzapine oral tablet 7.5 mg... 48 olanzapine oral tablet, disintegrating 10 mg... 48 olanzapine oral tablet, disintegrating 15 mg... 48 olanzapine oral tablet, disintegrating 20 mg... 48 olanzapine oral tablet, disintegrating 5 mg... 48 OLYSIO... 11 omega-3 acid ethyl esters... 60 omeprazole oral capsule, delayed release(dr/ec)... 89 OMEPRAZOLE ORAL TABLET,DELAYED RELEASE (DR/EC)... 89 OMNITROPE... 90 ONCASPAR... 26 ondansetron hcl intravenous... 86 ondansetron hcl oral solution... 86 ondansetron hcl oral tablet 24 mg... 86 ondansetron hcl oral tablet 4 mg, 8 mg... 87 ondansetron hcl (pf) injection solution... 86 ondansetron hcl (pf) injection syringe... 86 ondansetron odt... 87 ONE DAILY PRENATAL ORAL COMBO PACK 28-800-440 MG-MCG-MG... 121 ONETOUCH DELICA LANCETS... 77 ONETOUCH ULTRA TEST... 77 ONETOUCH VERIO... 77 ONFI ORAL SUSPENSION... 32 ONFI ORAL TABLET 10 MG... 32? 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 149

ONFI ORAL TABLET 20 MG... 32 OPCICON ONE-STEP... 98 OPDIVO... 26 OPIUM TINCTURE... 81 ORAL SALINE LAXATIVE ORAL LIQUID... 87 ORAP... 48 ORENCIA... 94 ORENCIA (WITH MALTOSE)... 94 ORFADIN ORAL CAPSULE... 71 ORTHO MICRONOR... 95 oxacillin injection... 18 oxacillin intravenous... 18 oxaliplatin intravenous recon soln 100 mg... 26 oxaliplatin intravenous recon soln 50 mg... 26 oxaliplatin intravenous solution... 26 oxandrolone oral tablet 10 mg... 79 oxandrolone oral tablet 2.5 mg... 79 oxaprozin... 41 oxcarbazepine... 32 OXSORALEN... 62 OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR 150 MG... 32 OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR 300 MG... 32 OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR 600 MG... 32 oxybutynin chloride oral syrup... 112 oxybutynin chloride oral tablet... 112 oxybutynin chloride oral tablet extended release 24hr 10 mg, 15 mg... 112 oxybutynin chloride oral tablet extended release 24hr 5 mg... 112 oxycodone oral capsule... 37 oxycodone oral concentrate... 38 oxycodone oral tablet 10 mg, 5 mg... 38 oxycodone oral tablet 15 mg... 38 oxycodone oral tablet 20 mg, 30 mg... 38 oxycodone-acetaminophen oral solution... 38 oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg... 38 oxycodone-aspirin... 38 OYSCO 500/D ORAL TABLET... 116 OYSCO D... 116 OYSCO-500... 116 OYST-CAL-500... 116 OYSTER SHELL + D3... 116 OYSTER SHELL CALCIUM... 116 OYSTER SHELL CALCIUM 500... 116 OYSTER SHELL CALCIUM WITH D... 121 OYSTER SHELL CALCIUM- VIT D3... 116 OYSTERCAL-D... 116 P pacerone oral tablet 100 mg, 200 mg, 400 mg... 52 paclitaxel... 26 PAIN AND FEVER ORAL TABLET 500 MG... 41 PAIN RELIEF EXTRA STRENGTH... 41 PAIN RELIEF ORAL TABLET... 41 PAIN RELIEF (ACETAMIN- ASP-CAF)... 41 PAIN RELIEVER EXTRA STRENGTH... 41 PAIN RELIEVER ORAL CAPSULE... 41 PAIN RELIEVER ORAL TABLET 500 MG... 41 PAIN RELIEVER PLUS... 41 PAIN RELIEVER (ACETAM- ASPIRIN)... 41 PAIN-OFF... 41 paliperidone oral tablet extended release 24hr 1.5 mg... 48 paliperidone oral tablet extended release 24hr 3 mg... 48 paliperidone oral tablet extended release 24hr 6 mg... 48 paliperidone oral tablet extended release 24hr 9 mg... 48 pamidronate intravenous recon soln... 79 pamidronate intravenous solution 30 mg/10 ml (3 mg/ ml), 90 mg/10 ml (9 mg/ ml)... 79 pamidronate intravenous solution 60 mg/10 ml (6 mg/ ml)... 79 PAMPRIN MAX... 41 PANRETIN... 62 pantoprazole intravenous... 89 pantoprazole oral... 89 paricalcitol oral... 79 PAROEX ORAL RINSE... 72 paromomycin... 16 paroxetine hcl oral tablet 10 mg... 48 paroxetine hcl oral tablet 20 mg... 48 paroxetine hcl oral tablet 30 mg... 48 paroxetine hcl oral tablet 40 mg... 48 paroxetine hcl oral tablet extended release 24 hr 12.5 mg... 48? 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 150

paroxetine hcl oral tablet extended release 24 hr 25 mg... 48 paroxetine hcl oral tablet extended release 24 hr 37.5 mg... 48 PASER... 16 PATADAY... 101 PAXIL ORAL SUSPENSION... 48 PAZEO... 101 PEDIACARE FEVER REDUCER... 41 PEDVAX HIB (PF)... 92 peg 3350-electrolytes oral recon soln 236-22.74-6.74-5.86 gram... 87 peg 3350-electrolytes oral recon soln 240-22.72-6.72-5.84 gram... 87 peg-electrolyte soln... 87 PEG3350... 87 PEGANONE... 32 PEGASYS... 90 PEGASYS PROCLICK... 90 PEGINTRON... 90 PEGINTRON REDIPEN... 90 PENICILLIN G POT IN DEXTROSE... 18 penicillin g potassium... 18 penicillin g procaine intramuscular syringe 1.2 million unit/2 ml... 18 penicillin g procaine intramuscular syringe 600,000 unit/ml... 18 penicillin g sodium... 18 penicillin v potassium... 18 PENTAM... 16 PENTASA... 87 pentoxifylline... 59 pepcid ac oral tablet 20 mg... 89 PEPTIC RELIEF... 81 PEPTO-BISL ORAL TABLET,CHEWABLE... 81 PEPTO-BISL TO- GO... 81 PERFOROMIST... 111 perindopril erbumine... 56 periogard... 72 PERJETA... 26 permethrin topical cream... 69 permethrin topical liquid... 69 perphenazine... 48 PERSA-GEL... 63 PHARBETOL ORAL TABLET 500 MG... 41 PHAZYME ORAL CAPSULE 180 MG... 87 phenelzine... 48 phenobarbital oral elixir... 32 phenobarbital oral tablet 100 mg... 32 phenobarbital oral tablet 15 mg... 32 phenobarbital oral tablet 16.2 mg... 32 phenobarbital oral tablet 30 mg... 32 phenobarbital oral tablet 32.4 mg... 32 phenobarbital oral tablet 60 mg... 32 phenobarbital oral tablet 64.8 mg... 32 phenobarbital oral tablet 97.2 mg... 32 phentermine... 69 PHENYTEK... 32 PHENYTOIN ORAL SUSPENSION 100 MG/4 ML... 32 phenytoin oral suspension 125 mg/5 ml... 32 phenytoin oral tablet, chewable... 32 phenytoin sodium extended... 32 phenytoin sodium intravenous solution... 32 phenytoin sodium intravenous syringe... 32 PHOSPHATE LAXATIVE ORAL LIQUID... 87 PHOSPHOLINE IODIDE... 99 PICATO... 62 PILOCARPINE HCL OPHTHALMIC DROPS 1 %, 2 %, 4 %... 99 pilocarpine hcl oral... 71 pimozide... 48 pindolol... 56 PINK BISMUTH MAXIMUM STRENGTH... 81 PINK BISMUTH ORAL SUSPENSION... 81 PINK BISMUTH ORAL TABLET... 81 PINK BISMUTH ORAL TABLET,CHEWABLE... 81 pioglitazone oral tablet 15 mg... 77 pioglitazone oral tablet 30 mg... 77 pioglitazone oral tablet 45 mg... 77 pioglitazone-glimepiride... 77 pioglitazone-metformin... 77 piperacillin-tazobactam... 18 piroxicam... 41 PLAN B ONE-STEP... 98 PLASMA-LYTE 148... 118 PLASMA-LYTE-56 IN 5 % DEXTROSE... 118 podofilox... 62 POLY BACITRACIN... 64 POLY-IRON... 121 POLY-VITA... 121 POLY-VITAMIN... 121 POLYCIN... 99 polyethylene glycol 3350 oral powder... 87 polyethylene glycol 3350 oral powder in packet... 87 polymyxin b sulftrimethoprim... 99 polysaccharide iron complex... 121 polyvinyl alcohol... 101 POMALYST ORAL CAPSULE 1 MG... 26? 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 151

POMALYST ORAL CAPSULE 2 MG... 26 POMALYST ORAL CAPSULE 3 MG, 4 MG... 26 portia... 98 PORTRAZZA... 26 potassium chlorid-d5-0.45%nacl intravenous parenteral solution 10 meq/l, 30 meq/l, 40 meq/l... 116 potassium chlorid-d5-0.45%nacl intravenous parenteral solution 20 meq/ l... 116 potassium chloride in 0.9%nacl intravenous parenteral solution 20 meq/ l... 116 potassium chloride in 5 % dex intravenous parenteral solution 20 meq/l, 30 meq/l, 40 meq/l... 116 potassium chloride in lr-d5 intravenous parenteral solution 20 meq/l... 116 potassium chloride in lr-d5 intravenous parenteral solution 40 meq/l... 116 potassium chloride intravenous piggyback 10 meq/100 ml, 20 meq/100 ml, 40 meq/100 ml... 116 POTASSIUM CHLORIDE INTRAVENOUS PIGGYBACK 10 MEQ/50 ML... 116 POTASSIUM CHLORIDE INTRAVENOUS PIGGYBACK 20 MEQ/50 ML, 30 MEQ/100 ML... 116 potassium chloride intravenous solution... 116 potassium chloride oral capsule, extended release... 116 potassium chloride oral tablet extended release... 116 potassium chloride oral tablet, er particles/crystals... 116 potassium chloride-0.45 % nacl... 117 potassium chloride-d5-0.2%nacl intravenous parenteral solution 20 meq/ l... 117 potassium chloride-d5-0.2%nacl intravenous parenteral solution 30 meq/l, 40 meq/l... 117 potassium chloride-d5-0.3%nacl intravenous parenteral solution 20 meq/ l... 117 potassium chloride-d5-0.9%nacl intravenous parenteral solution 20 meq/ l... 117 potassium chloride-d5-0.9%nacl intravenous parenteral solution 40 meq/ l... 117 potassium citrate oral tablet extended release 10 meq (1, 080 mg), 5 meq (540 mg)... 112 POTIGA ORAL TABLET 200 MG, 300 MG, 400 MG... 32 POTIGA ORAL TABLET 50 MG... 32 POWDERLAX... 87 PRADAXA... 59 PRALUENT PEN... 60 PRALUENT SYRINGE... 60 pramipexole oral tablet... 34 pravastatin... 60 prazosin oral... 56 prednisolone acetate... 102 prednisolone oral solution 15 mg/5 ml... 73 prednisolone sodium phosphate ophthalmic... 102 prednisolone sodium phosphate oral solution 15 mg/ 5 ml (3 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml)... 73 prednisolone sodium phosphate oral tablet, disintegrating... 73 prednisone intensol... 73 prednisone oral... 74 PREMARIN ORAL... 95 PREMARIN VAGINAL... 95 PREMPRO... 95 PRENATAL FORMULA ORAL TABLET 28 MG IRON- 800 MCG... 121 PRENATAL ONE DAILY... 121 PRENATAL TABLET... 121 PRENATAL VITAMIN ORAL CAPSULE 13.5-0.4 MG... 121 prenatal vitamin oral tablet... 121 PRENATAL VITAMIN ORAL TABLET, 27-0.8 MG... 121 PRENATAL VITAMIN ORAL TABLET 27 MG IRON- 800 MCG... 121 prenatal vitamin oral tablet 28 mg iron- 800 mcg... 121 prevalite... 60 previfem... 98 PREZCOBIX... 11 PREZISTA ORAL SUSPENSION... 11 PREZISTA ORAL TABLET 150 MG... 11 PREZISTA ORAL TABLET 600 MG, 800 MG... 11 PREZISTA ORAL TABLET 75 MG... 11 PRIFTIN... 16 PRIMAQUINE... 16 primidone... 32 PRIVIGEN... 92 PROAIR HFA... 111 PROAIR RESPICLICK... 111 probenecid... 93 procainamide injection solution 100 mg/ml... 52? 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 152

procainamide injection solution 500 mg/ml... 52 prochlorperazine edisylate injection solution 10 mg/2 ml (5 mg/ml)... 87 prochlorperazine maleate oral... 87 prochlorperazine maleate rectal... 87 PROCRIT... 90 procto-pak... 87 proctosol hc... 87 proctozone-hc... 87 PRODIGY LANCETS 28 GAUGE... 77 PRODIGY TWIST TOP LANCET... 77 progesterone micronized... 95 PROGLYCEM... 77 PROGRAF INTRAVENOUS... 26 PROLASTIN-C... 71 PROLEUKIN... 90 PROLIA... 93 PROMACTA ORAL TABLET 12.5 MG, 25 MG, 75 MG... 59 PROMACTA ORAL TABLET 50 MG... 59 promethazine injection solution... 106 promethazine oral tablet 12.5 mg, 25 mg... 106 PROMETHAZINE VC- CODEINE... 106 promethazine-codeine... 106 promethazine-dm... 107 promethazine-phenylephcodeine... 107 PROMETHEGAN RECTAL SUPPOSITORY 12.5 MG... 107 PROLAXIN... 87 propafenone oral tablet... 52 propranolol intravenous... 56 propranolol oral... 56 propranololhydrochlorothiazid... 56 propylthiouracil... 74 PROQUAD (PF)... 92 PROTONIX INTRAVENOUS... 89 protriptyline... 48 PROVIL... 41 PSEUDOEPHEDRINE 120 MG ER... 107 pseudoephedrine hcl oral liquid... 107 pseudoephedrine hcl oral tablet 30 mg... 107 pseudoephedrine hcl oral tablet 60 mg... 107 pseudoephedrine hcl oral tablet extended release... 107 PULZYME... 111 PURELAX... 87 PURIXAN... 26 pyrazinamide... 16 pyridostigmine bromide... 35 pyridoxine (vitamin b6) oral tablet 100 mg, 25 mg, 50 mg... 122 Q Q-DRYL ORAL CAPSULE... 107 Q-DRYL ORAL LIQUID... 107 Q-PAP EXTRA STRENGTH... 41 Q-PAP ORAL TABLET 500 MG... 41 Q-TUSSIN... 107 QUADRACEL (PF)... 92 QUENALIN... 107 quetiapine oral tablet 100 mg... 48 quetiapine oral tablet 200 mg... 48 quetiapine oral tablet 25 mg... 48 quetiapine oral tablet 300 mg... 48 quetiapine oral tablet 400 mg... 49 quetiapine oral tablet 50 mg... 49 quinapril... 56 quinaprilhydrochlorothiazide... 56 quinidine sulfate oral tablet 200 mg, 300 mg... 52 QUIT 2 BUCCAL GUM... 72 quit 2 buccal lozenge... 72 QUIT 4 BUCCAL GUM... 72 quit 4 buccal lozenge... 72 QVAR INHALATION AEROSOL 40 MCG/ ACTUATION... 111 QVAR INHALATION AEROSOL 80 MCG/ ACTUATION... 111 R RABAVERT (PF)... 92 raloxifene... 93 ramipril... 56 RANEXA... 61 ranitidine hcl injection... 89 ranitidine hcl oral syrup... 89 ranitidine hcl oral tablet 150 mg, 300 mg... 89 ranitidine hcl oral tablet 75 mg... 89 RAPAMUNE ORAL SOLUTION... 26 RAVICTI... 71 READY-TO-USE ENEMA (MIN OIL)... 87 REBIF REBIDOSE... 90 REBIF TITRATION PACK... 90 REBIF (WITH ALBUMIN)... 90 reclipsen (28)... 98 RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION... 92 RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 10 MCG/ML... 92 RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 5 MCG/0.5 ML... 92 RECORT PLUS... 68? 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 153

REDNESS RELIEVER LUBRICANT... 102 RELCOF C... 107 RELENZA DISKHALER... 11 RELISTOR SUBCUTANEOUS SOLUTION... 87 RELISTOR SUBCUTANEOUS SYRINGE... 87 REMEDY PHYTOPLEX ANTIFUNGAL TOPICAL POWDER... 66 REMICADE... 87 RENA-VITE... 122 RENAGEL... 71 RENVELA ORAL POWDER IN PACKET 0.8 GRAM... 71 RENVELA ORAL POWDER IN PACKET 2.4 GRAM... 71 RENVELA ORAL TABLET... 71 repaglinide-metformin... 77 REPATHA SURECLICK... 60 REPATHA SYRINGE... 60 RESCRIPTOR ORAL TABLET... 11 RESCRIPTOR ORAL TABLET, DISPERSIBLE... 11 REST SIMPLY NIGHTTIME SLEEP... 107 RESTASIS... 101 RESTFULLY SLEEP... 107 RETAINE CMC... 101 RETROVIR INTRAVENOUS... 11 REVIVE PLUS... 101 REVLIMID ORAL CAPSULE 10 MG... 26 REVLIMID ORAL CAPSULE 15 MG, 2.5 MG, 20 MG, 25 MG... 26 REVLIMID ORAL CAPSULE 5 MG... 26 REXULTI ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG... 49 REXULTI ORAL TABLET 3 MG, 4 MG... 49 REYATAZ ORAL CAPSULE 150 MG, 200 MG... 11 REYATAZ ORAL CAPSULE 300 MG... 11 REYATAZ ORAL POWDER IN PACKET... 11 RI-GEL... 87 RI-GEL II... 87 RI-X... 87 RI-TUSSIN... 107 ribasphere oral capsule... 11 ribasphere oral tablet 200 mg... 11 ribavirin oral capsule... 11 ribavirin oral tablet 200 mg... 11 riboflavin (vitamin b2) oral tablet 100 mg, 50 mg... 122 RID COMPLETE LICE ELIM KIT TOPICAL... 69 RIDAURA... 94 rifabutin... 16 rifampin... 17 RIFATER... 17 riluzole... 71 rimantadine... 11 ringers intravenous... 117 ringers irrigation... 69 RINGWORM... 66 RISACAL-D... 122 RISPERDAL CONSTA INTRAMUSCULAR SYRINGE 12.5 MG/2 ML, 25 MG/2 ML, 37.5 MG/2 ML... 49 RISPERDAL CONSTA INTRAMUSCULAR SYRINGE 50 MG/2 ML... 49 risperidone oral solution... 49 risperidone oral tablet 0.25 mg... 49 risperidone oral tablet 0.5 mg... 49 risperidone oral tablet 1 mg... 49 risperidone oral tablet 2 mg... 49 risperidone oral tablet 3 mg... 49 risperidone oral tablet 4 mg... 49 risperidone oral tablet, disintegrating 0.25 mg... 49 risperidone oral tablet, disintegrating 0.5 mg... 49 risperidone oral tablet, disintegrating 1 mg... 49 risperidone oral tablet, disintegrating 2 mg... 49 risperidone oral tablet, disintegrating 3 mg... 49 risperidone oral tablet, disintegrating 4 mg... 49 RITUXAN... 27 rivastigmine... 35 rivastigmine tartrate... 35 rizatriptan... 34 ROBAFEN... 107 ROBAFEN DM COUGH... 107 ropinirole oral tablet... 34 ROSADAN TOPICAL CREAM... 63 rosuvastatin... 60 ROTARIX... 92 ROTATEQ VACCINE... 92 roweepra... 33 ROZEREM... 49 RYDEX... 107 S SABRIL... 33 SALICYLIC ACID TOPICAL LIQUID 3 %... 61 SANI-SUPP (ADULT)... 88 SANTYL... 68 SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 10 MG... 49 SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 2.5 MG... 49? 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 154

SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 5 MG... 49 SAVELLA ORAL TABLET 100 MG... 94 SAVELLA ORAL TABLET 12.5 MG... 94 SAVELLA ORAL TABLET 25 MG... 94 SAVELLA ORAL TABLET 50 MG... 94 SAVELLA ORAL TABLETS, DOSE PACK... 94 SCALP RELIEF HYDROCORTISONE SOLUTION TOPICAL LIQUID 3 %... 61 SCALP RELIEF HYDROCORTISONE SOLUTION TOPICAL SOLUTION 1 %... 68 SCALPICIN ANTI- ITCH... 68 SCOT-TUSSIN EXPECTORANT... 107 SECURA ANTIFUNGAL... 66 SECURA ANTIFUNGAL EXTRA THICK... 66 selegiline hcl... 34 selenium sulfide topical lotion... 61 SELZENTRY... 11 SENSIPAR ORAL TABLET 30 MG, 60 MG... 79 SENSIPAR ORAL TABLET 90 MG... 79 SEREVENT DISKUS... 111 SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 150 MG... 49 SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 200 MG... 50 SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 300 MG... 50 SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 400 MG... 50 SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 50 MG... 50 sertraline oral concentrate... 50 sertraline oral tablet 100 mg... 50 sertraline oral tablet 25 mg... 50 sertraline oral tablet 50 mg... 50 SHAKE THAT ACHE... 41 SIGNIFOR... 27 SILACE ORAL LIQUID... 88 SILACE ORAL SYRUP... 88 SILADRYL SA... 107 sildenafil oral... 111 SILTUSSIN DM DAS... 107 SILTUSSIN SA... 107 silver sulfadiazine... 61 simethicone oral capsule... 88 simethicone oral tablet, chewable... 88 SIMPONI... 94 SIMULECT INTRAVENOUS RECON SOLN 10 MG... 27 SIMULECT INTRAVENOUS RECON SOLN 20 MG... 27 simvastatin... 60 SINUS 12 HOUR... 107 SINUS AND ALLERGY PE... 107 SINUS-ALLERGY (PHENYLEPHRINE)... 107 sirolimus... 27 SIRTURO... 17 SKIN TREATMENT... 62 SLEEP... 107 SLEEP AID MAX STR (DIPHENHYDR)... 108 SLEEP AID (DIPHENHYDRAMINE) ORAL CAPSULE 50 MG... 107 SLEEP AID (DIPHENHYDRAMINE) ORAL TABLET... 108 SLEEP AID (DOXYLAMINE)... 50 SLEEP II... 108 SLEEP TABLET (DIPHENHYDRAMINE)... 108 SLEEP-TABS... 108 SLOW RELEASE IRON ORAL TABLET EXTENDED RELEASE 160 MG (50 MG IRON), 47.5 MG IRON... 122 SOTH ANTACID... 117 smoothlax... 88 sodium chloride 0.45 % intravenous parenteral solution... 117 SODIUM CHLORIDE 0.45 % INTRAVENOUS PIGGYBACK... 117 sodium chloride 0.9 % intravenous... 71 SODIUM CHLORIDE 0.9 % INTRAVENOUS... 71 sodium chloride 3 %... 117 sodium chloride 5 %... 117 sodium chloride inhalation solution for nebulization 3 %... 111 sodium chloride intravenous... 117 sodium chloride irrigation... 71 sodium fluoride oral tablet... 122 sodium fluoride oral tablet, chewable 1 mg fluoride (2.2 mg)... 122 sodium polystyrene sulfonate oral powder... 71? 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 155

sodium polystyrene sulfonate oral suspension... 71 sodium polystyrene sulfonate rectal... 71 SODIUM POLYSTYRENE SULFONATE RECTAL... 71 sodium polystyrene (sorb free)... 71 sof-lax... 88 SOLTAX... 27 SOMATULINE DEPOT... 27 SOMAVERT... 79 SOOTHE REGULAR STRENGTH... 81 SOOTHE (BISMUTH SUBSALICYLATE)... 81 SOOTHING CARE (HYDROCORTISONE)... 68 SOOTHING PUREWAY- C... 122 SORBUGEN NR... 108 sorine oral tablet 120 mg, 160 mg, 80 mg... 52 sorine oral tablet 240 mg... 52 sotalol af oral tablet 120 mg... 52 SOTALOL AF ORAL TABLET 160 MG, 80 MG... 52 sotalol oral tablet 120 mg... 52 sotalol oral tablet 160 mg, 240 mg, 80 mg... 52 SOVALDI... 12 SPIRIVA RESPIMAT... 111 SPIRIVA WITH HANDIHALER... 111 spironolactonhydrochlorothiaz... 56 spironolactone... 56 sprintec (28)... 98 SPRITAM ORAL TABLET FOR SUSPENSION 1,000 MG, 250 MG, 500 MG... 33 SPRITAM ORAL TABLET FOR SUSPENSION 750 MG... 33 SPRYCEL... 27 SPS ORAL... 71 SPS RECTAL... 71 ssd... 61 stavudine oral capsule 15 mg, 20 mg... 12 stavudine oral capsule 30 mg, 40 mg... 12 stavudine oral recon soln... 12 STERILE EYE DROPS OPHTHALMIC DROPS 0.012-0.2 %, 0.03-0.5 %... 102 STERILE EYE WASH... 101 STERILE SALINE NASAL... 72 STIMATE... 79 STIOLTO RESPIMAT... 111 STIVARGA... 27 STOMACH RELIEF... 81 STOMACH RELIEF MAX STRENGTH... 81 STOMACH RELIEF ORIGINAL... 81 stool softener oral capsule 100 mg... 88 STOOL SOFTENER ORAL CAPSULE 240 MG, 250 MG... 88 STOOL SOFTENER ORAL CAPSULE 50 MG... 88 STOOL SOFTENER ORAL LIQUID... 88 STOOL SOFTENER ORAL SYRUP... 88 STOOL SOFTENER ORAL TABLET... 88 STOP LICE... 69 stop smoking aid... 72 STRATTERA ORAL CAPSULE 10 MG, 18 MG, 25 MG, 40 MG... 50 STRATTERA ORAL CAPSULE 100 MG, 60 MG, 80 MG... 50 STRAWBERRY C... 122 STREPTOMYCIN INTRAMUSCULAR... 17 STRIBILD... 12 SUBOXONE SUBLINGUAL FILM 12-3 MG... 41 SUBOXONE SUBLINGUAL FILM 2-0.5 MG... 41 SUBOXONE SUBLINGUAL FILM 4-1 MG... 41 SUBOXONE SUBLINGUAL FILM 8-2 MG... 41 sucralfate oral tablet... 89 SUDOGEST... 108 SUDOGEST 12-HOUR... 108 SUDOGEST COLD AND ALLERGY... 108 SUDOGEST SINUS AND ALLERGY... 108 sulfacetamide sodium ophthalmic drops... 102 sulfacetamide sodium (acne)... 64 sulfacetamideprednisolone... 102 sulfadiazine oral... 18 sulfamethoxazoletrimethoprim... 19 SULFAMYLON TOPICAL CREAM... 64 sulfasalazine... 88 sulindac oral... 41 sumatriptan succinate oral... 34 sumatriptan succinate subcutaneous cartridge... 34 sumatriptan succinate subcutaneous pen injector... 34 sumatriptan succinate subcutaneous solution... 34 SUMATRIPTAN SUCCINATE SUBCUTANEOUS SYRINGE 6 MG/0.5 ML... 34 SUPER CALCIUM... 117 SUPER PAIN RELIEF... 42 SUPHEDRIN... 108 SUPHEDRIN 12 HOUR... 108 SUPHEDRINE... 108? 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 156

SUPHEDRINE 12 HOUR... 108 SUPHEDRINE PE COLD AND ALLERGY... 108 SUPHEDRINE PE SINUS ANDALLERGY... 108 SUPPOSITORY ADULT... 88 SURFAK... 88 SURNTIL... 50 SUSTIVA ORAL CAPSULE 200 MG... 12 SUSTIVA ORAL CAPSULE 50 MG... 12 SUSTIVA ORAL TABLET... 12 SUTENT ORAL CAPSULE 12.5 MG... 27 SUTENT ORAL CAPSULE 25 MG, 37.5 MG, 50 MG... 27 SYEDA... 98 SYLATRON... 90 SYMLINPEN 120... 77 SYMLINPEN 60... 77 SYNAGIS... 12 SYNAREL... 79 SYNERCID... 17 SYNJARDY... 77 SYNRIBO... 27 SYNTHROID... 80 SYPRINE... 71 T TABLOID... 27 tacrolimus oral... 27 tacrolimus topical... 62 TAFINLAR ORAL CAPSULE 50 MG... 27 TAFINLAR ORAL CAPSULE 75 MG... 27 TAGRISSO ORAL TABLET 40 MG... 27 TAGRISSO ORAL TABLET 80 MG... 27 TAKE ACTION... 98 TAMIFLU... 12 tamoxifen... 27 tamsulosin... 112 TANZEUM... 77 TARCEVA ORAL TABLET 100 MG, 150 MG... 27 TARCEVA ORAL TABLET 25 MG... 27 TARGRETIN ORAL... 27 TARGRETIN TOPICAL... 27 TASIGNA... 27 TAZORAC... 63 taztia xt... 56 TEARS AGAIN (PVA)... 101 TEARS NATURALE FREE (PF)... 101 TECENTRIQ... 27 TECFIDERA... 35 TECHNIVIE... 12 TEFLARO... 14 TEKTURNA... 56 TEKTURNA HCT... 56 telmisartan oral tablet 20 mg, 40 mg... 56 telmisartan oral tablet 80 mg... 56 telmisartan-amlodipine... 56 telmisartan-hydrochlorothiazid oral tablet 40-12.5 mg, 80-25 mg... 56 telmisartan-hydrochlorothiazid oral tablet 80-12.5 mg... 56 temazepam oral capsule 15 mg, 22.5 mg, 30 mg... 50 terazosin... 56 terbinafine hcl oral... 8 terbinafine hcl topical... 66 terbutaline oral... 111 terbutaline subcutaneous... 111 terconazole... 95 testosterone cypionate... 79 testosterone enanthate... 79 testosterone transdermal gel... 79 testosterone transdermal gel in metered-dose pump 1.25 gram/ actuation (1 %)... 79 testosterone transdermal gel in metered-dose pump 10 mg/ 0.5 gram /actuation... 79 testosterone transdermal gel in packet 1 % (25 mg/ 2.5gram)... 79 testosterone transdermal gel in packet 1 % (50 mg/5 gram)... 79 tetanus,diphtheria tox ped (pf)... 92 TETANUS-DIPHTHERIA TOXOIDS-TD... 92 tetrabenazine oral tablet 12.5 mg... 35 tetrabenazine oral tablet 25 mg... 35 tetracycline... 19 THALOMID ORAL CAPSULE 100 MG, 50 MG... 27 THALOMID ORAL CAPSULE 150 MG, 200 MG... 27 THE MAGIC BULLET... 88 theophylline oral tablet extended release... 111 theophylline oral tablet extended release 12 hr... 111 THERA-D... 122 thiamine hcl (vitamin b1) oral tablet 100 mg, 250 mg, 50 mg... 122 thiamine mononitrate (vit b1)... 122 thioridazine... 50 thiotepa... 27 thiothixene... 50 THYGLOBULIN... 92 tiagabine... 33 TICE BCG... 92 TIKOSYN... 52 timolol maleate ophthalmic... 99 timolol maleate oral... 56 TIPTIC OCUDOSE (PF)... 99 TINACTIN TOPICAL AEROSOL POWDER... 66 TIVICAY ORAL TABLET 10 MG, 25 MG... 12? 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 157

TIVICAY ORAL TABLET 50 MG... 12 tizanidine oral tablet... 35 tobramycin... 99 tobramycin in 0.225 % nacl... 17 tobramycin sulfate injection recon soln... 17 tobramycin sulfate injection solution... 17 tobramycin-dexamethasone opthalmic suspension... 102 tolazamide oral tablet 250 mg... 77 tolazamide oral tablet 500 mg... 77 tolbutamide... 77 tolcapone... 34 tolmetin... 42 tolnaftate topical aerosol powder... 66 tolnaftate topical cream... 66 tolterodine oral capsule, extended release 24hr... 112 tolterodine oral tablet... 112 topiramate oral capsule, sprinkle... 33 topiramate oral tablet 100 mg... 33 topiramate oral tablet 200 mg... 33 topiramate oral tablet 25 mg... 33 topiramate oral tablet 50 mg... 33 toposar... 28 topotecan intravenous recon soln... 28 TOPOTECAN INTRAVENOUS SOLUTION... 28 TORISEL... 28 torsemide oral... 56 TOTAL ALLERGY MEDICINE... 108 TOUJEO SOLOSTAR... 77 TOVIAZ... 112 TRACLEER... 111 TRADJENTA... 77 tramadol oral tablet... 42 tramadol-acetaminophen... 42 trandolapril... 56 tranexamic acid intravenous... 59 tranexamic acid oral... 95 tranylcypromine... 50 travasol 10 %... 118 TRAVATAN Z... 101 TRAVEL SICKNESS (MECLIZINE)... 88 trazodone... 50 TREANDA INTRAVENOUS RECON SOLN... 28 TRECATOR... 17 TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION... 28 TRELSTAR INTRAMUSCULAR SYRINGE 11.25 MG/2 ML, 3.75 MG/2 ML... 28 TRELSTAR INTRAMUSCULAR SYRINGE 22.5 MG/2 ML... 28 tretinoin topical cream... 63 tretinoin topical gel 0.01 %, 0.025 %... 63 tretinoin (chemotherapy)... 28 TREXALL... 28 TRI-BIOZENE... 64 tri-previfem (28)... 98 tri-sprintec (28)... 98 triamcinolone acetonide dental... 72 triamcinolone acetonide injection suspension 10 mg/ ml... 74 triamcinolone acetonide injection suspension 40 mg/ ml... 74 triamcinolone acetonide topical cream... 68 triamcinolone acetonide topical lotion... 68 triamcinolone acetonide topical ointment 0.025 %, 0.1 %, 0.5 %... 68 triamterenehydrochlorothiazid oral capsule 37.5-25 mg... 56 triamterenehydrochlorothiazid oral tablet... 56 trianex... 68 TRIBENZOR... 56 triderm topical cream... 68 trifluoperazine... 50 trifluridine... 99 trimethoprim... 19 TRINTELLIX ORAL TABLET 10 MG... 50 TRINTELLIX ORAL TABLET 20 MG... 50 TRINTELLIX ORAL TABLET 5 MG... 50 TRIPLE ANTIBIOTIC PLUS... 64 TRIPLE ANTIBIOTIC TOPICAL OINTMENT... 64 TRIPLE ANTIBIOTIC TOPICAL OINTMENT IN PACKET... 64 TRIPLE ANTIBIOTIC (PRAM) EXTRA... 64 TRIPLE ANTIBIOTIC-PAIN RELIEF... 64 TRISENOX... 28 TRIUMEQ... 12 trivora (28)... 98 TROPHAMINE 10 %... 118 TROPHAMINE 6%... 118 trospium oral tablet... 112 TRULICITY... 77 TRUMENBA... 92 TRUSTEX LATEX CONDOM... 77 TRUSTEX LUBRICATED CONDOMS... 77 TRUSTEX-RIA LUBRICATED CONDOMS... 77? 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 158

TRUVADA ORAL TABLET 100-150 MG, 133-200 MG, 167-250 MG... 12 TRUVADA ORAL TABLET 200-300 MG... 12 TUMS ULTRA ORAL TABLET,CHEWABLE 400 MG (1,000 MG)... 117 TUSNEL DIABETIC... 108 TUSSI PRES-B ORAL LIQUID 4-10-20 MG/5 ML... 108 TUSSIGON... 108 TUSSIN CHEST CONGESTION... 108 TUSSIN COUGH-CHEST CONGESTION... 108 TUSSIN DM COUGH AND CHEST ORAL LIQUID 10-100 MG/5 ML... 108 TUSSIN DM ORAL LIQUID... 108 TUSSIN EXPECTORANT... 108 TUSSIN HONEY... 108 TUSSIN ORAL LIQUID... 108 TWINRIX (PF)... 92 TYBOST... 12 TYGACIL... 17 TYKERB... 28 TYPHIM VI INTRAMUSCULAR SOLUTION... 92 TYPHIM VI INTRAMUSCULAR SYRINGE... 92 TYSABRI... 35 TYZEKA... 12 TYZINE NASAL DROPS 0.05 %... 73 U ULORIC... 93 ULTRA FRESH... 101 ULTRA SLEEP (DOXYLAMINE SUCC)... 50 ULTRA STRENGTH ANTACID... 117 ULTRA STRENGTH CALCIUM ANTACID... 117 ULTRA THIN LANCETS... 77 ULTRA THIN LANCETS 28 GAUGE, 33 GAUGE... 77 UNILET COMFORTOUCH LANCET... 77 UNILET COMFORTOUCH LANCET 26 GAUGE... 77 UNILET EXCELITE II LANCET... 77 UNILET GP LANCET... 78 UNISOM SLEEPGELS... 108 UNISTIK 3 COMFORT LANCET... 78 UNISTIK 3 EXTRA LANCET... 78 UNISTIK 3 LANCETS... 78 UNISTIK 3 NORMAL LANCET... 78 UNISTIK CZT LANCET 23 GAUGE... 78 UNISTIK CZT LANCET 28 GAUGE... 78 UNITHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG... 80 UNITUXIN... 28 urea topical cream 10 %, 20 %... 62 UREA TOPICAL CREAM 20%... 62 urea topical lotion 10 %... 62 UREACIN-20... 62 URINARY PAIN RELIEF ORAL TABLET 95 MG... 113 URINARY TRACT... 113 ursodiol... 88 UVADEX... 62 V VAGINAL CONTRACEPTIVE FOAM... 95 VAGISTAT-3... 95 valacyclovir... 12 VALCHLOR... 62 valganciclovir... 12 valproate sodium... 33 valproic acid... 33 valproic acid (as sodium salt) oral solution 250 mg/5 ml... 33 VALPROIC ACID (AS SODIUM SALT) ORAL SOLUTION 250 MG/5 ML (5 ML), 500 MG/10 ML (10 ML)... 33 valsartan oral tablet 160 mg... 57 valsartan oral tablet 320 mg... 57 valsartan oral tablet 40 mg, 80 mg... 57 valsartanhydrochlorothiazide... 57 VALU-DRYL ALLERGY ORAL CAPSULE... 108 VANCOMYCIN IN 0.9% SODIUM CL INTRAVENOUS PIGGYBACK 500 MG/100 ML, 750 MG/150 ML... 19 vancomycin in dextrose 5 % intravenous piggyback 1 gram/ 200 ml... 19 vancomycin in dextrose 5 % intravenous piggyback 500 mg/ 100 ml... 19 VANCOMYCIN IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK 750 MG/150 ML... 19 vancomycin intravenous... 19 VANCOMYCIN INTRAVENOUS... 19? 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 159

vancomycin oral capsule 125 mg... 19 vancomycin oral capsule 250 mg... 19 VAQTA (PF) INTRAMUSCULAR SUSPENSION... 92 VAQTA (PF) INTRAMUSCULAR SYRINGE... 92 VARIVAX (PF)... 92 VARIZIG... 92 VASCEPA... 60 VECAMYL... 61 VECTIBIX... 28 VELCADE... 28 velivet triphasic regimen (28)... 98 VENCLEXTA ORAL TABLET 10 MG... 28 VENCLEXTA ORAL TABLET 100 MG... 28 VENCLEXTA ORAL TABLET 50 MG... 28 VENCLEXTA STARTING PACK... 28 venlafaxine oral capsule, extended release 24hr 150 mg... 50 venlafaxine oral capsule, extended release 24hr 37.5 mg... 50 venlafaxine oral capsule, extended release 24hr 75 mg... 51 venlafaxine oral tablet 100 mg... 51 venlafaxine oral tablet 25 mg... 51 venlafaxine oral tablet 37.5 mg... 51 venlafaxine oral tablet 50 mg... 51 venlafaxine oral tablet 75 mg... 51 venlafaxine oral tablet extended release 24hr 150 mg... 51 venlafaxine oral tablet extended release 24hr 37.5 mg... 51 venlafaxine oral tablet extended release 24hr 75 mg... 51 VENTAVIS... 112 VENTOLIN HFA... 112 verapamil intravenous solution... 57 verapamil intravenous syringe... 57 verapamil oral capsule, 24 hr er pellet ct... 57 verapamil oral capsule,ext rel. pellets 24 hr... 57 verapamil oral tablet... 57 verapamil oral tablet extended release 120 mg (24 hours)... 57 verapamil oral tablet extended release 120 mg, 180 mg, 240 mg... 57 VERSACLOZ... 51 VESICARE... 112 VICKS QLEARQUIL ALLERGY... 109 VICKS QLEARQUIL NIGHTTIME RLF... 109 VICTOZA 2-PAK... 78 VICTOZA 3-PAK... 78 VIDEX 2 GRAM PEDIATRIC... 12 VIDEX 4 GRAM PEDIATRIC... 12 VIEKIRA PAK... 12 VIGAX... 99 VIIBRYD ORAL TABLET 10 MG... 51 VIIBRYD ORAL TABLET 20 MG... 51 VIIBRYD ORAL TABLET 40 MG... 51 VIIBRYD ORAL TABLETS, DOSE PACK 10 MG (7)- 20 MG (23)... 51 VIMPAT INTRAVENOUS... 33 VIMPAT ORAL SOLUTION... 33 VIMPAT ORAL TABLET 100 MG... 33 VIMPAT ORAL TABLET 150 MG... 33 VIMPAT ORAL TABLET 200 MG... 33 VIMPAT ORAL TABLET 50 MG... 33 vinblastine intravenous solution... 28 VINCASAR PFS INTRAVENOUS SOLUTION 1 MG/ML... 28 VINCASAR PFS INTRAVENOUS SOLUTION 2 MG/2 ML... 28 vincristine... 28 vinorelbine... 28 VIORELE (28)... 98 VIRACEPT ORAL TABLET 250 MG... 12 VIRACEPT ORAL TABLET 625 MG... 12 VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 HR 100 MG... 12 VIRAZOLE... 12 VIREAD ORAL POWDER... 12 VIREAD ORAL TABLET... 12 VIRTUSSIN AC... 109 vitamin a palmitate oral... 122 VITAMIN A PALMITATE ORAL... 122 VITAMIN B-1... 122 VITAMIN B-1 (NONITRATE)... 122 VITAMIN B-12 ORAL TABLET 1,000 MCG, 100 MCG, 250 MCG, 500 MCG... 122 VITAMIN B-12 ORAL TABLET EXTENDED RELEASE 1,000 MCG... 122? 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 160

VITAMIN B-12 ORAL TABLET EXTENDED RELEASE 2,000 MCG... 122 VITAMIN B-12 SUBLINGUAL TABLET 2, 500 MCG... 122 VITAMIN B-2... 122 VITAMIN B-6 ORAL TABLET 100 MG, 25 MG, 50 MG... 122 VITAMIN C ORAL CAPSULE, EXTENDED RELEASE... 122 VITAMIN C ORAL TABLET 1,000 MG, 250 MG, 500 MG... 123 VITAMIN C ORAL TABLET, CHEWABLE 250 MG, 500 MG... 123 VITAMIN C WITH ROSE HIPS ORAL TABLET... 123 VITAMIN D2... 123 VITAMIN D3 ORAL CAPSULE 1,000 UNIT, 2,000 UNIT, 400 UNIT... 123 VITAMIN D3 ORAL TABLET 1,000 UNIT, 400 UNIT... 123 VITAMIN D3 ORAL TABLET 2,000 UNIT, 5,000 UNIT... 123 vitamin e oral capsule 1,000 unit, 200 unit, 400 unit... 123 vitamin e oral capsule 100 unit... 123 VITAMIN E (DL, ACETATE) ORAL CAPSULE 100 UNIT... 123 VITEKTA... 13 VOLTAREN GEL TOPICAL GEL 1 %... 42 voriconazole intravenous... 8 voriconazole oral suspension for reconstitution... 8 voriconazole oral tablet 200 mg... 8 voriconazole oral tablet 50 mg... 9 VOTRIENT... 28 VPRIV... 79 VRAYLAR ORAL CAPSULE... 51 VRAYLAR ORAL CAPSULE,DOSE PACK... 51 W WAL-ACT D COLD AND ALLERGY... 109 WAL-DRYL ALLERGY... 109 WAL-DRYL-D ALLERGY AND SINUS... 109 WAL-FINATE-D... 109 wal-itin oral tablet... 109 wal-itin oral tablet, disintegrating... 109 WAL-PHED... 109 WAL-PHED 12 HOUR... 109 WAL-PHED PE SINUS AND ALLERGY... 109 WAL-PROFEN... 42 WAL-PROXEN... 42 WAL-SOM (DIPHENHYDRAMINE) ORAL CAPSULE... 109 WAL-SOM (DOXYLAMINE)... 51 wal-zan 150... 89 WAL-ZAN 75... 89 wal-zyr (cetirizine) oral tablet... 109 WAL-ZYR (KETOTIFEN)... 101 warfarin... 59 water for irrigation, sterile... 72 WELCHOL... 60 WOMAN'S LAXATIVE ORAL TABLET,DELAYED RELEASE (DR/EC)... 88 WOMEN'S GENTLE LAXATIVE(BISAC)... 88 WOMEN'S LAXATIVE (BISACODYL) ORAL TABLET,DELAYED RELEASE (DR/EC)... 88 X XALKORI... 28 XARELTO ORAL TABLET 10 MG, 20 MG... 59 XARELTO ORAL TABLET 15 MG... 59 XARELTO ORAL TABLETS, DOSE PACK... 59 XENAZINE ORAL TABLET 12.5 MG... 35 XENAZINE ORAL TABLET 25 MG... 35 XGEVA... 20 XOLAIR... 112 XOPENEX HFA... 112 XTANDI... 28 XULANE... 95 XYREM... 51 Y YERVOY... 29 YF-VAX (PF)... 92 YONDELIS... 29 Z zafirlukast... 112 zaleplon oral capsule 10 mg... 51 zaleplon oral capsule 5 mg... 51 ZALTRAP... 29 ZANOSAR... 29 ZANTAC MAXIMUM STRENGTH... 89 ZANTAC ORAL TABLET 150 MG... 89 ZARAH... 98 ZAVESCA... 80 ZEASORB (MICONAZOLE)... 66 ZELBORAF... 29 ZEMPLAR INTRAVENOUS... 80 zenchent (28)... 98 ZENPEP... 88 zenzedi oral tablet 10 mg... 51 zenzedi oral tablet 5 mg... 51 ZEPATIER... 13 ZETIA... 61? 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 161

ZIAGEN ORAL SOLUTION... 13 zidovudine oral capsule... 13 zidovudine oral syrup... 13 zidovudine oral tablet... 13 ziprasidone hcl oral capsule 20 mg... 51 ziprasidone hcl oral capsule 40 mg... 51 ziprasidone hcl oral capsule 60 mg, 80 mg... 51 ZIRGAN... 99 zoledronic acid intravenous recon soln 4 mg... 80 zoledronic acid intravenous solution 4 mg/5 ml... 80 ZOLINZA... 29 zolmitriptan... 34 zolpidem oral tablet... 51 ZOMETA INTRAVENOUS SOLUTION 4 MG/100 ML... 80 ZOMIG NASAL... 34 zonisamide... 33 ZORTRESS... 29 ZOSTAVAX (PF)... 92 zovia 1/35e (28)... 98 zovia 1/50e (28)... 98 ZYDELIG... 29 ZYKADIA... 29 ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 210 MG, 405 MG... 52 ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 300 MG... 52 ZYTIGA... 29 ZYVOX INTRAVENOUS PARENTERAL SOLUTION 200 MG/100 ML... 17 ZYVOX INTRAVENOUS PARENTERAL SOLUTION 600 MG/300 ML... 17 ZYVOX ORAL SUSPENSION FOR RECONSTITUTION... 17? 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 162

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 點或者瀏覽 mss.anthem.com/cammp 給付藥物清單 和 / 或網路內藥房和醫療服務提供者可能於全年內隨時變動 在我們做的改變對您造成影響之前, 我們會向您寄送通知 福利 和 / 或共付費用可能於每年 1 月 1 日進行變動 處方藥物的共付費用可能會根據您所取得的 Extra Help( 額外補助 ) 等級而有所不同 請聯絡本計劃以取得更多詳情 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 您可以免費獲得其他格式的資料, 如大型字體印刷 點字 或語音版本 請致電會員服務部 1-855-817-5785 (TTY 711) 此為免付費電話 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劃, 從而為參保人提供這兩個計劃的福利 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 H6229_16_24684_T_007_CT CMS Approved 09/01/2015 處方藥物 ID: 16262 版本 : 13 發佈時間 08/01/2016 ACADMKT-0127-16 08.16 CT