2015 承保藥物清單 ( 處方一覽表 ) RiverSpring FIDA Plan (Medicare-Medicaid 計劃 ) ElderServe Health, Inc. / RiverSpring Health Plans

H6435_2015FormularyCH_Approved RiverSpring FIDA 計劃 (Medicare-Medicaid 計劃 ) 2015 年承保藥物清單 ( 處方一覽表 ) 版本 :2014 年 10 月 30 日 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org. 1

RiverSpring FIDA 計劃 2015 年承保藥物清單 ( 處方一覽表 ) 這是會員可透過 RiverSpring FIDA 計劃獲得的藥物清單 RiverSpring FIDA 計劃是一項與 Medicare 及紐約州衛生廳 (Medicaid) 訂立合約的管理式醫療保健計劃, 透過完整統籌 Duals Advantage (FIDA) 示範項目為其參與者提供這兩個項目的福利 保險福利 已承保藥物清單 藥房和提供者網絡在每年的 1 月 1 日及每年間會不時發生變化 您總是可線上檢視 RiverSpring FIDA 計劃最新藥物清單 www.riverspringfida.org 或致電 RiverSpring FIDA 計劃藥房服務部, 電話是 1-855-898-1482 限制和約束可能適用 欲瞭解更多資訊, 請致電 RiverSpring FIDA 計劃藥房服務部或閱讀 RiverSpring FIDA 計劃會員手冊 任何承保藥物無自付費用 您可以免費獲得以其他格式提供的這些資訊, 例如盲文或大字型印刷 請致電 1-800-950-9000 這是 免費電話 You can get this information for free in other languages. Call 1-800-950-9000 (TTY users please call 1-866-236-5800), Monday-Sunday, 8AM-8PM. The call is free. 您可免費取得以其他語言撰寫的資訊 請於週一至週日美國東部標準時間上午 8 時至下午 8 時, 東部時間. 時致電 : 1-800-950-9000,TTY/TDD 使用者 : 1-866-236-5800 每週 7 天服務 此為免付費電話 이정보는다른언어로도제공됩니다 ( 무료 ). 주 7일 8:00 am 8:00 pm 동부시간중 1-800-950-9000 나 TTY/TDD: 1-866-236-5800으로전화주십시오. 통화료는무료입니다. Usted puede obtener esta información en otros idiomas de forma gratuita. Llame al 1-800-950-9000 y TTY/TDD: 1-866-236-5800, 8 a.m. - 8 p.m. Hora del Este, los 7 días de la semana. La llamada es gratuita. È possibile ricevere queste informazioni in altre lingue gratuitamente. Contatta il 1-800-950-9000 e TTY/TDD: 1-866-236-5800 dalle ore 8:00 alle ore 20:00 (ora standard orientale degli Stati Uniti), 7 giorni su 7. Il servizio è gratuito.. Ou ka jwenn enfòmasyon sa a gratis nan lòt lang. Rele nan 1-800-950-9000 ak nan TTY/TDD: 1-800-236-5800 ant 8:00 am ak 8:00 pm., Lè Zòn Lès, 7 jou pa semèn. Koutfil la gratis. Vous pouvez obtenir ces informations gratuitement dans d autres langues. Appelez le 1-800-950-9000 ou notre numéro TTY/TDD: 1-866-236-5800 - 7 jours sur 7 de 8 a.m. à 8 p.m. Heure de l'est. L appel est gratuit.. Данная информация доступна бесплатно на других языках. Звоните по номеру 1-800-950-8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼 2

9000 или 1-866-236-5800 (линия TTY/TDD) с 8:00 до 20:00 по восточному поясному времени 7 дней в неделю. Звонок бесплатный. Eta New York la te kreye yon Pwogram Medyatè Patisipan pou bay Patisipan yo asistans gratis, konfidansyèl sou tout sèvis RiverSpring Plan FIDA ofri. Ou ka jwenn patisipan medyatè a nan liy telefòn gratis nan 1-844-614-8800 (TTY/TDD: 711) oswa sou entènèt nan www.icannys.org. 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼. 3

常見問題 (FAQ) 如果您對於承保藥物清單有任何疑問, 請在此尋找答案 您可以閱讀所有 FAQ 以瞭解更多資訊, 或尋找一個問題和答案 1. 承保藥物清單上包含哪些處方藥 ( 我們將承保藥物清單簡稱為 藥物清單 ) 從 13 頁開始的承保藥物清單上所列的各藥物為 RiverSpring FIDA 計劃承保藥物 這些藥物均可在我們網 絡藥房內獲得 如果藥房與我們簽訂合作協定並向您提供服務, 則藥房在我們的網絡內 我們把這些藥房稱為 網絡藥房 下列情況中 RiverSpring FlDA 計劃將承保藥物清單上的所有藥物 : 您的醫生或其他網絡開藥醫生表示您需要這些藥物以康復或維持健康, 藥物對治療您的病症具有醫療必要性, 以及 您在 RiverSpring FlDA 計劃網絡藥房內配藥 RiverSpring FlDA 計劃可能在獲得某些藥物上需要採取其他步驟 ( 請檢視以下第 5 個問題 ) 在 一些情況下, 您在獲得藥物之前可能需要做其他事, 例如先嘗試其他藥物 檢視最新承保藥物清單, 您可瀏覽我們的網站 http://www.riverspringfida.org 或致電藥房服務部, 電話 是 1-855-898-1482 2. 藥物清單是否會變更 是 一年當中 RiverSpring FIDA 計劃可能會新增或移除藥物清單中的某些藥物 通常, 只有在下列情況中藥物清單才會有所變更 : 出現了一種新藥, 其藥效與藥物清單上藥物效果相同, 或者 我們瞭解到一種藥物並不安全 我們可能也會變更我們的藥物規則 例如, 我們可以 : 決定一種藥物是否需要事先核准 ( 事先核准是在使用藥物之前獲得 RiverSpring FIDA 計劃或您的跨學科小組 (IDT) 的許可 ) 增加或變更您可獲得的藥量 ( 稱為 數量限制 ) 增加或變更藥物逐步治療限制 ( 逐步治療是指在我們承保其他種類的藥物之前, 您必須先試用一種藥物 ) 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼 4

( 有關這些藥物規則的更多資訊, 請參閱第 6 頁 ) 一旦您正在服用的藥物從藥物清單上除名, 我們將告知您 一旦我們變更藥物的承保規則, 我們將告知您 以下第 3 4 以及 7 個問題就藥物清單變更會發生什麼的問題有更多闡述 您可以隨時線上檢視 RiverSpring FIDA 計劃最新藥物清單, 網址為 www.riverspringfida.org 您亦可致電藥房服務部瞭解最新的藥物清單, 電話是 1-855-898-1482 3. 如果現出現了一種與藥物清單上的藥物效果相同的新藥, 會發生什麼 如果出現了一種與藥物清單上藥物效果相同價格更便宜的新藥 : 您的藥劑師可能在您下次配藥時向您提供較便宜的藥物 如果您和您的提供者認定便宜的藥物對您並不適用, 您的提供者可讓藥劑師繼續向您提供您正在服用的藥物 RiverSpring FlDA 計劃可能決定將較貴的藥物從藥物清單上移除 如果我們因為較為便宜的藥具有相同藥效而將您正在服用的一種藥物從藥物清單上移除, 我們將在藥物從藥物清單上移除至少 60 天前或者當您要求續配藥時通知您 隨後您可在藥物清單變更前購買 60 天的藥 一旦出現這種情況, 我們將透過郵遞信件通知您 4. 如果我們發現一種藥物並不安全, 會發生什麼 如果食品和藥品管理局 (FDA) 表示您服用的藥物並不安全, 我們會立即將此藥從藥物清單上移除 我們亦將發函通知您這種不安全的藥物已從藥物清單上移除 收到此信後, 您應連絡向您開此藥的醫生 5. 藥物承保是否有約束或限制 或者為獲得某些藥品是否要求採取一些措施 是的, 一些藥物有承保規則或限制您所能獲得的藥量 一些情況下, 您在獲得藥物之前必須先做某件事情 例如.. 事先核准 ( 或事先核准 ): 對於一些藥品, 您或您的醫生或其他開藥醫生必須在您配藥之前獲得 RiverSpring FIDA 計劃或您的跨學科小組 (IDT) 的核准 如果您未獲得核准,RiverSpring FIDA 計劃可能不會承保此藥 數量限制 : 有時,RiverSpring FIDA 計劃限制您能獲得的藥量 逐步治療 : 有時 RiverSpring FIDA 計劃要求您採取逐步治療 這意味著在應對您的醫療病症時, 您將必須按一定順序試用藥物 在我們會承保其他種類藥物之前, 您可能需要先試用一種藥物 如果您的醫生認為第一種藥物對您並不適用, 之後我們將承保第二種藥物 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼. 5

瞭解您的藥物是否有其他額外要求或限制, 您可從第 13 頁開始檢視各表格 您亦可透過瀏覽我們網站瞭解更多資訊, 網址為 www.riverspringfida.org 我們在網上發佈檔案, 解釋我們的事先核准和逐步治療限制 您還可以要求我們向您傳送一份副本 您可請求對這些限制進行 例外處理 瞭解例外處理的更多資訊, 請檢視第 11 個問題 如果您在護理設施或其他長期護理設施內, 並且需要藥物清單外的一種藥物, 或者如果您獲得所需藥物並不方便, 我們可提供協助 我們將承保一次 31 天急救藥物用量 ( 除非您處方箋上註明的天數較少 ), 不論您是否為 RiverSpring FIDA Plan 新會員 這將給您與您的醫生或其他開藥醫生商討留出時間 他或她可協助您決定是否採用藥物清單上的相似藥或是否需要要求例外處理 瞭解例外處理的更多資訊, 請檢視第 11 個問題 6. 您將如何得知您想要的藥物是否有限制或獲得藥物是否需要採取行動 第 13 頁的承保藥物清單有一張柱狀圖, 標題是 必要行動, 約束或使用限制 7. 如果我們變更了藥物承保方式的規則, 會發生什麼 例如, 如果我們增加了一種藥物的事先核准 ( 核准 ) 數量限制 以及 / 或者逐步治療 我將向您告知如果我們增加藥物的事先核准 數量限制, 以及 / 或者逐步治療限制 我們將在增加限制至少提前 60 天或在您要求下次續配藥時通知您 隨後您可在藥物清單變更前購買 60 天的藥 這將給您與您的醫生或其他開藥醫生商討下一步操作留出時間 8. 您如何在藥品清單上尋找一種藥物 尋找藥物有兩個方法 : 您可按字母尋找 ( 如果您知道如何拼字 ), 或者 您可按醫療病症查詢 按字母查詢, 請翻至第 92 頁檢視字母清單部分 然後在清單上尋找您所需藥物的名稱 按醫療病症查詢, 請翻至第 13 頁檢視 按醫療病症排列藥物清單 隨後尋找您的醫療病症 例如, 如果您心臟有問題, 您應該尋找這部分 您可在那裏找到應對心臟問題的藥物 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼 6

9. 如果您想服用的藥品未在藥物清單上, 該怎麼辦 如果您在藥物清單上並未看到您所需的藥物, 請致電 1-855-898-1482, 連絡藥房服務部詢問情況 如果您瞭解到 RiverSpring FIDA 計劃將不會對該藥物進行承保, 您可採取以下一項操作 : 向藥房服務部索取一份您想要服用的藥物清單 然後將清單給您的醫生或其他開藥醫生看 他或她可向您開立類似您想要服用且在藥物清單上的藥物 或者 您可要求計劃或您的跨學科小組 (ldt) 做例外處理, 承保您的藥物 瞭解例外處理的更多資訊, 請檢視第 11 個問題 10. 如果您新加入 RiverSpring FIDA 計劃, 並且在藥物清單上找不到或很難找到您的藥物, 該怎麼辦 我們竭誠相助 我們必須按需要承保在您成為 RiverSpring FIDA 計劃會員最初 90 天的藥物暫時用量 這將給您與您的醫生或其他開藥醫生商討留出時間 他或她可協助您決定是否採用藥物清單上的相似藥或是否需要要求例外處理 我們將向您承保最多 90 天的暫時藥物用量, 如果 : 您所服用的藥物並不在我們藥物清單上, 或者 健康計劃規則並不能讓您獲得您的開藥醫生開立的藥量, 或者 藥物需要 RiverSpring FIDA 計劃或您的跨學科小組 (ldt) 事先核准, 或者 您所服用的藥物為逐步治療限制的一部分 如果您在護理設施或其他長期護理設施內, 您可獲得的再次配藥藥量為 至多 91 天 在 91 天期間, 您可以多次續配藥 這給予您的開藥醫生留出時間將您的藥物改為藥物清單上的藥物或者要求例外處理 如果作為會員的您目前剛加入或離開長期護理設施, 必要時您將能早點進行續配藥 11. 您是否能夠要求例外處理以承保您的藥物 是 您可要求 RiverSpring FIDA 計劃或您的跨學科小組 (IDT) 作例外處理, 承保未在藥物清單上的藥物 您亦可要求 RiverSpring FIDA 計劃或您的跨學科小組 (IDT) 變更藥物規則 例如,RiverSpring FIDA 計劃可能限制了我們將承保藥物的劑量 如果您的藥物有限制, 您可要求我們或您的跨學科小組 (IDT) 變更限制或承保更多劑量 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼. 7

其他範例 : 您可要求我們或您的跨學科小組 (IDT) 捨棄逐步治療限制或事先核准要求 12. 獲得例外處理需要多少時間 首先,RiverSpring FIDA 計劃或您的跨學科小組 (IDT) 必須收到來自您的開藥醫生支援您例外處理要求的聲明 您將在我們收到聲明後 72 小時內獲得我們對於您的例外處理要求的決定 如果您或您的開藥醫生認為 72 小時的必須等待可能有損您的健康, 您可要求加快例外處理 這就是快速決定 如果您的開藥醫生支援您的要求, 您將在我們收到您的開藥醫生的支援性聲明後 24 小時內獲得決定 13. 您如何要求進行例外處理 要求例外處理, 您可致電您的護理經理 您的護理經理將協助您和您的提供者協助您要求例外處理 14. 什麼是普通藥物 普通藥物成分與品牌藥物相同 它們通常比品牌藥價格更低並且通常名字並不被熟知 普通藥獲食品與藥品管理局 (FDA) 核准 RiverSpring FlDA 計劃承保品牌藥和普通藥 15. 什麼是非處方 (OTC) 藥物 OTC 表示 " 非處方藥 " 當非處方藥是由您的提供者開立時,RiverSpring FIDA 計劃將承保這些非處方藥 您可閱讀 RiverSpring FIDA 計劃藥物清單瞭解哪些非處方藥在承保之列 16. RiverSpring FIDA 計劃是否承保非處方非藥劑產品 當非處方非藥劑產品, 如創口貼等, 由您的提供者開立時,RiverSpring FIDA 計劃將承保這些產品 您可閱讀 RiverSpring FIDA 計劃藥物清單瞭解哪些非處方非藥劑產品在承保之列 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼 8

17. 什麼是您的自付費用 藥物清單上的藥物您不必支付自付費用 18. 什麼是藥物 藥物即藥品組 任一您均不必支付費用 通常普通藥為 1 級, 品牌藥為 2 級, 其他藥物和非 藥劑產品包括非處方藥 (OTC) 為 3 級 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼. 9

承保藥物清單 從下頁開始的承保藥物清單向您說明 RiverSpring FIDA 計劃承保的藥物資訊 如果您在藥物清單上找藥物有困難, 請翻至 Index 部分, 位於第 92 頁上 圖表第一列是 品牌藥名稱採用大寫 ( 如 :VYTORIN) 普通藥採用斜體小寫 ( 如 : warfarin sodium 1 mg 口服片劑 ) 在列中的資訊將向您說明 RiverSpring FIDA 計劃承保您的藥物是否有任何規則 注意 : 藥品邊上的 * 表示此藥並非 D 部分藥品 這些藥品有不同的上訴規則 上訴即要求我們審核並且在您認為存在錯誤的情況下變更承保決定的正式方式 例如,RiverSpring FIDA 計劃或您的跨學科小組 (IDT) 可能決定您想要的藥物並未或不再受到 Medicare 或 Medicaid 承保 如果您或您的醫生或其他開藥醫生對該決定有異議, 您可提起上訴 瞭解如何上訴的說明, 請致電藥房服務部, 電話是 1-855-898-1482 或者 FIDA 會員調查員, 電話是 1-844-614-8800 (TTY/TDD:711) 您亦可閱讀會員手冊, 瞭解如何對決定提起上訴 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼 10

RiverSpring FIDA 計劃 圖例 圖例 描述 1 普通藥 ($0) 2 品牌藥 ($0) 3 非處方藥 (OTC) 以及非藥劑產品 ($0) 標識 QL PA ST 描述 數量限制 30 天配藥限制, 除非有其他說明 要求您 ( 或您的醫生 ) 在配藥之前獲得事先核准 沒有事先核准, 我們可能不承保此藥 逐步治療要求例外處理 BD Medicare B 或 D 部分承保 * Medicaid 承保下的非 D 部分藥物或非處方藥 (OTC) 項目 (g) 此類藥只有普通藥獲得承保 品牌藥不在承保之列 M 此藥的品牌藥在 2 級 普通藥在 1 級 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼. 11

其他承保藥物 其他承保藥物 benzonatate (100 mg capsule, 200 mg capsule) cyanocobalamin (vitamin b-12) 1000mcg/ml vial ergocalciferol (vitamin d2) 50000 unit capsule 3 $0 (g), * 3 $0 (g), * 3 $0 (g), * folic acid 1 mg tablet 3 $0 (g), * levonorgestrel 0.75 mg tablet 3 $0 (g), * MEPHYTON 5 MG TABLET 3 $0 * ZONATUSS 150 MG CAPSULE 3 $0 * 鎮痛藥 鴉片類鎮痛藥, 長效 DURAMORPH (0.5 MG/ML AMPUL, 1 MG/ML AMPUL, 10 MG/10 ML AMPUL, 5 MG/10 ML AMPUL) methadone hcl 10 mg/ml vial (g) 抗癮 / 物質濫用治療劑 酒精抑制劑 / 抗癮 acamprosate calcium 333 mg tablet dr (g) 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼 12

抗感染藥 抗病毒藥物 abacavir sulfate 300 mg tablet abacavir/lamivudine/zidovudine 150-300mg tablet acyclovir (200 mg capsule, 200 mg/5ml oral susp, 400 mg tablet, 800 mg tablet) acyclovir sodium (1000 mg vial, 50 mg/ml vial, 500 mg vial) amantadine hcl (100 mg capsule, 100 mg tablet, 50 mg/5 ml syrup) APTIVUS (100 MG/ML SOLUTION, 250 MG CAPSULE) ATRIPLA TABLET BARACLUDE (0.05 MG/ML SOLUTION, 0.5 MG TABLET, 1 MG TABLET) cidofovir 75 mg/ml vial COMPLERA TABLET CRIXIVAN (200 MG CAPSULE, 400 MG CAPSULE) didanosine (125 mg capsule dr, 200 mg capsule dr, 250 mg capsule dr, 400 mg capsule dr) EDURANT 25 MG TABLET EMTRIVA (10 MG/ML SOLUTION, 200 MG CAPSULE) EPIVIR 10 MG/ML ORAL SOLN EPIVIR HBV (100 MG TABLET, 25 MG/5 ML SOLN) EPZICOM TABLET famciclovir (125 mg tablet, 250 mg tablet, 500 mg tablet) foscarnet sodium 24 mg/ml infus. btl 1 $0 PA, (g) FUZEON (90 MG VIAL, CONVENIENCE KIT) 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼. 13

抗感染藥 HEPSERA 10 MG TABLET INCIVEK 375 MG TABLET PA INTELENCE (100 MG TABLET, 200 MG TABLET, 25 MG TABLET) INVIRASE (200 MG CAPSULE, 500 MG TABLET) ISENTRESS (100 MG POWDER PACKET, 100 MG TABLET CHEW, 25 MG TABLET CHEW, 400 MG TABLET) KALETRA (100-25 MG TABLET, 200-50 MG TABLET, 400-100/5 ML ORAL SOLU) lamivudine (150 mg tablet, 300 mg tablet) lamivudine/zidovudine 150-300mg tablet LEXIVA (50 MG/ML SUSPENSION, 700 MG TABLET) nevirapine (200 mg tablet, 400 mg tab er 24h) NORVIR (100 MG SOFTGEL CAP, 100 MG TABLET, 80 MG/ML SOLUTION) PEGASYS (180 MCG/0.5 ML SYRINGE, 180 MCG/ML VIAL) PA PEGASYS PROCLICK 180 MCG/0.5 PA PEGINTRON 50 MCG KIT PA PEGINTRON REDIPEN (120 MCG, 120 MCG 4PK, 150 MCG, 150 MCG 4PK, 50 MCG, 50 MCG 4PK, 80 MCG, 80 MCG 4PK) PREZISTA (100 MG/ML SUSPENSION, 150 MG TABLET, 600 MG TABLET, 75 MG TABLET, 800 MG TABLET) PA REBETOL 40 MG/ML SOLUTION PA RELENZA 5 MG DISKHALER RESCRIPTOR (100 MG TABLET, 200 MG TABLET) 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼 14

抗感染藥 REYATAZ (150 MG CAPSULE, 200 MG CAPSULE, 300 MG CAPSULE) RIBASPHERE (400 MG TABLET, 600 MG TABLET) ribavirin (200 mg capsule, 200 mg tablet) PA 1 $0 PA, (g) rimantadine hcl 100 mg tablet SELZENTRY (150 MG TABLET, 300 MG TABLET) stavudine (1 mg/ml soln recon, 15 mg capsule, 20 mg capsule, 30 mg capsule, 40 mg capsule) STRIBILD TABLET SUSTIVA (200 MG CAPSULE, 50 MG CAPSULE, 600 MG TABLET) SYLATRON (200 MCG KIT, 300 MCG KIT, 600 MCG KIT) SYLATRON 4-PACK (200 MCG 4-PACK, 300 MCG 4-PACK, 888 MCG 4-PACK) SYNAGIS (100 MG/1 ML VIAL, 50 MG/0.5 ML VIAL) TAMIFLU (30 MG CAPSULE, 45 MG CAPSULE, 6 MG/ML SUSPENSION, 75 MG CAPSULE) PA TIVICAY 50 MG TABLET TRIZIVIR TABLET TRUVADA 200 MG-300 MG TABLET TYZEKA 600 MG TABLET PA valacyclovir hcl (1000 mg tablet, 500 mg tablet) VALCYTE (450 MG TABLET, 50 MG/ML SOLUTION) VICTRELIS 200 MG CAPSULE PA VIDEX (2 GM PEDIATRIC SOLN, 4 GM PEDIATRIC SOLN) 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼. 15

抗感染藥 VIRAMUNE 50 MG/5 ML SUSP VIRAMUNE XR (100 MG TABLET, 400 MG TABLET) VIRAZOLE 6 GM VIAL VIREAD (150 MG TABLET, 200 MG TABLET, 250 MG TABLET, 300 MG TABLET, POWDER) ZIAGEN 20 MG/ML SOLUTION zidovudine (10 mg/ml syrup, 100 mg capsule, 300 mg tablet) 抗感染藥 驅腸蟲劑 ALBENZA 200 MG TABLET BILTRICIDE 600 MG TABLET STROMECTOL 3 MG TABLET Antibacterials amikacin sulfate (1000mg/4ml vial, 500 mg/2ml vial) amoxicillin (125 mg tab chew, 125 mg/5ml susp recon, 200 mg/5ml susp recon, 250 mg capsule, 250 mg tab chew, 250 mg/5ml susp recon, 400 mg/5ml susp recon, 500 mg capsule, 500 mg tablet, 875 mg tablet, 875mg tablet) amoxicillin/potassium clavulanate (1000-62.5 tab er 12h, 200-28.5/5 susp recon, 200-28.5mg tab chew, 250-125 mg tablet, 250-62.5/5 susp recon, 400-57mg tab chew, 400-57mg/5 susp recon, 500-125 mg tablet, 600-42.9/5 susp recon, 875-125 mg tablet) 1 $0 BD, (g) 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼 16

抗感染藥 ampicillin sodium/sulbactam sodium (1.5 g vial, 15 g vial, 3 g vial) ampicillin trihydrate (125 mg/5ml susp recon, 250 mg capsule, 250 mg/5ml susp recon, 500 mg capsule) AVELOX 400 MG TABLET AVELOX IV 400 MG/250 ML azithromycin (100 mg/5ml susp recon, 200 mg/5ml susp recon, 250 mg tablet, 500 mg tablet, 500 mg vial, 500 mg vial port, 600 mg tablet) bacitracin 500 unit/g oint. (g) BICILLIN C-R (1.2 MILLION UNIT, 900-300 SYRINGE) BICILLIN L-A (1,200,000 UNITS, 2,400,000 UNITS, 600,000 UNIT/ML) cefaclor (250 mg capsule, 500 mg capsule, 500 mg tab er 12h) cefadroxil (1 g tablet, 250 mg/5ml susp recon, 500 mg capsule, 500 mg/5ml susp recon) cefadroxil hydrate 500 mg capsule cefazolin sodium (1 g vial, 10 g vial, 100g bulkbaginj, 20 g vial, 300g bulkbaginj, 500 mg vial) cefazolin sodium/dextrose, iso-osmotic (1 g/50 ml froz.piggy, 1 g/50 ml piggyback) cefdinir (125 mg/5ml susp recon, 250 mg/5ml susp recon, 300 mg capsule) cefepime hcl (1 g vial, 2 g vial) cefotaxime sodium 10 g vial cefotetan disodium (1 g vial, 10 g vial, 2 g vial) cefoxitin sodium (1 g vial, 10 g vial, 2 g vial) 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼. 17

抗感染藥 cefpodoxime proxetil (100 mg tablet, 100 mg/5ml susp recon, 200 mg tablet, 50 mg/5 ml susp recon) cefprozil (125 mg/5ml susp recon, 250 mg tablet, 250 mg/5ml susp recon, 500 mg tablet) ceftazidime pentahydrate (1 g vial, 2 g vial, 6g vial) ceftazidime pentahydrate in dextrose 5%-water (1 g/50 ml piggyback, 2 g/50 ml piggyback) ceftriaxone sodium (1 g vial, 1 g vial port, 10 g vial, 100g bulkbaginj, 2 g vial, 2 g vial port, 250 mg vial, 500 mg vial) cefuroxime axetil (250 mg tablet, 500 mg tablet) cefuroxime sodium (1.5 g vial, 7.5g vial, 750 mg vial) cephalexin (125 mg/5ml susp recon, 250 mg capsule, 250 mg tablet, 250 mg/5ml susp recon, 500 mg capsule, 500 mg tablet) chloramphenicol sod succ 1 g vial CIPRO (10% SUSPENSION, 5% SUSPENSION) CIPRO I.V. (200 MG/100 ML D5W, 400 MG/200 ML D5W) ciprofloxacin hcl (100 mg tablet, 250 mg tablet, 500 mg tablet, 750 mg tablet) ciprofloxacin lactate (200mg/20ml vial, 400mg/40ml vial) ciprofloxacin/ciprofloxacin hcl (1000 mg tbmp 24hr, 500 mg tbmp 24hr) clarithromycin (125 mg/5ml susp recon, 250 mg tablet, 250 mg/5ml susp recon, 500 mg tab er 24h, 500 mg tablet) CLEOCIN HCL 75 MG CAPSULE 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼 18

抗感染藥 clindamycin phosphate (150 mg/ml vial, 300 mg/2ml vial port, 600 mg/4ml vial port, 900mg/6ml vial port) CUBICIN 500 MG VIAL PA dicloxacillin sodium (250 mg capsule, 500 mg capsule) DIFICID 200 MG TABLET PA DORIBAX 500 MG VIAL PA doxycycline hyclate (100 mg capsule, 100 mg tablet, 100 mg tablet dr, 150 mg tablet dr, 20 mg tablet, 50 mg capsule, 75 mg tablet dr) doxycycline monohydrate (150 mg tablet, 50 mg tablet, 75 mg capsule, 75 mg tablet) E.E.S. 200 MG/5 ML GRANULES ERYPED 200 (200 MG/5 ML GRANULES, 200 MG/5 ML SUSPENSION) ERYPED 400 MG/5 ML SUSPENSION ERYTHROCIN 250 MG FILMTAB ERYTHROCIN LACTOBIONATE (500 MG ADDVNT VL, 500 MG VIAL) erythromycin base (250 mg tablet, 5 mg/g oint. (g), 500 mg tablet, 5mg/g oint. (g)) erythromycin base/ethyl alcohol (2 % gel (gram), 2 % solution) erythromycin ethylsuccinate 400 mg tablet gentamicin sulfate (0.1 % cream (g), 0.1 % oint. (g), 40 mg/ml vial) 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼. 19

抗感染藥 gentamicin sulfate/pf (100mg/10ml vial port, 20 mg/2 ml vial, 60 mg/6 ml vial port, 80 mg/8 ml vial port) imipenem/cilastatin sodium (250 mg vial, 500 mg vial) 1 $0 PA, (g) KETEK (300 MG TABLET, 400 MG TABLET) PA levofloxacin (25 mg/ml vial, 250 mg tablet, 250mg/10ml solution, 500 mg tablet, 500mg/20ml solution, 750 mg tablet) levofloxacin/dextrose 5 % in water (250mg/50ml piggyback, 500mg/0.1l piggyback, 750mg/.15l piggyback) meropenem (1 g vial, 500 mg vial) metronidazole (250 mg tablet, 500 mg tablet) metronidazole/sodium chloride 500mg/0.1l piggyback minocycline hcl (100 mg capsule, 100 mg tablet, 135 mg tab er 24h, 45 mg tab er 24h, 50 mg capsule, 50 mg tablet, 75 mg capsule, 75 mg tablet, 90 mg tab er 24h) nafcillin in dextrose, iso-osmotic (1 g/50 ml froz.piggy, 2 g/100 ml froz.piggy) nafcillin sodium (1 g vial, 10 g vial, 2 g vial) neomycin sulfate 500 mg tablet ofloxacin (200 mg tablet, 300 mg tablet, 400 mg tablet) oxacillin sodium (1 g vial, 10 g vial, 2 g vial, 2 g vial port) oxacillin sodium/dextrose, iso-osmotic (1 g/50 ml froz.piggy, 2 g/50 ml froz.piggy) paromomycin sulfate 250 mg capsule penicillin g potassium (20mm unit vial, 5mm unit vial) 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼 20

抗感染藥 penicillin g procaine 1.2mm/2 ml syringe penicillin g sodium 5mm unit vial penicillin v potassium (125 mg/5ml soln recon, 250 mg tablet, 250 mg/5ml soln recon, 500 mg tablet) piperacillin sodium/tazobactam sodium (2.25 g vial, 3.375 g vial, 3.375 g vial port, 4.5 g vial, 4.5 g vial port, 40.5 g vial) 1 $0 PA, (g) polymyxin b sulf/trimethoprim 10000-1/ml drops RIFAMATE CAPSULE rifampin (150 mg capsule, 300 mg capsule, 600 mg vial) RIFATER TABLET streptomycin sulfate 1 g vial sulfadiazine 500 mg tablet sulfamethoxazole/trimethoprim (200-40mg/5 oral susp, 400mg-80mg tablet, 80-16mg/ml vial, 800-160 mg tablet, 800-160/20 oral susp) SUPRAX (100 MG/5 ML SUSPENSION, 200 MG/5 ML SUSPENSION) TOBI 300 MG/5 ML SOLUTION PA TOBI PODHALER 28 MG INHALE CAP PA tobramycin sulfate (1.2 g vial, 10 mg/ml vial, 40 mg/ml vial, 60 mg/6 ml vial port, 80 mg/8 ml vial port) tobramycin/sodium chloride 80mg/100ml piggyback vancomycin hcl (1 g vial, 1 g vial port, 10 g vial, 125 mg capsule, 250 mg capsule, 5 g vial, 500 mg vial, 500 mg vial port, 750 mg vial) XIFAXAN (200 MG TABLET, 550 MG TABLET) PA 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼. 21

抗感染藥 ZYVOX (100 MG/5 ML SUSPENSION, 200 MG/100 ML IV SOLN, 600 MG TABLET, 600 MG/300 ML IV SOLN) PA 抗真菌藥 ABELCET 100 MG/20 ML VIAL PA AMBISOME 50 MG VIAL PA amphotericin b 50 mg vial CANCIDAS (50 MG VIAL, 70 MG VIAL) PA fluconazole (10 mg/ml susp recon, 100 mg tablet, 150 mg tablet, 200 mg tablet, 40 mg/ml susp recon, 50 mg tablet) fluconazole in dextrose, iso-osmotic (200mg/0.1l piggyback, 400mg/0.2l piggyback) flucytosine (250 mg capsule, 500 mg capsule) GRIS-PEG (125 MG TABLET, 250 MG TABLET) griseofulvin, microsize 125 mg/5ml oral susp itraconazole 100 mg capsule ketoconazole 200 mg tablet LAMISIL (125 MG GRANULES PACKET, 187.5 MG GRANULES PACK) NOXAFIL 40 MG/ML SUSPENSION ST nystatin (100000/g cream (g), 100000/g oint. (g), 100000/g powder, 100000/ml oral susp, 150mm unit powder(ea), 500k unit tablet, 500mm unit powder(ea), 50mm unit powder(ea)) SPORANOX 10 MG/ML SOLUTION ST terbinafine hcl 250 mg tablet VFEND 40 MG/ML SUSPENSION ST voriconazole (200 mg tablet, 50 mg tablet) dapsone (100 mg tablet, 25 mg tablet) 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼 22

抗感染藥 ethambutol hcl (100 mg tablet, 400 mg tablet) isoniazid (100 mg tablet, 100 mg/ml vial, 300 mg tablet, 50 mg/5 ml solution) 抗原蟲藥 ALINIA (100 MG/5 ML SUSPENSION, 500 MG TABLET) atovaquone/proguanil hcl 250-100 mg tablet chloroquine phosphate (250 mg tablet, 500 mg tablet) COARTEM TABLETS DARAPRIM 25 MG TABLET hydroxychloroquine sulfate 200 mg tablet mefloquine hcl 250 mg tablet MEPRON 750 MG/5 ML SUSPENSION NEBUPENT 300 MG INHAL POWDER BD PENTAM 300 VIAL primaquine phosphate 26.3 mg tablet quinine sulfate 324 mg capsule tinidazole (250 mg tablet, 500 mg tablet) Urinary Anti-infectives MACRODANTIN 25 MG CAPSULE methenamine hippurate 1 g tablet nitrofurantoin (25 mg/5 ml oral susp, 50 mg capsule) nitrofurantoin macrocrystal 50 mg capsule nitrofurantoin monohyd/m-cryst 100 mg capsule 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼. 23

抗菌藥物 抗菌藥物, 其他 SYNERCID 500 MG VIAL TYGACIL 50 MG VIAL β- 內醯胺類 頭孢菌素 SUPRAX (100 MG TABLET CHEWABLE, 200 MG TABLET CHEWABLE, 400 MG CAPSULE, 400 MG TABLET, 500 MG/5 ML SUSPENSION) TEFLARO (400 MG VIAL, 600 MG VIAL) β- 內醯胺類, 其他 AZACTAM-ISO-OSMOTIC DEXTROSE (1 GM/50 ML, 2 GM/50 ML) aztreonam (1 g vial, 2 g vial) (g) CAYSTON 75 MG INHAL SOLUTION INVANZ 1 GM VIAL 止吐藥 止吐藥, 其他 TRANSDERM-SCOP 1.5 MG/72HR 抗真菌藥 抗真菌藥 voriconazole 200 mg vial 1 $0 PA, (g) 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼 24

抗組胺藥 第一代抗組胺藥 clemastine fumarate 2.68 mg tablet cyproheptadine hcl (2 mg/5 ml syrup, 4 mg tablet, 4 mg/10 ml syrup) meclizine hcl (12.5 mg tablet, 25 mg tablet) 其他抗組胺藥 cimetidine (200 mg tablet, 300 mg tablet, 400 mg tablet, 800 mg tablet) cimetidine hcl 300 mg/5ml solution famotidine (20 mg tablet, 40 mg tablet, 40mg/5ml oral susp) famotidine in nacl,iso-osm/pf 20 mg/50ml piggyback famotidine/pf 20 mg/2 ml vial nizatidine (150 mg capsule, 150mg/10ml solution, 300 mg capsule) ranitidine hcl (15 mg/ml syrup, 150 mg capsule, 150 mg tablet, 25 mg/ml vial, 300 mg capsule, 300 mg tablet, 50 mg/2 ml vial) 第二代抗組胺藥 ALOMIDE 0.1% EYE DROPS CLARINEX 0.5 MG/ML (2.5 MG/5) ST desloratadine (2.5 mg tab rapdis, 5 mg tab rapdis, 5 mg tablet) levocetirizine dihydrochloride (2.5 mg/5ml solution, 5 mg tablet) 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼. 25

抗分支桿菌藥 抗分支桿菌藥, 其他 MYCOBUTIN 150 MG CAPSULE 抗結核藥 CAPASTAT SULFATE 1 GM VIAL PASER GRANULES 4 GM PACKET PRIFTIN 150 MG TABLET pyrazinamide 500 mg tablet (g) TRECATOR 250 MG TABLET 抗腫瘤藥 抗腫瘤藥 ABRAXANE 100 MG VIAL BD AFINITOR (10 MG TABLET, 2.5 MG PA TABLET, 5 MG TABLET, 7.5 MG TABLET) AFINITOR DISPERZ (2 MG TABLET, 3 MG TABLET, 5 MG TABLET) ALIMTA (100 MG VIAL, 500 MG VIAL) BD anastrozole 1 mg tablet ARRANON 250 MG VIAL BD ARZERRA (1,000 MG/50 ML VIAL, 100 BD MG/5 ML VIAL) AVASTIN (100 MG/4 ML VIAL, PA 400 MG/16 ML VIAL) azacitidine 100 mg vial bicalutamide 50 mg tablet BICNU 100 MG VIAL BD bleomycin sulfate (15 unit vial, 30 unit vial) BOSULIF (100 MG TABLET, 500 MG TABLET) PA 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼 26

抗腫瘤藥 CAPRELSA (100 MG TABLET, 300 MG PA TABLET) CARAC (, 0.5%) carboplatin (10 mg/ml vial, 150 mg vial, 1 $0 BD, (g) 450 mg vial, 50 mg vial) cisplatin 1 mg/ml vial 1 $0 BD, (g) cladribine 10 mg/10ml vial 1 $0 BD, (g) CLOLAR 20 MG/20 ML VIAL BD COMETRIQ (100 MG DAILY-DOSE PK, PA 140 MG DAILY-DOSE PK, 60 MG DAILY- DOSE PACK) COSMEGEN 0.5 MG VIAL BD cromolyn sodium 20 mg/ml solution cyclophosphamide (25 mg tablet, 50 mg 1 $0 BD, (g) tablet) cytarabine 20 mg/ml vial 1 $0 BD, (g) cytarabine/pf (1 g vial, 100 mg/5ml 1 $0 BD, (g) vial, 2 g vial, 2 g/20 ml vial, 20 mg/ml vial, 500 mg vial) dacarbazine (100 mg vial, 200 mg vial) 1 $0 BD, (g) DACOGEN 50 MG VIAL BD daunorubicin hcl (20 mg vial, 5 mg/ 1 $0 BD, (g) ml vial) decitabine 50 mg vial DEPO-PROVERA 400 MG/ML VIAL diclofenac sodium 3 % gel (gram) DOCEFREZ (20 MG VIAL, 80 MG VIAL) BD docetaxel (160mg/16ml vial, 20 mg/ 1 $0 BD, (g) 2 ml vial, 20mg/ml(1) vial, 80 mg/4 ml vial, 80 mg/8 ml vial) DOXIL 2 MG/ML VIAL doxorubicin hcl (10 mg vial, 10 mg/5 ml vial, 2 mg/ml vial, 20 mg/10ml vial, 50 mg vial, 50 mg/25ml vial) 1 $0 BD, (g) 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼. 27

抗腫瘤藥 ELIGARD (22.5 MG SYRINGE KIT, 30 MG BD SYRINGE KIT, 45 MG SYRINGE KIT, 7.5 MG SYRINGE KIT) EMCYT 140 MG CAPSULE epirubicin hcl (200 mg vial, 200mg/0.1l 1 $0 BD, (g) vial, 50 mg vial, 50 mg/25ml vial) ERBITUX (100 MG/50 ML VIAL, 200 BD MG/100 ML VIAL) ERIVEDGE 150 MG CAPSULE PA ERWINAZE 10,000 UNITS VIAL etoposide 20 mg/ml vial 1 $0 BD, (g) exemestane 25 mg tablet FARESTON 60 MG TABLET FASLODEX 250 MG/5 ML SYRINGE BD FIRMAGON (2 X 120 MG KIT, 2 X 120 BD MG VIALS, 80 MG KIT, 80 MG VIAL) fludarabine phosphate (50 mg vial, 1 $0 BD, (g) 50 mg/2 ml vial) fluorouracil (1 g/20 ml vial, 2.5 g/50ml 1 $0 BD, (g) vial, 5 g/100 ml vial, 500mg/10ml vial) fluorouracil (2 % solution, 5 % solution) flutamide 125 mg capsule FOLOTYN (20 MG/ML VIAL, 40 MG/ BD 2ML VIAL) gemcitabine hcl (1 g vial, 1 g/26.3ml 1 $0 BD, (g) vial, 2 g vial, 2 g/52.6ml vial, 200 mg vial, 200mg/5.26 vial) GILOTRIF (20 MG TABLET, 30 MG TABLET, 40 MG TABLET) GLEEVEC (100 MG TABLET, 400 MG PA TABLET) HALAVEN 1 MG/2 ML VIAL HERCEPTIN 440 MG VIAL BD HEXALEN 50 MG CAPSULE PA hydroxyurea 500 mg capsule 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼 28

抗腫瘤藥 ifosfamide (1 g vial, 1 g/20 ml vial, 3 g 1 $0 BD, (g) vial, 3g/60ml vial) IMBRUVICA 140 MG CAPSULE INLYTA (1 MG TABLET, 5 MG TABLET) PA INTRON A (10 MILLION UNIT/ML, BD 10 MILLION UNITS VIL, 6 MILLION UNIT/ML VL) irinotecan hcl (100 mg/5ml vial, 40 1 $0 BD, (g) mg/2 ml vial, 500mg/25ml vial) ISTODAX 10 MG VIAL BD IXEMPRA (15 MG KIT, 45 MG KIT) BD JAKAFI (10 MG TABLET, 15 MG TABLET, PA 20 MG TABLET, 25 MG TABLET, 5 MG TABLET) JEVTANA 60 MG/1.5 ML KIT BD KADCYLA (100 MG VIAL, 160 MG VIAL) letrozole 2.5 mg tablet LEUKERAN 2 MG TABLET leuprolide acetate 1 mg/0.2ml kit lomustine (10 mg capsule, 100 mg capsule, 40 mg capsule) LUPRON DEPOT (DEPOT 22.5 MG 3MO KIT, DEPOT 7.5 MG KIT, DEPOT- 4 MONTH KIT) LUPRON DEPOT 45 MG 6MO KIT BD LUPRON DEPOT-PED (30 MG 3MO KIT, 7.5 MG KIT) LYSODREN 500 MG TABLET MATULANE 50 MG CAPSULE MEGACE ES 625 MG/5 ML SUSP megestrol acetate (20 mg tablet, 40 mg tablet, 400mg/10ml oral susp, 800mg/20ml oral susp) MEKINIST (0.5 MG TABLET, 2 MG TABLET) PA 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼. 29

抗腫瘤藥 mercaptopurine 50 mg tablet methotrexate sodium 2.5 mg tablet 1 $0 BD, (g) methotrexate sodium/pf (1 g vial, 25 mg/ml vial) mitomycin (20 mg vial, 40 mg vial, 5 mg vial) 1 $0 BD, (g) 1 $0 BD, (g) mitoxantrone hcl 2 mg/ml vial 1 $0 BD, (g) MUSTARGEN 10 MG VIAL BD NEXAVAR 200 MG TABLET PA NILANDRON 150 MG TABLET ONCASPAR 750 UNIT/ML VIAL oxaliplatin (100 mg vial, 100mg/20ml vial, 50 mg vial, 50 mg/10ml vial) 1 $0 BD, (g) paclitaxel 6 mg/ml vial 1 $0 BD, (g) PERJETA 420 MG/14 ML VIAL BD PICATO (0.015% GEL, 0.05% GEL) POMALYST (1 MG CAPSULE, 2 MG CAPSULE, 3 MG CAPSULE, 4 MG CAPSULE) PA PROLEUKIN 22 MILLION UNIT VIAL PA REVLIMID (10 MG CAPSULE, 15 MG CAPSULE, 2.5 MG CAPSULE, 20 MG CAPSULE, 25 MG CAPSULE, 5 MG CAPSULE) RITUXAN 10 MG/ML VIAL BD SOLARAZE 3% GEL SOLTAMOX 10 MG/5 ML SOLN SPRYCEL (100 MG TABLET, 140 MG TABLET, 20 MG TABLET, 50 MG TABLET, 70 MG TABLET, 80 MG TABLET) PA STIVARGA 40 MG TABLET PA SUTENT (12.5 MG CAPSULE, 25 MG CAPSULE, 50 MG CAPSULE) PA SYNRIBO 3.5 MG/ML VIAL BD 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼 30

抗腫瘤藥 TAFINLAR (50 MG CAPSULE, 75 MG CAPSULE) tamoxifen citrate (10 mg tablet, 20 mg tablet) TARCEVA (100 MG TABLET, 150 MG TABLET, 25 MG TABLET) TARGRETIN (1% GEL, 75 MG CAPSULE, 75 MG SOFTGEL) TASIGNA (150 MG CAPSULE, 200 MG CAPSULE) topotecan hcl (4 mg vial, 4 mg/4 ml vial) PA PA PA 1 $0 BD, (g) TORISEL 25 MG KIT BD TREANDA (100 MG VIAL, 25 MG VIAL) TRELSTAR (11.25 MG SYRINGE, 22.5 MG SYRINGE, 22.5 MG VIAL, 3.75 MG SYRINGE) BD TRELSTAR DEPOT 3.75 MG VIAL BD TRELSTAR LA 11.25 MG VIAL BD tretinoin 10 mg capsule TREXALL (10 MG TABLET, 15 MG TABLET, 5 MG TABLET, 7.5 MG TABLET) TRISENOX 10 MG/10 ML AMPULE BD TYKERB 250 MG TABLET PA UVADEX 20 MCG/ML VIAL VECTIBIX (100 MG/5 ML VIAL, 400 BD MG/20 ML VIAL) VELCADE 3.5 MG VIAL BD VIDAZA 100 MG VIAL vinblastine sulfate (1 mg/ml vial, 10 mg vial) vincristine sulfate (1 mg/ml vial, 2 mg/2 ml vial) vinorelbine tartrate (10 mg/ml vial, 50 mg/5 ml vial) 1 $0 BD, (g) 1 $0 BD, (g) 1 $0 BD, (g) 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼. 31

抗腫瘤藥 XALKORI (200 MG CAPSULE, 250 MG CAPSULE) XTANDI 40 MG CAPSULE YERVOY (200 MG/40 ML VIAL, 50 MG/10 ML VIAL) ZALTRAP (100 MG/4 ML VIAL, 200 MG/8 ML VIAL) PA BD ZANOSAR 1 GM POWDER VIAL BD ZELBORAF 240 MG TABLET PA ZOLINZA 100 MG CAPSULE PA ZORTRESS (0.25 MG TABLET, 0.5 MG TABLET, 0.75 MG TABLET) ZYKADIA 150 MG CAPSULE BD ZYTIGA 250 MG TABLET PA 抗帕金森氏病藥物 多巴胺受體激動劑 NEUPRO (1 MG/24 HR PATCH, 2 MG/24 HR PATCH, 3 MG/24 HR PATCH, 4 MG/24 HR PATCH, 6 MG/24 HR PATCH, 8 MG/24 HR PATCH) 抗病毒藥物 抗丙型肝炎病毒 (HCV) 劑 OLYSIO 150 MG CAPSULE PA SOVALDI 400 MG TABLET PA 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼 32

自主神經藥物 抗膽鹼能藥物 ATROVENT HFA INHALER dicyclomine hcl (10 mg capsule, 10 mg/5 ml solution, 20 mg tablet) diphenoxylate hcl/atropine 2.5-.025mg tablet glycopyrrolate (1 mg tablet, 2 mg tablet) ipratropium bromide (21 mcg spray, 42mcg spray) ipratropium bromide 0.2 mg/ml solution ipratropium/albuterol sulfate 0.5-3mg/3 ampul-neb methscopolamine bromide (2.5 mg tablet, 5 mg tablet) 1 $0 PA, (g) 1 $0 BD, (g) 1 $0 BD, (g) propantheline bromide 15 mg tablet SPIRIVA 18 MCG CP-HANDIHALER 自主神經藥物, 雜項 BUPROBAN 150 MG TABLET CHANTIX (0.5 MG TABLET, 1 MG TABLET) ST, QL ( 每 90 天 180) NICOTROL NS 10 MG/ML SPRAY ST, QL ( 每 30 天 30 毫升 ) 擬副交感神經 ( 類膽鹼能 ) 劑 bethanechol chloride (10 mg tablet, 25 mg tablet, 5 mg tablet, 50 mg tablet) cevimeline hcl 30 mg capsule donepezil hcl (10 mg tab rapdis, 10 mg tablet, 5 mg tab rapdis, 5 mg tablet) EXELON (4.6 MG/24HR PATCH, 9.5 MG/24HR PATCH) EXELON 13.3 MG/24HR PATCH QL ( 每 30 天 30) 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼. 33

自主神經藥物 MESTINON (180 MG TIMESPAN, 60 MG/5 ML SYRUP) pyridostigmine bromide 60 mg tablet rivastigmine tartrate (1.5 mg capsule, 3 mg capsule, 4.5 mg capsule, 6 mg capsule) 骨骼肌鬆弛劑 baclofen (10 mg tablet, 20 mg tablet) BOTOX 100 UNITS VIAL PA carisoprodol 350 mg tablet 1 $0 PA, (g) chlorzoxazone 500 mg tablet cyclobenzaprine hcl (10 mg tablet, 5 mg tablet, 7.5 mg tablet) dantrolene sodium (100 mg capsule, 25 mg capsule, 50 mg capsule) methocarbamol (500 mg tablet, 750 mg tablet) 1 $0 PA, (g) 1 $0 PA, (g) orphenadrine citrate 100 mg tablet er 1 $0 PA, (g) tizanidine hcl (2 mg tablet, 4 mg tablet) 交感神經阻斷劑 ( 腎上腺素能阻滯 ) acebutolol hcl (200 mg capsule, 400 mg capsule) alfuzosin hcl 10 mg tab er 24h atenolol (100 mg tablet, 25 mg tablet, 50 mg tablet) atenolol/chlorthalidone (100mg-25mg tablet, 50 mg-25mg tablet) betaxolol hcl 20 mg tablet bisoprolol fumarate (10 mg tablet, 5 mg tablet) bisoprolol fumarate/hydrochlorothiazide (10-6.25mg tablet, 2.5-6.25mg tablet, 5-6.25mg tablet) 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼 34

自主神經藥物 carvedilol (12.5 mg tablet, 25 mg tablet, 3.125 mg tablet, 6.25 mg tablet) DIBENZYLINE 10 MG CAPSULE dihydroergotamine mesylate (1 mg/ml ampul, 1 mg/ml vial) doxazosin mesylate (1 mg tablet, 2 mg tablet, 4 mg tablet, 8 mg tablet) ergoloid mesylates 1 mg tablet JALYN 0.5-0.4 MG CAPSULE ST labetalol hcl (100 mg tablet, 200 mg tablet, 300 mg tablet) metoprolol succinate (100 mg tab er 24h, 200 mg tab er 24h, 25 mg tab er 24h, 50 mg tab er 24h) metoprolol tartrate (100 mg tablet, 25 mg tablet, 50 mg tablet) metoprolol tartrate/hydrochlorothiazide (100mg- 25mg tablet, 100mg-50mg tablet, 50 mg-25mg tablet) MIGERGOT SUPPOSITORY nadolol (20 mg tablet, 40 mg tablet, 80 mg tablet) pindolol (10 mg tablet, 5 mg tablet) prazosin hcl (1 mg capsule, 2 mg capsule, 5 mg capsule) propranolol hcl (10 mg tablet, 120 mg cap sa 24h, 160 mg cap sa 24h, 20 mg tablet, 20 mg/5 ml solution, 40 mg tablet, 40mg/5ml solution, 60 mg cap sa 24h, 60 mg tablet, 80 mg cap sa 24h, 80 mg tablet) propranolol hcl/hydrochlorothiazide (40 mg-25mg tablet, 80 mg-25mg tablet) RAPAFLO (4 MG CAPSULE, 8 MG CAPSULE) sotalol hcl (120 mg tablet, 160 mg tablet, 240 mg tablet, 80 mg tablet) ST 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼. 35

自主神經藥物 terazosin hcl (1 mg capsule, 10 mg capsule, 2 mg capsule, 5 mg capsule) timolol maleate (10 mg tablet, 20 mg tablet, 5 mg tablet) 擬交感神經藥物 ( 腎上腺素 ) albuterol sulfate (0.63mg/3ml vial-neb, 1.25mg/3ml vial-neb, 2.5 mg/0.5 vialneb, 2.5 mg/3ml vial-neb, 5 mg/ml solution) albuterol sulfate (2 mg tablet, 2 mg/5 ml syrup, 4 mg tab er 12h, 4 mg tablet, 8 mg tab er 12h) clonidine (0.1mg/24hr patch tdwk, 0.2mg/24hr patch tdwk, 0.3mg/24hr patch tdwk) clonidine hcl (0.1 mg tablet, 0.2 mg tablet, 0.3 mg tablet) CLORPRES (0.1-15 TABLET, 0.2-15 TABLET, 0.3-15 TABLET) DULERA (100 MCG/5 MCG INHALER, 200 MCG/5 MCG INHALER) 1 $0 BD, (g) EPIPEN 0.3 MG AUTO-INJECTOR EPIPEN 2-PAK 0.3 MG AUTO-INJCT EPIPEN JR 0.15 MG AUTO-INJCT EPIPEN JR 2-PAK 0.15 MG INJCTR metaproterenol sulfate (10 mg tablet, 10 mg/5 ml syrup, 20 mg tablet) methyldopa (250 mg tablet, 500 mg tablet) methyldopa/hydrochlorothiazide (250mg-15mg tablet, 250mg-25mg tablet) midodrine hcl (10 mg tablet, 2.5 mg tablet, 5 mg tablet) phenylephrine hcl/promethazine hcl (/prometh syrup, /prometh 5-6.25mg/5 syrup) ST, QL ( 每 30 天 60 克 ) 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼 36

自主神經藥物 PROVENTIL HFA 90 MCG INHALER QL ( 每 30 天 13 克 ) SEREVENT DISKUS 50 MCG SYMBICORT (160-4.5 MCG INHALER, 80-4.5 MCG INHALER) terbutaline sulfate (1 mg/ml ampul, 1 mg/ml vial, 2.5 mg tablet, 5 mg tablet) VENTOLIN HFA (90 MCG INHALER, RELION 90 MCG INH) ST QL ( 每 30 天 36 克 ) 血液形成 凝固和血栓形成劑 抗貧血藥物 ARANESP (100 MCG/0.5 ML SYRINGE, 100 MCG/ML VIAL, 150 MCG/0.3 ML SYRINGE, 150 MCG/0.75 ML VIAL, 200 MCG/0.4 ML SYRINGE, 200 MCG/ML VIAL, 25 MCG/0.42 ML SYRING, 25 MCG/ML VIAL, 300 MCG/0.6 ML SYRINGE, 300 MCG/ML VIAL, 40 MCG/0.4 ML SYRINGE, 40 MCG/ML VIAL, 500 MCG/1 ML SYRINGE, 60 MCG/0.3 ML SYRINGE, 60 MCG/ML VIAL) EPOGEN (10,000 UNITS/ML VIAL, 2,000 UNITS/ML VIAL, 20,000 UNITS/2 ML VIAL, 20,000 UNITS/ML VIAL, 3,000 UNITS/ML VIAL, 4,000 UNITS/ML VIAL) PROCRIT (10,000 UNITS/ML VIAL, 2,000 UNITS/ML VIAL, 20,000 UNITS/ML VIAL, 3,000 UNITS/ML VIAL, 4,000 UNITS/ML VIAL, 40,000 UNITS/ML VIAL) 止血劑 desmopressin acetate (0.1 mg tablet, 0.2 mg tablet, 10/spray spray/pump) BD BD BD 止血劑 AGGRENOX 25 MG-200 MG CAPSULE 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼. 37

血液形成 凝固和血栓形成劑 cilostazol (100 mg tablet, 50 mg tablet) clopidogrel bisulfate (300 mg tablet, 75 mg tablet) dipyridamole (25 mg tablet, 50 mg tablet, 75 mg tablet) EFFIENT (10 MG TABLET, 5 MG TABLET) enoxaparin sodium (100 mg/ml syringe, 1 $0 PA, (g) 120mg/.8ml syringe, 150 mg/ml syringe, 30mg/0.3ml syringe, 40mg/0.4ml syringe, 60mg/0.6ml syringe, 80mg/0.8ml syringe) fondaparinux sodium (10mg/0.8ml syringe, 2.5 mg/0.5 syringe, 5mg/0.4ml syringe, 7.5mg/0.6 syringe) FRAGMIN (10,000 UNITS SYRINGE, QL ( 每 180 天 30 毫升 ) 25,000 UNITS/ML VIAL) FRAGMIN (12,500 UNITS SYRINGE, QL ( 每 180 天 150 毫升 ) 15,000 UNITS SYRINGE, 18,000 UNITS SYRINGE, 5,000 UNITS SYRINGE, 7,500 UNITS SYRINGE) FRAGMIN 2,500 UNITS SYRINGE QL ( 每 180 天 60 毫升 ) heparin sodium,porcine (1000/ml vial, 10000/ml vial, 20000/ml vial, 5000/ml vial, 5000/ml(1) cartridge) heparin sodium,porcine in 0.9 % sodium chloride/pf (1000/500ml iv soln, 2k/1000ml iv soln) heparin sodium,porcine/dextrose 5 % in water (12500/250 iv soln, 20k/500ml iv soln, 25000/250 iv soln, 25000/500 iv soln) oxycodone hcl/aspirin 4.8355-325 tablet PRADAXA (150 MG CAPSULE, 75 MG CAPSULE) ticlopidine hcl 250 mg tablet warfarin sodium (1 mg tablet, 10 mg tablet, 2 mg tablet, 2.5 mg tablet, 3 mg tablet, 4 mg tablet, 5 mg tablet, 6 mg tablet, 7.5 mg tablet) 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼 38

血液形成 凝固和血栓形成劑 造血劑 LEUKINE 250 MCG VIAL PA MOZOBIL (20 MG/ML VIAL, 24 MG/1.2 ML VIAL) PA NEULASTA 6 MG/0.6 ML SYRINGE PA NEUMEGA 5 MG VIAL PA NEUPOGEN (300 MCG/0.5 ML SYR, 300 MCG/ML VIAL, 480 MCG/0.8 ML SYR, 480 MCG/1.6 ML VIAL) PROMACTA (25 MG TABLET, 50 MG TABLET, 75 MG TABLET) tranexamic acid (1000 mg/10 ampul, 1000 mg/10 vial) PA PA 流變劑 pentoxifylline 400 mg tablet er 血糖調節劑 血糖劑 PROGLYCEM 50 MG/ML ORAL SUSP 血液製品 / 改性劑 / 體積膨脹劑 凝結劑 tranexamic acid 650 mg tablet (g) 血小板改性劑 BRILINTA 90 MG TABLET 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼. 39

心血管藥物 α- 腎上腺素受體激動劑 DEMSER 250 MG CAPSULE 心血管藥物 降血脂藥 atorvastatin calcium (10 mg tablet, 20 mg tablet, 40 mg tablet, 80 mg tablet) cholestyramine/aspartame (4 g powd pack, 4 g powder) colestipol hcl (1 g tablet, 5 g granules, 5 g packet) CRESTOR (10 MG TABLET, 20 MG TABLET, 40 MG TABLET, 5 MG TABLET) fenofibrate (160 mg tablet, 54 mg tablet) fenofibrate nanocrystallized (145mg tablet, 48 mg tablet) fenofibrate,micronized (134mg capsule, 200 mg capsule, 67 mg capsule) fluvastatin sodium (20 mg capsule, 40 mg capsule) ST gemfibrozil 600 mg tablet lovastatin (10 mg tablet, 20 mg tablet, 40 mg tablet) LOVAZA 1 GM CAPSULE NIACOR 500 MG TABLET NIASPAN (ER 1,000 MG TABLET, ER 500 MG TABLET, ER 750 MG TABLET) pravastatin sodium (10 mg tablet, 20 mg tablet, 40 mg tablet, 80 mg tablet) SIMCOR (1,000-40 MG TABLET, 500-20 MG TABLET, 500-40 MG TABLET, 750-20 MG TABLET) ST 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼 40

心血管藥物 TRILIPIX (135 MG CAPSULE, 45 MG CAPSULE) VYTORIN (10-10 MG TABLET, 10-20 MG TABLET, 10-40 MG TABLET, 10-80 MG TABLET) WELCHOL (3.75G PACKET, 625 MG TABLET) ZETIA 10 MG TABLET ST ST ST 鈣通道阻斷劑 amlodipine besylate (10 mg tablet, 2.5 mg tablet, 5 mg tablet) nifedipine (10 mg capsule, 20 mg capsule, 30 mg tab er 24, 30 mg tablet er, 60 mg tab er 24, 60 mg tablet er, 90 mg tab er 24, 90 mg tablet er) 心臟藥物 amiodarone hcl (200 mg tablet, 400 mg tablet) digoxin (125 mcg tablet, 250 mcg tablet, 50 mcg/ml solution) DILANTIN 50 MG INFATAB diltiazem hcl (120 mg cap er 12h, 120 mg cap er 24h, 120 mg cap er deg, 120 mg capsule er, 120 mg tablet, 180 mg cap er 24h, 180 mg cap er deg, 180 mg capsule er, 240 mg cap er 24h, 240 mg cap er deg, 240 mg capsule er, 30 mg tablet, 300 mg cap er 24h, 300 mg capsule er, 360 mg cap er 24h, 360 mg capsule er, 60 mg cap er 12h, 60 mg tablet, 90 mg cap er 12h, 90 mg tablet) disopyramide phosphate (100 mg capsule, 150 mg capsule) flecainide acetate (100 mg tablet, 150 mg tablet, 50 mg tablet) mexiletine hcl (150 mg capsule, 200 mg capsule, 250 mg capsule) MULTAQ 400 MG TABLET PA 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼. 41

心血管藥物 phenytoin (100 mg/4ml oral susp, 125 mg/5ml oral susp) phenytoin sodium extended (100 mg capsule, 200 mg capsule, 300 mg capsule) propafenone hcl (150 mg tablet, 225 mg cap er 12h, 225 mg tablet, 300 mg tablet, 325 mg cap er 12h, 425 mg cap er 12h) quinidine gluconate 324 mg tablet er quinidine sulfate (200 mg tablet, 300 mg tablet, 300 mg tablet er) RANEXA (ER 1,000 MG TABLET, ER 500 MG TABLET) TARKA (ER 1-240 MG TABLET, ER 2-180 MG TABLET, ER 2-240 MG TABLET, ER 4-240 MG TABLET) TIKOSYN (125 MCG CAPSULE, 250 MCG CAPSULE, 500 MCG CAPSULE) verapamil hcl (100 mg cap24h pct, 120 mg cap24h pel, 120 mg tablet, 120 mg tablet er, 180 mg cap24h pel, 180 mg tablet er, 200 mg cap24h pct, 240 mg cap24h pel, 240 mg tablet er, 300 mg cap24h pct, 40 mg tablet, 80 mg tablet) PA ST VERELAN 360 MG CAP PELLET 降壓藥物 acetazolamide (125 mg tablet, 250 mg tablet, 500 mg capsule er) amiloride/hydrochlorothiazide 5mg- 50mg tablet amlodipine besylate/benazepril hcl (10 mg-20mg capsule, 10 mg-40mg capsule, 2.5mg-10mg capsule, 5 mg-10 mg capsule, 5 mg-20 mg capsule, 5 mg- 40 mg capsule) AMTURNIDE (150-5-12.5 MG TAB, 300-10-12.5 MG TAB, 300-10-25 MG TAB, 300-5-12.5 MG TAB, 300-5-25 MG TAB) ST 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼 42

心血管藥物 benazepril hcl (10 mg tablet, 20 mg tablet, 40 mg tablet, 5 mg tablet) benazepril hcl/hydrochlorothiazide (10-12.5mg tablet, 20-12.5 mg tablet, 20-25mg tablet, 5-6.25mg tablet) BENICAR (20 MG TABLET, 40 MG TABLET, 5 MG TABLET) BENICAR HCT (20-12.5 MG TABLET, 40-12.5 MG TABLET, 40-25 MG TABLET) bumetanide (0.5 mg tablet, 1 mg tablet, 2 mg tablet) captopril (100 mg tablet, 12.5 mg tablet, 25 mg tablet, 50 mg tablet) captopril/hydrochlorothiazide (25 mg- 15mg tablet, 25 mg-25mg tablet, 50 mg-15mg tablet, 50 mg-25mg tablet) chlorothiazide (250 mg tablet, 500 mg tablet) chlorthalidone (25 mg tablet, 50 mg tablet) DIOVAN (160 MG TABLET, 320 MG TABLET, 40 MG TABLET, 80 MG TABLET) DYRENIUM (100 MG CAPSULE, 50 MG CAPSULE) ST ELIXOPHYLLIN 80 MG/15 ML ELIX enalapril maleate (10 mg tablet, 2.5 mg tablet, 20 mg tablet, 5 mg tablet) enalapril maleate/hydrochlorothiazide (10 mg-25mg tablet, 5mg-12.5mg tablet) eplerenone (25 mg tablet, 50 mg tablet) EXFORGE (10-160 MG TABLET, 10-320 MG TABLET, 5-160 MG TABLET, 5-320 MG TABLET) EXFORGE HCT (10-160-12.5 MG TAB, 10-160-25 MG TAB, 10-320-25 MG TAB, 5-160-12.5 MG TAB, 5-160-25 MG TAB) ST ST 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼. 43

心血管藥物 fosinopril sodium (10 mg tablet, 20 mg tablet, 40 mg tablet) fosinopril sodium/hydrochlorothiazide (10-12.5mg tablet, 20-12.5 mg tablet) furosemide (10 mg/ml solution, 10 mg/ml vial, 20 mg tablet, 40 mg tablet, 40mg/5ml solution, 80 mg tablet) guanfacine hcl (1 mg tablet, 2 mg tablet) hydralazine hcl (10 mg tablet, 100 mg tablet, 25 mg tablet, 50 mg tablet) hydrochlorothiazide (12.5 mg capsule, 12.5 mg tablet, 25 mg tablet, 50 mg tablet) indapamide (1.25 mg tablet, 2.5 mg tablet) INTUNIV (ER 3 MG TABLET, ER 4 MG TABLET) irbesartan/hydrochlorothiazide (150-12.5mg tablet, 300-12.5mg tablet) isradipine (2.5 mg capsule, 5 mg capsule) lisinopril (10 mg tablet, 2.5 mg tablet, 20 mg tablet, 30 mg tablet, 40 mg tablet, 5 mg tablet) lisinopril/hydrochlorothiazide (10-12.5mg tablet, 20-12.5 mg tablet, 20-25mg tablet) losartan potassium/hydrochlorothiazide (100-12.5mg tablet, 100mg-25mg tablet, 50-12.5 mg tablet) PA methyclothiazide 5 mg tablet metolazone (10 mg tablet, 2.5 mg tablet, 5 mg tablet) MICARDIS (20 MG TABLET, 40 MG TABLET, 80 MG TABLET) MICARDIS HCT (40-12.5 MG TABLET, 80-12.5 MG TABLET, 80-25 MG TABLET) ST 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼 44

心血管藥物 moexipril hcl 15 mg tablet moexipril hcl/hydrochlorothiazide (15-12.5mg tablet, 15-25mg tablet, 7.5-12.5mg tablet) nicardipine hcl (20 mg capsule, 30 mg capsule) nimodipine 30 mg capsule nisoldipine (17 mg tab er 24h, 20 mg tab er 24h, 25.5 mg tab er 24h, 30 mg tab er 24h, 34 mg tab er 24h, 40 mg tab er 24h, 8.5mg tab er 24h) perindopril erbumine (2 mg tablet, 4 mg tablet, 8 mg tablet) quinapril hcl (10 mg tablet, 20 mg tablet, 40 mg tablet, 5 mg tablet) quinapril hcl/hydrochlorothiazide (10-12.5mg tablet, 20-12.5 mg tablet, 20-25mg tablet) ramipril (1.25 mg capsule, 10 mg capsule, 2.5 mg capsule, 5 mg capsule) reserpine (0.1 mg tablet, 0.25 mg tablet) spironolact/hydrochlorothiazid 25 mg- 25mg tablet TEKTURNA HCT (150-12.5 MG TAB, 150-25 MG TABLET, 300-12.5 MG TAB, 300-25 MG TABLET) theophylline anhydrous (100 mg tab er 12h, 200 mg tab er 12h, 300 mg tab er 12h, 400 mg tablet er, 450 mg tab er 12h, 600 mg tablet er) torsemide (10 mg tablet, 100 mg tablet, 20 mg tablet, 20 mg/2 ml vial, 5 mg tablet, 50 mg/5 ml vial) trandolapril (1 mg tablet, 2 mg tablet, 4 mg tablet) triamterene/hydrochlorothiazide (37.5-25 mg capsule, 37.5-25 mg tablet, 75 mg-50mg tablet) ST 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼. 45

心血管藥物 valsartan/hydrochlorothiazide (160-12.5mg tablet, 160-25mg tablet, 320-12.5mg tablet, 320mg-25mg tablet, 80-12.5mg tablet) 腎素 - 血管緊張素 - 醛固酮系統抑制劑 irbesartan (150 mg tablet, 300 mg tablet, 75 mg tablet) losartan potassium (100 mg tablet, 25 mg tablet, 50 mg tablet) TEKTURNA (150 MG TABLET, 300 MG TABLET) 血管擴張劑 ADCIRCA 20 MG TABLET PA CIALIS (2.5 MG TABLET, 5 MG TABLET) PA isosorbide dinitrate (10 mg tablet, 20 mg tablet, 30 mg tablet, 40 mg tablet er, 5 mg tablet) isosorbide mononitrate (10 mg tablet, 120 mg tab er 24h, 20 mg tablet, 30 mg tab er 24h, 60 mg tab er 24h) LETAIRIS (10 MG TABLET, 5 MG TABLET) PA NITRO-BID 2% OINTMENT nitroglycerin (0.1mg/hr patch td24, 0.2mg/hr patch td24, 0.4mg/hr patch td24, 0.6mg/hr patch td24) NITROMIST 400 MCG SPRAY NITROSTAT (0.3 MG TABLET SL, 0.4 MG TABLET SL, 0.6 MG TABLET SL) REMODULIN (1 MG/ML VIAL, 10 PA MG/ML VIAL, 2.5 MG/ML VIAL, 5 MG/ML VIAL) sildenafil citrate 20 mg tablet 1 $0 PA, (g) TEKAMLO (150 MG-10 MG TABLET, 150 MG-5 MG TABLET, 300 MG-10 MG TABLET, 300 MG-5 MG TABLET) TRACLEER (125 MG TABLET, 62.5 MG TABLET) PA 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼 46

中樞神經系統藥物 解熱鎮痛藥 acetaminophen with codeine phosphate (120-12mg/5 solution, 240-24/10 solution, 300mg/12.5 solution, 360-36/15 solution) acetaminophen with codeine phosphate (300mg-15mg tablet, 300mg-30mg tablet, 300mg-60mg tablet) AVINZA 90 MG CAPSULE buprenorphine hcl (2 mg tab subl, 8 mg tab subl) butalbit/acetamin/caff/codeine 50-325- 30 capsule butorphanol tartrate (1 mg/ml disp syrin, 1 mg/ml syringe, 1 mg/ml vial, 10 mg/ml spray, 2 mg/ml vial) CELEBREX (100 MG CAPSULE, 200 MG CAPSULE, 400 MG CAPSULE, 50 MG CAPSULE) codeine sulfate (15 mg tablet, 30 mg tablet, 60 mg tablet) 1 $0 QL ( 每 30 天 5000 毫升 ), (g) 1 $0 QL (( 每 30 天 360), (g) 1 $0 QL ( 每 30 天 360), (g) ST diclofenac potassium 50 mg tablet diclofenac sodium (100 mg tab er 24h, 25 mg tablet dr, 50 mg tablet dr, 75 mg tablet dr) diflunisal 500 mg tablet DILAUDID (1 MG/ML AMPUL, 1 MG/ML LIQUID) etodolac (200 mg capsule, 400 mg tab er 24h, 400 mg tablet, 500 mg tab er 24h, 500 mg tablet, 600 mg tab er 24h) fenoprofen calcium 600 mg tablet fentanyl (100 mcg/hr patch td72, 12 mcg/hr patch td72, 25mcg/hr patch td72, 50mcg/hr patch td72, 75mcg/hr patch td72) 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼. 47

中樞神經系統藥物 flurbiprofen (100 mg tablet, 50 mg tablet) gabapentin (100 mg capsule, 250 mg/5ml solution, 300 mg capsule, 300 mg/6ml solution, 400 mg capsule, 600 mg tablet, 800 mg tablet) HORIZANT ER 600 MG TABLET hydrocodone bit/acetaminophen 5mg- 325mg tablet 1 $0 QL ( 每 30 天 360), (g) hydrocodone bitartrate/acetaminophen 1 $0 (10mg-325mg tablet, 5mg-300mg QL ( 每 30 天 360), (g) tablet, 7.5-325mg tablet) tablet, 5mg-325mg tablet, 7.5-300mg hydrocodone bitartrate/acetaminophen (2.5-108/5 solution, 5-217mg/10 solution, 7.5-325/15 solution) hydrocodone/ibuprofen 7.5-200 mg tablet hydromorphone hcl (2 mg tablet, 4 mg 1 $0 tablet, 8 mg tablet) QL ( 每 30 天 120), (g) hydromorphone hcl/pf (10 mg/ml ampul, 10 mg/ml vial) ibuprofen (400 mg tablet, 600 mg tablet, 800 mg tablet) ibuprofen/oxycodone hcl 400mg-5mg tablet INDOCIN 25 MG/5 ML SUSPENSION indomethacin (25 mg capsule, 50 mg capsule, 75 mg capsule er) ketoprofen (200 mg cap24h pel, 50 mg capsule, 75 mg capsule) ketorolac tromethamine 10 mg tablet levorphanol tartrate 2 mg tablet meclofenamate sodium (100 mg capsule, 50 mg capsule) meloxicam (15 mg tablet, 7.5 mg tablet) meperidine hcl 50 mg tablet 1 $0 QL ( 每 30 天 120), (g) 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼 48

中樞神經系統藥物 meperidine hcl/pf (100 mg/ml vial, 25 mg/ml vial, 50 mg/ml vial) MEPERITAB 100 MG TABLET 1 $0 methadone hcl (10 mg tablet, 5 mg tablet) methadone hcl (10 mg/5 ml solution, 5 mg/5 ml solution) morphine sulfate (10 mg/5 ml solution, 100 mg/5ml solution, 20 mg/5 ml solution) 1 $0 QL ( 每 30 天 180), (g) morphine sulfate (100 mg cap er pel, 1 $0 QL ( 每 30 天 60), (g) 100 mg tablet er, 15 mg tablet, 15 mg tablet er, 20 mg cap er pel, 200 mg tablet er, 30 mg cap er pel, 30 mg tablet er, 50 mg cap er pel, 60 mg cap er pel, 60 mg tablet er, 80 mg cap er pel) morphine sulfate 30 mg tablet 1 $0 QL ( 每 30 天 120), (g) nabumetone (500 mg tablet, 750 mg tablet) nalbuphine hcl (10 mg/ml ampul, 10 mg/ml vial, 20 mg/ml ampul, 20 mg/ml vial) naproxen (250 mg tablet, 375 mg tablet, 375 mg tablet dr, 500 mg tablet, 500 mg tablet dr) naproxen sodium (275 mg tablet, 550 mg tablet) NUCYNTA (100 MG TABLET, 50 MG TABLET, 75 MG TABLET) 1 $0 BD, (g) NUCYNTA ER (ER 100 MG TABLET, ER 150 MG TABLET, ER 200 MG TABLET, ER 250 MG TABLET, ER 50 MG TABLET) oxaprozin 600 mg tablet oxycodone hcl (10 mg tablet, 20 mg tablet) oxycodone hcl (15 mg tablet, 20 mg/ml oral conc, 30 mg tablet, 5 mg capsule, 5 mg tablet) 1 $0 QL ( 每 30 天 120), (g) 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼. 49

中樞神經系統藥物 PENNSAID 1.5% SOLUTION pentazocine hcl/naloxone hcl 50mg- 0.5mg tablet piroxicam (10 mg capsule, 20 mg capsule) PONSTEL 250 MG KAPSEALS SPRIX 15.75 MG NASAL SPRAY sulindac (150 mg tablet, 200 mg tablet) tolmetin sodium (400 mg capsule, 600 mg tablet) tramadol hcl 50 mg tablet 1 $0 QL ( 每 30 天 240), (g) tramadol hcl/acetaminophen 37.5-1 $0 QL ( 每 30 天 360), (g) 325mg tablet TREXIMET 85-500 MG TABLET 厭食劑及呼吸與大腦興奮劑 ADDERALL XR 25 MG CAPSULE CONCERTA (ER 18 MG TABLET, ER 27 PA MG TABLET, ER 36 MG TABLET, ER 54 MG TABLET) DAYTRANA 15 MG/9 HR PATCH PA dexmethylphenidate hcl (10 mg tablet, 2.5 mg tablet, 5 mg tablet) dextroamphetamine sulfsaccharate/amphetamine sulfaspartate (10 mg tablet, 12.5 mg tablet, 15 mg tablet, 20 mg tablet, 30 mg tablet, 5 mg tablet, 7.5 mg tablet) dextroamphetamine sulfate (10 mg capsule er, 10 mg tablet, 15 mg capsule er, 5 mg capsule er, 5 mg tablet) FOCALIN XR (10 MG CAPSULE, 15 MG CAPSULE, 20 MG CAPSULE, 25 MG CAPSULE, 30 MG CAPSULE, 35 MG CAPSULE, 40 MG CAPSULE, 5 MG CAPSULE) METADATE CD (30 MG CAPSULE, 40 MG CAPSULE) 1 $0 PA, (g) 1 $0 PA, (g) PA PA 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼 50

中樞神經系統藥物 methylphenidate hcl (10 mg cpbp 30-70, 10 mg tablet, 10 mg/5 ml solution, 20 mg tablet, 20 mg tablet er, 5 mg tablet, 5 mg/5 ml solution, 50 mg cpbp 30-70, 60 mg cpbp 30-70) modafinil (100 mg tablet, 200 mg tablet) RITALIN LA (20 MG CAPSULE, 30 MG CAPSULE, 40 MG CAPSULE) VYVANSE (20 MG CAPSULE, 30 MG CAPSULE, 40 MG CAPSULE, 50 MG CAPSULE, 60 MG CAPSULE, 70 MG CAPSULE) 1 $0 PA, (g) 1 $0 PA, (g) PA PA 抗痙攣劑 APTIOM (200 MG TABLET, 400 MG TABLET, 600 MG TABLET, 800 MG TABLET) BANZEL (200 MG TABLET, 40 MG/ML SUSPENSION, 400 MG TABLET) carbamazepine (100 mg cpmp 12hr, 100 mg tab chew, 100 mg/5ml oral susp, 200 mg cpmp 12hr, 200 mg tab er 12h, 200 mg tablet, 200mg/10ml oral susp, 300 mg cpmp 12hr, 400 mg tab er 12h) CELONTIN 300 MG KAPSEAL clonazepam (0.125 mg tab rapdis, 0.25 mg tab rapdis, 0.5 mg tab rapdis, 0.5 mg tablet, 1 mg tab rapdis, 1 mg tablet, 2 mg tab rapdis, 2 mg tablet) clorazepate dipotassium (15 mg tablet, 3.75 mg tablet, 7.5 mg tablet) diazepam (10 mg tablet, 12.5-15-20 kit, 2 mg tablet, 2.5 mg kit, 5 mg tablet, 5 mg/5 ml solution, 5-7.5-10mg kit) DILANTIN 30 MG CAPSULE divalproex sodium (125 mg cap sprink, 125 mg tablet dr, 250 mg tab er 24h, 250 mg tablet dr, 500 mg tab er 24h, 500 mg tablet dr) 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼. 51

中樞神經系統藥物 felbamate (400 mg tablet, 600 mg tablet, 600 mg/5ml oral susp) fosphenytoin sodium (100mg pe/2 vial, 500 pe/10 vial) FYCOMPA (2 MG TABLET, 4 MG TABLET, 6 MG TABLET, 8 MG TABLET) GABITRIL (12 MG TABLET, 16 MG TABLET) LAMICTAL ODT (100 MG TABLET, 200 MG TABLET, 25 MG TABLET, 50 MG TABLET) LAMICTAL TAB START KIT (BLUE) LAMICTAL TAB START KIT (GREEN) LAMICTAL TB START KIT (ORANGE) LAMICTAL XR (100 MG TABLET, 200 MG TABLET, 25 MG TABLET, 300 MG TABLET, 50 MG TABLET) LAMICTAL XR START KIT (BLUE) LAMICTAL XR START KIT (GREEN) LAMICTAL XR START KIT (ORANGE) lamotrigine (100 mg tab er 24, 100 mg tablet, 150 mg tablet, 200 mg tab er 24, 200 mg tablet, 25 mg tab er 24, 25 mg tablet, 25 mg tb chw dsp, 250 mg tab er 24, 300 mg tab er 24, 5 mg tb chw dsp, 50 mg tab er 24) levetiracetam (100 mg/ml solution, 1000 mg tablet, 250 mg tablet, 500 mg tab er 24h, 500 mg tablet, 500 mg/5ml solution, 500 mg/5ml vial, 750 mg tab er 24h, 750 mg tablet) lorazepam (0.5 mg tablet, 1 mg tablet, 2 mg tablet) LORAZEPAM INTENSOL 2 MG/ML 1 $0 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼 52

中樞神經系統藥物 LYRICA (100 MG CAPSULE, 150 MG CAPSULE, 20 MG/ML ORAL SOLUTION, 200 MG CAPSULE, 225 MG CAPSULE, 25 MG CAPSULE, 300 MG CAPSULE, 50 MG CAPSULE, 75 MG CAPSULE) oxcarbazepine (150 mg tablet, 300 mg tablet, 300 mg/5ml oral susp, 600 mg tablet) OXTELLAR XR (150 MG TABLET, 300 MG TABLET, 600 MG TABLET) PEGANONE 250 MG TABLET phenytoin sodium (50 mg/ml ampul, 50 mg/ml vial) POTIGA (200 MG TABLET, 300 MG TABLET, 400 MG TABLET, 50 MG TABLET) primidone (250 mg tablet, 50 mg tablet) SABRIL (500 MG POWDER PACKET, 500 MG TABLET) TEGRETOL XR (100 MG TABLET, 200 MG TABLET, 400 MG TABLET) tiagabine hcl (2 mg tablet, 4 mg tablet) topiramate (100 mg tablet, 15 mg cap sprink, 200 mg tablet, 25 mg cap sprink, 25 mg tablet, 50 mg tablet) TROKENDI XR (100 MG CAPSULE, 200 MG CAPSULE, 25 MG CAPSULE, 50 MG CAPSULE) valproate sodium 250 mg/5ml solution valproic acid (as sodium salt) (valproate sodium) (250 mg/5ml solution, 500 mg/5ml vial, 500mg/10ml solution) valproic acid 250 mg capsule VIMPAT (10 MG/ML SOLUTION, 100 MG TABLET, 150 MG TABLET, 200 MG TABLET, 50 MG TABLET) VIMPAT 200 MG/20 ML VIAL BD zonisamide (100 mg capsule, 25 mg capsule, 50 mg capsule) 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼. 53

中樞神經系統藥物 抗躁狂劑 lithium carbonate (150 mg capsule, 300 mg capsule, 300 mg tablet, 300 mg tablet er, 450 mg tablet er, 600 mg capsule) lithium citrate 8 meq/5 ml solution 抗偏頭痛劑 IMITREX (20 MG NASAL SPRAY, 5 MG NASAL SPRAY) naratriptan hcl (1 mg tablet, 2.5 mg 1 $0 tablet) QL ( 每 30 天 9), (g) rizatriptan benzoate (10 mg tab rapdis, 10 mg tablet, 5 mg tab rapdis, 5 mg tablet) sumatriptan succinate (100 mg tablet, 1 $0 QL ( 每 30 天 9), (g) 25 mg tablet, 50 mg tablet) sumatriptan succinate (6 mg/0.5ml cartridge, 6 mg/0.5ml disp syrin, 6 mg/0.5ml pen injctr, 6 mg/0.5ml syringe, 6 mg/0.5ml vial) ZOMIG (2.5 MG TABLET, 5 MG TABLET) QL ( 每 30 天 9) ZOMIG 5 MG NASAL SPRAY ZOMIG ZMT (2.5 MG TABLET, 5 MG TABLET) 抗帕金森病藥物 APOKYN 30 MG/3 ML CARTRIDGE QL ( 每 30 天 9) benztropine mesylate (0.5 mg tablet, 1 mg tablet, 2 mg tablet) bromocriptine mesylate (2.5 mg tablet, 5 mg capsule) carbidopa/levodopa (10mg-100mg tab rapdis, 10mg-100mg tablet, 25mg- 100mg tab rapdis, 25mg-100mg tablet, 25mg-100mg tablet er, 25mg-250mg tab rapdis, 25mg-250mg tablet, 50mg- 200mg tablet er) COMTAN 200 MG TABLET CYCLOSET 0.8 MG TABLET 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼 54

中樞神經系統藥物 pramipexole di-hcl (0.125 mg tablet, 0.25 mg tablet, 0.5 mg tablet, 0.75 mg tablet, 1 mg tablet, 1.5 mg tablet) ropinirole hcl (0.25 mg tablet, 0.5 mg tablet, 1 mg tablet, 12 mg tab er 24h, 2 mg tab er 24h, 2 mg tablet, 3 mg tablet, 4 mg tab er 24h, 4 mg tablet, 5 mg tablet, 6 mg tab er 24h, 8 mg tab er 24h) STALEVO 100 TABLET STALEVO 125 TABLET STALEVO 150 TABLET STALEVO 200 TABLET STALEVO 50 TABLET STALEVO 75 TABLET TASMAR 100 MG TABLET trihexyphenidyl hcl (2 mg tablet, 2 mg/5 ml elixir, 5 mg tablet) 抗焦慮藥 鎮靜劑和安眠藥 alprazolam (0.25 mg tablet, 0.5 mg tablet, 1 mg tablet, 2 mg tablet) buspirone hcl (10 mg tablet, 15 mg tablet, 30 mg tablet, 5 mg tablet, 7.5 mg tablet) EDLUAR (10 MG SL TABLET, 5 MG SL TABLET) hydroxyzine hcl (10 mg tablet, 10 mg/5 ml syrup, 25 mg tablet, 50 mg tablet) hydroxyzine hcl (25 mg/ml vial, 50 mg/ml vial) hydroxyzine pamoate (100 mg capsule, 25 mg capsule, 50 mg capsule) meprobamate (200 mg tablet, 400 mg tablet) 1 $0 PA, (g) 1 $0 PA, (g) 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼. 55

中樞神經系統藥物 promethazine hcl (12.5 mg supp.rect, 12.5 mg tablet, 25 mg supp.rect, 25 mg tablet, 50 mg tablet, 6.25mg/5ml syrup) promethazine hcl (25 mg/ml ampul, 25 mg/ml syringe, 25 mg/ml vial, 50 mg/ml ampul, 50 mg/ml vial) ROZEREM 8 MG TABLET 1 $0 PA, (g) zaleplon (10 mg capsule, 5 mg capsule) zolpidem tartrate (10 mg tablet, 12.5 mg tab mphase, 5 mg tablet, 6.25 mg tab mphase) ZOLPIMIST 5 MG ORAL SPRAY 中樞神經系統藥物, 雜項 NAMENDA 10 MG/5 ML SOLUTION NUEDEXTA 20-10 MG CAPSULE PA RILUTEK 50 MG TABLET STRATTERA (10 MG CAPSULE, 18 MG CAPSULE, 25 MG CAPSULE, 40 MG CAPSULE) STRATTERA (100 MG CAPSULE, 60 MG CAPSULE, 80 MG CAPSULE) XENAZINE (12.5 MG TABLET, 25 MG TABLET) XYREM 500 MG/ML ORAL SOLUTION QL ( 每 60 天 30) QL ( 每 30 天 30) PA 鴉片受體拮抗劑 naloxone hcl 1 mg/ml syringe naltrexone hcl 50 mg tablet SUBOXONE (2 MG-0.5 MG SL FILM, 8 MG-2 MG SL FILM) VIVITROL (380 MG VIAL, 380 MG VIAL + DILUENT) 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼 56

中樞神經系統藥物 心理治療藥物 ABILIFY (1 MG/ML SOLUTION, 10 MG TABLET, 15 MG TABLET, 2 MG TABLET, 20 MG TABLET, 30 MG TABLET, 5 MG TABLET, 9.7 MG/1.3 ML VIAL) ABILIFY DISCMELT (10 MG TABLET, 15 MG TABLET) ABILIFY MAINTENA (ER 300 MG VL, ER 400 MG VL) amitriptyline hcl (10 mg tablet, 100 mg tablet, 150 mg tablet, 25 mg tablet, 50 mg tablet, 75 mg tablet) amitriptyline hcl/chlordiazepoxide (12.5mg-5mg tablet, 25 mg-10mg tablet) amoxapine (100 mg tablet, 150 mg tablet, 25 mg tablet, 50 mg tablet) APLENZIN (ER 174 MG TABLET, ER 348 MG TABLET, ER 522 MG TABLET) AZILECT (0.5 MG TABLET, 1 MG TABLET) BRINTELLIX (10 MG TABLET, 20 MG TABLET, 5 MG TABLET) BRISDELLE 7.5 MG CAPSULE bupropion hcl (100 mg tablet, 100 mg tablet er, 150 mg tab er 24h, 150 mg tablet er, 200 mg tablet er, 300 mg tab er 24h, 75 mg tablet) chlorpromazine hcl (10 mg tablet, 100 mg tablet, 200 mg tablet, 25 mg tablet, 25 mg/ml ampul, 50 mg tablet) citalopram hydrobromide (10 mg tablet, 10 mg/5 ml solution, 20 mg tablet, 40 mg tablet) clomipramine hcl (25 mg capsule, 50 mg capsule, 75 mg capsule) clozapine (100 mg tablet, 200 mg tablet, 25 mg tablet, 50 mg tablet) CYMBALTA (20 MG CAPSULE, 30 MG CAPSULE, 60 MG CAPSULE) 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼. 57

中樞神經系統藥物 doxepin hcl (10 mg capsule, 10 mg/ml oral conc, 100 mg capsule, 150 mg capsule, 25 mg capsule, 50 mg capsule, 75 mg capsule) duloxetine hcl (20 mg capsule dr, 30 mg capsule dr, 60 mg capsule dr) EMSAM (12 MG/24 HOURS PATCH, 6 MG/24 HOURS PATCH, 9 MG/24 HOURS PATCH) escitalopram oxalate (10 mg tablet, 20 mg tablet, 5 mg tablet, 5 mg/5 ml solution) FANAPT (1 MG TABLET, 10 MG TABLET, 12 MG TABLET, 2 MG TABLET, 4 MG TABLET, 6 MG TABLET, 8 MG TABLET, TITRATION PACK) FAZACLO (100 MG ODT, 12.5 MG ODT, 150 MG ODT, 200 MG ODT, 25 MG ODT) FETZIMA (20-40 MG TITRATION PAK, ER 120 MG CAPSULE, ER 20 MG CAPSULE, ER 40 MG CAPSULE, ER 80 MG CAPSULE) fluoxetine hcl (10 mg capsule, 10 mg tablet, 20 mg capsule, 20 mg tablet, 20 mg/5 ml solution, 40 mg capsule, 60 mg tablet, 90 mg capsule dr) fluphenazine decanoate 25 mg/ml vial fluphenazine hcl (1 mg tablet, 10 mg tablet, 2.5 mg tablet, 2.5 mg/5ml elixir, 2.5 mg/ml vial, 5 mg tablet, 5 mg/ml oral conc) fluvoxamine maleate (100 mg cap er 24h, 100 mg tablet, 150 mg cap er 24h, 25 mg tablet, 50 mg tablet) FORFIVO XL 450 MG TABLET GEODON 20 MG/ML VIAL haloperidol (0.5 mg tablet, 1 mg tablet, 10 mg tablet, 2 mg tablet, 20 mg tablet, 5 mg tablet) 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼 58

中樞神經系統藥物 haloperidol lactate (2 mg/ml oral conc, 5 mg/ml ampul, 5 mg/ml vial) imipramine hcl (10 mg tablet, 25 mg tablet, 50 mg tablet) imipramine pamoate (100 mg capsule, 125 mg capsule, 150 mg capsule, 75 mg capsule) INVEGA (ER 1.5 MG TABLET, ER 3 MG TABLET, ER 6 MG TABLET, ER 9 MG TABLET) INVEGA SUSTENNA (117 MG PREF SY, 156 MG PREF SY, 234 MG PREF SY, 39 MG PREF SYR, 78 MG PREF SYR) KHEDEZLA (ER 100 MG TABLET, ER 50 MG TABLET) LATUDA (120 MG TABLET, 20 MG TABLET, 40 MG TABLET, 60 MG TABLET, 80 MG TABLET) loxapine succinate (10 mg capsule, 25 mg capsule, 5 mg capsule, 50 mg capsule) LUVOX CR (100 MG CAPSULE, 150 MG CAPSULE) maprotiline hcl (25 mg tablet, 50 mg tablet, 75 mg tablet) MARPLAN 10 MG TABLET mirtazapine (15 mg tab rapdis, 15 mg tablet, 30 mg tab rapdis, 30 mg tablet, 45 mg tab rapdis, 45 mg tablet, 7.5 mg tablet) nefazodone hcl (100 mg tablet, 150 mg tablet, 200 mg tablet, 250 mg tablet, 50 mg tablet) NORPRAMIN (10 MG TABLET, 100 MG TABLET, 150 MG TABLET, 25 MG TABLET, 50 MG TABLET, 75 MG TABLET) nortriptyline hcl (10 mg capsule, 10 mg/5 ml solution, 25 mg capsule, 50 mg capsule, 75 mg capsule) 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼. 59

中樞神經系統藥物 olanzapine/fluoxetine hcl (12mg-25mg capsule, 12mg-50mg capsule, 3 mg-25 mg capsule, 6mg-25mg capsule, 6mg- 50mg capsule) ORAP (1 MG TABLET, 2 MG TABLET) paroxetine hcl (10 mg tablet, 12.5 mg tab er 24h, 20 mg tablet, 25 mg tab er 24h, 30 mg tablet, 37.5 mg tab er 24h, 40 mg tablet) PAXIL 10 MG/5 ML SUSPENSION perphenazine (16 mg tablet, 2 mg tablet, 4 mg tablet, 8 mg tablet) perphenazine/amitriptyline hcl (2 mg- 10 mg tablet, 2 mg-25 mg tablet, 4 mg- 25 mg tablet, 4mg-10mg tablet, 4mg- 50mg tablet) 1 $0 PA, (g) phenelzine sulfate 15 mg tablet PRISTIQ ER (ER 100 MG TABLET, ER 50 MG TABLET) prochlorperazine edisylate (10 mg/2 ml vial, 5 mg/ml vial) prochlorperazine maleate (10 mg tablet, 25 mg supp.rect, 5 mg tablet) protriptyline hcl (10 mg tablet, 5 mg tablet) quetiapine fumarate (100 mg tablet, 200 mg tablet, 25 mg tablet, 300 mg tablet, 400 mg tablet, 50 mg tablet) RISPERDAL CONSTA (12.5 MG SYR, 25 MG SYR, 37.5 MG SYR, 50 MG SYR) risperidone (0.25 mg tab rapdis, 0.25 mg tablet, 0.5 mg tab rapdis, 0.5 mg tablet, 1 mg tab rapdis, 1 mg tablet, 1 mg/ml solution, 2 mg tab rapdis, 2 mg tablet, 3 mg tab rapdis, 3 mg tablet, 4 mg tab rapdis, 4 mg tablet) SAPHRIS (10 MG TAB SL BLK CHERY, 10 MG TAB SUBLINGUAL, 5 MG TAB SL BLK CHERRY, 5 MG TABLET SUBLINGUAL) 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼 60

中樞神經系統藥物 selegiline hcl (5 mg capsule, 5 mg tablet) SEROQUEL XR (150 MG TABLET, 200 MG TABLET, 300 MG TABLET, 400 MG TABLET, 50 MG TABLET) sertraline hcl (100 mg tablet, 20 mg/ml oral conc, 25 mg tablet, 50 mg tablet) SILENOR (3 MG TABLET, 6 MG TABLET) SURMONTIL (100 MG CAPSULE, 25 MG CAPSULE, 50 MG CAPSULE) thioridazine hcl (10 mg tablet, 100 mg tablet, 25 mg tablet, 50 mg tablet) thiothixene (1 mg capsule, 10 mg capsule, 2 mg capsule, 5 mg capsule) 1 $0 PA, (g) tranylcypromine sulfate 10 mg tablet trazodone hcl (100 mg tablet, 150 mg tablet, 300 mg tablet, 50 mg tablet) trifluoperazine hcl (1 mg tablet, 10 mg tablet, 2 mg tablet, 5 mg tablet) venlafaxine hcl (100 mg tablet, 150 mg cap er 24h, 150 mg tab er 24, 225 mg tab er 24, 25 mg tablet, 37.5 mg cap er 24h, 37.5 mg tab er 24, 37.5 mg tablet, 50 mg tablet, 75 mg cap er 24h, 75 mg tab er 24, 75 mg tablet) VERSACLOZ 50 MG/ML SUSPENSION VIIBRYD (10 MG TABLET, 20 MG TABLET, 40 MG TABLET, TITRATION PACK) ZELAPAR 1.25 MG ODT TABLET ziprasidone hcl (20 mg capsule, 40 mg capsule, 60 mg capsule, 80 mg capsule) 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼. 61

牙齒和口腔藥物 牙齒和口腔藥物 chlorhexidine gluconate 0.12 % mouthwash (g) 糖尿病治療用品 糖尿病治療用品 alcohol antiseptic pads med. pad gauze bandage (2" x 2", 3" x 3", 4" x 4") needles, insulin disposable (29 gauge dis needle, 29gx1/2" dis needle, 29gx5/16" dis needle, 30gx1/3" dis needle, 30gx5/16" dis needle, 31 gauge dis needle, 31gx1/4" dis needle, 31gx3/16" dis needle, 31gx5/16" dis needle, 32 gx 1/6" dis needle, 32 gx0.2" dis needle, 32gx 5/32" dis needle, 32gx0.25" dis needle, 32gx3/16" dis needle, 32gx5/16" dis needle, 33gx 0.25" dis needle, 33gx 3/16" dis needle, 33gx 5/16" dis needle, 33gx 5/32" dis needle, dis needle) needles, insulin disposable, safety (29gx1/2" dis needle, 29gx3/16" dis needle, 29gx5/16" dis needle, 30gx1/3" dis needle) pen needle, diabetic, remover & disposal unit (29gx1/2" dis needle, 31gx1/4" dis needle, 31gx3/16" dis needle, 31gx5/16" dis needle, 32gx 5/32" dis needle) pen needle, diabetic, safety 30 gx3/16" dis needle syr,ndl,ins,safe,disp un,0.3ml 30gx5/16" disp syrin syring w-ndl,disp,insul,0.3 ml/container,empty (29gx1/2" syringe, 30gx5/16" syringe) 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼 62

糖尿病治療用品 syringe w/needle,insulin disposable 0.3 ml (half unit mark) (0.3 ml half mark 29gx1/2" disp in, 0.3 ml half mark 30gx5/16" disp in, 0.3 ml half mark 31gx15/64" disp in, 0.3 ml half mark 31gx5/16" disp in) syringe with needle, insulin, safety, 0.3 ml (29gx1/2" disp syrin, 30gx5/16" disp syrin) syringe with needle, insulin, safety, 0.5 ml (29gx1/2" disp syrin, 30gx5/16" disp syrin) syringe with needle, insulin, safety, 1 ml (29gx1/2" disp syrin, 30gx1/2" disp syrin, 30gx5/16" disp syrin) syringe with needle, insulin,1 ml and sharps container (29gx1/2" syringe, 30gx1/2" syringe, 30gx5/16" syringe, 31gx5/16" syringe) syringe with needle,disposable,insulin (29gx1/2" disp syrin, disp syrin) syringe with needle,disposable,insulin 1 ml (ml disp syrin, ml 25gx1" disp syrin, ml 25gx5/8" disp syrin, ml 26gx1/2" disp syrin, ml 27gx1/2" disp syrin, ml 27gx5/8" disp syrin, ml 28 gauge disp syrin, ml 28gx1/2" disp syrin, ml 29 gauge disp syrin, ml 29gx1/2" disp syrin, ml 29gx7/16" disp syrin, ml 30 gauge disp syrin, ml 30gx1/2" disp syrin, ml 30gx3/8" disp syrin, ml 30gx5/16" disp syrin, ml 31gx15/64" disp syrin, ml 31gx3/8" disp syrin, ml 31gx5/16" disp syrin) 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼. 63

糖尿病治療用品 syringe with needle,insulin disposable,0.5 ml (w-ndl,disp,insul,0.5 ml 27gx1/2" disp syrin, w- ndl,disp,insul,0.5 ml 28 gauge disp syrin, w-ndl,disp,insul,0.5 ml 28gx1/2" disp syrin, w-ndl,disp,insul,0.5 ml 29 gauge disp syrin, w-ndl,disp,insul,0.5 ml 29gx1/2" disp syrin, w-ndl,disp,insul,0.5 ml 30 gauge disp syrin, w- ndl,disp,insul,0.5 ml 30gx1/2" disp syrin, w-ndl,disp,insul,0.5 ml 30gx3/8" disp syrin, w-ndl,disp,insul,0.5 ml 30gx5/16" disp syrin, w- ndl,disp,insul,0.5 ml 31gx15/64" disp syrin, w-ndl,disp,insul,0.5 ml 31gx3/8" disp syrin, w-ndl,disp,insul,0.5 ml 31gx5/16" disp syrin, w- ndl,disp,insul,0.5ml disp syrin, w- ndl,disp,insul,0.5ml 28 gauge disp syrin, w-ndl,disp,insul,0.5ml 28gx1/2" disp syrin, w-ndl,disp,insul,0.5ml 29 gauge disp syrin, w-ndl,disp,insul,0.5ml 29gx1/2" disp syrin, w- ndl,disp,insul,0.5ml 30 gauge disp syrin, w-ndl,disp,insul,0.5ml 30gx1/2" disp syrin, w-ndl,disp,insul,0.5ml 31gx5/16" disp syrin) syringe,needle,insulin,safety,disposal unit, 1 ml (1 ml 28gx1/2" disp syrin, 1 ml 29gx1/2" disp syrin) syringe,needle,insulin,safety,disposal unit,0.5 ml (29gx1/2" disp syrin, 30gx5/16" disp syrin) 電解 熱量, 和水分平衡 鹼化劑 potassium citrate (10 meq tablet er, 5 meq tablet er) sodium lactate 5 meq/ml vial ZEGERID (20 MG PACKET, 40 MG PACKET) 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼 64

電解 熱量, 和水分平衡 lactulose (10 g/15 ml solution, 20 g/30 ml solution) polyethylene glycol 3350 (3350 17g powd pack, 3350 17g/dose powder) 熱量劑 dextrose 10 % and 0.2 % sodium chloride (10 % and 0.2 % nacl 10 %-0.2 % dehp fr bg, 10 % and 0.2 % nacl 10 %- 0.2 % iv soln) dextrose 10 % and 0.45 % nacl 10%- 0.45% iv soln dextrose 10 % in water (10 % in water 10 % ampul, 10 % in water 10 % dehp fr bg, 10 % in water 10 % iv soln) dextrose 2.5 % and 0.45 % nacl 2.5%- 0.45% iv soln dextrose 5 % and 0.3 % nacl 5 %-0.3 % iv soln dextrose 5 % and 0.9 % nacl 5 %-0.9 % iv soln dextrose 5 % in water (5 % in water pggybk prt, 5 % in water pgy vl prt, 5 % in water 5 % iv soln, 5 % in water 5 % vial) dextrose 5 %-0.2 % nacl 5 %-0.2 % iv soln dextrose 5 %-0.45 % nacl 5 %-0.45 % iv soln INTRALIPID (20% IV FAT EMUL, 30% IV FAT EMUL) IONOSOL MB-D5W IV SOLUTION LIPOSYN III (10% IV FAT EMULSN, 20% IV FAT EMULSN) NORMOSOL-M AND DEXTROSE 5% NORMOSOL-R-DEXTROSE 5% IV SOLN PLASMA-LYTE 56-DEXTROSE 5% BD BD 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼. 65

電解 熱量, 和水分平衡 potassium chloride in dextrose 5 % and 0.9 % sodium chloride (20 meq/l iv soln, 40 meq/l iv soln) potassium chloride in dextrose 5 %-0.45 % sodium chloride (10 meq/l iv soln, 20 meq/l iv soln, 30 meq/l iv soln, 40 meq/l iv soln) potassium chloride/d5-0.2%nacl 20 meq/l iv soln potassium chloride/d5-0.3%nacl 20 meq/l iv soln 離子去除劑 FOSRENOL (1,000 MG TABLET CHEW, 500 MG TABLET CHEW, 750 MG TABLET CHEW) RENAGEL (400 MG TABLET, 800 MG TABLET) RENVELA (0.8 GM POWDER PACKET, 2.4 GM POWDER PACKET, 800 MG TABLET) sodium polystyrene sulfonate (15g/60ml oral susp, 30g/120ml enema, 50g/200ml enema, powder) 沖洗液 neomycin sulfate/polymyxin b sulfate (ampul, vial) water for irrigation,sterile irrig soln 保鉀利尿劑 amiloride hcl 5 mg tablet spironolactone (100 mg tablet, 25 mg tablet, 50 mg tablet) 替代製劑 0.9 % sodium chloride (0.9 % pggybk prt, 0.9 % pgy vl prt, 0.9 % 0.9 % iv soln, 0.9 % 0.9 % syringe, 0.9 % 0.9 % vial) AMINOSYN 8.5%-ELECTROLYTES SOL BD 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼 66

電解 熱量, 和水分平衡 AMINOSYN II 8.5%-ELECTROLYTES BD AMINOSYN M 3.5% IV SOLUTION BD AMINOSYN-HBC 7% IV SOLUTION BD AMINOSYN-PF (10% IV SOLUTION, 7% IV SOLUTION) CLINIMIX (2.75%-5% SOLUTION, 4.25%- 10% SOLUTION, 4.25%-20% SOLUTION, 4.25%-25% SOLUTION, 4.25%-5% SOLUTION, 5%-15% SOLUTION, 5%-20% SOLUTION, 5%-25% SOLUTION) CLINIMIX E (2.75%-10% SOLUTION, 2.75%-5% SOLUTION, 4.25%-25% SOLUTION, 4.25%-5% SOLUTION, 5%- 15% SOLUTION, 5%-20% SOLUTION, 5%-25% SOLUTION) BD BD CLINISOL 15% SOLUTION BD dextrose 5%-lactated ringers 5 % iv soln HEPATAMINE 8% IV SOLUTION BD HEPATASOL 8% IV SOLUTION BD ISOLYTE S IV SOLUTION-EXCEL KLOR-CON M15 TABLET NORMOSOL-R PH 7.4 IV SOLUTION PLASMA-LYTE 148 IV SOLUTION PLASMA-LYTE A PH 7.4 SOLN. potassium chloride (10 meq capsule er, 10 meq tab er prt, 10 meq tablet er, 10meq/0.1l piggyback, 10meq/50ml piggyback, 2 meq/ml iv soln, 2 meq/ml vial, 20 meq tab er prt, 20 meq tablet er, 20meq/0.1l piggyback, 20meq/50ml piggyback, 40meq/0.1l piggyback, 8 meq capsule er) potassium chloride in 0.9 % sodium chloride (20 meq/l iv soln, 40 meq/l iv soln) potassium chloride in lr-d5 20 meq/l iv soln 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼. 67

電解 熱量, 和水分平衡 PREMASOL (10% IV SOLUTION, 6% IV SOLUTION) BD PROCALAMINE IV SOLUTION BD PROSOL 20% INJECTION BD ringers solution iv soln ringers solution,lactated iv soln sodium chloride (2.5 meq/ml iv soln, 2.5 meq/ml vial) sodium chloride 0.45 % (0.45 % pggybk prt, 0.45 % 0.45 % iv soln) sodium chloride 3 % 3 % iv soln sodium chloride 5 % 5 % iv soln sodium chloride irrig solution 0.9 % irrig soln TPN ELECTROLYTES VIAL 1 $0 TRAVASOL 10% SOLN VIAFLEX BD TROPHAMINE (10% IV SOLUTION, 6% IV SOLUTION) BD 排尿酸劑 colchicine/probenecid 0.5-500mg tablet probenecid 500 mg tablet 血管加壓素拮抗劑 SAMSCA (15 MG TABLET, 30 MG TABLET) 酶替代 / 改性劑 酶替代 / 改性劑 LUMIZYME 50 MG VIAL PA 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼 68

酶 酶 ADAGEN 250 UNITS/ML VIAL CEREZYME (200 UNITS VIAL, 400 UNITS VIAL) CREON (12,000 UNITS CAPSULE, 24,000 UNITS CAPSULE, 6,000 UNITS CAPSULE) BD ELITEK (1.5 MG VIAL, 7.5 MG VIAL) BD FABRAZYME (35 MG VIAL, 5 MG VIAL) NAGLAZYME 5 MG/5 ML VIAL PANCREAZE (10,500 UNIT CAP, 16,800 UNIT CAP, 21,000 UNIT CAP, 4,200 UNIT CAP) PULMOZYME 1 MG/ML AMPUL BD ZENPEP (10,000 UNITS CAPSULE, 15,000 UNITS CAPSULE, 20,000 UNITS CAPSULE, 25,000 UNITS CAPSULE, 3,000 UNITS CAPSULE, 5,000 UNITS CAPSULE) 雌激素和雌激素受體激動劑 - 拮抗劑 雌激素 estradiol (0.5 mg tablet, 1 mg tablet, 2 mg tablet) estradiol/norethindrone acet 1 mg- 0.5mg tablet MENEST (0.3 MG TABLET, 0.625 MG TABLET, 1.25 MG TABLET, 2.5 MG TABLET) 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼. 69

眼 耳 鼻 喉 (EENT) 製劑 抗感染藥 acetic acid/hydrocortisone 2 %-1 % drops BLEPHAMIDE EYE DROPS BLEPHAMIDE EYE OINTMENT CILOXAN 0.3% OINTMENT CIPRO HC OTIC SUSPENSION CIPRODEX OTIC SUSPENSION ciprofloxacin hcl 0.3 % drops GENTAK 0.3 % EYE OINTMENT gentamicin sulfate 0.3 % drops MOXEZA 0.5% EYE DROPS neomy sulf/bacitra/polymyxin b 3.5mg- 400 oint. (g) neomy sulf/bacitrac zn/poly/hc 3.5-10k- 1 oint. (g) ofloxacin 0.3 % drops PRED-G 1% EYE DROPS sulfacetamide sodium (10 % drops, 10 % oint. (g), 10 % suspension) sulfacetamide/prednisolone sp 10 %- 0.23% drops TOBRADEX EYE OINTMENT TOBRADEX ST EYE DROPS tobramycin 0.3 % drops tobramycin/dexamethasone 0.3 %-0.1% drops susp TOBREX 0.3% EYE OINTMENT trifluridine 1 % drops VIGAMOX 0.5% EYE DROPS ZYMAXID 0.5% EYE DROPS 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼 70

眼 耳 鼻 喉 (EENT) 製劑 抗炎劑 ACUVAIL 0.45% OPHTH SOLUTION bromfenac sodium 0.09% drops budesonide 3 mg capdr - er CORTISPORIN CREAM dexamethasone sod phosphate 0.1 % drops DUREZOL 0.05% EYE DROPS fluocinolone acetonide (0.01 % cream (g), 0.01 % oil, 0.01 % solution, 0.025 % cream (g), 0.025 % oint. (g)) flurbiprofen sodium 0.03 % drops ketorolac tromethamine (0.4 % drops, 0.5 % drops) neomycin sulfate/polymyxin b sulfate/hydrocortisone (3.5-10k-1 drops susp, 3.5-10k-1 solution, 3.5-10k-10 drops susp) NEVANAC 0.1% DROPTAINER OMNARIS 50 MCG NASAL SPRAY PRED MILD 0.12% EYE DROPS prednisolone sod phosphate 1 % drops RESTASIS 0.05% EYE EMULSION 抗過敏藥 ALOCRIL 2% EYE DROPS epinastine hcl 0.05 % drops 抗青光眼藥物 ALPHAGAN P 0.1% DROPS AZOPT 1% EYE DROPS betaxolol hcl 0.5 % drops BETOPTIC S 0.25% EYE DROPS brimonidine tartrate (0.15 % drops, 0.2 % drops) COMBIGAN EYE DROPS 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼. 71

眼 耳 鼻 喉 (EENT) 製劑 dorzolamide hcl/timolol maleat 2 %-0.5 % drops ISOPTO CARPINE (1% EYE DROPS, 2% EYE DROPS, 4% EYE DROPS) latanoprost 0.005 % drops levobunolol hcl 0.5 % drops LUMIGAN 0.01% EYE DROPS QL (2 每 30 天 2.5 毫升 ) methazolamide (25 mg tablet, 50 mg tablet) pilocarpine hcl (5 mg tablet, 7.5 mg tablet) timolol maleate (0.25 % drops, 0.25 % sol-gel, 0.5 % drops, 0.5 % sol-gel) TRAVATAN Z 0.004% EYE DROP 眼 耳 鼻 喉藥物, 雜項 acetic acid 2 % solution apraclonidine hcl 0.5 % drops 局部麻醉藥 proparacaine hcl 0.5 % drops 胃腸道藥物 抗炎劑 APRISO ER 0.375 GRAM CAPSULE ASACOL HD DR 800 MG TABLET balsalazide disodium 750 mg capsule CANASA 1,000 MG SUPPOSITORY DIPENTUM 250 MG CAPSULE LIALDA DR 1.2 GM TABLET mesalamine w/cleansing wipes 4 g/60 ml enema kit 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼 72

胃腸道藥物 sulfasalazine 500 mg tablet SULFAZINE EC 500 MG TAB 1 $0 止瀉劑 diphenoxylate hcl/atropine 2.5-.025/5 liquid loperamide hcl 2 mg capsule 止吐藥 ALOXI 0.25 MG/5 ML VIAL BD ANZEMET (100 MG TABLET, 20 MG/ML BD VIAL, 50 MG TABLET) CESAMET 1 MG CAPSULE dronabinol (10 mg capsule, 2.5 mg 1 $0 BD, (g) capsule, 5 mg capsule) EMEND (125 MG CAPSULE, 40 MG BD CAPSULE, 80 MG CAPSULE) granisetron hcl (1 mg tablet, 1 mg/ml 1 $0 BD, (g) vial, 1 mg/ml(1) vial) granisetron hcl/pf (1 mg/ml(1) vial, 100 1 $0 BD, (g) mcg/ml vial) ondansetron (4 mg tab rapdis, 8 mg tab 1 $0 BD, (g) rapdis) ondansetron hcl (24 mg tablet, 4 mg 1 $0 BD, (g) tablet, 4 mg/5 ml solution, 8 mg tablet) ondansetron hcl/pf (4 mg/2 ml ampul, 4 1 $0 BD, (g) mg/2 ml vial) SANCUSO 3.1 MG/24 HR PATCH trimethobenzamide hcl 300 mg capsule 1 $0 PA, (g) 抗潰瘍劑和酸抑制劑 CARAFATE 1 GM/10 ML SUSP DEXILANT (30 MG CAPSULE, 60 MG ST CAPSULE) lansoprazole (15 mg capsule dr, 30 mg capsule dr) misoprostol 200 mcg tablet 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼. 73

胃腸道藥物 omeprazole (10 mg capsule dr, 20 mg capsule dr, 40 mg capsule dr) pantoprazole sodium (20 mg tablet dr, 40 mg tablet dr, 40 mg vial) sucralfate 1 g tablet 瀉藥和通便劑 AMITIZA (24 MCG CAPSULES, 8 MCG CAPSULE) LOTRONEX (0.5 MG TABLET, 1 MG TABLET) OSMOPREP TABLET 膽石溶解劑 CHENODAL 250 MG TABLET ursodiol (250 mg tablet, 300 mg capsule, 500 mg tablet) 胃腸道藥物, 雜項 HUMIRA (20 MG/0.4 ML SYRINGE, 40 MG/0.8 ML PEN, 40 MG/0.8 ML SYRINGE, CROHN'S STARTER PACK, PSORIASIS STARTER PACK) PA HUMIRA PED CROHN'S STARTER PK octreotide acetate (100 mcg/ml ampul, 1 $0 BD, (g) 100 mcg/ml vial, 1000mcg/ml vial, 200 mcg/ml vial, 50 mcg/ml ampul, 50 mcg/ml vial, 500 mcg/ml ampul, 500 mcg/ml vial) RELISTOR (12 MG/0.6 ML KIT, 12 MG/0.6 ML VIAL) REMICADE 100 MG VIAL PA SANDOSTATIN LAR (10 MG KIT, 20 MG KIT, 30 MG KIT) BD 促動力劑 metoclopramide hcl (10 mg tablet, 10 mg/10ml solution, 5 mg tablet, 5 mg/5 ml solution) 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼 74

泌尿生殖系統藥物 泌尿生殖系統的藥物, 其他 DEPEN 250 MG TITRATAB 重金屬拮抗劑 重金屬拮抗劑 CHEMET 100 MG CAPSULE EXJADE (125 MG TABLET, 250 MG TABLET, 500 MG TABLET) PA 激素類藥物 興奮劑 / 更換 / 修改 ( 性激素 / 改性劑 ) 孕激素 CAMILA TABLET norethindrone 0.35 mg tablet 荷爾蒙劑 抑制劑 ( 垂體 ) 荷爾蒙劑, 抑制劑 ( 垂體 ) cabergoline 0.5 mg tablet (g) LUPRON DEPOT 3.75 MG KIT LUPRON DEPOT-PED 11.25 MG KIT 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼. 75

激素類藥物 興奮劑 / 更換 / 改性劑 ( 垂體 ) 激素類藥物 興奮劑 / 更換 / 改性劑 ( 垂體 ) desmopressin acetate (ampul, vial) PA, (g) 激素和合成替代品 腎上腺 ASMANEX (TWISTHALER 110 MCG #30, TWISTHALER 220 MCG #30, TWISTHALER 220 MCG #60, TWISTHALR 220 MCG #120) budesonide (0.25mg/2ml ampul-neb, 0.5 mg/2ml ampul-neb) dexamethasone (0.5 mg tablet, 0.5 mg/5ml elixir, 0.5 mg/5ml solution, 0.75 mg tablet, 1 mg tablet, 1.5 mg tablet, 2 mg tablet, 4 mg tablet, 6 mg tablet) DEXAMETHASONE INTENSOL 1MG/1ML 1 $0 dexamethasone sod phosphate 4 mg/ml vial 1 $0 BD, (g) FLOVENT DISKUS (100 MCG DISKUS, QL ( 每 30 天 120) 250 MCG DISKUS, 50 MCG DISKUS) FLOVENT HFA (110 MCG INHALER, 220 QL ( 每 30 天 120 克 ) MCG INHALER, 44 MCG INHALER) fludrocortisone acetate 0.1 mg tablet fluticasone propionate (0.005 % oint. (g), 0.05 % cream (g)) hydrocortisone (10 mg tablet, 20 mg tablet, 5 mg tablet) methylprednisolone (16 mg tablet, 32 mg tablet, 4 mg tab ds pk, 4 mg tablet, 8 mg tablet) methylprednisolone acetate (40 mg/ml vial, 80 mg/ml vial) 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼 76

激素和合成替代品 prednisolone 15 mg/5 ml solution prednisolone sod phosphate (15 mg/5 ml solution, 5 mg/5 ml solution) prednisone (1 mg tablet, 10 mg tab ds pk, 10 mg tablet, 2.5 mg tablet, 20 mg tablet, 5 mg tab ds pk, 5 mg tablet, 5 mg/5 ml solution, 50 mg tablet) PREDNISONE 5 MG/ML SOLUTION 1 $0 SOLU-CORTEF (1,000 MG VIAL, 250 MG VIAL, 500 MG VIAL) SOLU-MEDROL 2,000 MG VIAL 雄激素類 ANDROGEL (1% GEL PUMP, 1%(2.5G) GEL PACKET, 1%(5G) GEL PACKET, 1.62% GEL PUMP, 1.62%(1.25G) GEL PCKT, 1.62%(2.5G) GEL PCKT) ANDROID 10 MG CAPSULE PA ANDROXY 10 MG TABLET AXIRON 30 MG/ACTUATION SOLN danazol (100 mg capsule, 200 mg capsule, 50 mg capsule) FORTESTA 10 MG GEL PUMP oxandrolone 10 mg tablet TESTIM 1% (50MG) GEL testosterone cypionate (100 mg/ml vial, 200 mg/ml vial) 降糖藥 acarbose (100 mg tablet, 25 mg tablet, 50 mg tablet) ACTOPLUS MET XR (15-1,000 MG TB, 30-1,000 MG TB) ST APIDRA 100 UNITS/ML VIAL APIDRA SOLOSTAR 100 UNITS/ML AVANDAMET (2 MG-1,000 MG TAB, 4 MG-1,000 MG TABLET) 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼. 77

激素和合成替代品 AVANDARYL (4 MG-1 MG TABLET, 4 MG-2 MG TABLET, 4 MG-4 MG TABLET, 8 MG-2 MG TABLET, 8 MG-4 MG TABLET) AVANDIA (2 MG TABLET, 4 MG TABLET, 8 MG TABLET) BYETTA (10 MCG DOSE PEN INJ, 5 MCG DOSE PEN INJ) chlorpropamide (100 mg tablet, 250 mg tablet) glimepiride (1 mg tablet, 2 mg tablet, 4 mg tablet) glipizide (10 mg tab er 24, 10 mg tablet, 2.5 mg tab er 24, 5 mg tab er 24, 5 mg tablet) glipizide/metformin hcl (2.5-250 mg tablet, 2.5-500 mg tablet, 5 mg-500mg tablet) glyburide (1.25 mg tablet, 2.5 mg tablet, 5 mg tablet) glyburide,micronized (1.5 mg tablet, 3 mg tablet, 6 mg tablet) glyburide/metformin hcl (1.25-250mg tablet, 2.5-500 mg tablet, 5 mg-500mg tablet) HUMULIN 70-30 (PEN, RELION VIAL, VIAL) ST PA HUMULIN 70/30 KWIKPEN HUMULIN N (HUMULI100 UITS/ML PE, HUMULI100 UITS/ML VIAL, RELIOHUMULI100 UIT/ML) HUMULIN N 100 UNITS/ML KWIKPEN HUMULIN R (100 UNITS/ML VIAL, ELION 100 UNIT/ML) HUMULIN R 500 UNITS/ML VIAL ST JANUMET (50-1,000 MG TABLET, 50-500 MG TABLET) ST 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼 78

激素和合成替代品 KOMBIGLYZE XR (2.5-1,000 MG TAB, 5-1,000 MG TAB, 5-500 MG TABLET) LANTUS (100 UNITS/ML CARTRIDGE, 100 UNITS/ML VIAL) ST LANTUS SOLOSTAR 100 UNITS/ML LEVEMIR 100 UNITS/ML VIAL LEVEMIR FLEXPEN 100 UNITS/ML LEVEMIR FLEXTOUCH 100 UNITS/ML metformin hcl (1000 mg tablet, 500 mg tab er 24, 500 mg tab er 24h, 500 mg tablet, 750 mg tab er 24h, 850 mg tablet) nateglinide (120 mg tablet, 60 mg tablet) NOVOLIN 70-30 (100 UNIT/ML, RELION) NOVOLIN N (OVOLI100 UITS/ML VIAL, RELIOOVOLI100 UIT/ML, RELIOOVOLI100 UITS/ML) NOVOLIN R (100 UNITS/ML VIAL, ELION 100 UNIT/ML, ELION 100 UNITS/ML) NOVOLOG (100 UNIT/ML CARTRIDGE, 100 UNITS/ML VIAL) NOVOLOG FLEXPEN SYRINGE NOVOLOG MIX 70-30 FLEXPEN SYRN NOVOLOG MIX 70-30 VIAL ONGLYZA (2.5 MG TABLET, 5 MG TABLET) pioglitazone hcl (15 mg tablet, 30 mg tablet, 45 mg tablet) pioglitazone hcl/glimepiride (30 mg-2 mg tablet, 30 mg-4 mg tablet) pioglitazone hcl/metformin hcl (15mg- 500mg tablet, 15mg-850mg tablet) PRANDIMET (1 MG-500 MG TABLET, 2 MG-500 MG TABLET) ST ST 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼. 79

激素和合成替代品 RIOMET 500 MG/5 ML SOLUTION ST SYMLINPEN 120 PEN INJECTOR PA SYMLINPEN 60 PEN INJECTOR PA tolazamide (250 mg tablet, 500 mg tablet) tolbutamide 500 mg tablet VICTOZA 2-PAK 18 MG/3 ML PEN PA VICTOZA 3-PAK 18 MG/3 ML PEN PA 避孕藥 ARANELLE 28 TABLET AVIANE-28 TABLET BALZIVA 28 TABLET CRYSELLE-28 TABLET DEPO-SUBQ PROVERA 104 SYRINGE ELLA 30 MG TABLET ENPRESSE-28 TABLET JINTELI 1 MG-5 MCG TABLET JUNEL (1 MG-20 MCG TABLET, 1.5 MG- 30 MCG TABLET) JUNEL FE (1 MG-20 MCG TABLET, 1.5 MG-30 MCG TABLET) LESSINA-28 TABLET levonorgestrel-ethinyl estradiol (tablet, tbdspk 3mo) LOW-OGESTREL-28 TABLET LUTERA-28 TABLET medroxyprogesterone acetate (10 mg tablet, 150 mg/ml syringe, 150 mg/ml vial, 5 mg tablet) MICROGESTIN (21 1-20 TABLET, 21 1.5-30 TAB) MICROGESTIN FE (1-20 TABLET, 1.5-30 TAB) 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼 80

激素和合成替代品 NECON (0.5-35-28 TABLET, 1-35-28 TABLET, 7-7-7-28 TABLET) NORTREL 0.5-35 TABLET OGESTREL TABLET ORTHO EVRA PATCH OVCON-35 28 TABLET progesterone,micronized (100 mg capsule, 200 mg capsule) SPRINTEC 28 DAY TABLET TRI-SPRINTEC TABLET TRINESSA TABLET TRIVORA-28 TABLET ZOVIA 1-35E TABLET ZOVIA 1-50E TABLET 雌激素和雌激素受體激動劑 - 拮抗劑 EVISTA 60 MG TABLET MENOSTAR 14 MCG/DAY PATCH PREMARIN (0.3 MG TABLET, 0.45 MG TABLET, 0.625 MG TABLET, 0.9 MG TABLET, 1.25 MG TABLET, 25 MG VIAL, VAGINAL CREAM-APPL) 促性腺激素 chorionic gonadotropin, human 10000 unit vial SYNAREL 2 MG/ML NASAL SPRAY 甲狀旁腺 calcitonin,salmon,synthetic 200/spray spray/pump FORTEO 600 MCG/2.4 ML PEN INJ MIACALCIN 200 UNIT/ML VIAL 垂體 GENOTROPIN (12 MG CARTRIDGE, 5 MG CARTRIDGE, MINIQUICK 0.2 MG, MINIQUICK 0.4 MG, MINIQUICK 0.6 MG, MINIQUICK 0.8 MG, MINIQUICK 1 MG, MINIQUICK 1.2 MG, MINIQUICK 1.4 MG, MINIQUICK 1.6 MG, MINIQUICK 1.8 MG, MINIQUICK 2 MG) PA 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼. 81

激素和合成替代品 HP ACTHAR GEL 80 UNIT/ML VIAL OMNITROPE (10 MG/1.5 ML CRTG, 5 MG/1.5 ML CRTG, 5.8 MG VIAL) 孕激素 medroxyprogesterone acetate 2.5 mg tablet PA norethindrone acetate 5 mg tablet 生長激素受體激動劑和拮抗劑 INCRELEX 40 MG/4 ML VIAL PA SOMAVERT (10 MG VIAL, 15 MG VIAL, 20 MG VIAL) 甲狀腺及甲狀腺拮抗劑 levothyroxine sodium (100 mcg tablet, 112 mcg tablet, 125 mcg tablet, 137 mcg tablet, 150 mcg tablet, 175mcg tablet, 200 mcg tablet, 25 mcg tablet, 300 mcg tablet, 50 mcg tablet, 75 mcg tablet, 88 mcg tablet) liothyronine sodium (25 mcg tablet, 5 mcg tablet, 50 mcg tablet) methimazole (10 mg tablet, 5 mg tablet) PA propylthiouracil 50 mg tablet 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼 82

免疫製劑 血管性水腫 (HAE) 劑 CINRYZE 500 UNIT VIAL PA FIRAZYR 30 MG/3 ML SYRINGE PA 免疫抑制劑 KINERET (100 MG/0.67 ML SYR, 100 MG/0.67 ML SYRINGE) PA 免疫調節劑 ILARIS 180 MG VIAL 局部麻醉藥 局部麻醉藥 lidocaine 5 % oint. (g) lidocaine hcl (2 % jel (ml), 2 % solution, 4 % solution, 40 mg/ml solution) lidocaine/prilocaine (2.5 %-2.5% cream (g), 2.5 %-2.5% kit) LIDODERM 5% PATCH PA 其他治療劑 5-α 還原酶抑制劑 AVODART 0.5 MG SOFTGEL finasteride 5 mg tablet 酒精抑制劑 disulfiram (250 mg tablet, 500 mg tablet) 通用解毒劑 acetylcysteine (100 mg/ml vial, 200 mg/ml vial) 1 $0 BD, (g) 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼. 83

其他治療劑 calcium acetate 667 mg capsule FUSILEV I.V. 50 MG VIAL GLUCAGON 1 MG EMERGENCY KIT 1 $0 抗痛風藥物 allopurinol (100 mg tablet, 300 mg tablet) COLCRYS 0.6 MG TABLET ULORIC (40 MG TABLET, 80 MG TABLET) 生物反應改性劑 ACTEMRA (200 MG/10 ML VIAL, 400 MG/20 ML VIAL, 80 MG/4 ML VIAL) ACTIMMUNE 100 MCG/0.5 ML VIAL PA AVONEX (30 MCG, 30 MCG KT) PA AVONEX ADMIN PACK 30 MCG VL PA AVONEX PEN 30 MCG/0.5 ML PA AZASAN (100 MG TABLET, 75 MG TABLET) BD azathioprine 50 mg tablet 1 $0 BD, (g) BETASERON (0.3 MG KIT, 0.3 MG VIAL) PA COPAXONE 20 MG/ML SYRINGE cyclosporine (100 mg capsule, 25 mg capsule, 250 mg/5ml ampul, 250 mg/5ml vial) 1 $0 BD, (g) cyclosporine, modified (100 mg capsule, 1 $0 BD, (g) 100 mg/ml solution, 25 mg capsule, 50 mg capsule) ENBREL (25 MG KIT, 25 MG/0.5 ML PA SYRINGE, 50 MG/ML SURECLICK SYR, 50 MG/ML SYRINGE) EXTAVIA (0.3 MG KIT, 0.3 MG VIAL) PA GILENYA 0.5 MG CAPSULE PA 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼 84

其他治療劑 REBIF (22 MCG/0.5 ML SYRINGE, 44 PA MCG/0.5 ML SYRINGE) REBIF REBIDOSE (22 MCG/0.5 ML, 44 PA MCG/0.5 ML) RIDAURA 3 MG CAPSULE SIMPONI (50 MG/0.5 ML PEN INJEC, 50 PA MG/0.5 ML SYRINGE) THALOMID (100 MG CAPSULE, 150 MG PA CAPSULE, 200 MG CAPSULE, 50 MG CAPSULE) TYSABRI 300 MG/15 ML VIAL PA 骨吸收抑制劑 ACTONEL (150 MG TABLET, 30 MG ST TABLET, 5 MG TABLET) alendronate sodium (10 mg tablet, 35 mg tablet, 40 mg tablet, 5 mg tablet, 70 mg tablet) BONIVA 3 MG/3 ML SYRINGE etidronate disodium (200 mg tablet, 400 mg tablet) ibandronate sodium 150 mg tablet pamidronate disodium (30 mg vial, 30mg/10ml vial, 60 mg/10ml vial, 90 mg vial, 90 mg/10ml vial) PROLIA 60 MG/ML SYRINGE PA RECLAST 5 MG/100 ML SOLUTION PA XGEVA 120 MG/1.7 ML VIAL PA ZOMETA 4 MG/5 ML VIAL BD 防齲劑 EPIFLUR (0.25 MG TABLET CHEW, 0.5 MG TABLET CHEWABLE, 1 MG TABLET CHEWABLE) FLUOR-A-DAY (0.25 MG TAB CHEW, 0.5 MG TAB CHEW, 1 MG TABLET CHEW) FLUORITAB (0.5 MG TABLET CHEW, 1 MG TABLET CHEW) 1 $0 1 $0 1 $0 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼. 85

其他治療劑 LUDENT FLUORIDE (0.25 MG TB CHW, 0.5 MG TB CHEW, 1 MG TAB CHEW) RENAF (0.25 MG TB CHEW, 0.5 MG TAB CHEW, 1 MG TAB CHEW) sodium fluoride (0.25(0.55) tab chew, 0.5(1.1)mg tab chew, 1mg(2.2mg) tab chew, 1mg(2.2mg) tablet) 免疫抑制劑 1 $0 1 $0 ASTAGRAF XL (0.5 MG CAPSULE, 1 MG BD CAPSULE, 5 MG CAPSULE) BENLYSTA (120 MG VIAL, 400 MG VIAL) PA CELLCEPT 200 MG/ML ORAL SUSP BD CELLCEPT 500 MG VIAL cyclosporine 100 mg/ml solution 1 $0 BD, (g) mycophenolate mofetil (250 mg 1 $0 BD, (g) capsule, 500 mg tablet) mycophenolate sodium (180 mg tablet 1 $0 BD, (g) dr, 360 mg tablet dr) MYFORTIC (180 MG TABLET, 360 MG BD TABLET) NULOJIX 250 MG VIAL PROGRAF 5 MG/ML AMPULE BD RAPAMUNE (0.5 MG TABLET, 1 MG BD TABLET, 1 MG/ML ORAL SOLN, 2 MG TABLET) SANDIMMUNE 100 MG/ML SOLN BD SIMULECT (10 MG VIAL, 20 MG VIAL) sirolimus 0.5 mg tablet 1 $0 BD, (g) tacrolimus (0.5 mg capsule, 1 mg capsule, 5 mg capsule) 其他治療劑 1 $0 BD, (g) AMPYRA ER 10 MG TABLET PA ARCALYST 220 MG INJECTION calcitriol 1 mcg/ml solution 1 $0 BD, (g) 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼 86

其他治療劑 KUVAN 100 MG TABLET PA leucovorin calcium (10 mg tablet, 15 mg tablet, 25 mg tablet, 5 mg tablet) leucovorin calcium (10 mg/ml vial, 100 mg vial, 200 mg vial, 350 mg vial, 50 mg vial, 500 mg vial, 500mg/50ml vial) levocarnitine (with sugar) 100 mg/ml solution 1 $0 BD, (g) 1 $0 BD, (g) levocarnitine 330 mg tablet 1 $0 BD, (g) SENSIPAR (30 MG TABLET, 60 MG TABLET, 90 MG TABLET) SOMATULINE DEPOT (120 MG/0.5 ML SYRGE, 60 MG/0.2 ML SYRING, 90 MG/0.3 ML SYRING) ZAVESCA 100 MG CAPSULE PA 保護劑 amifostine crystalline 500 mg vial dexrazoxane hcl (250 mg vial, 500 mg vial) 1 $0 PA, (g) mesna 100 mg/ml vial MESNEX 400 MG TABLET 催產藥 催產藥 methylergonovine maleate 0.2 mg tablet 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼. 87

呼吸道製劑 抗組胺藥 azelastine hcl (0.05 % drops, 137 mcg spray/pump) cetirizine hcl 1 mg/ml solution 呼吸道藥物 抗炎劑 cromolyn sodium 20 mg/2 ml ampulneb fluticasone propionate 50 mcg spray susp GASTROCROM 100 MG/5 ML CONC 1 $0 BD, (g) 1 $0 QL ( 每 30 天 120 克 ) montelukast sodium (10 mg tablet, 4 1 $0 QL ( 每 30 天 30), (g) mg gran pack, 4 mg tab chew, 5 mg tab chew) NASONEX 50 MCG NASAL SPRAY QVAR (40 MCG ORAL INHALER, 80 MCG ORAL INHALER) triamcinolone acetonide (0.1 % paste (g), 55 mcg spray) VERAMYST 27.5 MCG NASAL SPRAY zafirlukast (10 mg tablet, 20 mg tablet) 1 $0 QL ( 每 30 天 60), (g) ZYFLO CR 600 MG TABLET 第 4 類磷酸二酯酶抑制劑 DALIRESP 500 MCG TABLET PA 呼吸道藥物, 雜項 PROLASTIN C 1,000 MG VIAL PA XOLAIR 150 MG VIAL PA ZEMAIRA 1,000 MG VIAL PA 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼 88

呼吸道 / 肺部製劑 囊腫性纖維化藥物 KALYDECO 150 MG TABLET PA 血清 類毒素和疫苗 血清 CARIMUNE NF NANOFILTERED (12 GM VIAL, 3 GM VIAL, 6 GM VIAL) BD GAMMAGARD LIQUID 10% VIAL BD GAMMAGARD S-D (0.5 GM VL W-ST, 10 G (IGA<1) SOL, 10 GM VL W/ST, 2.5 GM BD VL W/ST, 5 G (IGA<1) SOLN, 5 GM VL W/SET) GAMMAPLEX 5% VIAL BD GAMUNEX 10% VIAL BD GAMUNEX-C (1 GRAM/10 ML VIAL, 10 GRAM/100 ML VIAL, 2.5 GRAM/25 ML BD VIAL, 20 GRAM/200 ML VIAL, 5 GRAM/50 ML VIAL) GAMUNEX-C 40 GRAM/400 ML VIAL PRIVIGEN 10% VIAL BD 類毒素 ADACEL TDAP VIAL BOOSTRIX TDAP (SYRINGE, VIAL) BOOSTRIX VACCINE SYRINGE DAPTACEL DTAP VACCINE INFANRIX DTAP VIAL ROTARIX (10E6/ML SUSPENSION, VACCINE SUSPENSION) tetanus & diphtheria tox,adult 2-2 lf/0.5 vial tetanus toxoid, adsorbed/pf 5 lf/0.5ml vial 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼. 89

血清 類毒素和疫苗 疫苗 ACTHIB (VIAL, WITH DILUENT) CERVARIX VACCINE SYRINGE COMVAX VACCINE VIAL ENGERIX-B ADULT (20 MCG/ML SYRN, 20 MCG/ML VIAL) ENGERIX-B PEDIATRIC-ADOLESCENT (10 MCG/0.5 ML PED VL, PEDI 10 MCG/0.5 SYRN) GARDASIL VIAL HAVRIX (1,440 UNITS/ML VIAL, 720 UNIT/0.5 ML SYRINGE, 720 UNITS/0.5 ML VIAL) IMOVAX RABIES VACCINE (VACCINE VIAL, VACCINE+DILUENT) BD BD IPOL (SINGLE DOSE SYRINGE, VIAL) IXIARO 6 MCG/0.5 ML SYRINGE M-M-R II VACCINE (VIAL, WITH DILUENT) MENACTRA VIAL MENOMUNE-A-C-Y-W-135 VIAL MENVEO A-C-Y-W-135-DIP VIAL PEDVAXHIB VACCINE VIAL PENTACEL ACTHIB COMPONENT VIAL PROQUAD VIAL RABAVERT RABIES VACCINE VIAL RECOMBIVAX HB (10 MCG/ML VIAL, 40 MCG/ML VIAL, 5 MCG/0.5 ML VL) ROTATEQ VACCINE TWINRIX VACCINE VIAL TYPHIM VI 25 MCG/0.5 ML VIAL VAQTA (25 UNITS/0.5 ML VIAL, 50 UNITS/ML VIAL) BD 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼 90

血清 類毒素和疫苗 YF-VAX (1 DOSE VIAL, 5 DOSE VIAL) ZOSTAVAX VIAL 皮膚和黏膜藥物 抗感染藥 ALTABAX 1% OINTMENT BACTROBAN 2% CREAM BACTROBAN NASAL 2% OINTMENT ciclopirox (0.77 % gel (gram), 8 % solution) ciclopirox olamine (0.77 % cream (g), 0.77 % suspension) clindamycin phosphate (1 % gel (gram), 1 % lotion, 1 % med. swab, 1 % solution, 2 % cream/appl) clotrimazole (1 % cream (g), 1 % solution, 10 mg troche) colistin (colistimethate na) 150 mg vial DENAVIR 1% CREAM econazole nitrate 1 % cream (g) erythromycin/benzoyl peroxide 3 %-5 % gel (gram) EXELDERM (CREAM, SOLUTION) ketoconazole (2 % cream (g), 2 % shampoo) lindane (1 % lotion, 1 % shampoo) malathion 0.5 % lotion metronidazole (0.75 % cream (g), 0.75 % gel (gram), 0.75 % gel w/appl, 0.75 % lotion) miconazole nitrate 200 mg supp.vag mupirocin 2 % oint. (g) 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼. 91

皮膚和黏膜藥物 nystatin/triamcinolone acetonide (cream (g), oint. (g)) OXISTAT (CREAM, LOTION) permethrin 5 % cream (g) silver sulfadiazine 1 % cream (g) terconazole (0.4 % cream/appl, 0.8 % cream/appl, 80 mg supp.vag) ZOVIRAX 5% OINTMENT 抗炎劑 ammonium lactate 12 % lotion betamethasone dipropionate (0.05 % cream (g), 0.05 % lotion, 0.05 % oint. (g)) betamethasone dipropionate/propylene glycol (0.05 % cream (g), 0.05 % lotion, 0.05 % oint. (g)) betamethasone valerate (0.1 % cream (g), 0.1 % lotion, 0.1 % oint. (g)) clobetasol propionate (0.05 % foam, 0.05 % gel (gram), 0.05 % lotion, 0.05 % oint. (g), 0.05 % shampoo, 0.05 % solution) clobetasol propionate/emoll 0.05 % cream (g) desonide (0.05 % cream (g), 0.05 % lotion, 0.05 % oint. (g)) desoximetasone (0.05 % cream (g), 0.05 % gel (gram), 0.25 % cream (g), 0.25 % oint. (g)) diflorasone diacetate (0.05 % cream (g), 0.05 % oint. (g)) fluocinonide (0.05 % gel (gram), 0.05 % oint. (g), 0.05 % solution) fluocinonide/emollient base 0.05 % cream (g) halobetasol propionate (0.05 % cream (g), 0.05 % oint. (g)) 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼 92

皮膚和黏膜藥物 hydrocortisone valerate (0.2 % cream (g), 0.2 % oint. (g)) KENALOG AEROSOL SPRAY mometasone furoate (0.1 % cream (g), 0.1 % oint. (g)) TACLONEX (0.005%-0.064% SUSPENS, OINTMENT) triamcinolone acetonide (0.025 % cream (g), 0.025 % lotion, 0.025 % oint. (g), 0.1 % cream (g), 0.1 % lotion, 0.1 % oint. (g), 0.5 % cream (g), 0.5 % oint. (g)) 止癢和局部麻醉 diphenhydramine hcl 50 mg/ml vial ZONALON 5% CREAM 細胞刺激劑及增生劑 KEPIVANCE 6.25 MG VIAL tretinoin (0.01 % gel (gram), 0.025 % cream (g), 0.025 % gel (gram), 0.05 % cream (g), 0.1 % cream (g)) 脫色和染色劑 OXSORALEN 1% LOTION PA OXSORALEN-ULTRA 10 MG CAP PA 皮膚和黏膜藥物, 雜項 adapalene (0.1 % cream (g), 0.1 % gel (gram)) AMNESTEEM (10 MG CAPSULE, 20 MG CAPSULE, 40 MG CAPSULE) calcipotriene (0.005 % oint. (g), 0.005 % solution) CLARAVIS (10 MG CAPSULE, 20 MG CAPSULE, 30 MG CAPSULE, 40 MG CAPSULE) ELIDEL 1% CREAM fluorouracil 5 % cream (g) 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼. 93

皮膚和黏膜藥物 PANRETIN 0.1% GEL podofilox 0.5 % solution PROTOPIC (0.03% OINTMENT, 0.1% OINTMENT) SANTYL OINTMENT SORIATANE (10 MG CAPSULE, 17.5 MG CAPSULE, 25 MG CAPSULE) TAZORAC (0.05% CREAM, 0.05% GEL, 0.1% CREAM, 0.1% GEL) VOLTAREN 1% GEL ZYCLARA (2.5% CREAM PUMP, 3.75% CREAM, 3.75% CREAM PUMP) 平滑肌鬆弛劑 泌尿生殖道平滑肌鬆弛劑 DETROL LA (2 MG CAPSULE, 4 MG CAPSULE) ST flavoxate hcl 100 mg tablet oxybutynin chloride (10 mg tab er 24, 15 mg tab er 24, 5 mg tab er 24, 5 mg tablet, 5 mg/5 ml syrup) OXYTROL 3.9 MG/24HR PATCH ST tolterodine tartrate (1 mg tablet, 2 mg tablet) trospium chloride (20 mg tablet, 60 mg cap er 24h) VESICARE (10 MG TABLET, 5 MG TABLET) ST 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼 94

治療營養素 / 礦物質 / 電解質 電解質 / 礦物改性劑 SYPRINE 250 MG CAPSULE 未分類 未分類 acetaminophen 160 mg/5ml liquid 3 $0 (g), * ampicillin sodium/sulbactam na 1.5 g vial port famotidine 10 mg tablet 3 $0 (g), * lidocaine hcl 2 % jel/pf app methotrexate sodium 25 mg/ml vial morphine sulfate (30 mg cpmp 24hr, 60 mg cpmp 24hr) 1 $0 QL ( 每 30 天 60), (g) sodium bicarbonate 650 mg tablet 3 $0 (g), * 未分類非處方藥 未分類非處方藥 ABREVA 10% CREAM 3 $0 * acetaminophen (100 mg/ml drops, 120 mg supp.rect, 160 mg/5ml oral susp, 325 mg tablet, 500 mg tablet) 3 $0 (g), * ACID CONTROL 75 MG TABLET 3 $0 * ADVANCED ANTACID LIQUID 3 $0 * ALL DAY ALLERGY (1 MG/ML SYRUP, 10 MG TABLET) 3 $0 * ALL DAY ALLERGY RLF 10 MG TAB 3 $0 * ALLER-TEC 10 MG TABLET 3 $0 * ALLERCLEAR 10 MG TABLET 3 $0 * 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼. 95

未分類非處方藥 ALLERGY D-12 TABLET 3 $0 * ALLERGY RELIEF (10 MG TABLET, 5 MG/5 ML SOLN, HM 4 MG TABLET) 3 $0 * ANTI-DIARRHEAL 2 MG CAPLET 3 $0 * ANTIOXIDANT VITAMIN TABLET 3 $0 * APRODINE TABLET 3 $0 * ARTIFICIAL TEARS 1.4 % DROPS 3 $0 * ascorbic acid (250 mg tablet, 500 mg tablet) 3 $0 (g), * ASPIR EC 81 MG TABLET 3 $0 * aspirin (300 mg supp.rect, 325 mg tablet, 325 mg tablet dr, 500 mg tablet dr, 600 mg supp.rect, 650 mg tablet dr, 81 mg tab chew) 3 $0 (g), * B COMPLETE TABLET 3 $0 * b complex with vitamin c tablet 3 $0 (g), * bacitracin 500 unit/g oint. (g) 3 $0 (g), * benzoyl peroxide (10 % cleanser, 10 % gel (gram), 10 % lotion, 5 % gel (gram)) bisacodyl (10 mg supp.rect, 5 mg tablet dr) bismuth subsalicylate (262 mg tab chew, 262mg/15ml oral susp) 3 $0 (g), * 3 $0 (g), * 3 $0 (g), * CALCIUM ANTACID 1,000 MG TAB 3 $0 * calcium carbonate (200(500)mg tab chew, 500(1250) tab chew, 500(1250) tablet) calcium carbonate/cholecalciferol (vitamin d3) (500 mg-200 tablet, 500 mg-400 tablet) 3 $0 (g), * 3 $0 (g), * CENTURY CARDIO TABLET 3 $0 * CENTURY TABLET 3 $0 * CENTURY ULTIMATE WOMEN'S TAB 3 $0 * cetirizine hcl (10 mg tablet, 5 mg tablet) 3 $0 (g), * 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼 96

未分類非處方藥 chlorpheniramine maleate 4 mg tablet 3 $0 (g), * cholecalciferol (vitamin d3) (1000 unit capsule, 1000 unit tablet, 2000 unit capsule, 2000 unit tablet, 400 unit capsule, 400 unit tablet, 400/ml drops, 5000 unit tablet) 3 $0 (g), * CLEARLAX POWDER 3 $0 * clotrimazole 1 % cream/appl 3 $0 (g), * CONGESTAC TABLET 3 $0 * COUGHTAB 200 MG TABLET 3 $0 * cromolyn sodium 5.2 mg spray/pump 3 $0 (g), * DIMETAPP COLD & COUGH LIQUID 3 $0 * docusate sodium (100 mg capsule, 100 mg tablet, 250 mg capsule, 50 mg/5 ml liquid, 60 mg/15ml syrup) 3 $0 (g), * DRIMINATE 50 MG TABLET 3 $0 * ED-CHLORTAN 4 MG TABLET 3 $0 * EYE ALLERGY RELIEF DROPS 3 $0 * FERGON 27 MG TABLET 3 $0 * FERREX 150 CAPSULE 3 $0 * ferrous gluconate 240(27)mg tablet 3 $0 (g), * ferrous sulfate (220(44)/5 solution, 3 $0 (g), * 324(65)mg tablet dr, 325(65) mg tablet, 325(65) mg tablet dr) FEVERALL 325 MG SUPPOSITORY 3 $0 * FIBER LAXATIVE 625 MG CAPLET 3 $0 * folic acid 0.4 mg tablet 3 $0 (g), * GAS RELIEF (125 MG CHEW TABLET, 20 3 $0 * MG/0.3 ML DROPS, 80 MG TABLET CHEW) GENTEAL GEL DROPS 3 $0 * GENTLE LAXATIVE EC 5 MG TABLET 3 $0 * GENTLELAX POWDER 3 $0 * 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼. 97

未分類非處方藥 guaifenesin/dextromethorphan 100-10mg/5 syrup 3 $0 (g), * HEARTBURN RELIEF 75 MG TABLET 3 $0 * HM ADULT TUSSIN DM SYRUP 3 $0 * hydrocortisone 1 % lotion 3 $0 (g), * hydrocortisone acetate 0.5 % cream (g) 3 $0 (g), * ibuprofen 200 mg tablet 3 $0 (g), * INFANT PAIN RLF 80 MG/0.8 ML 3 $0 * INFANTS PAIN RELIEF W-O ASA 3 $0 * kaolin/pectin oral susp 3 $0 (g), * LICE TREATMENT (1% CREME RINSE, SHAMPOO) loperamide hcl (1 mg/5 ml liquid, 2 mg tablet) loratadine (10 mg tablet, 5 mg/5 ml solution) 3 $0 * 3 $0 (g), * 3 $0 (g), * LORATADINE-D 24HR TABLET 3 $0 * mag hydrox/al hydrox/simeth 200-200- 20 oral susp magnesium oxide (250 mg tablet, 400 mg tablet, 500 mg tablet) 3 $0 (g), * 3 $0 (g), * meclizine hcl 25 mg tab chew 3 $0 (g), * METAMUCIL (PACKET, POWDER) 3 $0 * miconazole nitrate (100 mg supp.vag, 2 % cream (g), 2 % cream/appl, 200 mg-2 % kit) 3 $0 (g), * MOTION RELIEF 25 MG TABLET 3 $0 * MOTION SICKNESS RELIEF (50 MG TABLET, RELIEF TB CHEW) 3 $0 * multivitamin with minerals tablet 3 $0 (g), * multivitamins with iron tablet 3 $0 (g), * MURO-128 5% EYE OINTMENT 3 $0 * NEO-SYNEPHRINE 12 HOUR SPRAY 3 $0 * 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼 98

未分類非處方藥 nicotine (14mg/24hr patch td24, 21 3 $0 (g), * mg/24hr patch td24, 7mg/24hr patch td24) nicotine polacrilex (2 mg gum, 2 mg 3 $0 (g), * lozenge, 4 mg gum, 4 mg lozenge) omeprazole 20 mg tablet dr 3 $0 (g), * ONCE DAILY WITH IRON TABLET 3 $0 * ONE DAILY TABLET 3 $0 * pedi multivits a,c,&d3 no.21 1500-3 $0 (g), * 35/ml drops PEDIALYTE ELECTROLYTE SINGLES 3 $0 * PEDIATRIC ELECTROLYTE (PEDI FREEZER 3 $0 * POP, PEDIATRIC SOLN) permethrin 1 % liquid 3 $0 (g), * phytonadione 100 mcg tablet 3 $0 (g), * PLAN B ONE-STEP 1.5 MG TABLET 3 $0 * povidone-iodine (10 % med. pad, 10 % 3 $0 (g), * oint. (g), 10 % solution) PRILOSEC OTC 20.6 MG TABLET 3 $0 * pseudoephedrine hcl (30 mg tablet, 60 3 $0 (g), * mg tablet) PV NASAL ALLERGY SPRAY 3 $0 * pyridoxine hcl (100 mg tablet, 25 mg 3 $0 (g), * tablet, 250 mg tablet, 50 mg tablet) simethicone (125 mg tab chew, 3 $0 (g), * 40mg/0.6ml drops susp, 80 mg tab chew) SM STOMACH RELIEF 262 MG/15 ML 3 $0 * sodium chloride 5 % drops 3 $0 (g), * STOOL SOFTENER (100 MG SOFTGEL, 3 $0 * 250 MG SOFTGEL, 50 MG/5 ML LIQ, SYRUP) STRESS-C TABLET 3 $0 * SUPHEDRIN 30 MG TABLET 3 $0 * TAB-A-VITE WITH IRON TABLET 3 $0 * 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼. 99

未分類非處方藥 thiamine hcl (100 mg tablet, 250 mg tablet, 50 mg tablet) 3 $0 (g), * tolnaftate 1 % cream (g) 3 $0 (g), * TRI-VI-SOL DROPS 3 $0 * TRI-VI-SOL-IRON DROPS 3 $0 * TUMS TABLET CHEWABLE 3 $0 * TUSSIN CHEST CONGESTION LIQUID 3 $0 * TUSSIN DM (CLEAR LIQUID, COUGH SYRUP, LIQUID) 3 $0 * TUSSIN DM CLEAR SYRUP 3 $0 * TUSSIN DM COUGH & CHEST LIQUID 3 $0 * TUSSIN MUCUS-CONGEST 100 MG/5 3 $0 * vitamin a (10000 unit cpsule, 25000 unit cpsule) 3 $0 (g), * WAL-FINATE 4 MG TABLET 3 $0 * WAL-ITIN 10 MG TABLET 3 $0 * WAL-ZYR (10 MG TABLET, SOLUTION) 3 $0 * zinc sulfate 220(50)mg capsule 3 $0 (g), * ZOO CHEWS GUMMIE TABLET 3 $0 * 維生素 維生素 D calcitriol (0.25 mcg capsule, 0.5 mcg capsule) ZEMPLAR (10 MCG/2 ML VIAL, 2 MCG/ML VIAL, 5 MCG/ML VIAL) 8 點 ( 美國東部時間 ) 這是免費電話 更多詳細資訊, 請瀏覽網站 www.riverspringfida.org 您可翻至第 12 頁瞭解表格中的這些標識和縮寫代表什麼 100

按字母排列 0 0.9 % sodium chloride... 66 A abacavir sulfate... 13 abacavir/lamivudine/zidovudine... 13 ABELCET... 22 ABILIFY... 57 ABILIFY DISCMELT... 57 ABILIFY MAINTENA... 57 ABRAXANE... 26 ABREVA 10%... 95 acamprosate calcium... 12 acarbose... 77 acebutolol hcl... 34 acetaminophen... 95 acetaminophen with codeine phosphate... 47 acetazolamide... 42 acetic acid 2 %... 72 acetic acid/hydrocortisone 2 %-... 70 acetylcysteine... 83 ACID CONTROL... 95 ACTEMRA... 84 ACTHIB... 90 ACTIMMUNE... 84 ACTONEL... 85 ACTOPLUS MET XR... 77 ACUVAIL 0.45%... 71 acyclovir... 13 acyclovir sodium... 13 ADACEL TDAP... 89 ADAGEN... 69 adapalene... 93 ADCIRCA... 46 ADDERALL XR... 50 ADVANCED ANTACID... 95 AFINITOR... 26 AFINITOR DISPERZ... 26 AGGRENOX... 37 ALBENZA... 16 albuterol sulfate... 36 alcohol antiseptic pads... 62 alendronate sodium... 85 alfuzosin hcl... 34 ALIMTA... 26 ALINIA... 23 ALL DAY ALLERGY... 95 ALL DAY ALLERGY RLF... 95 ALLERCLEAR... 95 ALLERGY D-... 96 ALLERGY RELIEF... 96 ALLER-TEC... 95 allopurinol... 84 ALOCRIL 2%... 71 ALOMIDE... 25 ALOXI... 73 ALPHAGAN P 0.1%... 71 alprazolam... 55 ALTABAX 1%... 91 amantadine hcl... 13 AMBISOME... 22 amifostine crystalline... 87 amikacin sulfate... 16 amiloride hcl... 66 amiloride/hydrochlorothiazide... 42 AMINOSYN... 66 AMINOSYN II... 67 AMINOSYN M... 67 AMINOSYN-HBC... 67 AMINOSYN-PF... 67 amiodarone hcl... 41 AMITIZA... 74 amitriptyline hcl... 57 amitriptyline hcl/chlordiazepoxide... 57 amlodipine besylate... 41 amlodipine besylate/benazepril hcl... 42 ammonium lactate 12 %... 92 AMNESTEEM... 93 amoxapine... 57 amoxicillin... 16 amoxicillin/potassium clavulanate... 16 amphotericin... 22 101

ampicillin sodium/sulbactam na... 95 ampicillin sodium/sulbactam sodium... 17 ampicillin trihydrate... 17 AMPYRA ER... 86 AMTURNIDE... 42 anastrozole... 26 ANDROGEL... 77 ANDROID... 77 ANDROXY... 77 ANTI-DIARRHEAL... 96 ANTIOXIDANT... 96 ANZEMET... 73 APIDRA... 77 APIDRA SOLOSTAR... 77 APLENZIN... 57 APOKYN... 54 apraclonidine hcl 0.5 %... 72 APRISO ER 0.375... 72 APRODINE... 96 APTIOM... 51 APTIVUS... 13 ARANELLE... 80 ARANESP... 37 ARCALYST... 86 ARRANON... 26 ARTIFICIAL TEARS 1.4 %... 96 ARZERRA... 26 ASACOL HD DR... 72 ascorbic acid... 96 ASMANEX... 76 ASPIR EC... 96 aspirin... 96 ASTAGRAF XL... 86 atenolol... 34 atenolol/chlorthalidone... 34 atorvastatin calcium... 40 atovaquone/proguanil hcl... 23 ATRIPLA... 13 ATROVENT HFA... 33 AVANDAMET... 77 AVANDARYL... 78 AVANDIA... 78 AVASTIN... 26 AVELOX... 17 AVELOX IV... 17 AVIANE... 80 AVINZA... 47 AVODART... 83 AVONEX... 84 AVONEX ADMIN PACK... 84 AVONEX PEN... 84 AXIRON... 77 azacitidine... 26 AZACTAM-ISO-OSMOTIC DEXTROSE... 24 AZASAN... 84 azathioprine... 84 azelastine hcl... 88 AZILECT... 57 azithromycin... 17 AZOPT 1%... 71 aztreonam... 24 B B COMPLETE... 96 b complex with vitamin c... 96 bacitracin...17, 96 baclofen... 34 BACTROBAN 2%... 91 BACTROBAN NASAL 2%... 91 balsalazide disodium... 72 BALZIVA... 80 BANZEL... 51 BARACLUDE... 13 benazepril hcl... 43 benazepril hcl/hydrochlorothiazide... 43 BENICAR... 43 BENICAR HCT... 43 BENLYSTA... 86 benzonatate... 12 benzoyl peroxide... 96 benztropine mesylate... 54 betamethasone dipropionate... 92 betamethasone dipropionate/propylene glycol... 92 betamethasone valerate... 92 BETASERON... 84 betaxolol hcl... 34 102

betaxolol hcl 0.5 %... 71 BETOPTIC S 0.25%... 71 bicalutamide... 26 BICILLIN C-R... 17 BICILLIN L-A... 17 BICNU... 26 BILTRICIDE... 16 bisacodyl... 96 bismuth subsalicylate... 96 bisoprolol fumarate... 34 bisoprolol fumarate/hydrochlorothiazide... 34 bleomycin sulfate... 26 BLEPHAMIDE EYE DROPS... 70 BLEPHAMIDE EYE OINTMENT... 70 BONIVA... 85 BOOSTRIX TDAP... 89 BOOSTRIX VACCINE... 89 BOSULIF... 26 BOTOX... 34 BRILINTA... 39 brimonidine tartrate... 71 BRINTELLIX... 57 BRISDELLE... 57 bromfenac sodium 0.09%... 71 bromocriptine mesylate... 54 budesonide... 76 budesonide 3 mg... 71 bumetanide... 43 buprenorphine hcl... 47 BUPROBAN... 33 bupropion hcl... 57 buspirone hcl... 55 butalbit/acetamin/caff/codeine... 47 butorphanol tartrate... 47 BYETTA... 78 C cabergoline... 75 calcipotriene... 93 calcitonin,salmon,synthetic... 81 calcitriol... 86, 100 calcium acetate... 84 CALCIUM ANTACID... 96 calcium carbonate... 96 calcium carbonate/cholecalciferol... 96 CAMILA... 75 CANASA... 72 CANCIDAS... 22 CAPASTAT SULFATE... 26 CAPRELSA... 27 captopril... 43 captopril/hydrochlorothiazide... 43 CARAC... 27 CARAFATE... 73 carbamazepine... 51 carbidopa/levodopa... 54 carboplatin... 27 CARIMUNE NF NANOFILTERED... 89 carisoprodol... 34 carvedilol... 35 CAYSTON... 24 cefaclor... 17 cefadroxil... 17 cefadroxil hydrate... 17 cefazolin sodium... 17 cefazolin sodium/dextrose, iso-osmotic... 17 cefdinir... 17 cefepime hcl... 17 cefotaxime sodium... 17 cefotetan disodium... 17 cefoxitin sodium... 17 cefpodoxime proxetil... 18 cefprozil... 18 ceftazidime pentahydrate... 18 ceftazidime pentahydrate in dextrose... 18 ceftriaxone sodium... 18 cefuroxime axetil... 18 cefuroxime sodium... 18 CELEBREX... 47 CELLCEPT... 86 CELONTIN... 51 CENTURY... 96 CENTURY CARDIO... 96 CENTURY ULTIMATE WOMEN'S... 96 cephalexin... 18 CEREZYME... 69 CERVARIX VACCINE... 90 103

CESAMET... 73 cetirizine hcl... 88, 96 cevimeline hcl... 33 CHANTIX... 33 CHEMET... 75 CHENODAL... 74 chloramphenicol sod succ... 18 chlorhexidine gluconate... 62 chloride (10 mg tablet, 25... 33 chloroquine phosphate... 23 chlorothiazide... 43 chlorpheniramine maleate... 97 chlorpromazine hcl... 57 chlorpropamide... 78 chlorthalidone... 43 chlorzoxazone... 34 cholecalciferol... 97 cholestyramine/aspartame... 40 chorionic gonadotropin... 81 CIALIS... 46 ciclopirox... 91 ciclopirox olamine... 91 cidofovir... 13 cilostazol... 38 CILOXAN 0.3%... 70 cimetidine... 25 cimetidine hcl... 25 CINRYZE... 83 CIPRO... 18 CIPRO HC... 70 CIPRO I.V... 18 CIPRODEX... 70 ciprofloxacin hcl... 18, 70 ciprofloxacin lactate... 18 ciprofloxacin/ciprofloxacin hcl... 18 cisplatin... 27 citalopram hydrobromide... 57 cladribine... 27 CLARAVIS... 93 CLARINEX... 25 clarithromycin... 18 CLEARLAX... 97 clemastine fumarate... 25 CLEOCIN HCL... 18 clindamycin phosphate...19, 91 CLINIMIX... 67 CLINIMIX E... 67 CLINISOL... 67 clobetasol propionate... 92 clobetasol propionate/emoll 0.05 %... 92 CLOLAR... 27 clomipramine hcl... 57 clonazepam... 51 clonidine... 36 clonidine hcl... 36 clopidogrel bisulfate... 38 clorazepate dipotassium... 51 CLORPRES... 36 clotrimazole... 91 clotrimazole 1 %... 97 clozapine... 57 COARTEM... 23 codeine sulfate... 47 colchicine/probenecid 0.5... 68 COLCRYS... 84 colestipol hcl... 40 colistin... 91 COMBIGAN... 71 COMETRIQ... 27 COMPLERA... 13 COMTAN... 54 COMVAX VACCINE... 90 CONCERTA... 50 CONGESTAC... 97 COPAXONE... 84 CORTISPORIN CREAM... 71 COSMEGEN... 27 COUGHTAB... 97 CREON... 69 CRESTOR... 40 CRIXIVAN... 13 cromolyn sodium... 27, 88, 97 CRYSELLE... 80 CUBICIN... 19 cyanocobalamin... 12 cyclobenzaprine hcl... 34 104

cyclophosphamide... 27 CYCLOSET... 54 cyclosporine... 84, 86 cyclosporine, modified... 84 CYMBALTA... 57 cyproheptadine hcl... 25 cytarabine... 27 cytarabine/pf... 27 D dacarbazine... 27 DACOGEN... 27 DALIRESP... 88 danazol... 77 dantrolene sodium... 34 dapsone... 22 DAPTACEL DTAP VACCINE... 89 DARAPRIM... 23 daunorubicin hcl... 27 DAYTRANA... 50 decitabine... 27 DEMSER... 40 DENAVIR 1%... 91 DEPEN... 75 DEPO-PROVERA... 27 DEPO-SUBQ PROVERA... 80 desloratadine... 25 desmopressin acetate... 37, 76 desonide... 92 desoximetasone... 92 DETROL LA... 94 dexamethasone... 76 DEXAMETHASONE INTENSOL... 76 dexamethasone sod phosphate... 76 dexamethasone sod phosphate 0.1 %... 71 DEXILANT... 73 dexmethylphenidate hcl... 50 dexrazoxane hcl... 87 dextroamphetamine sulfsaccharate/amphetamine sulf- aspartate.. 50 dextroamphetamine sulfate... 50 dextrose... 65 dextrose 10 % in water... 65 dextrose 5 % in water... 65 dextrose 5%-lactated ringers... 67 diazepam... 51 DIBENZYLINE... 35 diclofenac potassium... 47 diclofenac sodium...27, 47 dicloxacillin sodium... 19 dicyclomine hcl... 33 didanosine... 13 DIFICID... 19 diflorasone diacetate... 92 diflunisal... 47 digoxin... 41 dihydroergotamine mesylate... 35 DILANTIN...41, 51 DILAUDID... 47 diltiazem hcl... 41 DIMETAPP COLD & COUGH... 97 DIOVAN... 43 DIPENTUM... 72 diphenhydramine hcl... 93 diphenoxylate hcl/atropine... 33 diphenoxylate hcl/atropine 2.5-... 73 dipyridamole... 38 disopyramide phosphate... 41 disulfiram... 83 divalproex sodium... 51 DOCEFREZ... 27 docetaxel... 27 docusate sodium... 97 donepezil hcl... 33 DORIBAX... 19 dorzolamide hcl/timolol maleat 2 %... 72 doxazosin mesylate... 35 doxepin hcl... 58 DOXIL... 27 doxorubicin hcl... 27 doxycycline hyclate... 19 doxycycline monohydrate... 19 DRIMINATE... 97 dronabinol... 73 DULERA... 36 duloxetine hcl... 58 DURAMORPH... 12 105

DYRENIUM... 43 E E.E.S.... 19 econazole nitrate 1 %... 91 ED-CHLORTAN... 97 EDLUAR... 55 EDURANT... 13 EFFIENT... 38 ELIDEL 1%... 93 ELIGARD... 28 ELITEK... 69 ELIXOPHYLLIN... 43 ELLA... 80 EMCYT... 28 EMEND... 73 EMSAM... 58 EMTRIVA... 13 enalapril maleate... 43 enalapril maleate/hydrochlorothiazide... 43 ENBREL... 84 ENGERIX-B ADULT... 90 ENGERIX-B PEDIATRIC-ADOLESCENT... 90 enoxaparin sodium... 38 ENPRESSE... 80 EPIFLUR... 85 epinastine hcl... 71 EPIPEN... 36 EPIPEN JR... 36 epirubicin hcl... 28 EPIVIR... 13 EPIVIR HBV... 13 eplerenone... 43 EPOGEN... 37 EPZICOM... 13 ERBITUX... 28 ergocalciferol... 12 ergoloid mesylates... 35 ERIVEDGE... 28 ERWINAZE... 28 ERYPED... 19 ERYTHROCIN... 19 ERYTHROCIN LACTOBIONATE... 19 erythromycin base... 19 erythromycin base/ethyl alcohol... 19 erythromycin ethylsuccinate... 19 erythromycin/benzoyl peroxide 3 %-5 %... 91 escitalopram oxalate... 58 estradiol... 69 estradiol/norethindrone acet 1 mg... 69 ethambutol hcl... 23 etidronate disodium... 85 etodolac... 47 etoposide... 28 EVISTA... 81 EXELDERM... 91 EXELON... 33 exemestane... 28 EXFORGE... 43 EXFORGE HCT... 43 EXJADE... 75 EXTAVIA... 84 EYE ALLERGY RELIEF... 97 F FABRAZYME... 69 famciclovir... 13 famotidine...25, 95 famotidine in nacl,iso-osm/pf... 25 FANAPT... 58 FARESTON... 28 FASLODEX... 28 FAZACLO... 58 felbamate... 52 fenofibrate... 40 fenofibrate nanocrystallized... 40 fenofibrate,micronized... 40 fenoprofen calcium... 47 fentanyl... 47 FERGON... 97 FERREX... 97 ferrous gluconate... 97 ferrous sulfate... 97 FETZIMA... 58 FEVERALL... 97 FIBER LAXATIVE... 97 finasteride... 83 FIRAZYR... 83 106

FIRMAGON... 28 flavoxate hcl... 94 flecainide acetate... 41 FLOVENT DISKUS... 76 FLOVENT HFA... 76 fluconazole... 22 fluconazole in dextrose, iso-osmotic... 22 flucytosine... 22 fludarabine phosphate... 28 fludrocortisone acetate... 76 fluocinolone acetonide... 71 fluocinonide... 92 fluocinonide/emollient base 0.05 %... 92 FLUOR-A-DAY... 85 FLUORITAB... 85 fluorouracil... 28 fluorouracil 5 %... 93 fluoxetine hcl... 58 fluphenazine decanoate... 58 fluphenazine hcl... 58 flurbiprofen... 48 flurbiprofen sodium 0.03 %... 71 flutamide... 28 fluticasone propionate... 76, 88 fluvastatin sodium... 40 fluvoxamine maleate... 58 FOCALIN XR... 50 folic acid... 12, 97 FOLOTYN... 28 fondaparinux sodium... 38 FORFIVO XL... 58 FORTEO... 81 FORTESTA... 77 foscarnet sodium... 13 fosinopril sodium... 44 fosinopril sodium/hydrochlorothiazide... 44 fosphenytoin sodium... 52 FOSRENOL... 66 FRAGMIN... 38 furosemide... 44 FUSILEV... 84 FUZEON... 13 FYCOMPA... 52 G gabapentin... 48 GABITRIL... 52 GAMMAGARD... 89 GAMMAGARD S-D... 89 GAMMAPLEX 5%... 89 GAMUNEX 10%... 89 GAMUNEX-C... 89 GARDASIL... 90 GAS RELIEF... 97 GASTROCROM... 88 gauze bandage... 62 gemcitabine hcl... 28 gemfibrozil... 40 GENOTROPIN... 81 GENTAK 0.3 %... 70 gentamicin sulfate... 19 gentamicin sulfate 0.3 %... 70 gentamicin sulfate/pf... 20 GENTEAL... 97 GENTLE LAXATIVE EC... 97 GENTLELAX... 97 GEODON... 58 GILENYA... 84 GILOTRIF... 28 GLEEVEC... 28 glimepiride... 78 glipizide... 78 glipizide/metformin hcl... 78 GLUCAGON... 84 glyburide... 78 glyburide,micronized... 78 glyburide/metformin hcl... 78 glycopyrrolate... 33 granisetron hcl... 73 granisetron hcl/pf... 73 griseofulvin, microsize... 22 GRIS-PEG... 22 guaifenesin/dextromethorphan... 98 guanfacine hcl... 44 H HALAVEN... 28 107

halobetasol propionate... 92 haloperidol... 58 haloperidol lactate... 59 HAVRIX... 90 hcl 50mg-... 50 HEARTBURN RELIEF... 98 heparin sodium,porcine... 38 heparin sodium,porcine in... 38 heparin sodium,porcine/dextrose... 38 HEPATAMINE... 67 HEPATASOL... 67 HEPSERA... 14 HERCEPTIN... 28 HEXALEN... 28 HM ADULT TUSSIN DM... 98 HORIZANT ER... 48 HP ACTHAR GEL... 82 HUMIRA... 74 HUMIRA PED CROHN'S STARTER PK... 74 HUMULIN 70/30 KWIKPEN... 78 HUMULIN 70-30... 78 HUMULIN N... 78 HUMULIN R... 78 hydralazine hcl... 44 hydrochlorothiazide... 44 hydrocodone bit/acetaminophen... 48 hydrocodone bitartrate/acetaminophen... 48 hydrocodone/ibuprofen... 48 hydrocortisone... 76 hydrocortisone 1 %... 98 hydrocortisone acetate 0.5 %... 98 hydrocortisone valerate... 93 hydromorphone hcl... 48 hydromorphone hcl/pf... 48 hydroxychloroquine sulfate... 23 hydroxyurea... 28 hydroxyzine hcl... 55 hydroxyzine pamoate... 55 I ibandronate sodium... 85 ibuprofen... 48, 98 ibuprofen/oxycodone hcl... 48 ifosfamide... 29 ILARIS... 83 IMBRUVICA... 29 imipenem/cilastatin sodium... 20 imipramine hcl... 59 imipramine pamoate... 59 IMITREX... 54 IMOVAX RABIES VACCINE... 90 INCIVEK... 14 INCRELEX... 82 indapamide... 44 INDOCIN... 48 indomethacin... 48 INFANRIX DTAP... 89 INFANT PAIN RLF... 98 INFANTS PAIN RELIEF W-O ASA... 98 INLYTA... 29 INTELENCE... 14 INTRALIPID... 65 INTRON A... 29 INTUNIV... 44 INVANZ... 24 INVEGA... 59 INVEGA SUSTENNA... 59 INVIRASE... 14 IONOSOL MB-D5W... 65 IPOL... 90 ipratropium bromide... 33 ipratropium/albuterol sulfate... 33 irbesartan... 46 irbesartan/hydrochlorothiazide... 44 irinotecan hcl... 29 ISENTRESS... 14 ISOLYTE S... 67 isoniazid... 23 ISOPTO CARPINE... 72 isosorbide dinitrate... 46 isosorbide mononitrate... 46 isradipine... 44 ISTODAX... 29 itraconazole... 22 IXEMPRA... 29 IXIARO... 90 108

J JAKAFI... 29 JALYN... 35 JANUMET... 78 JEVTANA... 29 JINTELI... 80 JUNEL... 80 JUNEL FE... 80 K KADCYLA... 29 KALETRA... 14 KALYDECO... 89 kaolin/pectin... 98 KENALOG... 93 KEPIVANCE... 93 KETEK... 20 ketoconazole... 22, 91 ketoprofen... 48 ketorolac tromethamine... 48, 71 KHEDEZLA... 59 KINERET... 83 KLOR-CON... 67 KOMBIGLYZE XR... 79 KUVAN... 87 L labetalol hcl... 35 lactulose... 65 LAMICTAL... 52 LAMICTAL ODT... 52 LAMICTAL TB... 52 LAMICTAL XR... 52 LAMISIL... 22 lamivudine... 14 lamivudine/zidovudine... 14 lamotrigine... 52 lansoprazole... 73 LANTUS... 79 LANTUS SOLOSTAR... 79 latanoprost 0.005 %... 72 LATUDA... 59 LESSINA... 80 LETAIRIS... 46 letrozole... 29 leucovorin calcium... 87 LEUKERAN... 29 LEUKINE... 39 leuprolide acetate... 29 LEVEMIR... 79 LEVEMIR FLEXPEN... 79 LEVEMIR FLEXTOUCH... 79 levetiracetam... 52 levobunolol hcl 0.5 %... 72 levocarnitine... 87 levocarnitine (with sugar)... 87 levocetirizine dihydrochloride... 25 levofloxacin... 20 levofloxacin/dextrose 5 % in water... 20 levonorgestrel... 12 levonorgestrel-ethinyl estradiol... 80 levorphanol tartrate... 48 levothyroxine sodium... 82 LEXIVA... 14 LIALDA DR... 72 LICE TREATMENT... 98 lidocaine... 83 lidocaine hcl...83, 95 lidocaine/prilocaine... 83 LIDODERM... 83 lindane... 91 liothyronine sodium... 82 LIPOSYN III... 65 lisinopril... 44 lisinopril/hydrochlorothiazide... 44 lithium carbonate... 54 lithium citrate... 54 lomustine... 29 loperamide hcl...73, 98 loratadine... 98 LORATADINE-D... 98 lorazepam... 52 LORAZEPAM INTENSOL... 52 losartan potassium... 46 losartan potassium/hydrochlorothiazide... 44 LOTRONEX... 74 lovastatin... 40 109

LOVAZA... 40 LOW-OGESTREL... 80 loxapine succinate (... 59 LUDENT FLUORIDE... 86 LUMIGAN 0.01%... 72 LUMIZYME... 68 LUPRON DEPOT... 29, 75 LUPRON DEPOT-PED... 75 LUTERA... 80 LUVOX CR... 59 LYRICA... 53 LYSODREN... 29 M MACRODANTIN... 23 mag hydrox/al hydrox/simeth 200... 98 magnesium oxide... 98 malathion 0.5 %... 91 maprotiline hcl... 59 MARPLAN... 59 MATULANE... 29 meclizine hcl... 25, 98 meclofenamate sodium... 48 medroxyprogesterone acetate... 80, 82 mefloquine... 23 MEGACE ES... 29 megestrol acetate... 29 MEKINIST... 29 meloxicam... 48 MENACTRA... 90 MENEST... 69 MENOMUNE-A-C-Y-W-135... 90 MENOSTAR... 81 MENVEO A-C-Y-W-135... 90 meperidine hcl... 48 meperidine hcl/pf... 49 MEPERITAB... 49 MEPHYTON... 12 meprobamate... 55 MEPRON... 23 mercaptopurine... 30 meropenem... 20 mesalamine w/cleansing wipes... 72 mesna... 87 MESNEX... 87 MESTINON... 34 METADATE CD... 50 METAMUCIL... 98 metaproterenol sulfate... 36 metformin hcl... 79 methadone hcl...12, 49 methazolamide... 72 methenamine hippurate... 23 methimazole... 82 methocarbamol... 34 methotrexate sodium...30, 95 methotrexate sodium/pf... 30 methscopolamine bromide... 33 methyclothiazide... 44 methyldopa... 36 methyldopa/hydrochlorothiazide... 36 methylergonovine maleate... 87 methylphenidate hcl... 51 methylprednisolone... 76 methylprednisolone acetate... 76 metoclopramide hcl... 74 metolazone... 44 metoprolol succinate... 35 metoprolol tartrate... 35 metoprolol tartrate/hydrochlorothiazide... 35 metronidazole...20, 91 metronidazole/sodium chloride... 20 mexiletine hcl... 41 MIACALCIN... 81 MICARDIS... 44 MICARDIS HCT... 44 miconazole nitrate...91, 98 MICROGESTIN... 80 MICROGESTIN FE... 80 midodrine hcl... 36 MIGERGOT... 35 minocycline hcl... 20 mirtazapine... 59 misoprostol... 73 mitomycin... 30 mitoxantrone hcl... 30 M-M-R II VACCINE... 90 110

modafinil... 51 moexipril hcl... 45 moexipril hcl/hydrochlorothiazide... 45 mometasone furoate... 93 montelukast sodium... 88 morphine sulfate... 49, 95 MOTION RELIEF... 98 MOTION SICKNESS RELIEF... 98 MOXEZA 0.5%... 70 MOZOBIL... 39 multivitamin with minerals... 98 multivitamins with iron... 98 mupirocin 2 %... 91 MURO-128 5%... 98 MUSTARGEN... 30 MYCOBUTIN... 26 mycophenolate mofetil... 86 mycophenolate sodium... 86 MYFORTIC... 86 N nabumetone... 49 nadolol... 35 nafcillin in dextrose, iso-osmotic... 20 nafcillin sodium... 20 NAGLAZYME... 69 nalbuphine hcl... 49 naloxone hcl... 56 naltrexone hcl... 56 NAMENDA... 56 naproxen... 49 naproxen sodium... 49 naratriptan hcl... 54 NASONEX... 88 nateglinide... 79 NEBUPENT... 23 NECON... 81 needles, insulin disposable... 62 needles, insulin disposable, safety... 62 nefazodone hcl... 59 neomy sulf/bacitra/polymyxin... 70 neomy sulf/bacitrac zn/poly/hc... 70 neomycin sulfate... 20 neomycin sulfate/polymyxin b sulfate... 66 neomycin sulfate/polymyxin b sulfate/hydrocortisone... 71 NEO-SYNEPHRINE 12 HOUR... 98 NEULASTA... 39 NEUMEGA... 39 NEUPOGEN... 39 NEUPRO... 32 NEVANAC 0.1%... 71 nevirapine... 14 NEXAVAR... 30 NIACOR... 40 NIASPAN... 40 nicardipine hcl... 45 nicotine... 99 nicotine polacrilex... 99 NICOTROL NS... 33 nifedipine... 41 NILANDRON... 30 nimodipine... 45 nisoldipine... 45 NITRO-BID... 46 nitrofurantoin... 23 nitrofurantoin macrocrystal... 23 nitrofurantoin monohyd/m-cryst... 23 nitroglycerin... 46 NITROMIST... 46 NITROSTAT... 46 nizatidine... 25 norethindrone... 75 norethindrone acetate... 82 NORMOSOL-M AND DEXTROSE... 65 NORMOSOL-R... 67 NORMOSOL-R-DEXTROSE... 65 NORPRAMIN... 59 NORTREL... 81 nortriptyline hcl... 59 NORVIR... 14 NOVOLIN 70-30... 79 NOVOLIN N... 79 NOVOLIN R... 79 NOVOLOG... 79 NOVOLOG FLEXPEN SYRINGE... 79 NOVOLOG MIX 70-30 FLEXPEN SYRN... 79 111

NOVOLOG MIX 70-30 VIAL... 79 NOXAFIL... 22 NUCYNTA... 49 NUCYNTA ER... 49 NUEDEXTA... 56 NULOJIX... 86 nystatin... 22 nystatin/triamcinolone acetonide... 92 O octreotide acetate... 74 ofloxacin... 20, 70 OGESTREL... 81 olanzapine/fluoxetine hcl... 60 OLYSIO... 32 omeprazole... 74, 99 OMNARIS... 71 OMNITROPE... 82 ONCASPAR... 30 ONCE DAILY WITH IRON... 99 ondansetron... 73 ondansetron hcl... 73 ondansetron hcl/pf... 73 ONE DAILY... 99 ONGLYZA... 79 ORAP... 60 orphenadrine citrate... 34 ORTHO EVRA PATCH... 81 OSMOPREP... 74 OVCON-35... 81 oxacillin sodium... 20 oxacillin sodium/dextrose, iso-osmotic... 20 oxaliplatin... 30 oxandrolone... 77 oxaprozin... 49 oxcarbazepine... 53 OXISTAT... 92 OXSORALEN 1%... 93 OXSORALEN-ULTRA... 93 OXTELLAR XR... 53 oxybutynin chloride... 94 oxycodone hcl... 49 oxycodone hcl/aspirin... 38 OXYTROL... 94 P paclitaxel... 30 pamidronate disodium... 85 PANCREAZE... 69 PANRETIN 0.1%... 94 pantoprazole sodium... 74 paromomycin sulfate... 20 paroxetine hcl... 60 PASER GRANULES... 26 PAXIL... 60 PED (30 MG 3MO KIT,... 29 pedi multivits a,c,&d3... 99 PEDIALYTE ELECTROLYTE SINGLES... 99 PEDIATRIC ELECTROLYTE... 99 PEDVAXHIB VACCINE... 90 PEGANONE... 53 PEGASYS... 14 PEGASYS PROCLICK... 14 PEGINTRON... 14 PEGINTRON REDIPEN... 14 pen needle, diabetic, remover &... 62 pen needle, diabetic, safety... 62 penicillin g potassium... 20 penicillin g procaine... 21 penicillin g sodium... 21 penicillin v potassium... 21 PENNSAID... 50 PENTACEL ACTHIB COMPONENT... 90 PENTAM... 23 pentoxifylline... 39 perindopril erbumine... 45 PERJETA... 30 permethrin 1 %... 99 permethrin 5 %... 92 perphenazine... 60 perphenazine/amitriptyline hcl... 60 phenelzine sulfate... 60 phenylephrine hcl/promethazine hcl... 36 phenytoin... 42 phenytoin sodium... 53 phenytoin sodium extended... 42 phytonadione... 99 PICATO... 30 112

pilocarpine hcl... 72 pindolol... 35 pioglitazone hcl... 79 pioglitazone hcl/glimepiride... 79 pioglitazone hcl/metformin hcl... 79 piperacillin sodium/tazobactam sodium... 21 piroxicam... 50 PLAN B ONE-STEP... 99 PLASMA-LYTE... 65 PLASMA-LYTE 148... 67 PLASMA-LYTE A... 67 podofilox 0.5 %... 94 polyethylene glycol... 65 polymyxin b sulf/trimethoprim... 21 POMALYST... 30 PONSTEL... 50 potassium chloride... 67 potassium chloride in 0.9 % sodium chloride 67 potassium chloride in dextrose... 66 potassium chloride in lr-d5... 67 potassium chloride/d5-0.2%nacl... 66 potassium chloride/d5-0.3%nacl... 66 potassium citrate... 64 POTIGA... 53 povidone-iodine... 99 PRADAXA... 38 pramipexole di-hcl... 55 PRANDIMET... 79 pravastatin sodium... 40 prazosin hcl... 35 PRED MILD 0.12%... 71 PRED-G 1%... 70 prednisolone... 77 prednisolone sod phosphate... 77 prednisolone sod phosphate 1 %... 71 prednisone... 77 PREDNISONE... 77 PREMARIN... 81 PREMASOL... 68 PREZISTA... 14 PRIFTIN... 26 PRILOSEC OTC... 99 primaquine phosphate... 23 primidone... 53 PRISTIQ ER... 60 PRIVIGEN... 89 probenecid... 68 PROCALAMINE... 68 prochlorperazine edisylate... 60 prochlorperazine maleate... 60 PROCRIT... 37 progesterone,micronized... 81 PROGLYCEM... 39 PROGRAF... 86 PROLASTIN C... 88 PROLEUKIN... 30 PROLIA... 85 PROMACTA... 39 promethazine hcl... 56 propafenone hcl... 42 propantheline bromide... 33 proparacaine hcl 0.5 %... 72 propranolol hcl... 35 propranolol hcl/hydrochlorothiazide... 35 propylthiouracil... 82 PROQUAD... 90 PROSOL... 68 PROTOPIC... 94 protriptyline hcl... 60 PROVENTIL... 37 pseudoephedrine hcl... 99 PULMOZYME... 69 PV NASAL ALLERGY... 99 pyrazinamide... 26 pyridostigmine bromide... 34 pyridoxine hcl... 99 Q quetiapine fumarate... 60 quinapril hcl... 45 quinapril hcl/hydrochlorothiazide... 45 quinidine gluconate... 42 quinidine sulfate... 42 quinine sulfate... 23 QVAR... 88 113

R RABAVERT RABIES VACCINE... 90 ramipril... 45 RANEXA... 42 ranitidine hcl... 25 RAPAFLO... 35 RAPAMUNE... 86 REBETOL... 14 REBIF... 85 REBIF REBIDOSE... 85 RECLAST... 85 RECOMBIVAX HB... 90 RELENZA... 14 RELISTOR... 74 REMICADE... 74 REMODULIN... 46 RENAF... 86 RENAGEL... 66 RENVELA... 66 RESCRIPTOR... 14 reserpine... 45 RESTASIS 0.05%... 71 REVLIMID... 30 REYATAZ... 15 RIBASPHERE... 15 ribavirin... 15 RIDAURA... 85 RIFAMATE... 21 rifampin... 21 RIFATER... 21 RILUTEK... 56 rimantadine hcl... 15 ringers solution... 68 ringers solution,lactated... 68 RIOMET... 80 RISPERDAL CONSTA... 60 risperidone... 60 RITALIN LA... 51 RITUXAN... 30 rivastigmine tartrate... 34 rizatriptan benzoate... 54 ropinirole hcl... 55 ROTARIX... 89 ROTATEQ VACCINE... 90 ROZEREM... 56 S SABRIL... 53 SAMSCA... 68 SANCUSO... 73 SANDIMMUNE... 86 SANDOSTATIN LAR... 74 SANTYL... 94 SAPHRIS... 60 selegiline hcl... 61 SELZENTRY... 15 SENSIPAR... 87 SEREVENT... 37 SEROQUEL XR... 61 sertraline hcl... 61 sildenafil citrate... 46 SILENOR... 61 silver sulfadiazine 1 %... 92 SIMCOR... 40 simethicone... 99 SIMPONI... 85 SIMULECT... 86 sirolimus... 86 SM STOMACH RELIEF... 99 sodium bicarbonate... 95 sodium chloride... 68 sodium chloride 0.45 %... 68 sodium chloride 3 %... 68 sodium chloride 5 %...68, 99 sodium chloride irrig solution... 68 sodium fluoride... 86 sodium lactate... 64 sodium polystyrene sulfonate... 66 SOLARAZE... 30 SOLTAMOX... 30 SOLU-CORTEF... 77 SOLU-MEDROL... 77 SOMATULINE DEPOT... 87 SOMAVERT... 82 SORIATANE... 94 sotalol hcl... 35 SOVALDI... 32 114

SPIRIVA... 33 spironolact/hydrochlorothiazid... 45 spironolactone... 66 SPORANOX... 22 SPRINTEC... 81 SPRIX... 50 SPRYCEL... 30 STALEVO... 55 stavudine... 15 STIVARGA... 30 STOOL SOFTENER... 99 STRATTERA... 56 streptomycin sulfate... 21 STRESS-C... 99 STRIBILD... 15 STROMECTOL... 16 SUBOXONE... 56 sucralfate... 74 sulfacetamide sodium... 70 sulfacetamide/prednisolone sp... 70 sulfadiazine... 21 sulfamethoxazole/trimethoprim... 21 sulfasalazine... 73 SULFAZINE EC... 73 sulindac... 50 sumatriptan succinate... 54 SUPHEDRIN... 99 SUPRAX... 21, 24 SURMONTIL... 61 SUSTIVA... 15 SUTENT... 30 SYLATRON... 15 SYMBICORT... 37 SYMLINPEN 120... 80 SYMLINPEN 60... 80 SYNAGIS... 15 SYNAREL... 81 SYNERCID... 24 SYNRIBO... 30 SYPRINE... 95 syr,ndl,ins,safe,disp un... 62 syring w-ndl,disp,insul... 62 syringe w/needle,insulin disposable... 63 syringe with needle, insulin... 63 syringe with needle, insulin, safety... 63 syringe with needle,disposable,insulin... 63 syringe with needle,insulin disposable... 64 syringe,needle,insulin,safety,disposal unit... 64 T TAB-A-VITE WITH IRON... 99 TACLONEX... 93 tacrolimus... 86 TAFINLAR... 31 TAMIFLU... 15 tamoxifen citrate... 31 TARCEVA... 31 TARGRETIN... 31 TARKA... 42 TASIGNA... 31 TASMAR... 55 TAZORAC... 94 TEFLARO... 24 TEGRETOL XR... 53 TEKAMLO... 46 TEKTURNA... 46 TEKTURNA HCT... 45 terazosin hcl... 36 terbinafine hcl... 22 terbutaline sulfate... 37 terconazole... 92 TESTIM 1%... 77 testosterone cypionate... 77 tetanus & diphtheria tox,adult... 89 tetanus toxoid, adsorbed/pf 5 lf/0.5ml... 89 THALOMID... 85 theophylline anhydrous... 45 thiamine hcl... 100 thioridazine hcl... 61 thiothixene... 61 tiagabine hcl... 53 ticlopidine hcl... 38 TIKOSYN... 42 timolol maleate...36, 72 tinidazole... 23 TIVICAY... 15 tizanidine hcl... 34 115

TOBI... 21 TOBI PODHALER... 21 TOBRADEX EYE OINTMENT... 70 TOBRADEX ST EYE DROPS... 70 tobramycin 0.3 %... 70 tobramycin sulfate... 21 tobramycin/dexamethasone 0.3 %-... 70 tobramycin/sodium chloride... 21 TOBREX 0.3%... 70 tolazamide... 80 tolbutamide... 80 tolmetin sodium... 50 tolnaftate 1 %... 100 tolterodine tartrate... 94 topiramate... 53 topotecan hcl... 31 TORISEL... 31 torsemide... 45 TPN ELECTROLYTES VIAL... 68 TRACLEER... 46 tramadol hcl... 50 tramadol hcl/acetaminophen... 50 trandolapril... 45 tranexamic acid... 39 TRANSDERM-SCOP... 24 tranylcypromine sulfate... 61 TRAVASOL... 68 TRAVATAN Z 0.004%... 72 trazodone hcl... 61 TREANDA... 31 TRECATOR... 26 TRELSTAR... 31 TRELSTAR DEPOT... 31 TRELSTAR LA... 31 tretinoin... 31, 93 TREXALL... 31 TREXIMET... 50 triamcinolone acetonide... 88, 93 triamterene/hydrochlorothiazide... 45 trifluoperazine hcl... 61 trifluridine 1 %... 70 trihexyphenidyl hcl... 55 TRILIPIX... 41 trimethobenzamide hcl... 73 TRINESSA... 81 TRISENOX... 31 TRI-SPRINTEC... 81 TRI-VI-SOL... 100 TRI-VI-SOL-IRON... 100 TRIVORA... 81 TRIZIVIR... 15 TROKENDI XR... 53 TROPHAMINE... 68 trospium chloride... 94 TRUVADA... 15 TUMS... 100 TUSSIN CHEST CONGESTION... 100 TUSSIN DM... 100 TUSSIN DM CLEAR... 100 TUSSIN DM COUGH & CHEST... 100 TUSSIN MUCUS-CONGEST... 100 TWINRIX VACCINE... 90 TYGACIL... 24 TYKERB... 31 TYPHIM VI 25 MCG/0.5 ML... 90 TYSABRI... 85 TYZEKA... 15 U ULORIC... 84 ursodiol... 74 UVADEX... 31 V valacyclovir hcl... 15 VALCYTE... 15 valproate sodium... 53 valproic acid... 53 valsartan/hydrochlorothiazide... 46 vancomycin hcl... 21 VAQTA... 90 VECTIBIX... 31 VELCADE... 31 venlafaxine hcl... 61 VENTOLIN HFA... 37 VERAMYST... 88 verapamil hcl... 42 116

VERELAN... 42 VERSACLOZ... 61 VESICARE... 94 VFEND... 22 VICTOZA 2-PAK... 80 VICTOZA 3-PAK... 80 VICTRELIS... 15 VIDAZA... 31 VIDEX... 15 VIGAMOX 0.5%... 70 VIIBRYD... 61 VIMPAT... 53 vinblastine sulfate... 31 vincristine sulfate... 31 vinorelbine tartrate... 31 VIRAMUNE... 16 VIRAMUNE XR... 16 VIRAZOLE... 16 VIREAD... 16 vitamin a... 100 VIVITROL... 56 VOLTAREN 1%... 94 voriconazole... 22, 24 VYTORIN... 41 VYVANSE... 51 W WAL-FINATE... 100 WAL-ITIN... 100 WAL-ZYR... 100 warfarin sodium... 38 WELCHOL... 41 X XALKORI... 32 XENAZINE... 56 XGEVA... 85 XIFAXAN... 21 XOLAIR... 88 XTANDI... 32 XYREM... 56 Y YERVOY... 32 YF-VAX... 91 Z zafirlukast... 88 zaleplon... 56 ZALTRAP... 32 ZANOSAR... 32 ZAVESCA... 87 ZEGERID... 64 ZELAPAR... 61 ZELBORAF... 32 ZEMAIRA... 88 ZEMPLAR... 100 ZENPEP... 69 ZETIA... 41 ZIAGEN... 16 zidovudine... 16 zinc sulfate... 100 ziprasidone hcl... 61 ZOLINZA... 32 zolpidem tartrate... 56 ZOLPIMIST... 56 ZOMETA... 85 ZOMIG... 54 ZOMIG ZMT... 54 ZONALON 5%... 93 ZONATUSS... 12 zonisamide... 53 ZOO CHEWS... 100 ZORTRESS... 32 ZOSTAVAX... 91 ZOVIA... 81 ZOVIRAX 5%... 92 ZYCLARA... 94 ZYFLO CR... 88 ZYKADIA... 32 ZYMAXID 0.5%... 70 ZYTIGA... 32 ZYVOX... 22 117

本處方一覽表更新於 2014 年 10 月 9 日 瞭解更多更新資訊或其他問題, 請與我們連絡,RiverSpring FIDA 計劃電話為 1-800-950-9000 或者 TTY 使用者請撥 TTY/TDD 711 或者 1-800-456-7890, 工作時 間為每週 7 天, 每天早 8 點到晚 8 點 ( 美國東部時間 ), 或瀏覽我們網站 www.riverspringfida.org. 118

RiverSpring FIDA 計劃 2015 年承保藥物清單 ( 處方一覽表 ) 版本 : Si tiene alguna pregunta, llame al Plan RiverSpring FIDA al 1-800-950-9000, los 7 días de la semana, 8 am a 8 pm hora del Este. La llamada es gratuita. Para más información, visite www.riverspringfida.org. 119

RiverSpring FIDA Plan (Medicare-Medicaid 計劃 ) ElderServe Health, Inc. / RiverSpring Health Plans www.riverspringfida.org 1 (800) 950-9000 TTY/TDD:1 (866) 236-5800 ElderServe Health, Inc. 以 RiverSpring FIDA Plan 的名義展開業務, 是 Hebrew Home 在 Riverdale 的附屬公司 H6435_2015FormularyCH_Approved