Default - CareMore - CA - Chinese

處方藥物清單 藥物清單 CareMore Cal MediConnect Plan (Medicare-Medicaid Plan) 洛杉磯郡 加州 2016 請查閱 本文件包含本計劃中給付藥物的相關資訊 本處方藥物清單更新日期 10/05/2016. 如果您有任何疑問 請致電 CareMore Cal MediConnect Plan 會員服務部 電話號碼1-888-350-3447 (TTY 711), 太平洋時間週一至週五上午 8點至下午 8點 如需更多資訊 請瀏覽網站 duals.caremore.com. H6629_16_25137_T_001_CTCMS Approved 08/26/2015 處方藥物 ID: 16405 版本 22 發佈時間 1/1/2016

H6629_16_25137_T_001_CT CMS Approved 09/01/2015 CareMore Cal MediConnect Plan (Medicare-Medicaid Plan) 2016 給付藥物清單 ( 處方藥物清單 ) 這是會員可於 CareMore Cal MediConnect Plan (Medicare-Medicaid Plan) 取得的藥物清單 CareMore Cal MediConnect Plan 是一個同時與 Medicare 和 Medi-Cal 訂立合約的醫療保健 計劃, 從而為參保人提供這兩個計劃的福利 CareMore 代表 CareMore 的附屬公司執行合 約 CareMore 是 CareMore Health System 的註冊商標 給付藥物清單 及 / 或藥局與醫療服務提供者網路全年之中都會有所變更 在我們執行影 響您的變更前, 我們會向您寄送通知 福利和 / 或共付費用可能於每年 1 月 1 日進行變動 您可以隨時瀏覽網站 duals.caremore.com, 線上查看 CareMore Cal MediConnect Plan 的最 新 給付藥物清單, 或致電 1-888-350-3447 (TTY 711) 您可以免費獲得其他格式的資料, 如大型字體版本或音訊版本 請撥打電話 1-888-350-3447 (TTY 711) 此為免費電話 條件及限制可能適用 有關更多資訊, 請致電 CareMore Cal MediConnect Plan 會員服務部, 或閱讀 CareMore Cal MediConnect Plan 會員手冊 您可以免費取得此資訊的其他語言版本 請致電 1-888-350-3447 (TTY 711), 週一至週五, 上午 8 點至下午 8 點 此為免費電話 Դուք կարող եք ստանալ այս ձեռնարկն անվճար է այլ լեզուներով: Call երկուշաբթի - ուրբաթ `8:00 - ից 8:00 - ին: TTY օգտվողները պետք է զանգահարել 711. Կանչի ազատ է 您可以免費取得本手冊其他語言版本 請致電, 週一至週五, 上午 8:00 至晚上 8:00 TTY 使用者可撥打 711 此為免費電話 الخط الخاص 1-888-350-3447 بإمكانك الحصول على هذه المعلومات مجانا بلغات أخرى. اتصل على الرقم 8 من يوم االثنين لغاية يوم الجمعة ومن الساعة 711 TTY باالعضاء ممن لديهم ضعف في السمع أو النظر. مساءا. هذه المكالمة مجانية 8 صباحا لغاية 8:00 می توانید این دفترچه را به طور رایگان به سایر زبان ها دریافت کنید. از دوشنبه تا جمعه و از ساعت " تماس بگیرند. 711 باید با شماره TTY تماس بگیرید. کاربران 1-888-350-3447 شب با شماره 8:00 صبح تا " این تماس رایگان است 귀하께서는이안내서를다른언어로무료로받아보실수있습니다. 주중 ( 월 - 금 ) 오전 8:00 시 에서오후 8:00 시사이에번으로전화해주십시오. TTY 사용자는 711 로전화해주십시오. 통 화는무료입니다. Этот справочник можно бесплатно получить в переводе на другие языки. Звоните по телефону, линия работает с понедельника по пятницу с 8:00 до 20:00. Если вы пользуетесь устройством TTY, звоните по телефону 711. Звонки бесплатные. Puedes recibir este manual en otros idiomas sin cargo. Llama al de lunes a viernes, de 8.00 a.m. a 8.00 p.m. Los usuarios de TTY deben llamar al 711. La llamada es gratuita. Makukuha ninyo nang libre ang handbook na ito sa ibang wika. Tawagan ang, Lunes hanggang Biyernes 8:00 a.m. hanggang 8:00 p.m. Ang mga gumagamit ng TTY ay dapat tawagan ang 711. Libre ang pagtawag. Quy vi co thê nhâṇ sô tay naỳ miêñ phi băǹg cać ngôn ngư khać. Haỹ goị sô, tư Thư Hai đêń Thư Saú, từ 8 giơ sańg đêń 8 giơ tôí. Ngươì duǹg TTY câǹ goị đêń sô 711. Cuô c goị được miêñ phi. (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全 天候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 1

常見問題 (FAQ) 如果您對本 給付藥物清單 有疑問, 您可以在此尋找解答 您可閱讀所有常見問題 (Frequently Asked Questions, FAQ) 以了解更多資訊, 或僅查詢某問題的解答 1. 給付藥物清單 中有哪些處方藥物 ( 我們將 給付藥物清單 簡稱為 藥物清單 ) 藥物清單 中列出了 CareMore Cal MediConnect Plan 給付的藥物 您可在本計劃網路內的藥房 取得這些藥物 本計劃網路內的藥房是與本計劃簽訂協議, 並與本計劃合作為您提供服務的藥房 我們稱這些藥房為 網路藥房 CareMore Cal MediConnect Plan 在以下情況下給付 藥物清單 上的所有具有醫療必要性的藥 物 : 您的醫師或其他處方醫師表示您需要這些藥物使病情好轉或保持健康, 以及 您可以到 CareMore Cal MediConnect Plan 網路內藥房領取藥物 在某些情況下, 您必須在領取藥物之前採取一些行動 ( 請參閱後面的問題 5) 您也可以瀏覽我們的網站 duals.caremore.com 或撥打會員服務部電話 1-888-350-3447 (TTY 711), 查看我們給付的最新藥物清單 2. 藥物清單 的內容會變更嗎 是 CareMore Cal MediConnect Plan 可能會在年度內增加或刪除 藥物清單 上的某些藥物 一 般而言, 藥物清單 的內容僅有在下列情況下才會變更 : 價格較低且功效與現在 藥物清單 中之藥物相當的藥物出現, 或 我們得知該藥物不安全 我們也可能會變更本計劃的藥物相關規定 例如, 我們可以 : 決定某藥物是否需要事先批准 ( 事先批准是在取得藥物前獲得 CareMore Cal MediConnect Plan 的許可 ) 增加或變更您可領取的藥量 ( 稱為 供藥量限制 ) 新增或變更某藥物的漸進式治療限制 ( 漸進式治療表示您必須先使用某種藥物, 然後我們 才給付另外一種藥物 ) ( 如需了解關於這些藥物規定的更多資訊, 請參閱第 4 頁上的內容 ) 當我們將您正在服用的藥物自 藥物清單 中移除時, 我們將會告知您 當我們變更本計劃的藥物 給付規定時, 我們亦會告知您 以下的問題 3 4 和 7 將會提供更多有關 藥物清單 變更事宜的 資訊 您可以隨時瀏覽網站 duals.caremore.com, 線上查看 CareMore Cal MediConnect Plan 的最 新 藥物清單 您還可以撥打會員服務部電話 1-888-350-3447 (TTY 711), 查看目前 藥 物清單 (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全 天候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 2

3. 當有價格較低且功效與現在 藥物清單 中之藥物相當的藥物出現時將會 如何 如您正在服用的藥物因出現價格較低且功效相當的藥物而被移除, 我們會告知您 我們會在將其從 藥物清單 中移除或重新領取藥物之前至少 60 天告知您 那麼您能在藥物被從藥物清單移除前 獲得 60 天的供藥量 如果在年度內對藥物清單做出非例行性變更, 我們將寄信告知您 我們將在 網站上刊登通知信 4. 如果我們發現某項藥物並不安全將會如何 如果 Food and Drug Administration (FDA) 表示您正在服用的藥物並不安全, 我們會立刻將該藥物 自 藥物清單 中移除 我們亦會寄信給您告知您此事宜 如果您收到關於不安全藥物的通知, 請 立即致電您的醫師 您的醫師可以幫助您確定最適合您的其他藥物 5. 藥物的給付範圍是否有任何限制或上限 或者在領取某些藥物之前是否有 任何必須採取的行動 是, 部分藥物有給付規定或您可領取的藥量限制 在某些情況下, 您的醫師或其他處方醫師必須採 取一些行動, 您才能領取藥物 例如 : 事先批准 ( 或事先授權 ): 針對某些藥物, 在領取處方藥物之前, 您或您的醫師或者其他處 方醫師必須取得 CareMore Cal MediConnect Plan 的批准 如果您未得到批准,CareMore Cal MediConnect Plan 可能不給付藥物 供藥量限制 : 有時候,CareMore Cal MediConnect Plan 設定了您可以領取的藥物限制 漸進式治療 : 有時候,CareMore Cal MediConnect Plan 會要求您接受漸進式治療 這表示 您必須按一定的順序嘗試使用適用於您病況的藥物 您可能必須先試用某種藥物, 而後我們 才會給付其他藥物 如果您的醫師認為第一種藥物對您沒有療效, 那麼我們將會給付第二種 藥物 您可以查看第 9-129 頁上的表格, 查詢所需藥物是否有任何額外要求或限制 您也可以瀏覽我們的 網站 duals.caremore.com 了解更多資訊 我們已在網站上發佈文件, 解釋我們的事先授權限制 您亦可要求我們寄送一份副本給您 您可以要求對這些限制做出例外處理 請參閱問題 11 以了解更多有關例外處理的資訊 如果您住在療養院或其他長期照護機構且您需要不在 藥物清單 中的藥物, 或者您無法輕 易取得您所需的藥物, 我們可協助您 不管您是否是 CareMore Cal MediConnect Plan 新會 員, 我們將給付您所需要藥物的 31 天緊急供藥量 ( 除非您的處方規定更少天數的供藥量 ) 這將讓您有時間可以和您的醫師或其他處方開立者商量 其可協助您決定 藥物清單 中是 否有類似的藥物可以取代您服用的藥物, 或者協助您決定是否應該申請例外處理 請參閱問 題 11 以了解更多有關例外處理的資訊 6. 您該如何知道您需要的藥物是否有限制或您是否需要在領取藥物之前採取 任何行動 T 第 6 頁的 給付藥物清單 中有一欄標為 必須採取的行動 限制, 或使用限制 (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全 天候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 3

7. 如果我們變更本計劃部分藥物的給付方式將會如何 ( 例如, 我們新增了 某項藥物的事先授權 ( 批准 ) 供藥量限制和 / 或漸進式治療限制 ) 如果我們新增了某項藥物的事先批准 供藥量限制和 / 或漸進式治療限制, 我們將會告知您 我們 將會在新增限制前的至少 60 天內或在您下次要求藥房續配處方時告知您 而後, 您將可在給付規 定變更之前獲得該藥物 60 天的供藥量 這將讓您有時間和您的醫師或其他處方開立者商量下一步 該怎麼做 8. 您該如何在 藥物清單 中尋找藥物 尋找藥物的方式有兩種 : 您可按字母順序搜尋 ( 如您知道藥物如何拼寫 ), 或 您可按醫療的病症搜尋 如按字母順序搜尋, 請前往按字母順序的名單部分 您可以使用藥物名稱的首字母查找 如按醫療病症搜尋, 請找到第 9 頁的 按醫療病症分類的藥物清單 部分內容 本部分中的藥物根 據用於治療疾病的類型, 被分類到不同的類別 例如, 如果您患有心臟病, 您應該查看類別 心血 管 高血壓 / 血脂藥治療物 您將可在該類別中找到治療心臟病症的藥物 9. 如果您欲服用的藥物不在 藥物清單 中該怎麼辦 如果您在 藥物清單 上找不到您的藥物, 請撥打電話 1-888-350-3447 (TTY 711) 諮詢會員服務 部 如果您了解到 CareMore Cal MediConnect Plan 不給付該藥物, 您可以執行以下操作之一 : 向會員服務部索取與您欲服用之藥物的類似藥物清單 然後將該清單交給您的醫師或其他處 方開立者 其可開立 藥物清單 中與您欲服用之藥物類似的藥物 ; 或 您可要求保健計劃進行例外處理以給付您的藥物 請參閱問題 11 以了解更多有關例外處理的 資訊 10. 如果您是 CareMore Cal MediConnect Plan 新會員, 而且在 藥物清單 上找不到您的藥物或在獲取藥物方面存在問題, 您該怎麼辦 我們會為您提供協助 我們在您成為 CareMore Cal MediConnect Plan 會員後前 90 天給付暫時性 的 30 天供藥量 這將讓您有時間可以和您的醫師或其他處方開立者商量 其可協助您決定 藥物 清單 中是否有類似的藥物可以取代您服用的藥物, 或者協助您決定是否應該申請例外處理 我們在以下情況下為您給付 30 天的供藥量 : 您正在服用的藥物不在我們的 藥物清單 中, 或 保健計劃規定不允許您領取處方醫師指定的藥量, 或 該藥物需要 CareMore Cal MediConnect Plan 事先批准, 或 您正在服用的藥物是屬於漸進式治療限制中的藥物 (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全 天候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 4

如果您居住在療養院或其他長期照護機構, 您可以重新領取長達 91 98 天的處方藥物 在該計劃的 前 90 天中, 您可以多次重新領取藥物 這將能夠讓您的處方醫師有時間將您的藥物變更為 藥物 清單 上的藥物或者申請例外處理 如果您的照護級別發生變更, 需要您轉移機構或者治療中心, 您可能有資格領取一次性臨時處方藥 物供應 例如, 如果您從醫院出院並且根據醫院處方獲得出院藥物清單, 您可以一次性領取藥物 您可以臨時一次性例外領取藥物, 不管您是否處於加入計劃的前 90 天 請讓您的處方醫師致電我 們了解詳情 11. 您可以申請例外處理以使您的藥物獲得給付嗎 是 您可以要求 CareMore Cal MediConnect Plan 例外給付不在 藥物清單 上的藥物 您也可要求本計劃變更您藥物的相關規定 例如,CareMore Cal MediConnect Plan 可能會限制我們給付藥物的藥量 假如您的藥物具 有藥量限制, 您可以要求我們更改限制並給付更多的數量 其他範例 : 您可要求本計劃取消漸進式治療限制或事先批准規定 12. 例外處理申請需要多久時間 首先, 我們必須收到支持您例外處理申請的醫師或其他處方醫師的聲明 在我們收到聲明後, 我們 將會在 72 小時內告知您我們針對您例外處理申請所做的決定 如果您或您的處方開立者認為等待 72 小時將會使您的健康受損, 您可申請加速例外處理 這表示 您將可更快得到決定 如果您的處方開立者有為您的急件申請提供佐證, 我們將會在收到您處方開 立者所提供之支持聲明後的 24 小時內告知您我們的決定 13. 您該如何提出例外處理申請 如需提出例外處理申請, 請致電會員服務部 會員服務部將與您及您的醫療服務提供者合作, 幫助 您申請例外處理 14. 什麼是一般藥物 一般藥物的構成成份與原廠藥物一樣 一般藥物的價格通常比品牌藥低, 且一般藥物的名稱通常較 不廣為人知 一般藥物是經 Food and Drug Administration (FDA) 批准的藥物 CareMore Cal MediConnect Plan 給付原廠藥物和一般藥物 15. 什麼是非處方藥物 (OTC) OTC 全稱是 over-the-counter 當您的醫療服務提供者為您開具非處方藥物時,CareMore Cal MediConnect Plan 也給付這些藥物 您可以參閱 CareMore Cal MediConnect Plan 藥物清單, 了解所給付的 OTC 藥物 (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全 天候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 5

16. CareMore Cal MediConnect Plan 是否給付 OTC 非藥物產品 當您的醫療服務提供者為您開具 OTC 非藥物產品時,CareMore Cal MediConnect Plan 也給付這 些產品 您可以參閱 CareMore Cal MediConnect Plan 藥物清單, 了解所給付的 OTC 非藥物產品 17. 您需支付多少共付費用 您可以參閱 CareMore Cal MediConnect Plan 藥物清單, 了解每種藥物的共付費用 住在療養院或其他長期照護機構的 CareMore Cal MediConnect Plan 會員無需支付共付費用 一些 在社區中取得長期照護服務的會員也無需支付共付費用 共付費用按級別列出 同一級別的藥物群組具有相同的共付費用 第 1 級藥物為一般藥物 此級別藥物的共付費用為 $0 第 2 級藥物為原廠藥物 此級別藥物的共付費用為 $0 第 3 級藥物為 Medi-Cal 給付的處方藥物 此級別藥物的共付費用為 $0 第 4 級藥物為 Medi-Cal 給付的非處方 (OTC) 藥物 此級別藥物的共付費用為 $0 給付藥物清單 以下給付藥物清單為您提供 CareMore Cal MediConnect Plan 給付的藥物資訊 假如您在清單中 查找藥物時有困難, 請翻到從第 146 頁開始的索引 表格第一欄所列的是藥物名稱 原廠藥物的名稱為大寫 ( 例如 BRAND NAME EXAMPLE), 一般 藥物則為小寫斜體字 ( 例如 generic example) 透過 必須採取的行動 限制, 或使用限制 欄的資訊, 您將了解 CareMore Cal MediConnect Plan 對於給付您的藥物是否有任何規定 以下是我們使用的縮寫清單.. 縮寫 B/D HI LA PAR 描述 B 部分與 D 部分決定 居家點滴 限制供應 郵購藥物 需要事先授權 解釋 根據實際狀況, 該處方藥物可由 Medicare B 部分或 D 部分給 付 可能需要呈交藥物使用和設置的資訊, 以進行判定 我們的醫療福利給付本處方藥物 如需更多資訊, 請聯絡會員 服務部, 電話 1-888-350-3447 (TTY 711) 本處方藥物僅在特定的藥房供應 如需更多資訊, 請聯絡會員 服務部, 電話 1-888-350-3447 (TTY 711) 該處方藥物透過我們的郵購服務以及網路內零售藥房提供 考 慮透過郵購服務來取得長期使用的 ( 維持性 ) 藥物 ( 比如高血 壓藥物 ) 網路內零售藥房可能更適合於取得短期服用的處方 藥物 ( 比如抗生素 ) 此計劃要求您或您的醫師取得某些處方藥物的預先批准 這意 味著您需要在配藥前先取得批准 如果您沒有取得批准, 我們 可能不會給付此藥物 (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全 天候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 6

QLL ST 供藥量限 漸進式治療 對于某些藥物, 此計劃會限制給付藥物的數量 您必須先嘗試另一種藥物, 才可取得此藥物 請注意 : 藥物旁邊的星號 (*) 意味著該藥物並非 D 部分藥物 您不需要支付這些藥物的共付費 用 這類藥物也有不同的上訴規定 上訴是在您認為我們有錯誤的情況下, 要求我們審查我們對您 的給付福利做出之決定, 並要求我們做出變更的一種正式的方式 例如, 我們可能決定某項您欲取 得的藥物不屬於或不再屬於 Medicare 或 Medi-Cal 的給付範圍 如果您或您的醫師不同意我們的 決定, 您可以提出上訴 如果您有任何疑問, 請撥打會員服務部電話 1-888-350-3447 (TTY 711) 您也可參閱 會員手冊 以了解針對我們的決定提出上訴的方式 (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全 天候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 7

按醫療病症分類的藥物清單 本部分中的藥物根據用於治療疾病的類型, 被分類到不同的類別 例如, 如果您患有心臟病, 您應該查看 類別 心血管 高血壓 / 血脂藥治療物 您將可在該類別中找到治療心臟病症的藥物 藥物名稱 ANTI - INFECTIVES ANTIFUNGAL AGENTS ABELCET AMBISOME amphotericin b CANCIDAS clotrimazole mucous membrane ERAXIS(WATER DILUENT) fluconazole fluconazole in dextrose(iso-o) fluconazole in nacl (iso-osm) intravenous piggyback 100 mg/50 ml, 400 mg/200 ml fluconazole in nacl (iso-osm) intravenous piggyback 200 mg/100 ml flucytosine griseofulvin microsize oral suspension griseofulvin ultramicrosize itraconazole ketoconazole oral NOXAFIL ORAL SUSPENSION nystatin oral suspension nystatin oral tablet terbinafine hcl oral B/D; ; HI B/D; B/D; B/D; PAR; ; QLL (630 per 30 days) ; QLL (30 per 30 days) 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/2016 8

voriconazole intravenous voriconazole oral suspension for reconstitution voriconazole oral tablet 200 mg voriconazole oral tablet 50 mg ANTIVIRALS abacavir abacavir-lamivudine-zidovudine acyclovir oral capsule acyclovir oral suspension 200 mg/5 ml acyclovir oral tablet acyclovir sodium intravenous solution adefovir amantadine hcl oral capsule amantadine hcl oral tablet APTIVUS ORAL CAPSULE APTIVUS ORAL SOLUTION ATRIPLA BARACLUDE ORAL SOLUTION COMPLERA CRIXIVAN ORAL CAPSULE 200 MG CRIXIVAN ORAL CAPSULE 400 MG DESCOVY didanosine oral capsule,delayed release(dr/ec) 125 mg PAR; ; QLL (300 per 30 days) PAR; ; QLL (60 per 30 days) PAR; ; QLL (120 per 30 days) ; QLL (60 per 30 days) ; QLL (60 per 30 days) B/D; ; QLL (120 per 30 days) QLL (390 per 30 days) ; QLL (30 per 30 days) PAR; ; QLL (600 per 30 days) ; QLL (30 per 30 days) ; QLL (360 per 30 days) ; QLL (180 per 30 days) QLL (30 per 30 days) ; QLL (90 per 30 days) (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 9

didanosine oral capsule,delayed release(dr/ec) 200 mg didanosine oral capsule,delayed release(dr/ec) 250 mg, 400 mg EDURANT EMTRIVA ORAL CAPSULE EMTRIVA ORAL SOLUTION entecavir EPCLUSA EPIVIR HBV ORAL SOLUTION EPIVIR ORAL SOLUTION EPZICOM EVOTAZ famciclovir oral tablet 125 mg, 250 mg famciclovir oral tablet 500 mg foscarnet FUZEON SUBCUTANEOUS RECON SOLN ganciclovir sodium GENVOYA HARVONI INTELENCE ORAL TABLET 100 MG INTELENCE ORAL TABLET 200 MG INTELENCE ORAL TABLET 25 MG INVIRASE ORAL CAPSULE INVIRASE ORAL TABLET ISENTRESS ORAL POWDER IN PACKET ISENTRESS ORAL TABLET ; QLL (60 per 30 days) ; QLL (30 per 30 days) ; QLL (30 per 30 days) ; QLL (30 per 30 days) ; QLL (870 per 30 days) PAR; ; QLL (30 per 30 days) PAR; QLL (30 per 30 days) ; QLL (960 per 30 days) ; QLL (30 per 30 days) ; QLL (30 per 30 days) ; QLL (60 per 30 days) ; QLL (21 per 7 days) B/D ; QLL (60 per 30 days) ; QLL (30 per 30 days) PAR; ; QLL (28 per 28 days) ; QLL (120 per 30 days) ; QLL (60 per 30 days) ; QLL (480 per 30 days) ; QLL (300 per 30 days) ; QLL (120 per 30 days) ; QLL (120 per 30 days) 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/2016 10

ISENTRESS ORAL TABLET,CHEWABLE 100 MG ISENTRESS ORAL TABLET,CHEWABLE 25 MG KALETRA ORAL SOLUTION KALETRA ORAL TABLET 100-25 MG KALETRA ORAL TABLET 200-50 MG lamivudine oral solution lamivudine oral tablet 100 mg lamivudine oral tablet 150 mg lamivudine oral tablet 300 mg lamivudine-zidovudine LEXIVA ORAL SUSPENSION LEXIVA ORAL TABLET DERIBA nevirapine oral suspension nevirapine oral tablet nevirapine oral tablet extended release 24 hr 100 mg nevirapine oral tablet extended release 24 hr 400 mg NORVIR ORAL CAPSULE NORVIR ORAL SOLUTION NORVIR ORAL TABLET ODEFSEY OLYSIO PREZCOBIX ; QLL (180 per 30 days) ; QLL (720 per 30 days) ; QLL (480 per 30 days) ; QLL (300 per 30 days) ; QLL (120 per 30 days) ; QLL (900 per 30 days) ; QLL (60 per 30 days) ; QLL (30 per 30 days) ; QLL (60 per 30 days) ; QLL (1800 per 30 days) ; QLL (120 per 30 days) ; QLL (1200 per 30 days) ; QLL (60 per 30 days) ; QLL (30 per 30 days) ; QLL (360 per 30 days) ; QLL (480 per 30 days) ; QLL (360 per 30 days) QLL (30 per 30 days) PAR; ; QLL (30 per 30 days) (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 11

PREZISTA ORAL SUSPENSION PREZISTA ORAL TABLET 150 MG PREZISTA ORAL TABLET 600 MG, 800 MG PREZISTA ORAL TABLET 75 MG RELENZA DISKHALER RESCRIPTOR ORAL TABLET RESCRIPTOR ORAL TABLET, DISPERSIBLE RETROVIR INTRAVENOUS REYATAZ ORAL CAPSULE 150 MG, 200 MG REYATAZ ORAL CAPSULE 300 MG REYATAZ ORAL POWDER IN PACKET ribasphere oral capsule ribasphere oral tablet 200 mg ribavirin oral capsule ribavirin oral tablet 200 mg rimantadine SELZENTRY SOVALDI stavudine oral capsule 15 mg, 20 mg stavudine oral capsule 30 mg, 40 mg stavudine oral recon soln STRIBILD SUSTIVA ORAL CAPSULE 200 MG SUSTIVA ORAL CAPSULE 50 MG SUSTIVA ORAL TABLET SYNAGIS TAMIFLU ; QLL (420 per 30 days) ; QLL (180 per 30 days) ; QLL (60 per 30 days) ; QLL (300 per 30 days) ; QLL (60 per 180 days) ; QLL (180 per 30 days) ; QLL (360 per 30 days) ; QLL (60 per 30 days) ; QLL (30 per 30 days) ; QLL (240 per 30 days) ; QLL (120 per 30 days) PAR; ; QLL (120 per 30 days) ; QLL (60 per 30 days) ; QLL (2400 per 30 days) ; QLL (30 per 30 days) ; QLL (120 per 30 days) ; QLL (360 per 30 days) ; QLL (30 per 30 days) PAR; ; LA 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/2016 12

TECHNIVIE TIVICAY ORAL TABLET 10 MG, 25 MG TIVICAY ORAL TABLET 50 MG TRIUMEQ TRIZIVIR TRUVADA ORAL TABLET 100-150 MG, 133-200 MG, 167-250 MG TRUVADA ORAL TABLET 200-300 MG TYBOST TYZEKA valacyclovir valganciclovir oral tablet VIDEX 2 GRAM PEDIATRIC VIDEX 4 GRAM PEDIATRIC VIEKIRA PAK VIEKIRA XR VIRACEPT ORAL TABLET 250 MG VIRACEPT ORAL TABLET 625 MG VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 HR 100 MG VIRAZOLE VIREAD ORAL POWDER VIREAD ORAL TABLET VITEKTA ZEPATIER ZIAGEN ORAL SOLUTION PAR; ; QLL (56 per 28 days) QLL (60 per 30 days) ; QLL (60 per 30 days) ; QLL (30 per 30 days) ; QLL (60 per 30 days) QLL (30 per 30 days) ; QLL (30 per 30 days) ; QLL (30 per 30 days) ; QLL (30 per 2 days) ; QLL (1200 per 30 days) ; QLL (1200 per 30 days) PAR; PAR ; QLL (300 per 30 days) ; QLL (120 per 30 days) PAR; ; QLL (240 per 30 days) ; QLL (30 per 30 days) ; QLL (30 per 30 days) PAR; ; QLL (30 per 30 days) ; QLL (960 per 30 days) (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 13

zidovudine oral capsule zidovudine oral syrup zidovudine oral tablet CEPHALOSPORINS cefaclor oral capsule cefaclor oral suspension for reconstitution 125 mg/5 ml cefaclor oral suspension for reconstitution 250 mg/5 ml, 375 mg/5 ml cefaclor oral tablet extended release 12 hr cefadroxil oral capsule cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml cefadroxil oral tablet cefazolin in dextrose (iso-os) intravenous piggyback 1 gram/50 ml cefazolin injection recon soln 1 gram cefazolin injection recon soln 10 gram, 100 gram, 20 gram, 300 g cefazolin injection recon soln 500 mg cefazolin intravenous cefdinir cefepime cefoxitin in dextrose, iso-osm cefoxitin intravenous recon soln 1 gram ; QLL (180 per 30 days) ; QLL (1920 per 30 days) ; QLL (60 per 30 days) ; HI HI ; HI ; HI HI ; HI 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/2016 14

cefoxitin intravenous recon soln 10 gram, 2 gram cefpodoxime cefprozil ceftazidime injection recon soln 1 gram, 2 gram ceftazidime injection recon soln 6 gram ceftriaxone in dextrose,iso-os ceftriaxone injection recon soln 1 gram, 2 gram, 250 mg, 500 mg ceftriaxone injection recon soln 10 gram ceftriaxone intravenous cefuroxime axetil oral tablet cefuroxime sodium intravenous vial injection recon soln 1.5 gram, 750 mg cefuroxime sodium intravenous vial intravenous recon soln 7.5 gram cephalexin oral capsule 250 mg, 500 mg cephalexin oral suspension for reconstitution cephalexin oral tablet HI ; HI HI ; HI HI ; HI ; HI HI TEFLARO ERYTHROMYCINS / OTHER MACROLIDES azithromycin intravenous recon soln 500 mg (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 15

azithromycin intravenous recon soln 500 mg (2 mg/ml) azithromycin oral suspension for reconstitution azithromycin oral tablet clarithromycin oral suspension for reconstitution clarithromycin oral tablet clarithromycin oral tablet extended release 24 hr ery-tab oral tablet,delayed release (dr/ec) 250 mg, 333 mg ERY-TAB ORAL TABLET,DELAYED RELEASE (DR/EC) 500 MG erythrocin (as stearate) oral tablet 250 mg ERYTHROCIN INTRAVENOUS RECON SOLN 500 MG erythromycin ethylsuccinate oral tablet ; QLL (28 per 2 days) erythromycin oral tablet MISCELLANEOUS ANTIINFECTIVES ALBENZA ALINIA ORAL SUSPENSION FOR RECONSTITUTION ALINIA ORAL TABLET amikacin injection solution 1,000 mg/4 ml, 500 mg/2 ml atovaquone atovaquone-proguanil oral tablet 250-100 mg ; QLL (180 per 3 days) PAR; 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/2016 16

AZACTAM AZACTAM IN DEXTROSE (ISO-OSM) baciim bacitracin intramuscular BILTRICIDE CAPASTAT CAYSTON chloramphenicol sod succinate chloroquine phosphate oral clindamycin hcl clindamycin phosphate injection clindamycin phosphate intravenous solution 300 mg/2 ml, 900 mg/6 ml clindamycin phosphate intravenous solution 600 mg/4 ml COARTEM colistin (colistimethate na) CUBICIN DAPSONE daptomycin DARAPRIM ethambutol gentamicin injection gentamicin sulfate (ped) (pf) gentamicin sulfate (pf) intravenous solution 100 mg/10 ml ; HI HI PAR; ; LA ; HI (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 17

GENTAMICIN SULFATE (PF) INTRAVENOUS SOLUTION 60 MG/6 ML gentamicin sulfate (pf) intravenous solution 80 mg/8 ml hydroxychloroquine oral imipenem-cilastatin INVANZ INJECTION isoniazid oral linezolid oral suspension for reconstitution linezolid oral tablet mefloquine meropenem metro i.v. metronidazole in nacl (iso-os) metronidazole oral MYCOBUTIN NEBUPENT neomycin paromomycin PASER PENTAM PRIFTIN PRIMAQUINE pyrazinamide quinine sulfate rifampin RIFATER ; HI ; HI PAR; ; QLL (1800 per 2 days) ; QLL (28 per 2 days) ; HI B/D; PAR; 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/2016 18

SIRTURO STREPTOMYCIN INTRAMUSCULAR STROMECTOL SYNERCID TOBI tobramycin sulfate injection recon soln tobramycin sulfate injection solution TRECATOR TYGACIL XIFAXAN ORAL TABLET 550 MG ZYVOX INTRAVENOUS PARENTERAL SOLUTION 200 MG/100 ML ZYVOX INTRAVENOUS PARENTERAL SOLUTION 600 MG/300 ML ZYVOX ORAL SUSPENSION FOR RECONSTITUTION PENICILLINS amoxicillin oral capsule amoxicillin oral suspension for reconstitution amoxicillin oral tablet amoxicillin oral tablet,chewable 125 mg, 250 mg amoxicillin-pot clavulanate ampicillin ampicillin sodium injection PAR; ; LA PAR; ; QLL (280 per 28 days) HI ; HI ; HI PAR; ; QLL (84 per 28 days) HI ; HI PAR; ; QLL (1800 per 2 days) ; HI (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 19

ampicillin sodium intravenous recon soln 1 gram ampicillin sodium intravenous recon soln 2 gram ampicillin-sulbactam injection recon soln 1.5 gram, 3 gram ampicillin-sulbactam injection recon soln 15 gram ampicillin-sulbactam intravenous recon soln 3 gram BICILLIN C-R INTRAMUSCULAR SYRINGE 1, 200,000 UNIT/ 2 ML(600K/600K) dicloxacillin nafcillin injection recon soln 1 gram, 10 gram nafcillin injection recon soln 2 gram nafcillin intravenous recon soln 2 gram oxacillin injection recon soln 1 gram, 2 gram oxacillin injection recon soln 10 gram oxacillin intravenous recon soln 1 gram oxacillin intravenous recon soln 2 gram PENICILLIN G POT IN DEXTROSE INTRAVENOUS PIGGYBACK 1 MILLION UNIT/ 50 ML PENICILLIN G POT IN DEXTROSE INTRAVENOUS PIGGYBACK 2 MILLION UNIT/ 50 ML, 3 MILLION UNIT/50 ML HI ; HI HI ; HI ; HI HI HI 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/2016 20

penicillin g potassium injection recon soln 20 million unit penicillin g potassium injection recon soln 5 million unit penicillin g procaine intramuscular syringe 1.2 million unit/2 ml penicillin g procaine intramuscular syringe 600,000 unit/ml penicillin g sodium penicillin v potassium piperacillin-tazobactam ZOSYN IN DEXTROSE (ISO-OSM) INTRAVENOUS PIGGYBACK 2.25 GRAM/50 ML ZOSYN IN DEXTROSE (ISO-OSM) INTRAVENOUS PIGGYBACK 3.375 GRAM/50 ML, 4.5 GRAM/100 ML QUINOLONES ciprofloxacin er ciprofloxacin hcl oral ciprofloxacin lactate intravenous solution 200 mg/20 ml ciprofloxacin lactate intravenous solution 400 mg/40 ml levofloxacin intravenous levofloxacin oral ofloxacin oral tablet 400 mg ; HI ; HI ; HI HI ; HI (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 21

SULFA'S / RELATED AGENTS sulfadiazine oral sulfamethoxazole-trimethoprim TETRACYCLINES demeclocycline DOXY-100 doxycycline hyclate intravenous doxycycline hyclate oral capsule doxycycline hyclate oral tablet 100 mg, 20 mg doxycycline hyclate oral tablet 50 mg doxycycline hyclate oral tablet, delayed release (dr/ec) 100 mg, 150 mg, 75 mg doxycycline monohydrate oral capsule doxycycline monohydrate oral tablet minocycline oral capsule minocycline oral tablet morgidox oral capsule 100 mg morgidox oral capsule 50 mg tetracycline URINARY TRACT AGENTS MACRODANTIN ORAL CAPSULE 25 MG, 50 MG methenamine hippurate trimethoprim VANCOMYCIN vancomycin in 0.9% sodium cl intravenous piggyback 1 gram/200 ml 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/2016 22

VANCOMYCIN IN 0.9% SODIUM CL INTRAVENOUS PIGGYBACK 500 MG/100 ML, 750 MG/150 ML vancomycin in dextrose 5 % intravenous piggyback 1 gram/200 ml VANCOMYCIN IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK 500 MG/100 ML, 750 MG/150 ML vancomycin intravenous recon soln 1, 000 mg, 10 gram, 500 mg, 750 mg vancomycin intravenous recon soln 5 gram vancomycin oral capsule 125 mg ; HI PAR; ; QLL (40 per 2 days) vancomycin oral capsule 250 mg PAR; ; QLL (80 per 2 days) ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ADJUNCTIVE AGENTS amifostine crystalline dexrazoxane hcl intravenous recon soln 250 mg dexrazoxane hcl intravenous recon soln 500 mg ELITEK INTRAVENOUS RECON SOLN 1.5 MG elitek intravenous recon soln 7.5 mg FUSILEV KEPIVANCE leucovorin calcium injection recon soln 100 mg, 200 mg, 350 mg, 50 mg leucovorin calcium injection recon soln 500 mg PAR; PAR; (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 23

leucovorin calcium oral levoleucovorin calcium intravenous recon soln mesna MESNEX ORAL XGEVA PAR; ; QLL (1.7 per 28 days) ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ABRAXANE AFINITOR AFINITOR DISPERZ ALECENSA ALIMTA anastrozole ARRANON ARZERRA ASTAGRAF XL AVASTIN INTRAVENOUS SOLUTION 25 MG/ ML AVASTIN INTRAVENOUS SOLUTION 25 MG/ ML (16 ML) azacitidine AZASAN azathioprine azathioprine sodium BELEODAQ BENDEKA bexarotene bicalutamide PAR; PAR; ; QLL (30 per 30 days) B/D; B/D; B/D; B/D PAR; ; QLL (4 per 30 days) PAR; ; QLL (300 per 30 days) 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/2016 24

BICNU bleo 15k bleomycin BLINCYTO BOSULIF ORAL TABLET 100 MG BOSULIF ORAL TABLET 500 MG BUSULFEX CABOMETYX ORAL TABLET 20 MG CABOMETYX ORAL TABLET 40 MG, 60 MG CAPRELSA ORAL TABLET 100 MG CAPRELSA ORAL TABLET 300 MG carboplatin intravenous solution CELLCEPT INTRAVENOUS cisplatin cladribine CLOLAR COMETRIQ ORAL CAPSULE 100 MG/DAY(80 MG X1-20 MG X1) COMETRIQ ORAL CAPSULE 140 MG/DAY(80 MG X1-20 MG X3) COMETRIQ ORAL CAPSULE 60 MG/DAY (20 MG X 3/DAY) COTELLIC cyclophosphamide oral capsule cyclosporine intravenous cyclosporine modified PAR; PAR; ; QLL (120 per 30 days) PAR; ; QLL (30 per 30 days) B/D PAR; LA; QLL (90 per 30 days) PAR; LA; QLL (30 per 30 days) PAR; ; LA; QLL (90 per 30 days) PAR; ; LA; QLL (30 per 30 days) B/D; PAR; ; QLL (56 per 28 days) PAR; ; QLL (112 per 28 days) PAR; ; QLL (84 per 28 days) PAR; ; LA; QLL (90 per 30 days) B/D; B/D B/D; (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 25

cyclosporine oral capsule CYRAMZA INTRAVENOUS SOLUTION 10 MG/ ML CYRAMZA INTRAVENOUS SOLUTION 10 MG/ ML (50 ML) cytarabine cytarabine (pf) injection solution 100 mg/5 ml (20 mg/ml), 2 gram/20 ml (100 mg/ml) cytarabine (pf) injection solution 20 mg/ml dacarbazine DACOGEN DARZALEX daunorubicin intravenous solution decitabine DOCEFREZ INTRAVENOUS RECON SOLN 20 MG docetaxel intravenous solution 10 mg/ ml, 160 mg/16 ml (10 mg/ml), 160 mg/8 ml (20 mg/ml), 20 mg/2 ml (10 mg/ml) docetaxel intravenous solution 20 mg/ ml (1 ml), 80 mg/4 ml (20 mg/ml), 80 mg/ 8 ml (10 mg/ml) doxorubicin intravenous recon soln doxorubicin intravenous solution doxorubicin, peg-liposomal DROXIA EMCYT EMPLICITI B/D; PAR; PAR ; LA B/D; 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/2016 26

epirubicin intravenous solution 200 mg/100 ml epirubicin intravenous solution 50 mg/ 25 ml ERBITUX ERIVEDGE ERWINAZE ETOPOPHOS etoposide intravenous EVOMELA exemestane FARESTON FARYDAK ORAL CAPSULE 10 MG FARYDAK ORAL CAPSULE 15 MG, 20 MG FASLODEX FIRMAGON KIT W DILUENT SYRINGE fludarabine intravenous recon soln fludarabine intravenous solution fluorouracil intravenous flutamide FOLOTYN GAZYVA gemcitabine intravenous recon soln 1 gram, 200 mg gemcitabine intravenous recon soln 2 gram PAR; PAR; ; QLL (30 per 30 days) ; QLL (60 per 30 days) ; QLL (30 per 30 days) PAR; ; QLL (60 per 30 days) PAR; ; QLL (30 per 30 days) PAR; (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 27

gemcitabine intravenous solution 1 gram/26.3 ml (38 mg/ml), 200 mg/5.26 ml (38 mg/ml) gemcitabine intravenous solution 2 gram/52.6 ml (38 mg/ml) gengraf oral capsule 100 mg, 25 mg gengraf oral capsule 50 mg gengraf oral solution GILOTRIF GLEEVEC ORAL TABLET 100 MG GLEEVEC ORAL TABLET 400 MG GLEOSTINE HALAVEN HERCEPTIN HEXALEN hydroxyurea IBRANCE ICLUSIG ORAL TABLET 15 MG ICLUSIG ORAL TABLET 45 MG idarubicin ifosfamide intravenous recon soln ifosfamide intravenous solution imatinib oral tablet 100 mg imatinib oral tablet 400 mg IMBRUVICA INLYTA ORAL TABLET 1 MG INLYTA ORAL TABLET 5 MG IRESSA B/D; B/D B/D; PAR; ; QLL (30 per 30 days) PAR; ; QLL (240 per 30 days) PAR; ; QLL (60 per 30 days) PAR; PAR; ; QLL (30 per 30 days) PAR; ; QLL (60 per 30 days) PAR; ; QLL (30 per 30 days) PAR; ; QLL (240 per 30 days) PAR; ; QLL (60 per 30 days) PAR; ; QLL (120 per 30 days) PAR; ; QLL (240 per 30 days) PAR; ; QLL (120 per 30 days) 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/2016 28

irinotecan intravenous solution 100 mg/5 ml, 40 mg/2 ml irinotecan intravenous solution 500 mg/25 ml ISTODAX IXEMPRA JAKAFI ORAL TABLET 10 MG JAKAFI ORAL TABLET 15 MG JAKAFI ORAL TABLET 20 MG JAKAFI ORAL TABLET 25 MG JAKAFI ORAL TABLET 5 MG JEVTANA KADCYLA KEYTRUDA LENVIMA ORAL CAPSULE 10 MG/DAY (10 MG X 1/DAY) LENVIMA ORAL CAPSULE 14 MG/DAY(10 MG X 1-4 MG X 1), 20 MG/DAY (10 MG X 2) LENVIMA ORAL CAPSULE 18 MG/DAY (10 MG X 1-4 MG X2) LENVIMA ORAL CAPSULE 24 MG/DAY(10 MG X 2-4 MG X 1) LENVIMA ORAL CAPSULE 8 MG/DAY (4 MG X 2), 8 MG/DAY (4 MG X 2) (60 PACK) letrozole LEUKERAN leuprolide subcutaneous kit PAR; ; QLL (150 per 30 days) PAR; ; QLL (100 per 30 days) PAR; ; QLL (75 per 30 days) PAR; ; QLL (60 per 30 days) PAR; ; QLL (300 per 30 days) PAR; PAR; PAR; ; QLL (30 per 30 days) PAR; ; QLL (60 per 30 days) PAR; QLL (90 per 30 days) PAR; ; QLL (90 per 30 days) PAR; QLL (60 per 30 days) ; QLL (30 per 30 days) (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 29

LONSURF LUPRON DEPOT (3 NTH) INTRAMUSCULAR SYRINGE KIT 22.5 MG LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 3.75 MG LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 7.5 MG LYNPARZA LYSODREN MARQIBO MATULANE megestrol oral suspension 400 mg/10 ml (10 ml), 800 mg/20 ml (20 ml) megestrol oral suspension 400 mg/10 ml (40 mg/ml) megestrol oral tablet MEKINIST ORAL TABLET 0.5 MG MEKINIST ORAL TABLET 2 MG melphalan hcl mercaptopurine methotrexate sodium methotrexate sodium (pf) injection recon soln methotrexate sodium (pf) injection solution mitomycin mitoxantrone MUSTARGEN mycophenolate mofetil PAR; PAR; PAR; ; QLL (1 per 28 days) PAR; PAR; ; QLL (480 per 30 days) PAR; QLL (90 per 30 days) PAR; QLL (30 per 30 days) B/D; 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/2016 30

mycophenolate sodium NEXAVAR NILANDRON NINLARO NIPENT NULOJIX octreotide acetate ODOMZO ONCASPAR OPDIVO oxaliplatin intravenous recon soln 100 mg oxaliplatin intravenous recon soln 50 mg oxaliplatin intravenous solution paclitaxel PERJETA POMALYST ORAL CAPSULE 1 MG POMALYST ORAL CAPSULE 2 MG POMALYST ORAL CAPSULE 3 MG, 4 MG PORTRAZZA PROGRAF INTRAVENOUS PURIXAN RAPAMUNE REVLIMID ORAL CAPSULE 10 MG B/D; PAR; ; LA; QLL (120 per 30 days) ; QLL (30 per 30 days) PAR; ; QLL (3 per 28 days) B/D; PAR; PAR; ; LA; QLL (30 per 30 days) PAR; PAR; ; QLL (120 per 30 days) PAR; ; QLL (60 per 30 days) PAR; ; QLL (30 per 30 days) B/D; PAR; B/D; ; LA; QLL (60 per 30 days) (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 31

REVLIMID ORAL CAPSULE 15 MG, 2.5 MG, 20 MG, 25 MG REVLIMID ORAL CAPSULE 5 MG RITUXAN SANDIMMUNE ORAL SOLUTION SIGNIFOR SIMULECT INTRAVENOUS RECON SOLN 10 MG SIMULECT INTRAVENOUS RECON SOLN 20 MG sirolimus SOLTAX SOMATULINE DEPOT SPRYCEL STIVARGA SUTENT ORAL CAPSULE 12.5 MG SUTENT ORAL CAPSULE 25 MG, 37.5 MG, 50 MG SYNRIBO TABLOID tacrolimus oral TAFINLAR TAGRISSO ORAL TABLET 40 MG TAGRISSO ORAL TABLET 80 MG tamoxifen TARCEVA ORAL TABLET 100 MG, 150 MG TARCEVA ORAL TABLET 25 MG TARGRETIN ORAL ; LA; QLL (30 per 30 days) ; LA; QLL (150 per 30 days) PAR; B/D; B/D B/D; B/D; ; QLL (30 per 30 days) PAR; ; QLL (120 per 30 days) ; QLL (90 per 30 days) ; QLL (30 per 30 days) B/D; PAR; QLL (120 per 30 days) PAR; ; LA; QLL (60 per 30 days) PAR; ; LA; QLL (30 per 30 days) ; QLL (30 per 30 days) ; QLL (90 per 30 days) PAR; ; QLL (300 per 30 days) 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/2016 32

TARGRETIN TOPICAL TASIGNA TECENTRIQ THALOMID ORAL CAPSULE 100 MG, 50 MG THALOMID ORAL CAPSULE 150 MG, 200 MG thiotepa toposar topotecan intravenous recon soln topotecan intravenous solution TORISEL TREANDA INTRAVENOUS RECON SOLN TRELSTAR DEPOT TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION TRELSTAR INTRAMUSCULAR SYRINGE 11.25 MG/2 ML, 3.75 MG/2 ML TRELSTAR INTRAMUSCULAR SYRINGE 22.5 MG/2 ML TRELSTAR LA tretinoin (chemotherapy) TREXALL TRISENOX TYKERB UNITUXIN VECTIBIX VELCADE PAR; ; QLL (120 per 30 days) LA; QLL (20 per 21 days) ; QLL (30 per 30 days) ; QLL (60 per 30 days) ; QLL (1 per 168 days) ; QLL (1 per 168 days) ; LA; QLL (180 per 30 days) PAR; (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 33

VENCLEXTA ORAL TABLET 10 MG VENCLEXTA ORAL TABLET 100 MG VENCLEXTA ORAL TABLET 50 MG VENCLEXTA STARTING PACK vinblastine intravenous solution VINCASAR PFS INTRAVENOUS SOLUTION 1 MG/ML vincasar pfs intravenous solution 2 mg/2 ml vincristine vinorelbine VOTRIENT XALKORI XTANDI YERVOY YONDELIS ZALTRAP ZANOSAR ZELBORAF ZOLINZA ZORTRESS ZYDELIG ZYKADIA PAR; LA; QLL (60 per 30 days) PAR; LA; QLL (120 per 30 days) PAR; LA; QLL (30 per 30 days) PAR; LA; QLL (42 per 365 days) ; QLL (120 per 30 days) PAR; ; QLL (60 per 30 days) PAR; ; QLL (120 per 30 days) PAR; PAR; ; QLL (240 per 30 days) ; QLL (120 per 30 days) B/D; PAR; ; QLL (60 per 30 days) PAR; ; QLL (150 per 30 days) ZYTIGA PAR; ; QLL (120 per 30 days) AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH ANTICONVULSANTS APTIOM BANZEL ORAL SUSPENSION PAR; ; QLL (2400 per 30 days) 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/2016 34

BANZEL ORAL TABLET 200 MG BANZEL ORAL TABLET 400 MG BRIVIACT INTRAVENOUS BRIVIACT ORAL SOLUTION BRIVIACT ORAL TABLET 10 MG BRIVIACT ORAL TABLET 100 MG, 75 MG BRIVIACT ORAL TABLET 25 MG BRIVIACT ORAL TABLET 50 MG carbamazepine oral capsule, er multiphase 12 hr carbamazepine oral suspension 100 mg/ 5 ml carbamazepine oral suspension 200 mg/ 10 ml carbamazepine oral tablet carbamazepine oral tablet extended release 12 hr 100 mg carbamazepine oral tablet extended release 12 hr 200 mg, 400 mg carbamazepine oral tablet,chewable CELONTIN ORAL CAPSULE 300 MG clonazepam oral tablet 0.5 mg clonazepam oral tablet 1 mg clonazepam oral tablet 2 mg clonazepam oral tablet,disintegrating 0.125 mg PAR; ; QLL (480 per 30 days) PAR; ; QLL (240 per 30 days) PAR PAR; QLL (600 per 30 days) PAR; QLL (600 per 30 days) PAR; QLL (60 per 30 days) PAR; QLL (240 per 30 days) PAR; QLL (120 per 30 days) ; QLL (1200 per 30 days) ; QLL (600 per 30 days) ; QLL (300 per 30 days) ; QLL (4800 per 30 days) (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 35

clonazepam oral tablet,disintegrating 0.25 mg clonazepam oral tablet,disintegrating 0.5 mg clonazepam oral tablet,disintegrating 1 mg clonazepam oral tablet,disintegrating 2 mg diazepam rectal kit 12.5-15-17.5-20 mg diazepam rectal kit 2.5 mg, 5-7.5-10 mg DILANTIN DILANTIN EXTENDED ORAL CAPSULES 100 MG DILANTIN INFATABS divalproex epitol EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 100 MG EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 200 MG EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 300 MG ethosuximide felbamate fosphenytoin FYCOMPA ORAL SUSPENSION FYCOMPA ORAL TABLET 10 MG, 12 MG FYCOMPA ORAL TABLET 2 MG FYCOMPA ORAL TABLET 4 MG ; QLL (2400 per 30 days) ; QLL (1200 per 30 days) ; QLL (600 per 30 days) ; QLL (300 per 30 days) ; QLL (2 per 2 days) ; QLL (480 per 30 days) ; QLL (240 per 30 days) ; QLL (180 per 30 days) QLL (720 per 30 days) ; QLL (30 per 30 days) ; QLL (180 per 30 days) ; QLL (90 per 30 days) 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/2016 36

FYCOMPA ORAL TABLET 6 MG FYCOMPA ORAL TABLET 8 MG gabapentin oral capsule 100 mg gabapentin oral capsule 300 mg gabapentin oral capsule 400 mg gabapentin oral solution 250 mg/5 ml gabapentin oral solution 250 mg/5 ml (5 ml), 300 mg/6 ml (6 ml) gabapentin oral tablet 600 mg gabapentin oral tablet 800 mg GABITRIL ORAL TABLET 12 MG, 16 MG lamotrigine oral tablet lamotrigine oral tablet, chewable dispersible levetiracetam intravenous levetiracetam oral solution 100 mg/ml levetiracetam oral solution 500 mg/5 ml (5 ml) levetiracetam oral tablet levetiracetam oral tablet extended release 24 hr 500 mg levetiracetam oral tablet extended release 24 hr 750 mg LYRICA ORAL CAPSULE 100 MG LYRICA ORAL CAPSULE 150 MG LYRICA ORAL CAPSULE 200 MG LYRICA ORAL CAPSULE 225 MG, 300 MG ; QLL (60 per 30 days) ; QLL (45 per 30 days) ; QLL (1080 per 30 days) ; QLL (360 per 30 days) ; QLL (270 per 30 days) ; QLL (2160 per 30 days) QLL (2160 per 30 days) ; QLL (180 per 30 days) ; QLL (135 per 30 days) ; QLL (180 per 30 days) ; QLL (120 per 30 days) ; QLL (180 per 30 days) ; QLL (120 per 30 days) ; QLL (90 per 30 days) ; QLL (60 per 30 days) (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 37

LYRICA ORAL CAPSULE 25 MG LYRICA ORAL CAPSULE 50 MG LYRICA ORAL CAPSULE 75 MG LYRICA ORAL SOLUTION ONFI ORAL SUSPENSION ONFI ORAL TABLET 10 MG ONFI ORAL TABLET 20 MG oxcarbazepine oral tablet OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR 150 MG OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR 300 MG OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR 600 MG PEGANONE phenobarbital oral elixir phenobarbital oral tablet 100 mg phenobarbital oral tablet 15 mg phenobarbital oral tablet 16.2 mg phenobarbital oral tablet 30 mg phenobarbital oral tablet 32.4 mg phenobarbital oral tablet 60 mg phenobarbital oral tablet 64.8 mg phenobarbital oral tablet 97.2 mg phenytoin oral suspension 100 mg/4 ml phenytoin oral suspension 125 mg/5 ml phenytoin oral tablet,chewable phenytoin sodium extended ; QLL (720 per 30 days) ; QLL (360 per 30 days) ; QLL (240 per 30 days) ; QLL (900 per 30 days) PAR; ; QLL (480 per 30 days) PAR; ; QLL (120 per 30 days) PAR; ; QLL (60 per 30 days) ; QLL (480 per 30 days) ; QLL (240 per 30 days) ; QLL (120 per 30 days) ; QLL (3000 per 30 days) ; QLL (120 per 30 days) ; QLL (800 per 30 days) ; QLL (741 per 30 days) ; QLL (400 per 30 days) ; QLL (370 per 30 days) ; QLL (200 per 30 days) ; QLL (185 per 30 days) ; QLL (123 per 30 days) 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/2016 38

phenytoin sodium intravenous solution POTIGA ORAL TABLET 200 MG, 300 MG, 400 MG POTIGA ORAL TABLET 50 MG primidone roweepra SABRIL SPRITAM ORAL TABLET FOR SUSPENSION 1, 000 MG, 250 MG, 500 MG SPRITAM ORAL TABLET FOR SUSPENSION 750 MG tiagabine topiramate oral capsule, sprinkle topiramate oral tablet 100 mg topiramate oral tablet 200 mg topiramate oral tablet 25 mg topiramate oral tablet 50 mg TRILEPTAL ORAL SUSPENSION valproate sodium valproic acid valproic acid (as sodium salt) oral solution 250 mg/5 ml valproic acid (as sodium salt) oral solution 250 mg/5 ml (5 ml), 500 mg/10 ml (10 ml) VIMPAT INTRAVENOUS VIMPAT ORAL SOLUTION ; QLL (90 per 30 days) ; QLL (270 per 30 days) ; LA; QLL (180 per 30 days) QLL (60 per 30 days) QLL (120 per 30 days) ; QLL (480 per 30 days) ; QLL (240 per 30 days) ; QLL (1920 per 30 days) ; QLL (960 per 30 days) QLL (1200 per 30 days) ; QLL (1200 per 30 days) (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 39

VIMPAT ORAL TABLET 100 MG VIMPAT ORAL TABLET 150 MG VIMPAT ORAL TABLET 200 MG VIMPAT ORAL TABLET 50 MG zonisamide ANTIPARKINSONISM AGENTS APOKYN AZILECT benztropine oral bromocriptine carbidopa-levodopa entacapone NEUPRO pramipexole oral tablet ropinirole oral tablet selegiline hcl tolcapone ; QLL (120 per 30 days) ; QLL (80 per 30 days) ; QLL (60 per 30 days) ; QLL (240 per 30 days) PAR; ; LA PAR; ; QLL (30 per 30 days) trihexyphenidyl MIGRAINE / CLUSTER HEADACHE THERAPY ERGOMAR MIGRANAL rizatriptan sumatriptan succinate oral sumatriptan succinate subcutaneous cartridge sumatriptan succinate subcutaneous pen injector 4 mg/0.5 ml, 6 mg/0.5 ml ; QLL (8 per 28 days) ; QLL (12 per 30 days) ; QLL (9 per 30 days) ; QLL (4 per 30 days) ; QLL (4 per 30 days) 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/2016 40

sumatriptan succinate subcutaneous pen injector 6 mg/0.5 ml (autoinjector) sumatriptan succinate subcutaneous solution sumatriptan succinate subcutaneous syringe 6 mg/0.5 ml zolmitriptan QLL (4 per 30 days) ; QLL (4 per 30 days) QLL (4 per 30 days) ; QLL (9 per 30 days) ZOMIG NASAL MISCELLANEOUS NEUROLOGICAL THERAPY ; QLL (6 per 30 days) AMPYRA COPAXONE SUBCUTANEOUS SYRINGE 20 MG/ ML COPAXONE SUBCUTANEOUS SYRINGE 40 MG/ ML donepezil oral tablet 10 mg donepezil oral tablet 5 mg donepezil oral tablet,disintegrating 10 mg donepezil oral tablet,disintegrating 5 mg EXELON TRANSDERMAL galantamine oral capsule,ext rel. pellets 24 hr galantamine oral solution galantamine oral tablet GILENYA GLATOPA PAR; ; LA; QLL (60 per 30 days) PAR; ; QLL (30 per 30 days) PAR; ; QLL (12 per 28 days) ; QLL (30 per 30 days) ; QLL (30 per 30 days) ; QLL (30 per 30 days) ; QLL (30 per 30 days) ; QLL (180 per 30 days) ; QLL (60 per 30 days) PAR; ; QLL (30 per 30 days) PAR; ; QLL (30 per 30 days) (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 41

memantine oral solution memantine oral tablet 10 mg memantine oral tablet 5 mg NAMENDA ORAL SOLUTION NAMENDA ORAL TABLET 10 MG NAMENDA ORAL TABLET 5 MG NAMENDA TITRATION PAK NAMENDA XR ORAL CAP,SPRINKLE,ER 24HR DOSE PACK NAMENDA XR ORAL CAPSULE,SPRINKLE,ER 24HR NUEDEXTA rivastigmine rivastigmine tartrate tetrabenazine oral tablet 12.5 mg tetrabenazine oral tablet 25 mg TYSABRI XENAZINE ORAL TABLET 12.5 MG ; QLL (300 per 30 days) ; QLL (60 per 30 days) ; QLL (90 per 30 days) ; QLL (300 per 30 days) ; QLL (60 per 30 days) ; QLL (90 per 30 days) ; QLL (60 per 30 days) ; QLL (56 per 365 days) ; QLL (30 per 30 days) ; QLL (60 per 30 days) ; QLL (30 per 30 days) ; QLL (60 per 30 days) PAR; ; QLL (240 per 30 days) PAR; ; QLL (120 per 30 days) PAR; ; LA PAR; ; LA; QLL (240 per 30 days) XENAZINE ORAL TABLET 25 MG PAR; ; LA; QLL (120 per 30 days) MUSCLE RELAXANTS / ANTISPASDIC THERAPY AMRIX baclofen dantrolene MESTINON ORAL SYRUP MESTINON TIMESPAN pyridostigmine bromide tizanidine oral tablet PAR; 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/2016 42

NARCOTIC ANALGESICS ABSTRAL acetaminophen-codeine oral solution 120 mg-12 mg /5 ml (5 ml), 240 mg-24 mg /10 ml (10 ml), 300 mg-30 mg /12.5 ml acetaminophen-codeine oral solution 120-12 mg/5 ml acetaminophen-codeine oral tablet 300-15 mg acetaminophen-codeine oral tablet 300-30 mg acetaminophen-codeine oral tablet 300-60 mg buprenorphine hcl injection solution buprenorphine hcl injection syringe buprenorphine hcl sublingual tablet 2 mg buprenorphine hcl sublingual tablet 8 mg butalbital-acetaminop-caf-cod oral capsule 50-325-40-30 mg duramorph (pf) injection solution 0.5 mg/ml duramorph (pf) injection solution 1 mg/ml endocet oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg fentanyl citrate PAR; ; QLL (120 per 30 days) QLL (4500 per 30 days) ; QLL (4500 per 30 days) ; QLL (390 per 30 days) ; QLL (360 per 30 days) ; QLL (180 per 30 days) ; QLL (150 per 30 days) QLL (150 per 30 days) PAR; ; QLL (240 per 30 days) PAR; ; QLL (60 per 30 days) ; QLL (180 per 30 days) ; QLL (180 per 30 days) QLL (180 per 30 days) ; QLL (360 per 30 days) PAR; ; QLL (120 per 30 days) (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 43

fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr FENTORA hydrocodone-acetaminophen oral solution 10-325 mg/15 ml(15 ml), 2.5-167 mg/5 ml, 5-163 mg/7.5ml(7.5ml) hydrocodone-acetaminophen oral solution 7.5-325 mg/15 ml hydrocodone-acetaminophen oral tablet 10-300 mg, 5-300 mg, 7.5-300 mg hydrocodone-acetaminophen oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg hydrocodone-ibuprofen oral tablet 7.5-200 mg hydromorphone oral tablet 2 mg, 4 mg hydromorphone oral tablet 8 mg LAZANDA NASAL SPRAY,NON-AEROSOL 100 MCG/SPRAY, 400 MCG/SPRAY LAZANDA NASAL SPRAY,NON-AEROSOL 300 MCG/SPRAY levorphanol tartrate LORCET (HYDROCODONE) LORCET HD LORCET PLUS ORAL TABLET 7.5-325 MG LORTAB 10-325 LORTAB 5-325 LORTAB 7.5-325 methadone injection methadone intensol ; QLL (15 per 30 days) PAR; ; QLL (120 per 30 days) QLL (2700 per 30 days) ; QLL (2700 per 30 days) ; QLL (390 per 30 days) ; QLL (360 per 30 days) ; QLL (480 per 30 days) ; QLL (360 per 30 days) ; QLL (180 per 30 days) PAR; ; QLL (30 per 30 days) PAR; QLL (30 per 30 days) ; QLL (180 per 30 days) ; QLL (360 per 30 days) ; QLL (360 per 30 days) ; QLL (360 per 30 days) ; QLL (360 per 30 days) ; QLL (360 per 30 days) ; QLL (360 per 30 days) QLL (150 per 30 days) ; QLL (180 per 30 days) 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/2016 44

methadone oral concentrate methadone oral solution 10 mg/5 ml methadone oral solution 5 mg/5 ml methadone oral tablet 10 mg methadone oral tablet 5 mg methadose oral concentrate morphine (pf) injection solution 0.5 mg/ml morphine (pf) injection solution 1 mg/ ml morphine (pf) intravenous patient control.analgesia soln 150 mg/30 ml morphine (pf) intravenous patient control.analgesia soln 30 mg/30 ml morphine concentrate oral solution morphine intravenous cartridge 2 mg/ ml RPHINE INTRAVENOUS CARTRIDGE 8 MG/ ML morphine intravenous solution 10 mg/ ml, 50 mg/ml morphine intravenous solution 100 mg/ 4 ml, 25 mg/ml, 250 mg/10 ml RPHINE INTRAVENOUS SOLUTION 4 MG/ ML, 8 MG/ML morphine intravenous syringe 2 mg/ml, 4 mg/ml morphine oral capsule, er multiphase 24 hr 30 mg, 60 mg ; QLL (180 per 30 days) ; QLL (900 per 30 days) ; QLL (1800 per 30 days) ; QLL (180 per 30 days) ; QLL (360 per 30 days) ; QLL (180 per 30 days) ; QLL (180 per 30 days) ; QLL (120 per 30 days) B/D; QLL (180 per 30 days) ; QLL (270 per 30 days) QLL (120 per 30 days) QLL (120 per 30 days) ; QLL (120 per 30 days) QLL (120 per 30 days) ; QLL (180 per 30 days) QLL (120 per 30 days) ; QLL (30 per 30 days) (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 45

morphine oral capsule,extend.release pellets 100 mg, 20 mg, 30 mg, 50 mg, 60 mg, 80 mg morphine oral solution 10 mg/5 ml morphine oral solution 20 mg/5 ml (4 mg/ml) morphine oral tablet 15 mg morphine oral tablet 30 mg morphine oral tablet extended release 100 mg, 15 mg, 30 mg, 60 mg morphine oral tablet extended release 200 mg NORCO oxycodone oral capsule oxycodone oral concentrate oxycodone oral tablet 10 mg, 5 mg oxycodone oral tablet 15 mg oxycodone oral tablet 20 mg, 30 mg oxycodone-acetaminophen oral solution oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg oxycodone-aspirin SUBSYS vicodin vicodin es vicodin hp XODOL 10/300 XODOL 5/300 ; QLL (60 per 30 days) ; QLL (2700 per 30 days) ; QLL (1350 per 30 days) ; QLL (360 per 30 days) ; QLL (180 per 30 days) ; QLL (90 per 30 days) ; QLL (60 per 30 days) ; QLL (360 per 30 days) ; QLL (360 per 30 days) ; QLL (360 per 30 days) ; QLL (360 per 30 days) ; QLL (540 per 30 days) ; QLL (180 per 30 days) QLL (1800 per 30 days) ; QLL (360 per 30 days) ; QLL (360 per 30 days) PAR; ; QLL (120 per 30 days) ; QLL (390 per 30 days) ; QLL (390 per 30 days) ; QLL (390 per 30 days) ; QLL (390 per 30 days) ; QLL (390 per 30 days) 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/2016 46

XODOL 7.5/300 NON-NARCOTIC ANALGESICS ACEPHEN RECTAL SUPPOSITORY 650 MG ACETAMINOPHEN EXTRA STRENGTH ORAL CAPSULE 500 MG ACETAMINOPHEN EXTRA STRENGTH ORAL CAPSULE 500 MG ACETAMINOPHEN EXTRA STRENGTH ORAL LIQUID 500 MG/15 ML ACETAMINOPHEN EXTRA STRENGTH ORAL LIQUID 500 MG/15 ML ACETAMINOPHEN EXTRA STRENGTH ORAL SUSPENSION 160 MG/5 ML ACETAMINOPHEN LIQUID acetaminophen oral suspension 160 mg/ 5 ml acetaminophen oral tablet 500 mg ACETAMINOPHEN PAIN RELIEF acetaminophen rectal suppository 650 mg ADDED STRENGTH PAIN RELIEVER ADULT LOW DOSE ASPIRIN ALL DAY RELIEF ASPIR-LOW ASPIRIN LOW DOSE aspirin oral tablet ASPIRIN ORAL TABLET 325 MG aspirin oral tablet,chewable ; QLL (390 per 30 days) ; ; ; ; ; ; ; ; ; ; (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 47

ASPIRIN ORAL TABLET,DELAYED RELEASE (DR/EC) 325 MG ASPIRIN ORAL TABLET,DELAYED RELEASE (DR/EC) 325 MG aspirin oral tablet,delayed release (dr/ec) 325 mg, 81 mg BETATEMP buprenorphine-naloxone sublingual tablet 2-0.5 mg buprenorphine-naloxone sublingual tablet 8-2 mg butorphanol tartrate injection solution 1 mg/ml butorphanol tartrate injection solution 2 mg/ml butorphanol tartrate nasal diclofenac potassium diclofenac sodium oral diflunisal ECOTRIN LOW STRENGTH ENTERIC COATED ASPIRIN etodolac fenoprofen oral tablet FEVER REDUCER AN PAIN RELIEVER ORAL SUSPENSION FEVERALL RECTAL SUPPOSITORY 650 MG FLANAX (NAPROXEN) flurbiprofen HEADACHE RELIEF (ASA-ACET-CAF) ; ; PAR; ; QLL (360 per 30 days) PAR; ; QLL (90 per 30 days) ; QLL (240 per 30 days) ; QLL (120 per 30 days) ; QLL (5 per 28 days) ; 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/2016 48

I-PRIN IBUPROFEN IB ORAL TABLET ibuprofen oral capsule ibuprofen oral suspension ibuprofen oral tablet 200 mg ibuprofen oral tablet 400 mg, 600 mg, 800 mg MAPAP EXTRA STRENGTH MASOPHEN ORAL TABLET 500 MG meclofenamate oral MEDIPROXEN meloxicam oral suspension meloxicam oral tablet MENSTRUAL RELIEF MIGRAINE FORMULA MIGRAINE RELIEF nabumetone nalbuphine injection solution 10 mg/ml nalbuphine injection solution 20 mg/ml naloxone naltrexone oral naproxen naproxen sodium oral capsule naproxen sodium oral tablet 220 mg naproxen sodium oral tablet 275 mg, 550 mg ; ; ; QLL (300 per 30 days) ; QLL (30 per 30 days) ; QLL (180 per 30 days) ; QLL (90 per 30 days) ; (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 49

NARCAN NON-ASPIRIN ORAL SUSPENSION oxaprozin PAIN AND FEVER ORAL TABLET 500 MG PAIN RELIEF (ACETAMIN-ASP-CAF) PAIN RELIEF EXTRA STRENGTH PAIN RELIEF ORAL TABLET PAIN RELIEVER (ACETAM-ASPIRIN) PAIN RELIEVER EXTRA STRENGTH PAIN RELIEVER ORAL CAPSULE PAIN RELIEVER ORAL TABLET 500 MG PAIN RELIEVER PLUS PAIN-OFF PAMPRIN MAX PHARBETOL ORAL TABLET 500 MG piroxicam PROVIL Q-PAP EXTRA STRENGTH Q-PAP ORAL TABLET 500 MG sulindac oral SUPER PAIN RELIEF tolmetin tramadol oral tablet tramadol-acetaminophen VOLTAREN TOPICAL GEL 1 % PSYCHOTHERAPEUTIC DRUGS ABILIFY MAINTENA ; ; ; ; ; QLL (240 per 30 days) ; QLL (240 per 30 days) ; QLL (1000 per 30 days) ; QLL (1 per 28 days) 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/2016 50

ADASUVE alprazolam oral tablet amitriptyline amoxapine aripiprazole oral solution aripiprazole oral tablet 10 mg aripiprazole oral tablet 15 mg aripiprazole oral tablet 2 mg aripiprazole oral tablet 20 mg, 30 mg aripiprazole oral tablet 5 mg aripiprazole oral tablet, disintegrating 10 mg aripiprazole oral tablet, disintegrating 15 mg ARISTADA INTRAMUSCULAR SUSPENSION, EXTENDED REL SYRING 441 MG/1.6 ML ARISTADA INTRAMUSCULAR SUSPENSION, EXTENDED REL SYRING 662 MG/2.4 ML ARISTADA INTRAMUSCULAR SUSPENSION, EXTENDED REL SYRING 882 MG/3.2 ML bupropion hcl oral tablet 100 mg bupropion hcl oral tablet 75 mg bupropion hcl oral tablet extended release 100 mg bupropion hcl oral tablet extended release 150 mg, 200 mg bupropion hcl oral tablet extended release 24 hr 150 mg ; QLL (90 per 30 days) ; QLL (900 per 30 days) ; QLL (90 per 30 days) ; QLL (60 per 30 days) ; QLL (450 per 30 days) ; QLL (30 per 30 days) ; QLL (180 per 30 days) ; QLL (90 per 30 days) ; QLL (60 per 30 days) PAR; ; QLL (1.6 per 30 days) PAR; ; QLL (2.4 per 30 days) PAR; ; QLL (3.2 per 30 days) ; QLL (135 per 30 days) ; QLL (180 per 30 days) ; QLL (120 per 30 days) ; QLL (60 per 30 days) ; QLL (90 per 30 days) (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 51

bupropion hcl oral tablet extended release 24 hr 300 mg buspirone chlorpromazine citalopram oral solution citalopram oral tablet 10 mg citalopram oral tablet 20 mg citalopram oral tablet 40 mg clomipramine clorazepate dipotassium clozapine oral tablet 100 mg clozapine oral tablet 200 mg clozapine oral tablet 25 mg clozapine oral tablet 50 mg clozapine oral tablet,disintegrating 100 mg clozapine oral tablet,disintegrating 12.5 mg clozapine oral tablet,disintegrating 150 mg clozapine oral tablet,disintegrating 200 mg clozapine oral tablet,disintegrating 25 mg desipramine oral DESVENLAFAXINE FUMARATE ORAL TABLET EXTENDED RELEASE 24HR 100 MG DESVENLAFAXINE FUMARATE ORAL TABLET EXTENDED RELEASE 24HR 50 MG ; QLL (45 per 30 days) ; QLL (600 per 30 days) ; QLL (120 per 30 days) ; QLL (60 per 30 days) ; QLL (30 per 30 days) ; QLL (120 per 30 days) ; QLL (270 per 30 days) ; QLL (135 per 30 days) ; QLL (1080 per 30 days) ; QLL (540 per 30 days) QLL (270 per 30 days) QLL (2160 per 30 days) QLL (180 per 30 days) QLL (135 per 30 days) QLL (1080 per 30 days) ; QLL (120 per 30 days) ; QLL (240 per 30 days) 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/2016 52

DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE 24 HR 100 MG DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE 24 HR 50 MG DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE 24HR 100 MG DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE 24HR 50 MG dextroamphetamine oral capsule, extended release 10 mg, 5 mg dextroamphetamine oral capsule, extended release 15 mg dextroamphetamine oral tablet 10 mg dextroamphetamine oral tablet 5 mg dextroamphetamine-amphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 5 mg, 7.5 mg dextroamphetamine-amphetamine oral tablet 30 mg diazepam injection solution diazepam injection syringe diazepam intensol diazepam oral concentrate diazepam oral solution 5 mg/5 ml (1 mg/ ml) diazepam oral solution 5 mg/5 ml (1 mg/ ml, 5 ml) diazepam oral tablet 10 mg diazepam oral tablet 2 mg ; QLL (120 per 30 days) ; QLL (240 per 30 days) QLL (120 per 30 days) QLL (240 per 30 days) ; QLL (60 per 30 days) ; QLL (120 per 30 days) PAR; ; QLL (180 per 30 days) PAR; ; QLL (90 per 30 days) ; QLL (90 per 30 days) ; QLL (60 per 30 days) ; QLL (240 per 30 days) ; QLL (240 per 30 days) ; QLL (1200 per 30 days) QLL (1200 per 30 days) ; QLL (120 per 30 days) ; QLL (600 per 30 days) (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 53

diazepam oral tablet 5 mg doxepin oral duloxetine oral capsule,delayed release(dr/ec) 20 mg duloxetine oral capsule,delayed release(dr/ec) 30 mg duloxetine oral capsule,delayed release(dr/ec) 40 mg duloxetine oral capsule,delayed release(dr/ec) 60 mg EMSAM ergoloid escitalopram oxalate oral solution escitalopram oxalate oral tablet 10 mg escitalopram oxalate oral tablet 20 mg escitalopram oxalate oral tablet 5 mg FANAPT ORAL TABLET 1 MG FANAPT ORAL TABLET 10 MG FANAPT ORAL TABLET 12 MG FANAPT ORAL TABLET 2 MG FANAPT ORAL TABLET 4 MG FANAPT ORAL TABLET 6 MG FANAPT ORAL TABLET 8 MG FANAPT ORAL TABLETS,DOSE PACK FAZACLO ORAL TABLET,DISINTEGRATING 100 MG ; QLL (240 per 30 days) ; QLL (180 per 30 days) ; QLL (120 per 30 days) ; QLL (90 per 30 days) ; QLL (60 per 30 days) ; QLL (30 per 30 days) ; QLL (600 per 30 days) ; QLL (60 per 30 days) ; QLL (30 per 30 days) ; QLL (120 per 30 days) QLL (720 per 30 days) QLL (72 per 30 days) ; QLL (60 per 30 days) ; QLL (360 per 30 days) ; QLL (180 per 30 days) ; QLL (120 per 30 days) ; QLL (90 per 30 days) ; QLL (16 per 365 days) QLL (270 per 30 days) 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/2016 54

FAZACLO ORAL TABLET,DISINTEGRATING 12.5 MG FAZACLO ORAL TABLET,DISINTEGRATING 25 MG FETZIMA ORAL CAPSULE,EXT REL 24HR DOSE PACK FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR 120 MG, 80 MG FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR 20 MG FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR 40 MG fluoxetine oral capsule 10 mg fluoxetine oral capsule 20 mg fluoxetine oral capsule 40 mg fluoxetine oral solution fluoxetine oral tablet 10 mg fluoxetine oral tablet 20 mg fluphenazine decanoate fluphenazine hcl fluvoxamine oral tablet 100 mg fluvoxamine oral tablet 25 mg fluvoxamine oral tablet 50 mg GEODON INTRAMUSCULAR guanidine haloperidol haloperidol decanoate QLL (2160 per 30 days) QLL (1080 per 30 days) PAR; ; QLL (56 per 365 days) PAR; ; QLL (30 per 30 days) PAR; ; QLL (180 per 30 days) PAR; ; QLL (90 per 30 days) ; QLL (240 per 30 days) ; QLL (120 per 30 days) ; QLL (60 per 30 days) ; QLL (600 per 30 days) ; QLL (240 per 30 days) ; QLL (120 per 30 days) ; QLL (90 per 30 days) ; QLL (360 per 30 days) ; QLL (180 per 30 days) (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 55

haloperidol lactate HETLIOZ imipramine hcl INTUNIV ER INVEGA ORAL TABLET EXTENDED RELEASE 24HR 1.5 MG INVEGA ORAL TABLET EXTENDED RELEASE 24HR 3 MG INVEGA ORAL TABLET EXTENDED RELEASE 24HR 6 MG INVEGA ORAL TABLET EXTENDED RELEASE 24HR 9 MG INVEGA SUSTENNA INVEGA TRINZA INTRAMUSCULAR SYRINGE 273 MG/0.875 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 410 MG/1.315 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 546 MG/1.75 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 819 MG/2.625 ML KHEDEZLA ORAL TABLET EXTENDED RELEASE 24HR 100 MG KHEDEZLA ORAL TABLET EXTENDED RELEASE 24HR 50 MG LATUDA ORAL TABLET 120 MG LATUDA ORAL TABLET 20 MG LATUDA ORAL TABLET 40 MG LATUDA ORAL TABLET 60 MG LATUDA ORAL TABLET 80 MG PAR; ; QLL (30 per 30 days) ; QLL (30 per 30 days) ; QLL (240 per 30 days) ; QLL (120 per 30 days) ; QLL (60 per 30 days) ; QLL (30 per 30 days) ; QLL (2 per 28 days) ; QLL (0.875 per 90 days) ; QLL (1.315 per 90 days) ; QLL (1.75 per 90 days) ; QLL (2.625 per 90 days) ; QLL (120 per 30 days) ; QLL (240 per 30 days) ; QLL (30 per 30 days) ; QLL (240 per 30 days) ; QLL (120 per 30 days) ; QLL (75 per 30 days) ; QLL (60 per 30 days) 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/2016 56

lithium carbonate lithium citrate oral solution 8 meq/5 ml LORAZEPAM INTENSOL lorazepam oral tablet loxapine succinate LUNESTA maprotiline oral tablet 25 mg maprotiline oral tablet 50 mg maprotiline oral tablet 75 mg MARPLAN METADATE ER methylphenidate oral capsule, er biphasic 30-70 30 mg methylphenidate oral capsule, er biphasic 30-70 40 mg methylphenidate oral capsule,er biphasic 50-50 30 mg methylphenidate oral capsule,er biphasic 50-50 40 mg methylphenidate oral tablet methylphenidate oral tablet extended release methylphenidate oral tablet extended release 24hr 18 mg mirtazapine oral tablet 15 mg mirtazapine oral tablet 30 mg ; QLL (90 per 30 days) ; QLL (90 per 30 days) ; QLL (30 per 30 days) ; QLL (270 per 30 days) ; QLL (135 per 30 days) ; QLL (90 per 30 days) ; QLL (60 per 30 days) ; QLL (30 per 30 days) ; QLL (60 per 30 days) ; QLL (30 per 30 days) ; QLL (90 per 30 days) ; QLL (90 per 30 days) ; QLL (90 per 30 days) ; QLL (45 per 30 days) (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 57

mirtazapine oral tablet 45 mg mirtazapine oral tablet 7.5 mg mirtazapine oral tablet,disintegrating 15 mg mirtazapine oral tablet,disintegrating 30 mg mirtazapine oral tablet,disintegrating 45 mg modafinil oral tablet 100 mg modafinil oral tablet 200 mg molindone nefazodone oral tablet 100 mg nefazodone oral tablet 150 mg nefazodone oral tablet 200 mg nefazodone oral tablet 250 mg nefazodone oral tablet 50 mg nortriptyline NUPLAZID olanzapine intramuscular olanzapine oral tablet 10 mg olanzapine oral tablet 15 mg olanzapine oral tablet 2.5 mg olanzapine oral tablet 20 mg olanzapine oral tablet 5 mg olanzapine oral tablet 7.5 mg olanzapine oral tablet,disintegrating 10 mg olanzapine oral tablet,disintegrating 15 mg ; QLL (30 per 30 days) ; QLL (180 per 30 days) ; QLL (90 per 30 days) ; QLL (45 per 30 days) ; QLL (30 per 30 days) PAR; ; QLL (30 per 30 days) PAR; ; QLL (60 per 30 days) ; QLL (180 per 30 days) ; QLL (120 per 30 days) ; QLL (90 per 30 days) ; QLL (72 per 30 days) ; QLL (360 per 30 days) PAR; LA; QLL (60 per 30 days) ; QLL (60 per 30 days) ; QLL (60 per 30 days) ; QLL (40 per 30 days) ; QLL (240 per 30 days) ; QLL (30 per 30 days) ; QLL (120 per 30 days) ; QLL (80 per 30 days) ; QLL (60 per 30 days) ; QLL (40 per 30 days) 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/2016 58

olanzapine oral tablet,disintegrating 20 mg olanzapine oral tablet,disintegrating 5 mg olanzapine-fluoxetine oral capsule 12-25 mg, 12-50 mg, 6-50 mg olanzapine-fluoxetine oral capsule 3-25 mg, 6-25 mg ORAP paliperidone oral tablet extended release 24hr 1.5 mg paliperidone oral tablet extended release 24hr 3 mg paliperidone oral tablet extended release 24hr 6 mg paliperidone oral tablet extended release 24hr 9 mg paroxetine hcl oral tablet 10 mg paroxetine hcl oral tablet 20 mg paroxetine hcl oral tablet 30 mg paroxetine hcl oral tablet 40 mg paroxetine hcl oral tablet extended release 24 hr 12.5 mg paroxetine hcl oral tablet extended release 24 hr 25 mg paroxetine hcl oral tablet extended release 24 hr 37.5 mg PAXIL ORAL SUSPENSION perphenazine ; QLL (30 per 30 days) ; QLL (120 per 30 days) ; QLL (30 per 30 days) ; QLL (90 per 30 days) ; QLL (240 per 30 days) ; QLL (120 per 30 days) ; QLL (60 per 30 days) ; QLL (30 per 30 days) ; QLL (180 per 30 days) ; QLL (90 per 30 days) ; QLL (60 per 30 days) ; QLL (45 per 30 days) ; QLL (180 per 30 days) ; QLL (90 per 30 days) ; QLL (60 per 30 days) ; QLL (900 per 30 days) (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 59

phenelzine PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 100 MG PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 25 MG PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 50 MG protriptyline quetiapine oral tablet 100 mg quetiapine oral tablet 200 mg quetiapine oral tablet 25 mg quetiapine oral tablet 300 mg quetiapine oral tablet 400 mg quetiapine oral tablet 50 mg REXULTI ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG REXULTI ORAL TABLET 3 MG, 4 MG RISPERDAL CONSTA INTRAMUSCULAR SYRINGE 12.5 MG/2 ML, 25 MG/2 ML, 37.5 MG/2 ML RISPERDAL CONSTA INTRAMUSCULAR SYRINGE 50 MG/2 ML risperidone oral solution risperidone oral tablet 0.25 mg risperidone oral tablet 0.5 mg risperidone oral tablet 1 mg risperidone oral tablet 2 mg risperidone oral tablet 3 mg risperidone oral tablet 4 mg ; QLL (120 per 30 days) ; QLL (480 per 30 days) ; QLL (240 per 30 days) ; QLL (240 per 30 days) ; QLL (120 per 30 days) ; QLL (960 per 30 days) ; QLL (80 per 30 days) ; QLL (60 per 30 days) ; QLL (480 per 30 days) PAR; ; QLL (60 per 30 days) PAR; ; QLL (30 per 30 days) ; QLL (2 per 28 days) ; QLL (480 per 30 days) ; QLL (1920 per 30 days) ; QLL (960 per 30 days) ; QLL (480 per 30 days) ; QLL (240 per 30 days) ; QLL (150 per 30 days) ; QLL (120 per 30 days) 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/2016 60

risperidone oral tablet,disintegrating 0.25 mg risperidone oral tablet,disintegrating 0.5 mg risperidone oral tablet,disintegrating 1 mg risperidone oral tablet,disintegrating 2 mg risperidone oral tablet,disintegrating 3 mg risperidone oral tablet,disintegrating 4 mg ROZEREM SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 10 MG SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 2.5 MG SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 5 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 150 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 200 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 300 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 400 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 50 MG ; QLL (1920 per 30 days) ; QLL (960 per 30 days) ; QLL (480 per 30 days) ; QLL (240 per 30 days) ; QLL (150 per 30 days) ; QLL (120 per 30 days) ; QLL (30 per 30 days) ; QLL (60 per 30 days) ; QLL (240 per 30 days) ; QLL (120 per 30 days) ; QLL (150 per 30 days) ; QLL (120 per 30 days) ; QLL (80 per 30 days) ; QLL (60 per 30 days) ; QLL (480 per 30 days) (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 61

sertraline oral concentrate sertraline oral tablet 100 mg sertraline oral tablet 25 mg sertraline oral tablet 50 mg SLEEP AID (DOXYLAMINE) STRATTERA ORAL CAPSULE 10 MG, 18 MG, 25 MG, 40 MG STRATTERA ORAL CAPSULE 100 MG, 60 MG, 80 MG SURNTIL temazepam oral capsule 15 mg, 22.5 mg, 30 mg thioridazine thiothixene tranylcypromine trazodone trifluoperazine trintellix oral tablet 10 mg trintellix oral tablet 20 mg trintellix oral tablet 5 mg ULTRA SLEEP (DOXYLAMINE SUCC) venlafaxine oral capsule,extended release 24hr 150 mg venlafaxine oral capsule,extended release 24hr 37.5 mg venlafaxine oral capsule,extended release 24hr 75 mg venlafaxine oral tablet 100 mg venlafaxine oral tablet 25 mg ; QLL (300 per 30 days) ; QLL (60 per 30 days) ; QLL (240 per 30 days) ; QLL (120 per 30 days) ; QLL (60 per 30 days) ; QLL (30 per 30 days) ; QLL (30 per 30 days) QLL (60 per 30 days) QLL (30 per 30 days) QLL (120 per 30 days) ; QLL (60 per 30 days) ; QLL (180 per 30 days) ; QLL (90 per 30 days) ; QLL (113 per 30 days) ; QLL (450 per 30 days) 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/2016 62

venlafaxine oral tablet 37.5 mg venlafaxine oral tablet 50 mg venlafaxine oral tablet 75 mg venlafaxine oral tablet extended release 24hr 150 mg venlafaxine oral tablet extended release 24hr 37.5 mg venlafaxine oral tablet extended release 24hr 75 mg VERSACLOZ VIIBRYD ORAL TABLET 10 MG VIIBRYD ORAL TABLET 20 MG VIIBRYD ORAL TABLET 40 MG VRAYLAR ORAL CAPSULE VRAYLAR ORAL CAPSULE,DOSE PACK XYREM zaleplon oral capsule 10 mg zaleplon oral capsule 5 mg zenzedi oral tablet 10 mg zenzedi oral tablet 5 mg ziprasidone hcl oral capsule 20 mg ziprasidone hcl oral capsule 40 mg ziprasidone hcl oral capsule 60 mg, 80 mg ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 210 MG, 405 MG ; QLL (300 per 30 days) ; QLL (225 per 30 days) ; QLL (150 per 30 days) ; QLL (60 per 30 days) ; QLL (180 per 30 days) ; QLL (90 per 30 days) QLL (600 per 30 days) ; QLL (120 per 30 days) ; QLL (60 per 30 days) ; QLL (30 per 30 days) PAR; QLL (30 per 30 days) PAR; QLL (7 per 365 days) PAR; ; LA; QLL (540 per 30 days) ; QLL (60 per 30 days) ; QLL (30 per 30 days) PAR; ; QLL (180 per 30 days) PAR; ; QLL (90 per 30 days) ; QLL (240 per 30 days) ; QLL (120 per 30 days) ; QLL (60 per 30 days) QLL (2 per 28 days) (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 63

ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 300 MG CARDIOVASCULAR, HYPERTENSION / LIPIDS ANTIARRHYTHMIC AGENTS ; QLL (2 per 28 days) amiodarone intravenous solution amiodarone intravenous syringe amiodarone oral dofetilide flecainide lidocaine (pf) intravenous solution lidocaine (pf) intravenous syringe 100 mg/5 ml (2 %) mexiletine MULTAQ pacerone oral tablet 100 mg, 200 mg, 400 mg procainamide injection solution 100 mg/ml procainamide injection solution 500 mg/ml propafenone oral tablet quinidine gluconate oral quinidine sulfate oral tablet sorine oral tablet 120 mg, 160 mg, 80 mg sorine oral tablet 240 mg sotalol af sotalol oral TIKOSYN B/D; B/D ; QLL (60 per 30 days) 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/2016 64

ANTIHYPERTENSIVE THERAPY acebutolol afeditab cr amiloride amiloride-hydrochlorothiazide amlodipine besylate oral tablet 10 mg, 2.5 mg amlodipine besylate oral tablet 5 mg amlodipine-benazepril atenolol atenolol-chlorthalidone benazepril benazepril-hydrochlorothiazide betaxolol oral bisoprolol fumarate bisoprolol-hydrochlorothiazide bumetanide candesartan oral tablet 16 mg, 4 mg, 8 mg candesartan oral tablet 32 mg candesartan-hydrochlorothiazid oral tablet 16-12.5 mg candesartan-hydrochlorothiazid oral tablet 32-12.5 mg, 32-25 mg captopril captopril-hydrochlorothiazide cartia xt ; QLL (30 per 30 days) ; QLL (45 per 30 days) ; QLL (60 per 30 days) ; QLL (30 per 30 days) ; QLL (60 per 30 days) ; QLL (30 per 30 days) (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 65

carvedilol chlorothiazide chlorthalidone oral tablet 25 mg, 50 mg clonidine hcl oral tablet clonidine transdermal patch DEMSER dilt-xr diltiazem hcl intravenous solution diltiazem hcl oral capsule, extended release 120 mg, 180 mg, 240 mg, 300 mg, 360 mg diltiazem hcl oral capsule,ext release degradable diltiazem hcl oral capsule,extended release 12 hr diltiazem hcl oral capsule,extended release 24hr diltiazem hcl oral tablet diltiazem hcl oral tablet extended release 24 hr doxazosin enalapril maleate enalapril-hydrochlorothiazide eplerenone eprosartan felodipine oral er fosinopril fosinopril-hydrochlorothiazide ; QLL (4 per 28 days) ; QLL (30 per 30 days) 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/2016 66

furosemide injection solution furosemide oral solution 10 mg/ml, 40 mg/5 ml (8 mg/ml) furosemide oral tablet hydralazine hydrochlorothiazide indapamide irbesartan labetalol intravenous solution labetalol oral lisinopril lisinopril-hydrochlorothiazide losartan oral tablet 100 mg losartan oral tablet 25 mg, 50 mg losartan-hydrochlorothiazide matzim la methyclothiazide methyldopa methyldopa-hydrochlorothiazide methyldopate metolazone metoprolol succinate metoprolol ta-hydrochlorothiaz metoprolol tartrate intravenous solution ; QLL (30 per 30 days) ; QLL (30 per 30 days) ; QLL (60 per 30 days) ; QLL (30 per 30 days) (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 67

metoprolol tartrate intravenous syringe metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg minoxidil oral nadolol nadolol-bendroflumethiazide nicardipine oral nifedical xl nifedipine oral tablet extended release nifedipine oral tablet extended release 24hr pindolol prazosin oral propranolol intravenous propranolol oral propranolol-hydrochlorothiazid quinapril quinapril-hydrochlorothiazide ramipril spironolacton-hydrochlorothiaz spironolactone taztia xt telmisartan oral tablet 20 mg, 40 mg telmisartan oral tablet 80 mg terazosin timolol maleate oral ; QLL (30 per 30 days) ; QLL (60 per 30 days) 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/2016 68

torsemide oral trandolapril triamterene-hydrochlorothiazid oral capsule 37.5-25 mg triamterene-hydrochlorothiazid oral tablet valsartan oral tablet 160 mg valsartan oral tablet 320 mg valsartan oral tablet 40 mg, 80 mg valsartan-hydrochlorothiazide verapamil intravenous solution verapamil oral capsule, 24 hr er pellet ct verapamil oral capsule,ext rel. pellets 24 hr verapamil oral tablet verapamil oral tablet extended release 120 mg (24 hours) verapamil oral tablet extended release 120 mg, 180 mg, 240 mg CARDIAC GLYCOSIDES digox oral tablet 125 mcg digoxin injection solution digoxin oral solution 50 mcg/ml digoxin oral tablet 125 mcg LANOXIN ORAL TABLET 125 MCG, 62.5 MCG ; QLL (60 per 30 days) ; QLL (30 per 30 days) ; QLL (90 per 30 days) ; QLL (30 per 30 days) (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 69

COAGULATION THERAPY AGGRENOX BRILINTA cilostazol clopidogrel oral tablet 300 mg clopidogrel oral tablet 75 mg EFFIENT ELIQUIS ORAL TABLET 2.5 MG ELIQUIS ORAL TABLET 5 MG enoxaparin subcutaneous solution enoxaparin subcutaneous syringe 100 mg/ml, 150 mg/ml enoxaparin subcutaneous syringe 120 mg/0.8 ml, 80 mg/0.8 ml enoxaparin subcutaneous syringe 30 mg/0.3 ml enoxaparin subcutaneous syringe 40 mg/0.4 ml enoxaparin subcutaneous syringe 60 mg/0.6 ml fondaparinux subcutaneous syringe 10 mg/0.8 ml fondaparinux subcutaneous syringe 2.5 mg/0.5 ml fondaparinux subcutaneous syringe 5 mg/0.4 ml fondaparinux subcutaneous syringe 7.5 mg/0.6 ml ; QLL (60 per 30 days) ; QLL (60 per 30 days) ; QLL (1 per 30 days) ; QLL (30 per 30 days) ; QLL (30 per 30 days) ; QLL (60 per 30 days) ; QLL (74 per 30 days) ; QLL (84 per 30 days) ; QLL (28 per 30 days) ; QLL (22.4 per 30 days) ; QLL (8.4 per 30 days) ; QLL (11.2 per 30 days) ; QLL (16.8 per 30 days) ; QLL (24 per 30 days) ; QLL (15 per 30 days) ; QLL (12 per 30 days) ; QLL (18 per 30 days) 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/2016 70

FRAGMIN SUBCUTANEOUS SYRINGE 2,500 ANTI-XA UNIT/0.2 ML, 5,000 ANTI-XA UNIT/ 0.2 ML heparin (porcine) in 5 % dex intravenous parenteral solution 12, 500 unit/250 ml heparin (porcine) in 5 % dex intravenous parenteral solution 25, 000 unit/250 ml(100 unit/ml), 25,000 unit/500 ml (50 unit/ml) heparin (porcine) in nacl (pf) intravenous parenteral solution 1,000 unit/500 ml, 2,000 unit/1,000 ml heparin (porcine) injection cartridge heparin (porcine) injection solution HEPARIN FLUSH heparin lock flush intravenous kit 100 unit/ml heparin lock flush intravenous solution 10 unit/ml, 100 unit/ml heparin lock flush intravenous syringe 10 unit/ml HEPARIN LOCK FLUSH INTRAVENOUS SYRINGE 100 UNIT/ML HEPARIN LOCKFLUSH(PORCINE)(PF) HEPARIN(PORCINE) IN 0.45% NACL INTRAVENOUS PARENTERAL SOLUTION 12, 500 UNIT/250 ML $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) B/D; HI B/D; ; HI B/D; HI B/D; ; HI B/D; ; HI ; B/D; ; B/D; B/D; ; B/D; ; B/D (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 71

heparin(porcine) in 0.45% nacl intravenous parenteral solution 25, 000 unit/250 ml, 25,000 unit/500 ml heparin, porcine (pf) injection solution heparin, porcine (pf) intravenous solution 100 unit/ml (1 ml) HEPARIN, PORCINE (PF) INTRAVENOUS SYRINGE 1 UNIT/ML heparin, porcine (pf) intravenous syringe 10 unit/ml, 100 unit/ml jantoven MEPHYTON NOJECT PREFILL (PF) pentoxifylline PRADAXA ORAL CAPSULE 110 MG PRADAXA ORAL CAPSULE 150 MG, 75 MG PROMACTA ORAL TABLET 12.5 MG, 25 MG, 75 MG PROMACTA ORAL TABLET 50 MG tranexamic acid intravenous warfarin XARELTO ORAL TABLET 10 MG, 20 MG XARELTO ORAL TABLET 15 MG $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) B/D; B/D; B/D; B/D; B/D; ; ; B/D; ; QLL (60 per 30 days) PAR; ; LA; QLL (30 per 30 days) PAR; ; LA; QLL (60 per 30 days) ; QLL (30 per 30 days) ; QLL (42 per 30 days) XARELTO ORAL TABLETS,DOSE PACK LIPID/CHOLESTEROL LOWERING AGENTS ; QLL (102 per 365 days) atorvastatin cholestyramine (with sugar) cholestyramine light ; QLL (30 per 30 days) 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/2016 72

colestipol fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg fenofibrate nanocrystallized 48 mg, 145 mg fenofibrate oral tablet 160 mg, 54 mg gemfibrozil oral JUXTAPID KYNAMRO lovastatin oral tablet 10 mg, 20 mg lovastatin oral tablet 40 mg niacin oral capsule, extended release 250 mg, 500 mg niacin oral tablet 100 mg, 50 mg, 500 mg NIACIN ORAL TABLET 250 MG niacin oral tablet extended release 24 hr 1,000 mg, 750 mg niacin oral tablet extended release 24 hr 500 mg niacin oral tablet extended release 250 mg, 750 mg NIACOR NIASPAN EXTENDED-RELEASE ORAL TABLET EXTENDED RELEASE 24 HR 1,000 MG, 750 MG NIASPAN EXTENDED-RELEASE ORAL TABLET EXTENDED RELEASE 24 HR 500 MG omega-3 acid ethyl esters ; QLL (30 per 30 days) ; QLL (30 per 30 days) PAR; ; LA PAR; ; LA ; QLL (30 per 30 days) ; QLL (60 per 30 days) ; ; ; ; QLL (60 per 30 days) ; QLL (30 per 30 days) ; ; QLL (60 per 30 days) ; QLL (30 per 30 days) (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 73

PRALUENT PEN PRALUENT SYRINGE pravastatin prevalite REPATHA PUSHTRONEX REPATHA SURECLICK REPATHA SYRINGE simvastatin WELCHOL PAR; ; QLL (2 per 28 days) PAR; ; QLL (2 per 28 days) ; QLL (30 per 30 days) PAR; QLL (3.5 per 28 days) PAR; ; QLL (3 per 28 days) PAR; ; QLL (3 per 28 days) ; QLL (30 per 30 days) ZETIA MISCELLANEOUS CARDIOVASCULAR AGENTS ; QLL (30 per 30 days) RANEXA VECAMYL NITRATES isosorbide dinitrate oral isosorbide mononitrate nitro-bid nitroglycerin intravenous nitroglycerin sublingual nitroglycerin transdermal patch 24 hour B/D NITROSTAT DERMATOLOGICALS/TOPICAL THERAPY ANTIPSORIATIC / ANTISEBORRHEIC calcipotriene scalp calcipotriene topical selenium sulfide topical lotion ; QLL (60 per 30 days) ; QLL (120 per 30 days) 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/2016 74

SORIATANE ORAL CAPSULE 10 MG, 17.5 MG, 25 MG VECTICAL BURN THERAPY silver sulfadiazine ssd thermazene KERATOLYTICS SALICYLIC ACID TOPICAL LIQUID 3 % SCALP RELIEF HYDROCORTISONE TOPICAL LIQUID 3 % MISCELLANEOUS DERMATOLOGICALS 8-P AMLACTIN TOPICAL LOTION ammonium lactate AMNIUM LACTATE TOPICAL LOTION 12 % AMNIUM LACTATE TOPICAL LOTION 5 % calamine CALAMINE-ZINC OXIDE TOPICAL LOTION 8-8 % diclofenac sodium topical gel 3 % ELIDEL fluorouracil topical cream 5 % GORMEL TEN imiquimod methoxsalen rapid PAR; ; ; ; PAR; ; QLL (100 per 30 days) PAR; ; QLL (100 per 90 days) PAR; (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 75

OXSORALEN PANRETIN PICATO podofilox PROTOPIC SKIN TREATMENT urea topical cream 10 %, 20 % urea topical lotion 10 % UREACIN-20 UVADEX VALCHLOR THERAPY FOR ACNE ACNE TREATMENT (BENZOYL PEROX) TOPICAL GEL ACNE-CLEAR benzoyl peroxide topical gel 10 %, 5 % BP clindamycin phosphate topical DIFFERIN TOPICAL GEL 0.3 % DIFFERIN TOPICAL GEL WITH PUMP ery pads erythromycin with ethanol erythromycin-benzoyl peroxide metronidazole topical cream metronidazole topical gel 0.75 % metronidazole topical lotion PERSA-GEL rosadan topical cream PAR; ; QLL (100 per 90 days) ; ; ; 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/2016 76

TAZORAC tretinoin topical cream tretinoin topical gel 0.01 %, 0.025 % TOPICAL ANESTHETICS lidocaine (pf) injection solution 10 mg/ml (1 %), 20 mg/ml (2 %), 40 mg/ml (4 %), 5 mg/ml (0.5 %) lidocaine (pf) injection solution 15 mg/ml (1.5 %) lidocaine hcl injection solution 10 mg/ ml (1 %), 20 mg/ml (2 %) lidocaine hcl injection solution 5 mg/ ml (0.5 %) lidocaine hcl laryngotracheal lidocaine hcl mucous membrane lidocaine hcl urethral lidocaine topical adhesive patch, medicated lidocaine topical ointment lidocaine viscous lidocaine-prilocaine topical cream TOPICAL ANTIBACTERIALS ANTIBIOTIC (NEOMY-BACIT-POLYM) ANTIBIOTIC-PAIN RELIEF (BACIT) bacitracin topical ointment BACITRACIN TOPICAL PACKET BACITRACIN ZINC TOPICAL PACKET ; QLL (45 per 30 days) ; QLL (45 per 30 days) PAR; ; QLL (90 per 30 days) ; (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 77

bacitracin-polymyxin b topical ointment bacitracin-polymyxin b topical packet BACITRAYCIN PLUS TOPICAL OINTMENT 500 UNIT/GRAM DOUBLE ANTIBIOTIC gentamicin topical mupirocin topical ointment NEOSPORIN PLUS PAINRELIEF(BAC) POLY BACITRACIN sulfacetamide sodium (acne) SULFAMYLON TRI-BIOZENE TRIPLE ANTIBIOTIC (PRAM) EXTRA TRIPLE ANTIBIOTIC PLUS TRIPLE ANTIBIOTIC TOPICAL OINTMENT TRIPLE ANTIBIOTIC TOPICAL OINTMENT IN PACKET TRIPLE ANTIBIOTIC-PAIN RELIEF TOPICAL ANTIFUNGALS ANTI-FUNGAL MICONAZOLE POWDER TOPICAL POWDER 2 % ANTIFUNGAL (CLOTRIMAZOLE) ANTIFUNGAL (TOLNAFTATE) TOPICAL AEROSOL,SPRAY ANTIFUNGAL (TOLNAFTATE) TOPICAL CREAM ANTIFUNGAL MICONAZOLE CREAM ATHLETE'S FOOT (TERBINAFINE) ; ; ; 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/2016 78

ATHLETE'S FOOT (TOLNAFTATE) ATHLETE'S FOOT AF ciclodan topical solution ciclopirox topical cream ciclopirox topical gel ciclopirox topical shampoo ciclopirox topical solution ciclopirox topical suspension CLOTRIMAZOLE AF CLOTRIMAZOLE ANTIFUNGAL clotrimazole topical clotrimazole-betamethasone DESENEX TOPICAL POWDER econazole topical FUNGOID-D INZO ANTIFUNGAL JOCK ITCH JOCK ITCH (CLOTRIMAZOLE) JOCK ITCH (TERBINAFINE) ketoconazole topical LAMISIL AT TOPICAL CREAM LOTRIMIN AF TOPICAL CREAM LOTRIMIN AF TOPICAL POWDER MICATIN miconazole nitrate topical cream MICONAZORB AF PAR; PAR; ; ; ; ; ; (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 79

MICRO-GUARD nyamyc nystatin topical nystatin-triamcinolone nystop ODOR CONTROL FOOT-SNEAKER RINGWORM SECURA ANTIFUNGAL SECURA ANTIFUNGAL EXTRA THICK terbinafine hcl topical TINACTIN TOPICAL AEROSOL POWDER tolnaftate topical aerosol powder tolnaftate topical cream ZEASORB (MICONAZOLE) TOPICAL ANTIVIRALS acyclovir topical DENAVIR TOPICAL CORTICOSTEROIDS ala-cort topical cream alclometasone amcinonide ANTI-ITCH (HC) TOPICAL CREAM ANTI-ITCH (HC) TOPICAL OINTMENT BETA-HC betamethasone dipropionate betamethasone valerate topical cream betamethasone valerate topical lotion ; ; ; ; ; ; QLL (30 per 30 days) ; QLL (5 per 2 days) ; 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/2016 80

betamethasone valerate topical ointment betamethasone, augmented topical cream betamethasone, augmented topical lotion betamethasone, augmented topical ointment CAPEX clobetasol scalp clobetasol topical cream clobetasol topical gel clobetasol topical ointment clobetasol-emollient topical cream cormax scalp CORTISONE (HYDROCORTISONE) TOPICAL CREAM CORTIZONE-10 PLUS CORTIZONE-10 TOPICAL CREAM CORTIZONE-10 TOPICAL OINTMENT desonide desoximetasone diflorasone ECZEMA ANTI-ITCH fluocinolone fluocinolone and shower cap fluocinonide topical cream 0.05 % (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 81

fluocinonide topical gel fluocinonide topical ointment fluocinonide topical solution fluocinonide-e topical cream 0.05 % fluticasone topical cream fluticasone topical ointment halobetasol propionate HALOG hydrocortisone acetate topical HYDROCORTISONE PLUS hydrocortisone topical cream 0.5 % hydrocortisone topical cream 1 %, 2.5 % hydrocortisone topical lotion 1 % hydrocortisone topical lotion 2.5 % hydrocortisone topical ointment 0.5 % hydrocortisone topical ointment 1 %, 2.5 % hydrocortisone valerate hydrocortisone-min oil-wht pet HYDROCREAM HYDROSKIN TOPICAL LOTION LOKARA mometasone topical NEOSPORIN ANTI-ITCH NOBLE FORMULA HC TOPICAL CREAM RECORT PLUS ; ; ; 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/2016 82

SCALP RELIEF HYDROCORTISONE TOPICAL SOLUTION 1 % SCALPICIN ANTI-ITCH SOOTHING CARE (HYDROCORTISONE) triamcinolone acetonide topical cream triamcinolone acetonide topical lotion triamcinolone acetonide topical ointment 0.025 %, 0.1 %, 0.5 % trianex triderm topical cream TOPICAL ENZYMES ; SANTYL TOPICAL SCABICIDES / PEDICULICIDES ; QLL (30 per 30 days) COMPLETE LICE TREATMENT LICE BEDDING SPRAY LICE COMPLETE KIT 1-2-3 LICE CREAM RINSE LICE KILLING LICE KILLING (PERMETHRIN) LICE PYRINYL SHAMPOO LICE SOLUTION LICE TREATMENT (PERMETHRIN) LICE TREATMENT TOPICAL LIQUID 1 % LICE TREATMENT TOPICAL SHAMPOO lindane topical shampoo permethrin topical cream (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 83

permethrin topical liquid RID COMPLETE LICE ELIM KIT TOPICAL ; STOP LICE DIAGNOSTICS / MISCELLANEOUS AGENTS ANOREXIANTS benzphetamine oral tablet 50 mg phentermine ANTIDOTES acetylcysteine intravenous IRRIGATING SOLUTIONS lactated ringers irrigation neomycin-polymyxin b gu ringers irrigation MISCELLANEOUS AGENTS acamprosate ADAGEN alendronate oral tablet 40 mg anagrelide ARALAST NP BUPHENYL ORAL TABLET CARBAGLU cevimeline CLINIMIX 4.25%/D5W SULFIT FREE CLINIMIX E 2.75%/D10W SUL FREE CLINIMIX E 2.75%/D5W SULF FREE d10 %-0.45 % sodium chloride d2.5 %-0.45 % sodium chloride $0 (Tier 3) $0 (Tier 3) PAR; ; PAR; ; B/D; B/D; ; QLL (30 per 30 days) PAR; ; LA PAR; PAR; ; LA B/D; HI B/D; HI B/D; HI HI HI 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/2016 84

d5 % and 0.9 % sodium chloride d5 %-0.45 % sodium chloride DEX4 GLUCOSE ORAL TABLET,CHEWABLE DEX4 GLUCOSE POUCH PACK DEX4 GLUCOSE QUICK DISSOLVE dextrose 10 % and 0.2 % nacl dextrose 10 % in water (d10w) dextrose 25 % in water (d25w) dextrose 30 % in water (d30w) dextrose 40 % in water (d40w) dextrose 5 % in water (d5w) dextrose 5 %-lactated ringers dextrose 5%-0.2 % sod chloride dextrose 5%-0.3 % sod.chloride dextrose 50 % in water (d50w) intravenous parenteral solution dextrose 50 % in water (d50w) intravenous syringe dextrose 70 % in water (d70w) dextrose oral gel dextrose with sodium chloride disulfiram EXJADE FERRIPROX ORAL SOLUTION FERRIPROX ORAL TABLET GLUCO BURST ; HI ; HI ; HI ; HI ; HI ; HI HI HI B/D; HI PAR; ; LA PAR PAR; (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 85

GLUCOSE GEL glucose oral tablet,chewable 4 gram GLUTOSE 15 GLUTOSE 45 INCRELEX INSTA-GLUCOSE kionex (with sorbitol) levocarnitine (with sugar) levocarnitine oral tablet midodrine ORFADIN ORAL CAPSULE 10 MG, 2 MG, 5 MG ORFADIN ORAL CAPSULE 20 MG ORFADIN ORAL SUSPENSION pilocarpine hcl oral RAVICTI RENAGEL RENVELA ORAL POWDER IN PACKET 0.8 GRAM RENVELA ORAL POWDER IN PACKET 2.4 GRAM RENVELA ORAL TABLET riluzole sodium chloride 0.9 % intravenous sodium chloride irrigation sodium polystyrene (sorb free) sodium polystyrene sulfonate oral powder sodium polystyrene sulfonate oral suspension ; ; ; PAR; ; LA ; B/D; LA LA PAR; ; QLL (525 per 30 days) ; QLL (180 per 30 days) ; QLL (90 per 30 days) ; QLL (270 per 30 days) ; HI 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/2016 86

sodium polystyrene sulfonate rectal enema 30 gram/120 ml SODIUM POLYSTYRENE SULFONATE RECTAL ENEMA 50 GRAM/200 ML sps (with sorbitol) oral sps (with sorbitol) rectal SYPRINE water for irrigation, sterile ZEMAIRA SKING DETERRENTS bupropion hcl (smoking deter) CHANTIX CHANTIX CONTINUING NTH BOX CHANTIX STARTING NTH BOX NICORELIEF nicotine (polacrilex) NICOTINE TRANSDERMAL nicotine transdermal system transdermal patch 24 hour 14 mg/24 hr, 21 mg/24 hr, 7 mg/24 hr nicotine transdermal system transdermal patch, td daily, sequential 21-14-7 mg/24 hr NICOTROL NS QUIT 2 QUIT 4 BUCCAL GUM STOP SKING AID PAR; ; LA ; QLL (60 per 30 days) ; QLL (60 per 30 days) ; QLL (56 per 28 days) ; QLL (106 per 365 days) ; ; ; ; ; QLL (120 per 30 days) (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 87

EAR, NOSE / THROAT MEDICATIONS MISCELLANEOUS AGENTS ASTEPRO NASAL SPRAY,NON-AEROSOL azelastine nasal aerosol,spray chlorhexidine gluconate mucous membrane ipratropium bromide nasal NASAL MIST oralone paroex oral rinse periogard STERILE SALINE NASAL triamcinolone acetonide dental ; QLL (30 per 25 days) ; QLL (30 per 25 days) ; QLL (30 per 30 days) TYZINE NASAL DROPS 0.05 % MISCELLANEOUS OTIC PREPARATIONS acetic acid otic acetic acid-aluminum acetate fluocinolone acetonide oil hydrocortisone-acetic acid ofloxacin otic OTIC STEROID / ANTIBIOTIC CIPRODEX COLY-MYCIN S neomycin-polymyxin-hc otic ENDOCRINE/DIABETES ADRENAL HORNES ACTHAR H.P. cortisone PAR; 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/2016 88

dexamethasone dexamethasone sodium phos (pf) dexamethasone sodium phosphate injection fludrocortisone hydrocortisone oral methylprednisolone acetate methylprednisolone oral tablets methylprednisolone sodium succ injection recon soln 125 mg, 40 mg methylprednisolone sodium succ intravenous prednisolone oral solution 15 mg/5 ml prednisolone sodium phosphate oral solution 15 mg/5 ml (3 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml) prednisolone sodium phosphate oral tablet,disintegrating prednisone intensol prednisone oral triamcinolone acetonide injection suspension 10 mg/ml triamcinolone acetonide injection suspension 40 mg/ml ANTITHYROID AGENTS methimazole oral tablet 10 mg, 5 mg propylthiouracil (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 89

DIABETES THERAPY acarbose oral tablet 100 mg acarbose oral tablet 25 mg acarbose oral tablet 50 mg alcohol pads BYDUREON BYETTA SUBCUTANEOUS PEN INJECTOR 10 MCG/DOSE(250 MCG/ML) 2.4 ML BYETTA SUBCUTANEOUS PEN INJECTOR 5 MCG/DOSE (250 MCG/ML) 1.2 ML CONDOMS, LATEX, LUBRICATED CONDOMS, LATEX, LUBRICATED DEVICE CONDOMS, LATEX, NON-LUBRICATED DEVICE CYCLOSET FREESTYLE INSULINX STRIP FREESTYLE INSULINX TEST STRIPS FREESTYLE LANCETS FREESTYLE LITE STRIPS FREESTYLE TEST GAUZE PADS 2 X 2 glimepiride oral tablet 1 mg glimepiride oral tablet 2 mg glimepiride oral tablet 4 mg glipizide oral tablet 10 mg glipizide oral tablet 5 mg glipizide oral tablet extended release 24hr 10 mg ; QLL (90 per 30 days) ; QLL (360 per 30 days) ; QLL (180 per 30 days) ; QLL (4 per 28 days) ; QLL (2.4 per 30 days) ; QLL (1.2 per 30 days) ; QLL (180 per 30 days) ; ; QLL (100 per 30 days) ; ; QLL (100 per 30 days) ; ; ; QLL (100 per 30 days) ; ; QLL (100 per 30 days) ; QLL (240 per 30 days) ; QLL (120 per 30 days) ; QLL (60 per 30 days) ; QLL (120 per 30 days) ; QLL (240 per 30 days) ; QLL (60 per 30 days) 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/2016 90

glipizide oral tablet extended release 24hr 2.5 mg glipizide oral tablet extended release 24hr 5 mg glipizide-metformin oral tablet 2.5-250 mg glipizide-metformin oral tablet 2.5-500 mg, 5-500 mg GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT (HUMAN) insulin pen needle INSULIN SYRINGE (DISP) U-100 0.3 ML, 1 ML, 1/2 ML INVOKANA ORAL TABLET 100 MG INVOKANA ORAL TABLET 300 MG JANUMET JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 100-1,000 MG JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 50-1,000 MG, 50-500 MG JANUVIA ORAL TABLET 100 MG JANUVIA ORAL TABLET 25 MG JANUVIA ORAL TABLET 50 MG JARDIANCE LANTUS LANTUS SOLOSTAR LEVEMIR ; QLL (240 per 30 days) ; QLL (120 per 30 days) ; QLL (240 per 30 days) ; QLL (120 per 30 days) PAR; ; QLL (90 per 30 days) PAR; ; QLL (30 per 30 days) ; QLL (60 per 30 days) ; QLL (30 per 30 days) ; QLL (60 per 30 days) ; QLL (30 per 30 days) ; QLL (120 per 30 days) ; QLL (60 per 30 days) PAR; ; QLL (30 per 30 days) (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 91

LEVEMIR FLEXTOUCH metformin oral tablet 1,000 mg metformin oral tablet 500 mg metformin oral tablet 850 mg metformin oral tablet extended release 24 hr 500 mg metformin oral tablet extended release 24 hr 750 mg metformin oral tablet extended release 24hr 1,000 mg nateglinide oral tablet 120 mg nateglinide oral tablet 60 mg needles, insulin disp.,safety NOVOLIN 70/30 NOVOLIN N NOVOLIN R NOVOLOG NOVOLOG FLEXPEN NOVOLOG MIX 70-30 NOVOLOG MIX 70-30 FLEXPEN NOVOLOG PENFILL pioglitazone oral tablet 15 mg pioglitazone oral tablet 30 mg pioglitazone oral tablet 45 mg pioglitazone-metformin PROGLYCEM repaglinide oral tablet 0.5 mg repaglinide oral tablet 1 mg ; QLL (76 per 30 days) ; QLL (153 per 30 days) ; QLL (90 per 30 days) ; QLL (120 per 30 days) ; QLL (80 per 30 days) ; QLL (75 per 30 days) ; QLL (90 per 30 days) ; QLL (180 per 30 days) ; QLL (90 per 30 days) ; QLL (45 per 30 days) ; QLL (30 per 30 days) ; QLL (90 per 30 days) ; QLL (960 per 30 days) ; QLL (480 per 30 days) 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/2016 92

repaglinide oral tablet 2 mg SYMLINPEN 120 SYMLINPEN 60 TOUJEO SOLOSTAR VICTOZA 2-PAK VICTOZA 3-PAK MISCELLANEOUS HORNES ALDURAZYME ANDRODERM ANDROGEL TRANSDERMAL GEL IN METERED- DOSE PUMP 20.25 MG/1.25 GRAM (1.62 %) ANDROGEL TRANSDERMAL GEL IN PACKET 1 % (25 MG/2.5GRAM) ANDROGEL TRANSDERMAL GEL IN PACKET 1 % (50 MG/5 GRAM) ANDROGEL TRANSDERMAL GEL IN PACKET 1.62 % (20.25 MG/1.25 GRAM) ANDROGEL TRANSDERMAL GEL IN PACKET 1.62 % (40.5 MG/2.5 GRAM) androxy AXIRON cabergoline calcitonin (salmon) calcitriol intravenous solution 1 mcg/ ml calcitriol oral capsule CEREZYME INTRAVENOUS RECON SOLN 400 UNIT ; QLL (240 per 30 days) ; QLL (11 per 30 days) ; QLL (6 per 30 days) ; QLL (9 per 30 days) ; QLL (9 per 30 days) PAR; ; QLL (30 per 30 days) ; QLL (150 per 30 days) ; QLL (225 per 30 days) ; QLL (300 per 30 days) ; QLL (112.5 per 30 days) ; QLL (150 per 30 days) PAR; ; QLL (180 per 30 days) ; QLL (4 per 30 days) B/D; B/D; PAR; (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 93

danazol oral desmopressin injection desmopressin nasal aerosol,spray desmopressin nasal spray,non-aerosol desmopressin oral ELAPRASE FABRAZYME KORLYM KUVAN ORAL TABLET,SOLUBLE MIACALCIN INJECTION MYOZYME NAGLAZYME NATPARA oxandrolone oral tablet 10 mg oxandrolone oral tablet 2.5 mg pamidronate SENSIPAR ORAL TABLET 30 MG, 60 MG SENSIPAR ORAL TABLET 90 MG SOMAVERT SUBCUTANEOUS RECON SOLN 10 MG, 15 MG, 20 MG SOMAVERT SUBCUTANEOUS RECON SOLN 25 MG, 30 MG STIMATE SYNAREL TESTIM testosterone cypionate testosterone enanthate VPRIV PAR; PAR; PAR; PAR; B/D; PAR; ; LA PAR; ; LA ; QLL (60 per 30 days) ; QLL (120 per 30 days) B/D; ; QLL (60 per 30 days) ; QLL (120 per 30 days) PAR; ; LA PAR; PAR; ; QLL (300 per 30 days) PAR; 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/2016 94

ZAVESCA zoledronic acid intravenous recon soln 4 mg zoledronic acid intravenous solution 4 mg/5 ml ZOMETA INTRAVENOUS SOLUTION 4 MG/100 ML THYROID HORNES levothyroxine oral levoxyl oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg liothyronine oral SYNTHROID PAR; ; LA UNITHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG GASTROENTEROLOGY ANTIDIARRHEALS / ANTISPASDICS ANTI-DIARRHEAL (LOPERAMIDE) ORAL LIQUID 1 MG/5 ML atropine injection syringe 0.05 mg/ml, 0.1 mg/ml BISMATROL ORAL SUSPENSION 262 MG/15 ML BISMATROL ORAL SUSPENSION 525 MG/15 ML BISMATROL ORAL TABLET,CHEWABLE BISMUTH ; (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 95

BISMUTH MAXIMUM STRENGTH DIARRHEA RELIEF (BISMUTH SUBS) dicyclomine oral capsule dicyclomine oral solution dicyclomine oral tablet DIOTAME diphenoxylate-atropine glycopyrrolate oral K-PEC ANTIDIARRHEAL (BISM SUB) KAO-TIN (BISMUTH SUBSALICYLAT) KAOPECTATE (BISMUTH SUBSALICY) KAOPECTATE EX STR (BISMUTH SS) loperamide oral capsule loperamide oral liquid 1 mg/5 ml PEPTIC RELIEF PEPTO-BISL ORAL TABLET,CHEWABLE PEPTO-BISL TO-GO PINK BISMUTH MAXIMUM STRENGTH PINK BISMUTH ORAL SUSPENSION PINK BISMUTH ORAL TABLET PINK BISMUTH ORAL TABLET,CHEWABLE SOOTHE (BISMUTH SUBSALICYLATE) SOOTHE REGULAR STRENGTH STOMACH RELIEF STOMACH RELIEF MAX STRENGTH STOMACH RELIEF ORIGINAL ; ; ; ; 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/2016 96

MISCELLANEOUS GASTROINTESTINAL AGENTS ACID GONE ANTACID E.STRENGTH ADVANCED ANTACID-ANTIGAS ALOPHEN alosetron ALUMINA AND MAGNESIUM ANTACID ORAL SUSPENSION 95-358 MG/15 ML ALUMINA AND MAGNESIUM ANTACID ORAL TABLET,CHEWABLE 80-20 MG ALUMINA, MAGNESIA, SIMETHICONE SUSPENSION ORAL SUSPENSION 200-200- 20 MG/5 ML, 400-400-40 MG/5 ML aluminum hydroxide gel oral suspension 320 mg/5 ml aluminum hydroxide gel oral suspension 600 mg/5 ml ANTACID ANTACID ANTI-GAS ANTACID ANTI-GAS DOUBLE STR ANTACID EXST (MAG CARB-AL HYD) ANTACID EXTRA-STRENGTH ORAL SUSPENSION 200-200-20 MG/5 ML ANTACID LIQUID ANTACID MAXIMUM STRENGTH ANTACID PLUS ANTI-GAS ANTACID REGULAR STRENGTH ANTACID WITH SIMETHICONE ANTACID-ANTIGAS ; QLL (60 per 30 days) ; (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 97

ANTACID-SIMETHICONE APRISO ASACOL HD balsalazide BISA-LAX BISAC-EVAC bisacodyl oral bisacodyl rectal BISCOLAX budesonide oral CALCIUM CARBONATE AND MAGNESIA ANTACID ORAL SUSPENSION 200-200-20 MG/5 ML, 400-400-40 MG/5 ML CALCIUM CARBONATE AND MAGNESIA ANTACID ORAL TABLET,CHEWABLE 700-300 MG CANASA CITRATE OF MAGNESIA CITROMA CLEARLAX COL-RITE colocort COMFORT GEL COMFORT GEL EXTRA STRENGTH compro constulose CREON CYSTADANE ; ; ; ; ; 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/2016 98

DELZICOL ORAL CAPSULE (WITH DEL REL TABLETS) DIOCTO ORAL LIQUID DIOCTO ORAL SYRUP DIOCTYL DIPENTUM DOC-Q-LACE DOCU DOCUPRENE docusate calcium docusate sodium oral capsule 100 mg docusate sodium oral capsule 250 mg docusate sodium oral liquid docusate sodium oral tablet DOCUSIL DOK ORAL CAPSULE 100 MG DOK ORAL CAPSULE 250 MG DOK ORAL TABLET DRAMAMINE LESS DROWSY dronabinol DSS DUCODYL DULCOLAX STOOL SOFTENER (DSS) EMEND ORAL CAPSULE 125 MG EMEND ORAL CAPSULE 40 MG EMEND ORAL CAPSULE 80 MG ; ; ; ; ; ; ; ; ; B/D; ; QLL (120 per 30 days) ; B/D; ; QLL (5 per 30 days) B/D; ; QLL (1 per 2 days) B/D; ; QLL (10 per 30 days) (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 99

EMEND ORAL CAPSULE,DOSE PACK EMEND ORAL SUSPENSION FOR RECONSTITUTION enulose FLANAX ANTACID FLEET GLYCERIN (ADULT) FLEET LAXATIVE GAS RELIEF 80 GAS RELIEF ULTRA STRENGTH GATTEX 30-VIAL GATTEX ONE-VIAL GAVILAX ORAL POWDER gavilyte-c gavilyte-g gavilyte-n generlac GENTLE LAXATIVE GENTLELAX GERI-LANTA GERI-X ANTACID-ANTIGAS glycerin (adult) GLYCOLAX ORAL POWDER HEALTHYLAX HEARTBURN ANTACID HEARTBURN RELIEF hydrocortisone rectal cream 2.5 % hydrocortisone rectal enema KAO-TIN (DOCUSATE CALCIUM) B/D; ; QLL (15 per 30 days) B/D; QLL (15 per 30 days) ; 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/2016 100

lactulose LAXA CLEAR LAXATIVE (BISACODYL) ORAL TABLET, DELAYED RELEASE (DR/EC) LAXATIVE (BISACODYL) RECTAL LAXATIVE PEG 3350 ORAL POWDER LINZESS LIQUID ANTACID MAALOX MAXIMUM STRENGTH MAG-AL PLUS MAG-AL PLUS EXTRA STRENGTH magnesium citrate oral solution MASANTI DOUBLE STRENGTH meclizine oral tablet 12.5 mg, 25 mg meclizine oral tablet,chewable MEDI-MECLIZINE MESALAMINE ORAL mesalamine rectal mesalamine with cleansing wipe metoclopramide hcl injection solution metoclopramide hcl injection syringe metoclopramide hcl oral solution metoclopramide hcl oral tablet MI-ACID GAS RELIEF MILK OF MAGNESIA MILK OF MAGNESIA CONCENTRATED ; ; ; ; (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 101

MINERAL OIL EXTRA HEAVY MINERAL OIL HEAVY ORAL MINERAL OIL LAXATIVE mineral oil oral mineral oil rectal MINTOX MINTOX MAXIMUM STRENGTH MINTOX PLUS MIRALAX ORAL POWDER IN PACKET TION RELIEF (MECLIZINE) TION SICKNESS (MECLIZINE) TION SICKNESS RELIEF(MECLIZ) VIPREP MYTAB GAS MYTAB GAS MAXIMUM STRENGTH ondansetron hcl (pf) injection solution ondansetron hcl (pf) injection syringe ondansetron hcl intravenous ondansetron hcl oral solution ondansetron hcl oral tablet 24 mg ondansetron hcl oral tablet 4 mg, 8 mg ondansetron odt ORAL SALINE LAXATIVE ORAL LIQUID PANCREAZE peg 3350-electrolytes oral recon soln 236-22.74-6.74-5.86 gram ; ; ; ; ; ; ; B/D; ; QLL (450 per 30 days) B/D; QLL (30 per 30 days) B/D; ; QLL (90 per 30 days) B/D; ; QLL (90 per 30 days) 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/2016 102

peg 3350-electrolytes oral recon soln 240-22.72-6.72-5.84 gram peg-electrolyte soln PENTASA PHOSPHATE LAXATIVE ORAL LIQUID polyethylene glycol 3350 oral powder polyethylene glycol 3350 oral powder in packet POWDERLAX prochlorperazine edisylate injection solution 10 mg/2 ml (5 mg/ml) prochlorperazine maleate oral tablet 10 mg, 5 mg prochlorperazine maleate rectal procto-pak proctosol hc proctozone-hc PROLAXIN PURELAX READY-TO-USE ENEMA (MIN OIL) RELISTOR SUBCUTANEOUS SOLUTION REMICADE RI-GEL RI-GEL II RI-X SANI-SUPP (ADULT) SILACE ORAL LIQUID ; PAR; PAR; ; ; (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 103

SILACE ORAL SYRUP SIMETHICONE ORAL CAPSULE 125 MG, 180 MG simethicone oral capsule 180 mg simethicone oral tablet,chewable SIMETHICONE ORAL TABLET,CHEWABLE 125 MG SIMETHICONE ORAL TABLET,CHEWABLE 125 MG, 80 MG SOTHLAX SOF-LAX STOOL SOFTENER ORAL CAPSULE 100 MG, 240 MG, 250 MG STOOL SOFTENER ORAL CAPSULE 50 MG STOOL SOFTENER ORAL LIQUID STOOL SOFTENER ORAL SYRUP STOOL SOFTENER ORAL TABLET sulfasalazine SUPPOSITORY ADULT SUPREP BOWEL PREP KIT SURFAK THE MAGIC BULLET TRANSDERM-SCOP TRAVEL SICKNESS (MECLIZINE) ursodiol WOMAN'S LAXATIVE ORAL TABLET,DELAYED RELEASE (DR/EC) WOMEN'S GENTLE LAXATIVE(BISAC) ; ; ; ; ; QLL (4 per 12 days) ; 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/2016 104

WOMEN'S LAXATIVE (BISACODYL) ORAL TABLET,DELAYED RELEASE (DR/EC) ULCER THERAPY ACID CONTROL (RANITIDINE) ORAL TABLET 150 MG ACID REDUCER (FATIDINE) ACID REDUCER (RANITIDINE) DEXILANT famotidine (pf) famotidine (pf)-nacl (iso-os) famotidine intravenous famotidine oral suspension famotidine oral tablet 10 mg famotidine oral tablet 20 mg, 40 mg HEARTBURN PREVENTION HEARTBURN RELIEF (FATIDINE) HEARTBURN RELIEF (RANITIDINE) lansoprazole oral capsule,delayed release(dr/ec) misoprostol omeprazole oral capsule,delayed release(dr/ec) OMEPRAZOLE ORAL TABLET,DELAYED RELEASE (DR/EC) pantoprazole PEPCID AC ORAL TABLET 20 MG PROTONIX INTRAVENOUS ; QLL (30 per 30 days) ; ; QLL (30 per 30 days) ; ; (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 105

ranitidine hcl oral syrup ranitidine hcl oral tablet 150 mg, 300 mg ranitidine hcl oral tablet 75 mg ; sucralfate oral tablet IMMUNOLOGY, VACCINES / BIOTECHNOLOGY BIOTECHNOLOGY DRUGS ACTIMMUNE ARANESP (IN POLYSORBATE) INJECTION SOLUTION 100 MCG/ML, 200 MCG/ML, 25 MCG/ML, 300 MCG/ML, 40 MCG/ML, 60 MCG/ ML ARANESP (IN POLYSORBATE) INJECTION SYRINGE 10 MCG/0.4 ML, 200 MCG/0.4 ML, 40 MCG/0.4 ML ARANESP (IN POLYSORBATE) INJECTION SYRINGE 100 MCG/0.5 ML ARANESP (IN POLYSORBATE) INJECTION SYRINGE 150 MCG/0.3 ML, 60 MCG/0.3 ML ARANESP (IN POLYSORBATE) INJECTION SYRINGE 25 MCG/0.42 ML ARANESP (IN POLYSORBATE) INJECTION SYRINGE 300 MCG/0.6 ML ARANESP (IN POLYSORBATE) INJECTION SYRINGE 500 MCG/ML ARCALYST AVONEX (WITH ALBUMIN) AVONEX INTRAMUSCULAR PEN INJECTOR KIT AVONEX INTRAMUSCULAR SYRINGE AVONEX INTRAMUSCULAR SYRINGE KIT PAR; PAR; ; QLL (4 per 28 days) PAR; ; QLL (1.6 per 28 days) PAR; ; QLL (2 per 28 days) PAR; ; QLL (1.2 per 28 days) PAR; ; QLL (1.68 per 28 days) PAR; ; QLL (2.4 per 28 days) PAR; ; QLL (4 per 28 days) PAR; PAR; ; QLL (4 per 28 days) PAR; ; QLL (4 per 28 days) PAR; ; QLL (4 per 28 days) PAR; ; QLL (4 per 28 days) 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/2016 106

BETASERON SUBCUTANEOUS KIT GENOTROPIN GENOTROPIN MINIQUICK HUMATROPE INJECTION CARTRIDGE 12 MG (36 UNIT), 24 MG (72 UNIT) ILARIS (PF) INTRON A INJECTION LEUKINE INJECTION RECON SOLN ZOBIL NEULASTA SUBCUTANEOUS SYRINGE NEUPOGEN NORDITROPIN FLEXPRO SUBCUTANEOUS PEN INJECTOR 10 MG/1.5 ML (6.7 MG/ML), 15 MG/1.5 ML (10 MG/ML), 5 MG/1.5 ML (3.3 MG/ML) PEGINTRON PEGINTRON REDIPEN PROCRIT PROLEUKIN REBIF (WITH ALBUMIN) REBIF REBIDOSE REBIF TITRATION PACK PAR; PAR; PAR; PAR; PAR; ; LA PAR; PAR; PAR; ; QLL (2 per 28 days) PAR; PAR; PAR; PAR; ; QLL (4 per 28 days) PAR; ; QLL (12 per 28 days) PAR; PAR; PAR; SYLATRON PAR; VACCINES / MISCELLANEOUS IMMUNOLOGICALS ACTHIB (PF) ADACEL(TDAP ADOLESN/ADULT)(PF) ATGAM B/D (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 107

BCG VACCINE, LIVE (PF) BEXSERO (PF) BOOSTRIX TDAP CARIMUNE NF NANOFILTERED INTRAVENOUS RECON SOLN 12 GRAM, 6 GRAM CERVARIX VACCINE (PF) DAPTACEL (DTAP PEDIATRIC) (PF) ENGERIX-B (PF) ENGERIX-B PEDIATRIC (PF) FLEBOGAMMA DIF GAMASTAN S/D GAMMAGARD LIQUID GAMMAGARD S-D (IGA < 1 MCG/ML) GAMUNEX-C GARDASIL (PF) GARDASIL 9 (PF) HAVRIX (PF) INTRAMUSCULAR SUSPENSION HAVRIX (PF) INTRAMUSCULAR SYRINGE 1, 440 ELISA UNIT/ML HAVRIX (PF) INTRAMUSCULAR SYRINGE 720 ELISA UNIT/0.5 ML HIBERIX (PF) IVAX RABIES VACCINE (PF) INFANRIX (DTAP) (PF) INTRAMUSCULAR SUSPENSION IPOL INJECTION SUSPENSION IXIARO (PF) M-M-R II (PF) PAR; B/D; B/D; PAR; PAR; PAR; PAR; PAR; 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/2016 108

MENACTRA (PF) INTRAMUSCULAR SOLUTION MENOMUNE - A/C/Y/W-135 MENOMUNE - A/C/Y/W-135 (PF) MENVEO A-C-Y-W-135-DIP (PF) PEDVAX HIB (PF) PENTACEL ACTHIB COMPONENT (PF) PROQUAD (PF) QUADRACEL (PF) RABAVERT (PF) RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 10 MCG/ML RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 5 MCG/0.5 ML ROTARIX ROTATEQ VACCINE tetanus,diphtheria tox ped(pf) TETANUS-DIPHTHERIA TOXOIDS-TD THYGLOBULIN TICE BCG TRUMENBA TWINRIX (PF) TYPHIM VI INTRAMUSCULAR SOLUTION TYPHIM VI INTRAMUSCULAR SYRINGE VAQTA (PF) $0 (Tier 3) B/D; B/D; B/D B/D (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 109

VARIVAX (PF) VARIZIG YF-VAX (PF) ZOSTAVAX (PF) MUSCULOSKELETAL / RHEUMATOLOGY GOUT THERAPY allopurinol colchicine-probenecid COLCRYS probenecid OSTEOPOROSIS THERAPY alendronate oral tablet 10 mg, 5 mg alendronate oral tablet 35 mg, 70 mg BONIVA INTRAVENOUS FORTEO ibandronate intravenous ibandronate oral PROLIA raloxifene OTHER RHEUMATOLOGICALS ACTEMRA INTRAVENOUS VIAL BENLYSTA DEPEN TITRATABS ENBREL SUBCUTANEOUS RECON SOLN ENBREL SUBCUTANEOUS SYRINGE 25 MG/ 0.5ML (0.51) ENBREL SUBCUTANEOUS SYRINGE 50 MG/ ML (0.98 ML) ; QLL (30 per 30 days) ; QLL (4 per 28 days) B/D; PAR; ; QLL (3 per 28 days) B/D; ; QLL (1 per 28 days) PAR; ; QLL (2 per 365 days) ; QLL (30 per 30 days) PAR; PAR; PAR; ; QLL (8 per 28 days) PAR; ; QLL (4.08 per 28 days) PAR; ; QLL (8 per 28 days) 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/2016 110

ENBREL SURECLICK HUMIRA PEDIATRIC CROHN'S START SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML HUMIRA PEDIATRIC CROHN'S START SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML (6 PACK) HUMIRA PEN HUMIRA PEN CROHN'S-UC-HS START HUMIRA PEN PSORIASIS-UVEITIS HUMIRA SUBCUTANEOUS SYRINGE KIT 10 MG/0.2 ML, 20 MG/0.4 ML HUMIRA SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML KINERET leflunomide ORENCIA ORENCIA (WITH MALTOSE) ORENCIA CLICKJECT RIDAURA SAVELLA ORAL TABLET 100 MG SAVELLA ORAL TABLET 12.5 MG SAVELLA ORAL TABLET 25 MG SAVELLA ORAL TABLET 50 MG SAVELLA ORAL TABLETS,DOSE PACK OBSTETRICS / GYNECOLOGY ESTROGENS / PROGESTINS camila PAR; ; QLL (8 per 28 days) PAR; ; QLL (4.8 per 365 days) PAR; QLL (4.8 per 365 days) PAR; ; QLL (3.2 per 28 days) PAR; ; QLL (9.6 per 365 days) PAR; ; QLL (3.2 per 28 days) PAR; ; QLL (2 per 28 days) PAR; ; QLL (3.2 per 28 days) PAR; ; QLL (28 per 28 days) PAR; ; QLL (4 per 28 days) PAR; PAR; QLL (4 per 28 days) ; QLL (60 per 30 days) ; QLL (480 per 30 days) ; QLL (240 per 30 days) ; QLL (120 per 30 days) ; QLL (110 per 365 days) (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 111

DEBLITANE DEPO-PROVERA INTRAMUSCULAR SOLUTION 400 MG/ML errin ESTRACE VAGINAL estradiol oral estradiol transdermal patch weekly ESTRING heather hydroxyprogesterone caproate jencycla jolivette lyza medroxyprogesterone intramuscular medroxyprogesterone oral MENEST nora-be norethindrone (contraceptive) norethindrone acetate NORLYROC PREMARIN PREMPHASE PREMPRO SHAROBEL VAGIFEM VIVELLE-DOT MISCELLANEOUS OB/GYN 3-DAY VAGINAL ; QLL (4 per 28 days) ; QLL (1 per 90 days) ; QLL (1 per 90 days) ; QLL (8 per 28 days) ; 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/2016 112

clindamycin phosphate vaginal CLOTRIMAZOLE 3 DAY clotrimazole vaginal cream CLOTRIMAZOLE-3 CLOTRIMAZOLE-7 metronidazole vaginal MICONAZOLE 3 DAY VAGINAL CREAM MICONAZOLE 7 miconazole nitrate vaginal comb pack, prefill appl, cream miconazole nitrate vaginal cream miconazole nitrate vaginal suppository MICONAZOLE-3 VAGINAL KIT miconazole-3 vaginal suppository NUVARING terconazole tranexamic acid oral VAGINAL CONTRACEPTIVE FOAM ; ; ; ; QLL (6 per 30 days) VAGISTAT-3 ORAL CONTRACEPTIVES / RELATED AGENTS AFTERA altavera (28) alyacen 1/35 (28) alyacen 7/7/7 (28) apri (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 113

aranelle (28) AUBRA aviane azurette (28) balziva (28) briellyn caziant (28) cryselle (28) cyclafem 7/7/7 (28) dasetta 7/7/7 (28) DELYLA (28) desog-e.estradiol/e.estradiol drospirenone-ethinyl estradiol oral tablet 3-0.03 mg ECONTRA EZ elinest ELLA enpresse FALLBACK SOLO falmina (28) gildagia gildess 1.5/30 (21) jolessa junel 1.5/30 (21) junel 1/20 (21) junel fe 1.5/30 (28) junel fe 1/20 (28) JUNEL FE 24 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/2016 114

kariva (28) kelnor 1/35 (28) kurvelo LARIN 1.5/30 (21) LARIN FE 1/20 (28) lessina levonest (28) levonorg-eth estrad triphasic levonorgestrel oral tablet 1.5 mg levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg, 0.15-0.03 mg levonorgestrel-ethinyl estrad oral tablets,dose pack,3 month low-ogestrel (28) lutera (28) marlissa MICROGESTIN 1.5/30 (21) MICROGESTIN 1/20 (21) MICROGESTIN FE 1.5/30 (28) MICROGESTIN FE 1/20 (28) MIRCETTE (28) mono-linyah mononessa (28) MY WAY myzilra necon 0.5/35 (28) (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 115

necon 1/35 (28) necon 10/11 (28) necon 7/7/7 (28) NEXT CHOICE ONE DOSE norethindrone-e.estradiol-iron norgestimate-ethinyl estradiol oral tablet 0.18/0.215/0.25 mg-35 mcg (28), 0.25-35 mg-mcg nortrel 0.5/35 (28) nortrel 1/35 (21) nortrel 1/35 (28) nortrel 7/7/7 (28) ocella ogestrel (28) OPCICON ONE-STEP orsythia philith PIMTREA (28) pirmella portia previfem reclipsen (28) sprintec (28) sronyx syeda TAKE ACTION TARINA FE 1/20 (28) tri-estarylla 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/2016 116

tri-linyah tri-previfem (28) tri-sprintec (28) trinessa (28) trivora (28) velivet triphasic regimen (28) viorele (28) VYFEMLA (28) zarah zenchent (28) zovia 1/35e (28) zovia 1/50e (28) OPHTHALLOGY ANTIBIOTICS bacitracin ophthalmic bacitracin-polymyxin b ophthalmic ciprofloxacin hcl ophthalmic erythromycin ophthalmic gentak ophthalmic ointment gentamicin ophthalmic NATACYN neo-polycin neomycin-bacitracin-polymyxin neomycin-polymyxin-gramicidin ofloxacin ophthalmic polycin (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 117

polymyxin b sulf-trimethoprim tobramycin VIGAX ANTIVIRALS trifluridine ZIRGAN BETA-BLOCKERS betaxolol ophthalmic carteolol levobunolol ophthalmic drops 0.5 % metipranolol timolol maleate ophthalmic CHOLINESTERASE INHIBITOR MIOTICS PHOSPHOLINE IODIDE CYCLOPLEGIC MYDRIATICS atropine ophthalmic drops MISCELLANEOUS OPHTHALLOGICS AKWA TEARS (POLYVINYL ALCOHOL) ALAWAY ALLERGY EYE (KETOTIFEN) ARTIFICIAL TEARS (PF) OPHTHALMIC DROPPERETTE 0.1-0.3 % ARTIFICIAL TEARS (POLYVIN ALC) ARTIFICIAL TEARS(GLYCERIN-PEG) ARTIFICIAL TEARS(PG-HYPM-GLYC) ARTIFICIAL TEARS(PVALCH-POVID) azelastine ophthalmic BION TEARS (PF) ; ; ; ; 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/2016 118

COLLYRIUM cromolyn ophthalmic DRY EYE RELIEF EYE DROP TEARS EYE IRRIGATING SOLUTION EYE ITCH RELIEF EYE STREAM EYE WASH EYE WASH STERILE ITCHY EYE DROPS KETOTIFEN FUM 0.025% EYE DROPS ketotifen fumarate LIQUITEARS LUBRICANT EYE (PG-PEG 400) LUBRICANT EYE DROPS LUBRICANT EYE DROPS (GLYC-PG) LUBRICATING PLUS MEDIWASH MEDIWASH EYE IRRIGANT ISTURE DROPS NATURAL TEARS (PF) OCUSOFT IRRIGATING OPHTH SOLN olopatadine ophthalmic PATADAY PATANOL PAZEO ; ; ; ; ; ; ; (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 119

polyvinyl alcohol RESTASIS REVIVE PLUS STERILE EYE WASH TEARS AGAIN (PVA) TEARS NATURALE FREE (PF) ; QLL (60 per 30 days) ; ; ULTRA FRESH NON-STEROIDAL ANTI-INFLAMMATORY AGENTS flurbiprofen ophthalmic drops ILEVRO ketorolac ophthalmic NEVANAC ORAL DRUGS FOR GLAUCOMA acetazolamide acetazolamide sodium methazolamide oral OTHER GLAUCOMA DRUGS AZOPT COMBIGAN dorzolamide dorzolamide-timolol latanoprost LUMIGAN OPHTHALMIC DROPS 0.01 % TRAVATAN Z travoprost (benzalkonium) STEROID-ANTIBIOTIC COMBINATIONS neo-polycin hc 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/2016 120

neomycin-bacitracin-poly-hc neomycin-polymyxin b-dexameth neomycin-polymyxin-hc ophthalmic tobramycin-dexamethasone opthalmic suspension STEROID-SULFONAMIDE COMBINATIONS BLEPHAMIDE S.O.P. sulfacetamide-prednisolone STEROIDS dexamethasone sodium phosphate ophthalmic DUREZOL fluorometholone prednisolone acetate prednisolone sodium phosphate ophthalmic SULFONAMIDES sulfacetamide sodium ophthalmic drops SYMPATHOMIMETICS ALPHAGAN P OPHTHALMIC DROPS 0.1 % apraclonidine brimonidine ophthalmic drops 0.2 % VASOCONSTRICTOR DECONGESTANTS LUBRICANT REDNESS RELIEVER OPHTHALMIC DROPS 0.03-0.5 % MAXIMUM REDNESS RELIEF REDNESS RELIEVER LUBRICANT (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 121

STERILE EYE DROPS OPHTHALMIC DROPS 0.012-0.2 %, 0.03-0.5 % RESPIRATORY AND ALLERGY ANTIHISTAMINE / ANTIALLERGENIC AGENTS ACTA-TABS PE ADULT TUSSIN CHEST CONGESTION ADULT TUSSIN COUGH CONGEST DM ALA-HIST DM ALAVERT ALKA-SELTZER PLUS ALLERGY ALL DAY ALLERGY (CETIRIZINE) ORAL TABLET ALL DAY ALLERGY RELIEF(CETIR) ALLER-G-TIME ALLER-TEC ALLERGY (DIPHENHYDRAMINE) ALLERGY AND SINUS RELIEF ALLERGY RELIEF (CETIRIZINE) ORAL TABLET ALLERGY RELIEF (CLEMASTINE) ALLERGY RELIEF (LORATADINE) ORAL TABLET ALLERGY RELIEF (LORATADINE) ORAL TABLET,DISINTEGRATING ALLERGY RELIEF(DIPHENHYDRAMIN) AP-HIST DM APRODINE arbinoxa BANOPHEN ALLERGY ; ; ; QLL (30 per 30 days) ; QLL (30 per 30 days) ; ; ; ; 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/2016 122

BANOPHEN ORAL CAPSULE 25 MG BANOPHEN ORAL CAPSULE 50 MG BANOPHEN ORAL LIQUID BANOPHEN ORAL TABLET benzonatate oral capsule 100 mg, 200 mg BIOCOTRON brompheniramin-phenylephrin-dm oral liquid 2-5-10 mg/5 ml cetirizine oral tablet CHERATUSSIN AC clemastine oral tablet 1.34 mg clemastine oral tablet 2.68 mg codeine-guaifenesin COLD AND ALLERGY COLD AND ALLERGY PE COMPLETE ALLERGY COMPLETE ALLERGY MEDICINE COUGH CONTROL (GUAIFENESIN) COUGH CONTROL DM ORAL LIQUID COUGH SYRUP cyproheptadine oral tablet DAYHIST ALLERGY DIABETIC SILTUSSIN DAS-NA DIABETIC SILTUSSIN-DM $0 (Tier 3) ; ; ; ; ; QLL (30 per 30 days) ; ; ; (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 123

DIABETIC TUSSIN DM ORAL LIQUID 10-100 MG/5 ML DIABETIC TUSSIN EX DIPHEDRYL ALLERGY DIPHEDRYL ORAL CAPSULE DIPHEDRYL ORAL LIQUID DIPHEDRYL ORAL TABLET DIPHENHIST ORAL CAPSULE DIPHENHIST ORAL LIQUID DIPHENHIST ORAL TABLET 25 MG diphenhydramine hcl injection solution 50 mg/ml diphenhydramine hcl injection syringe diphenhydramine hcl oral capsule diphenhydramine hcl oral elixir diphenhydramine hcl oral liquid diphenhydramine hcl oral syrup diphenhydramine hcl oral tablet 25 mg DIPHENHYDRAMINE ORAL CAPSULE 25 MG, 50 MG DIPHENHYDRAMINE ORAL ELIXIR 12.5 MG/5 ML DIPHENHYDRAMINE ORAL LIQUID 12.5 MG/5 ML DIPHENHYDRAMINE ORAL SYRUP 12.5 MG/5 ML ED A-HIST ORAL TABLET ED A-HIST PSE ENTRE-HIST PSE ; ; ; ; ; ; ; ; 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/2016 124

epinephrine injection syringe 0.1 mg/ ml EPIPEN 2-PAK EPIPEN JR 2-PAK EXPECTORANT COUGH SYRUP EXPECTORANT ORAL LIQUID G-TRON GERI-TUSSIN GUAIFENESIN AC guaifenesin oral liquid GUAIFENESIN-DM hydrocodone-chlorpheniramine hydrocodone-homatropine oral syrup 5-1.5 mg/5 ml HYDROCODONE-HOMATROPINE ORAL SYRUP 5-1.5 MG/5 ML (5 ML) hydrocodone-homatropine oral tablet HYDROMET IOPHEN C-NR IOPHEN DM-NR IOPHEN-NR levocetirizine oral tablet LOHIST-DM LORADAMED loratadine oral tablet loratadine oral tablet,disintegrating $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) ; QLL (2 per 2 days) ; QLL (2 per 2 days) ; ; ; ; ; ; ; ; QLL (30 per 30 days) ; ; ; ; (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 125

M-CLEAR WC NASAL DECONGESTANT (PSEUDOEPH) ORAL LIQUID NASAL DECONGESTANT (PSEUDOEPH) ORAL TABLET NASAL DECONGESTANT (PSEUDOEPH) ORAL TABLET EXTENDED RELEASE NIGHTIME SLEEP NIGHTTIME SLEEP AID (DIPHEN) ORAL CAPSULE 50 MG NIGHTTIME SLEEP AID (DIPHEN) ORAL TABLET NON-DROWSY ALLERGY phenadoz PHENYLEPHRINE HCL/DIPHENHYDRAMINE HCL promethazine oral tablet PROMETHAZINE VC-CODEINE promethazine-codeine promethazine-dm promethazine-phenyleph-codeine promethegan rectal suppository 12.5 mg PSEUDOEPHEDRINE 120 MG ER pseudoephedrine hcl oral liquid pseudoephedrine hcl oral tablet 30 mg pseudoephedrine hcl oral tablet 60 mg pseudoephedrine hcl oral tablet extended release $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) ; PAR; ; ; ; ; ; ; ; 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/2016 126

PSEUDOEPHEDRINE HCL/ CHLORPHENIRAMINE MALEATE ORAL TABLET 4-10 MG, 4-60 MG PSEUDOEPHEDRINE HCL/ CHLORPHENIRAMINE MALEATE TABLET PSEUDOEPHEDRINE HCL/TRIPROLIDINE HCL ORAL TABLET Q-DRYL ORAL CAPSULE Q-DRYL ORAL LIQUID Q-TUSSIN RELCOF C REST SIMPLY NIGHTTIME SLEEP RESTFULLY SLEEP RI-TUSSIN ROBAFEN ROBAFEN DM COUGH RYDEX SCOT-TUSSIN EXPECTORANT SILADRYL SA SILTUSSIN DM DAS SILTUSSIN SA SINUS 12 HOUR SINUS AND ALLERGY PE SINUS-ALLERGY (PHENYLEPHRINE) SLEEP AID (DIPHENHYDRAMINE) ORAL CAPSULE 50 MG ; ; ; (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 127

SLEEP AID (DIPHENHYDRAMINE) ORAL TABLET SLEEP AID MAX STR (DIPHENHYDR) SLEEP TABLET (DIPHENHYDRAMINE) SLEEP-TABS SUDOGEST SUDOGEST 12-HOUR SUDOGEST COLD AND ALLERGY SUDOGEST SINUS AND ALLERGY SUPHEDRIN SUPHEDRIN 12 HOUR SUPHEDRINE SUPHEDRINE 12 HOUR SUPHEDRINE PE COLD AND ALLERGY SUPHEDRINE PE SINUS ANDALLERGY TUSNEL DIABETIC TUSSI PRES-B ORAL LIQUID 4-10-20 MG/5 ML TUSSIGON TUSSIN CHEST CONGESTION TUSSIN COUGH-CHEST CONGESTION TUSSIN DM COUGH AND CHEST ORAL LIQUID 10-100 MG/5 ML TUSSIN DM ORAL LIQUID TUSSIN EXPECTORANT TUSSIN HONEY TUSSIN ORAL LIQUID VALU-DRYL ALLERGY ORAL CAPSULE $0 (Tier 3) ; ; ; 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/2016 128

VIRTUSSIN AC PULNARY AGENTS acetylcysteine ADEMPAS ADVAIR DISKUS ADVAIR HFA albuterol sulfate inhalation solution for nebulization 0.63 mg/3 ml, 1.25 mg/ 3 ml, 2.5 mg /3 ml (0.083 %) albuterol sulfate inhalation solution for nebulization 2.5 mg/0.5 ml, 5 mg/ml albuterol sulfate oral ATROVENT HFA budesonide inhalation suspension for nebulization 0.25 mg/2 ml, 0.5 mg/2 ml CINRYZE COMBIVENT RESPIMAT cromolyn inhalation DALIRESP DULERA ESBRIET FIRAZYR FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 250 MCG/ACTUATION, 50 MCG/ ACTUATION ; B/D; PAR; ; LA ; QLL (60 per 30 days) ; QLL (12 per 30 days) B/D; ; QLL (360 per 30 days) B/D; ; QLL (60 per 30 days) ; QLL (26 per 30 days) B/D; ; QLL (120 per 30 days) PAR; ; QLL (8 per 30 days) B/D; ; QLL (240 per 30 days) PAR; ; QLL (30 per 30 days) ; QLL (13 per 30 days) PAR; QLL (270 per 30 days) ; QLL (60 per 30 days) ; QLL (240 per 30 days) (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 129

FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 220 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 44 MCG/ACTUATION flunisolide nasal spray,non-aerosol 25 mcg (0.025 %) fluticasone nasal FORADIL AEROLIZER ipratropium bromide inhalation ipratropium-albuterol KALYDECO ORAL TABLET LETAIRIS levalbuterol hcl inhalation solution for nebulization 0.31 mg/3 ml, 1.25 mg/ 0.5 ml, 1.25 mg/3 ml levalbuterol hcl inhalation solution for nebulization 0.63 mg/3 ml metaproterenol montelukast PROAIR HFA PROAIR RESPICLICK PULZYME QVAR INHALATION AEROSOL 40 MCG/ ACTUATION QVAR INHALATION AEROSOL 80 MCG/ ACTUATION SEREVENT DISKUS sildenafil oral ; QLL (12 per 30 days) ; QLL (24 per 30 days) ; QLL (11 per 30 days) ; QLL (75 per 30 days) ; QLL (16 per 30 days) ; QLL (60 per 30 days) B/D; B/D; ; QLL (540 per 30 days) PAR; ; QLL (60 per 30 days) PAR; ; LA; QLL (30 per 30 days) B/D; ; QLL (270 per 30 days) B/D; ; QLL (540 per 30 days) ; QLL (30 per 30 days) ; QLL (18 per 30 days) ; QLL (2 per 30 days) B/D; ; QLL (9 per 30 days) ; QLL (18 per 30 days) ; QLL (60 per 30 days) PAR; ; QLL (90 per 30 days) 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/2016 130

sodium chloride inhalation solution for nebulization 0.9 %, 3 % SPIRIVA RESPIMAT SPIRIVA WITH HANDIHALER SYMBICORT terbutaline oral terbutaline subcutaneous theophylline oral tablet extended release 12 hr theophylline oral tablet extended release 24 hr TRACLEER TUDORZA PRESSAIR INHALATION AEROSOL POWDR BREATH ACTIVATED 400 MCG/ ACTUATION TUDORZA PRESSAIR INHALATION AEROSOL POWDR BREATH ACTIVATED 400 MCG/ ACTUATION (30 ACTUAT) VENTAVIS VENTOLIN HFA VOSPIRE ER XOLAIR $0 (Tier 3) ; ; QLL (4 per 30 days) ; QLL (30 per 30 days) ; QLL (11 per 30 days) PAR; ; LA; QLL (60 per 30 days) ; QLL (1 per 30 days) QLL (1 per 30 days) PAR; ; QLL (36 per 30 days) PAR; ; LA; QLL (6 per 28 days) zafirlukast UROLOGICALS ANTICHOLINERGICS / ANTISPASDICS ; QLL (60 per 30 days) MYRBETRIQ oxybutynin chloride oral syrup oxybutynin chloride oral tablet ; QLL (30 per 30 days) ; QLL (600 per 30 days) ; QLL (120 per 30 days) (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 131

oxybutynin chloride oral tablet extended release 24hr 10 mg, 15 mg oxybutynin chloride oral tablet extended release 24hr 5 mg tolterodine oral capsule,extended release 24hr tolterodine oral tablet TOVIAZ ; QLL (60 per 30 days) ; QLL (30 per 30 days) ; QLL (30 per 30 days) ; QLL (60 per 30 days) ; QLL (30 per 30 days) VESICARE ; QLL (30 per 30 days) BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPY alfuzosin AVODART dutasteride dutasteride-tamsulosin finasteride oral tablet 5 mg JALYN tamsulosin CHOLINERGIC STIMULANTS bethanechol chloride MISCELLANEOUS UROLOGICALS CYSTAGON potassium citrate oral tablet extended release 10 meq (1,080 mg), 5 meq (540 mg) URINARY ANESTHETICS URINARY PAIN RELIEF ORAL TABLET 95 MG URINARY TRACT ; QLL (30 per 30 days) ; QLL (30 per 30 days) ; QLL (30 per 30 days) ; QLL (30 per 30 days) ; QLL (60 per 30 days) ; LA 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/2016 132

VITAMINS, HEMATINICS / ELECTROLYTES ELECTROLYTES ALCALAK ANTACID (CALCIUM CARBONATE) ANTACID EXT STR (CALCIUM CARB) ANTACID EXTRA-STRENGTH ORAL TABLET, CHEWABLE 168 MG (420 MG), 300 MG (750 MG) CAL-GEST ANTACID CALCI-CHEW CALCIONATE CALCITRATE CALCIUM 500 CALCIUM 500 + D (D3) CALCIUM 500 + D ORAL TABLET 500 MG(1, 250MG) -200 UNIT CALCIUM 500 + D ORAL TABLET 500 MG(1, 250MG) -400 UNIT CALCIUM 500 + D ORAL TABLET,CHEWABLE CALCIUM 500 WITH D CALCIUM 600 CALCIUM 600 + D(3) ORAL TABLET 600 MG (1,500MG) -200 UNIT, 600 MG(1,500MG) - 400 UNIT CALCIUM 600 WITH VITAMIN D3 ORAL TABLET calcium acetate oral capsule calcium acetate oral tablet 667 mg ; ; ; ; ; ; ; ; (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 133

CALCIUM ANTACID ORAL TABLET,CHEWABLE 200 MG CALCIUM (500 MG) CALCIUM ANTACID ORAL TABLET,CHEWABLE 300 MG (750 MG), 400 MG (1,000 MG) CALCIUM ANTACID TROPICAL CALCIUM ANTACID ULTRA MAX ST calcium carbonate - d3 oral tablet 500 mg(1,250mg) -125 unit, 500 mg(1,250mg) -200 unit, 500 mg(1,250mg) -400 unit, 500mg (1,250mg) -600 unit calcium carbonate - d3 oral tablet 600 mg(1,500mg) -200 unit, 600 mg(1,500mg) -400 unit, 600 mg(1,500mg) -800 unit calcium carbonate - d3 oral tablet, chewable 500 mg(1,250mg) -400 unit CALCIUM CARBONATE - D3 ORAL TABLET, CHEWABLE 500-100 MG-UNIT CALCIUM CARBONATE ANTACID ORAL TABLET,CHEWABLE 400 MG (1,000 MG) CALCIUM CARBONATE ORAL SUSPENSION calcium carbonate oral tablet 500 mg calcium (1,250 mg), 600 mg (1,500 mg) calcium carbonate oral tablet,chewable 200 mg calcium (500 mg), 400 mg (1,000 mg), 500 mg calcium (1,250 mg) CALCIUM CITRATE + D calcium citrate oral tablet 200 mg (950 mg) CALCIUM CITRATE ORAL TABLET 250 MG CALCIUM ; ; ; ; ; ; ; 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/2016 134

calcium citrate-vitamin d3 oral tablet 200 mg calcium -250 unit, 250 mg calcium- 200 unit calcium citrate-vitamin d3 oral tablet 315-200 mg-unit, 315-250 mg-unit CALCIUM GLUCONATE ORAL TABLET 45 MG (500 MG) CALCIUM GLUCONATE ORAL TABLET 60 MG (650 MG) CALCIUM LACTATE ORAL TABLET 84 MG (648 MG) CALCIUM WITH VITAMIN D calcium-magnesium-zinc oral tablet CALCIUM-MAGNESIUM-ZINC ORAL TABLET 333-133-5 MG CERASPORT ORAL LIQUID CITRUS CALCIUM ORAL TABLET 200 MG CALCIUM -250 UNIT CITRUS CALCIUM ORAL TABLET 315-250 MG-UNIT dextrose-kcl-nacl HI-CAL PLUS VIT D KLOR-CON 10 KLOR-CON 8 klor-con m10 KLOR-CON M15 KLOR-CON M20 lactated ringers intravenous ; ; ; ; B/D; HI ; HI (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 135

MAGNESIUM OXIDE ORAL CAPSULE 500 MG magnesium sulfate in water intravenous parenteral solution magnesium sulfate in water intravenous piggyback 2 gram/50 ml (4 %), 4 gram/50 ml (8 %) magnesium sulfate in water intravenous piggyback 4 gram/100 ml (4 %) magnesium sulfate injection solution magnesium sulfate injection syringe NORSOL-R NORSOL-R IN 5 % DEXTROSE OYSCO 500/D ORAL TABLET OYSCO D OYSCO-500 OYST-CAL-500 OYSTER SHELL + D3 OYSTER SHELL CALCIUM OYSTER SHELL CALCIUM 500 OYSTER SHELL CALCIUM-VIT D3 OYSTERCAL-D potassium chlorid-d5-0.45%nacl intravenous parenteral solution 10 meq/l, 30 meq/l, 40 meq/l potassium chlorid-d5-0.45%nacl intravenous parenteral solution 20 meq/l HI HI ; ; ; ; ; ; HI ; HI 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/2016 136

potassium chloride in 0.9%nacl intravenous parenteral solution 20 meq/l potassium chloride in 5 % dex intravenous parenteral solution 20 meq/l, 40 meq/l potassium chloride in 5 % dex intravenous parenteral solution 30 meq/l potassium chloride in lr-d5 intravenous parenteral solution 20 meq/l potassium chloride in lr-d5 intravenous parenteral solution 40 meq/l potassium chloride intravenous piggyback 10 meq/100 ml, 20 meq/100 ml, 20 meq/50 ml, 40 meq/100 ml potassium chloride intravenous piggyback 10 meq/50 ml potassium chloride intravenous piggyback 30 meq/100 ml potassium chloride intravenous solution potassium chloride oral capsule, extended release potassium chloride oral tablet extended release potassium chloride oral tablet,er particles/crystals potassium chloride-0.45 % nacl HI HI ; HI HI ; HI ; HI HI (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 137

potassium chloride-d5-0.2%nacl intravenous parenteral solution 20 meq/l potassium chloride-d5-0.2%nacl intravenous parenteral solution 40 meq/l potassium chloride-d5-0.3%nacl intravenous parenteral solution 20 meq/l potassium chloride-d5-0.9%nacl intravenous parenteral solution 20 meq/l potassium chloride-d5-0.9%nacl intravenous parenteral solution 40 meq/l ringers intravenous SOTH ANTACID sodium chloride 0.45 % intravenous parenteral solution sodium chloride 0.45 % intravenous piggyback sodium chloride 3 % sodium chloride 5 % sodium chloride intravenous parenteral solution 2.5 meq/ml sodium chloride intravenous parenteral solution 4 meq/ml SUPER CALCIUM TPN ELECTROLYTES TUMS ULTRA ORAL TABLET,CHEWABLE 400 MG (1,000 MG) ; HI HI ; HI HI B/D; HI ; HI HI ; HI HI ; HI HI ; 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/2016 138

ULTRA STRENGTH ANTACID ULTRA STRENGTH CALCIUM ANTACID MISCELLANEOUS NUTRITION PRODUCTS AMINOSYN 8.5 % AMINOSYN 8.5 %-ELECTROLYTES AMINOSYN II 10 % AMINOSYN II 7 % AMINOSYN II 8.5 % AMINOSYN II 8.5 %-ELECTROLYTES AMINOSYN M 3.5 % AMINOSYN-HBC 7% AMINOSYN-PF 10 % AMINOSYN-PF 7 % (SULFITE-FREE) CLINIMIX 5%/D15W SULFITE FREE CLINIMIX 5%/D25W SULFITE-FREE CLINIMIX 2.75%/D5W SULFIT FREE CLINIMIX 4.25%-D20W SULF-FREE CLINIMIX 4.25%-D25W SULF-FREE CLINIMIX 4.25%/D10W SULF FREE CLINIMIX 5%-D20W(SULFITE-FREE) CLINIMIX E 4.25%/D25W SUL FREE CLINIMIX E 4.25%/D5W SULF FREE CLINIMIX E 5%/D15W SULFIT FREE CLINIMIX E 5%/D20W SULFIT FREE CLINIMIX E 5%/D25W SULFIT FREE CLINISOL SF 15 % B/D B/D; HI B/D; HI B/D; HI B/D; HI B/D; HI B/D; HI B/D; HI B/D; HI B/D; HI B/D; HI B/D; HI B/D; HI B/D; HI B/D; HI B/D; HI B/D; HI B/D; HI B/D; HI B/D; HI B/D; HI B/D; HI B/D; ; HI (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 139

freamine iii 10 % HEPATAMINE 8% intralipid intravenous emulsion 20 % NORSOL-M IN 5 % DEXTROSE NORSOL-R PH 7.4 PLASMA-LYTE 148 PLASMA-LYTE-56 IN 5 % DEXTROSE travasol 10 % TROPHAMINE 10 % TROPHAMINE 6% VITAMINS / HEMATINICS ascorbic acid (vitamin c) oral capsule, extended release ascorbic acid (vitamin c) oral tablet 1,000 mg B-12 DOTS C-500 ORAL TABLET C-500 ORAL TABLET,CHEWABLE CA-D3-MAG OX-ZINC-COP-MANG-BOR ORAL TABLET,CHEWABLE 600 MG CALCIUM- 400 UNIT-40 MG CALCIUM 600 + MINERALS calcium carbonate-vit d3-min oral tablet CALCIUM FOR WOMEN CALCIUM SOFT CHEW ORAL TABLET, CHEWABLE 500-100-40 MG-UNIT-MCG, 500-200-40 MG-UNIT-MCG calcium-vitamin d3-vitamin k oral tablet,chewable 500-200-40 mg-unit-mcg B/D B/D; HI B/D; HI HI HI HI B/D; ; HI B/D; ; HI B/D; HI ; ; 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/2016 140

cholecalciferol (vitamin d3) oral capsule 1,000 unit, 5,000 unit cholecalciferol (vitamin d3) oral capsule 2,000 unit, 400 unit cholecalciferol (vitamin d3) oral drops 400 unit/ml cholecalciferol (vitamin d3) oral tablet 1,000 unit, 5,000 unit cholecalciferol (vitamin d3) oral tablet 2,000 unit, 400 unit CLASSIC PRENATAL cyanocobalamin (vitamin b-12) injection cyanocobalamin (vitamin b-12) oral tablet 1,000 mcg, 100 mcg, 500 mcg cyanocobalamin (vitamin b-12) oral tablet extended release cyanocobalamin (vitamin b-12) sublingual tablet 1,000 mcg cyanocobalamin (vitamin b-12) sublingual tablet 2,500 mcg D-VI-SOL D-VITA D3-2000 DAILY PRENATAL DELTA D3 DIALYVITE 800 DIALYVITE VITAMIN D $0 (Tier 3) ; ; ; ; ; ; ; ; ; ; ; (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 141

ergocalciferol (vitamin d2) oral capsule ergocalciferol (vitamin d2) oral tablet 400 unit EZFE 200 FEOSOL ORAL TABLET 325 MG (65 MG IRON) FERATE ORAL TABLET 240 MG (27 MG IRON) FEROSUL ORAL TABLET FERRETTS FERREX 150 FERRO-TIME ferrous gluconate oral tablet 240 mg (27 mg iron) ferrous gluconate oral tablet 256 mg (28 mg iron) FERROUS GLUCONATE ORAL TABLET 324 MG (36 MG IRON), 324 MG (37.5 MG IRON), 324 MG (38 MG IRON) ferrous sulfate oral tablet 325 mg (65 mg iron) FERROUS SULFATE ORAL TABLET,DELAYED RELEASE (DR/EC) 324 MG (65 MG IRON) ferrous sulfate oral tablet,delayed release (dr/ec) 325 mg (65 mg iron) FERROUSUL folic acid oral tablet 1 mg folic acid oral tablet 400 mcg, 800 mcg FULL SPECTRUM B-VITAMIN C HIGH POTENCY IRON IFEREX 150 $0 (Tier 3) $0 (Tier 3) ; ; ; ; ; ; ; ; ; ; ; ; ; ; ; ; ; 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/2016 142

IRON (DRIED) IRON (FERROUS SULFATE) IRON HIGH POTENCY IRON ORAL TABLET 325 MG (65 MG IRON) KPN MYFERON 150 ONE DAILY PRENATAL ORAL COMBO PACK 28-800-440 MG-MCG-MG OYSTER SHELL CALCIUM-VIT D2 ORAL TABLET 250 (625)-125 MG-UNIT POLY-IRON POLY-VITA POLY-VITAMIN polysaccharide iron complex PRENATAL FORMULA ORAL TABLET 28 MG IRON- 800 MCG PRENATAL ONE DAILY PRENATAL TABLET PRENATAL VITAMIN ORAL CAPSULE 13.5-0.4 MG prenatal vitamin oral tablet PRENATAL VITAMIN ORAL TABLET, 27-0.8 MG, 28 MG IRON- 800 MCG PRENATAL VITAMIN ORAL TABLET 27 MG IRON- 800 MCG prenatal vitamin oral tablet 28 mg iron- 800 mcg ; ; ; ; ; (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 143

pyridoxine (vitamin b6) oral tablet 100 mg, 25 mg, 50 mg RENA-VITE RISACAL-D SLOW RELEASE IRON ORAL TABLET EXTENDED RELEASE 160 MG (50 MG IRON), 250 MG (50 MG IRON), 47.5 MG IRON sodium fluoride oral tablet sodium fluoride oral tablet,chewable 1 mg fluoride (2.2 mg) STRAWBERRY C THERA-D thiamine hcl (vitamin b1) oral tablet 100 mg, 250 mg, 50 mg thiamine mononitrate (vit b1) VITAMIN A PALMITATE ORAL CAPSULE VITAMIN A PALMITATE ORAL TABLET 10,000 UNIT vitamin a palmitate oral tablet 15,000 unit VITAMIN B-1 VITAMIN B-1 (NONITRATE) VITAMIN B-12 ORAL TABLET 1,000 MCG, 100 MCG, 250 MCG, 500 MCG VITAMIN B-12 ORAL TABLET EXTENDED RELEASE 1,000 MCG VITAMIN B-12 ORAL TABLET EXTENDED RELEASE 2,000 MCG VITAMIN B-12 SUBLINGUAL TABLET 2,500 MCG ; ; ; ; ; ; 有關本表格所含標誌與縮寫的含義, 可參見第 6 頁 更新日期.. 10/05/2016 144

VITAMIN B-2 VITAMIN B-6 ORAL TABLET 100 MG, 25 MG, 50 MG VITAMIN C ORAL CAPSULE, EXTENDED RELEASE VITAMIN C ORAL TABLET 1,000 MG, 250 MG, 500 MG VITAMIN C ORAL TABLET,CHEWABLE 250 MG, 500 MG VITAMIN C WITH ROSE HIPS ORAL TABLET VITAMIN D2 VITAMIN D3 ORAL CAPSULE 1,000 UNIT, 2, 000 UNIT, 400 UNIT VITAMIN D3 ORAL TABLET 1,000 UNIT, 2, 000 UNIT, 400 UNIT VITAMIN D3 ORAL TABLET 5,000 UNIT VITAMIN E (DL, ACETATE) ORAL CAPSULE 100 UNIT vitamin e oral capsule 1,000 unit, 200 unit, 400 unit vitamin e oral capsule 100 unit $0 (Tier 3) ; ; ; ; ; ; ; ; ; ; ; (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全天 候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 145

索引 3 3-DAY VAGINAL... 112 8 8-P... 75 A abacavir... 9 abacavir-lamivudinezidovudine... 9 ABELCET... 8 ABILIFY MAINTENA... 50 ABRAXANE... 24 ABSTRAL... 43 acamprosate... 84 acarbose oral tablet 100 mg... 90 acarbose oral tablet 25 mg... 90 acarbose oral tablet 50 mg... 90 acebutolol... 65 ACEPHEN RECTAL SUPPOSITORY 650 MG... 47 ACETAMINOPHEN EXTRA STRENGTH ORAL CAPSULE 500 MG... 47 ACETAMINOPHEN EXTRA STRENGTH ORAL CAPSULE 500 MG... 47 ACETAMINOPHEN EXTRA STRENGTH ORAL LIQUID 500 MG/15 ML... 47 ACETAMINOPHEN EXTRA STRENGTH ORAL LIQUID 500 MG/15 ML... 47 ACETAMINOPHEN EXTRA STRENGTH ORAL SUSPENSION 160 MG/5 ML... 47 ACETAMINOPHEN LIQUID... 47 acetaminophen oral suspension 160 mg/5 ml... 47 acetaminophen oral tablet 500 mg... 47 ACETAMINOPHEN PAIN RELIEF... 47 acetaminophen rectal suppository 650 mg... 47 acetaminophen-codeine oral solution 120 mg-12 mg /5 ml (5 ml), 240 mg-24 mg /10 ml (10 ml), 300 mg-30 mg /12.5 ml... 43 acetaminophen-codeine oral solution 120-12 mg/5 ml... 43 acetaminophen-codeine oral tablet 300-15 mg... 43 acetaminophen-codeine oral tablet 300-30 mg... 43 acetaminophen-codeine oral tablet 300-60 mg... 43 acetazolamide... 120 acetazolamide sodium... 120 acetic acid otic... 88 acetic acid-aluminum acetate... 88 acetylcysteine... 129 acetylcysteine intravenous... 84 ACID CONTROL (RANITIDINE) ORAL TABLET 150 MG... 105 ACID GONE ANTACID E.STRENGTH... 97 ACID REDUCER (FATIDINE)... 105 ACID REDUCER (RANITIDINE)... 105 ACNE TREATMENT (BENZOYL PEROX) TOPICAL GEL... 76 ACNE-CLEAR... 76 ACTA-TABS PE... 122 ACTEMRA INTRAVENOUS VIAL... 110 ACTHAR H.P.... 88 ACTHIB (PF)... 107 ACTIMMUNE... 106 acyclovir oral capsule... 9 acyclovir oral suspension 200 mg/5 ml... 9 acyclovir oral tablet... 9 acyclovir sodium intravenous solution... 9 acyclovir topical... 80 ADACEL(TDAP ADOLESN/ ADULT)(PF)... 107 ADAGEN... 84 ADASUVE... 51 ADDED STRENGTH PAIN RELIEVER... 47 adefovir... 9 ADEMPAS... 129 ADULT LOW DOSE ASPIRIN... 47 ADULT TUSSIN CHEST CONGESTION... 122 ADULT TUSSIN COUGH CONGEST DM... 122 ADVAIR DISKUS... 129 ADVAIR HFA... 129 ADVANCED ANTACID- ANTIGAS... 97 afeditab cr... 65 AFINITOR... 24 AFINITOR DISPERZ... 24 AFTERA... 113 AGGRENOX... 70 AKWA TEARS (POLYVINYL ALCOHOL)... 118 ala-cort topical cream... 80 (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全 天候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 146

ALA-HIST DM... 122 ALAVERT... 122 ALAWAY... 118 ALBENZA... 16 albuterol sulfate inhalation solution for nebulization 0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 mg /3 ml (0.083 %)... 129 albuterol sulfate inhalation solution for nebulization 2.5 mg/0.5 ml, 5 mg/ml... 129 albuterol sulfate oral... 129 ALCALAK... 133 alclometasone... 80 alcohol pads... 90 ALDURAZYME... 93 ALECENSA... 24 alendronate oral tablet 10 mg, 5 mg... 110 alendronate oral tablet 35 mg, 70 mg... 110 alendronate oral tablet 40 mg... 84 alfuzosin... 132 ALIMTA... 24 ALINIA ORAL SUSPENSION FOR RECONSTITUTION... 16 ALINIA ORAL TABLET... 16 ALKA-SELTZER PLUS ALLERGY... 122 ALL DAY ALLERGY RELIEF (CETIR)... 122 ALL DAY ALLERGY (CETIRIZINE) ORAL TABLET... 122 ALL DAY RELIEF... 47 ALLER-G-TIME... 122 ALLER-TEC... 122 ALLERGY AND SINUS RELIEF... 122 ALLERGY EYE (KETOTIFEN)... 118 ALLERGY RELIEF (CETIRIZINE) ORAL TABLET... 122 ALLERGY RELIEF (CLEMASTINE)... 122 ALLERGY RELIEF (LORATADINE) ORAL TABLET... 122 ALLERGY RELIEF (LORATADINE) ORAL TABLET, DISINTEGRATING... 122 ALLERGY RELIEF (DIPHENHYDRAMIN)... 122 ALLERGY (DIPHENHYDRAMINE)... 122 allopurinol... 110 ALOPHEN... 97 alosetron... 97 ALPHAGAN P OPHTHALMIC DROPS 0.1 %... 121 alprazolam oral tablet... 51 altavera (28)... 113 ALUMINA AND MAGNESIUM ANTACID ORAL SUSPENSION 95-358 MG/15 ML... 97 ALUMINA AND MAGNESIUM ANTACID ORAL TABLET, CHEWABLE 80-20 MG... 97 ALUMINA, MAGNESIA, SIMETHICONE SUSPENSION ORAL SUSPENSION 200-200-20 MG/5 ML, 400-400-40 MG/5 ML... 97 aluminum hydroxide gel oral suspension 320 mg/5 ml... 97 aluminum hydroxide gel oral suspension 600 mg/5 ml... 97 alyacen 1/35 (28)... 113 alyacen 7/7/7 (28)... 113 amantadine hcl oral capsule... 9 amantadine hcl oral tablet... 9 AMBISOME... 8 amcinonide... 80 amifostine crystalline... 23 amikacin injection solution 1,000 mg/4 ml, 500 mg/2 ml... 16 amiloride... 65 amiloridehydrochlorothiazide... 65 AMINOSYN 8.5 %... 139 AMINOSYN 8.5 %- ELECTROLYTES... 139 AMINOSYN II 10 %... 139 AMINOSYN II 7 %... 139 AMINOSYN II 8.5 %... 139 AMINOSYN II 8.5 %- ELECTROLYTES... 139 AMINOSYN M 3.5 %... 139 AMINOSYN-HBC 7%... 139 AMINOSYN-PF 10 %... 139 AMINOSYN-PF 7 % (SULFITE- FREE)... 139 amiodarone intravenous solution... 64 amiodarone intravenous syringe... 64 amiodarone oral... 64 amitriptyline... 51 AMLACTIN TOPICAL LOTION... 75 amlodipine besylate oral tablet 10 mg, 2.5 mg... 65 amlodipine besylate oral tablet 5 mg... 65 amlodipine-benazepril... 65 ammonium lactate... 75 AMNIUM LACTATE TOPICAL LOTION 12 %... 75 AMNIUM LACTATE TOPICAL LOTION 5 %... 75 amoxapine... 51 amoxicillin oral capsule... 19 amoxicillin oral suspension for reconstitution... 19 (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全 天候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 147

amoxicillin oral tablet... 19 amoxicillin oral tablet, chewable 125 mg, 250 mg... 19 amoxicillin-pot clavulanate... 19 amphotericin b... 8 ampicillin... 19 ampicillin sodium injection... 19 ampicillin sodium intravenous recon soln 1 gram... 20 ampicillin sodium intravenous recon soln 2 gram... 20 ampicillin-sulbactam injection recon soln 1.5 gram, 3 gram... 20 ampicillin-sulbactam injection recon soln 15 gram... 20 ampicillin-sulbactam intravenous recon soln 3 gram... 20 AMPYRA... 41 AMRIX... 42 anagrelide... 84 anastrozole... 24 ANDRODERM... 93 ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP 20.25 MG/1.25 GRAM (1.62 %)... 93 ANDROGEL TRANSDERMAL GEL IN PACKET 1 % (25 MG/ 2.5GRAM)... 93 ANDROGEL TRANSDERMAL GEL IN PACKET 1 % (50 MG/5 GRAM)... 93 ANDROGEL TRANSDERMAL GEL IN PACKET 1.62 % (20.25 MG/ 1.25 GRAM)... 93 ANDROGEL TRANSDERMAL GEL IN PACKET 1.62 % (40.5 MG/2.5 GRAM)... 93 androxy... 93 ANTACID... 97 ANTACID ANTI-GAS... 97 ANTACID ANTI-GAS DOUBLE STR... 97 ANTACID EXST (MAG CARB-AL HYD)... 97 ANTACID EXT STR (CALCIUM CARB)... 133 ANTACID EXTRA-STRENGTH ORAL SUSPENSION 200-200-20 MG/5 ML... 97 ANTACID EXTRA-STRENGTH ORAL TABLET,CHEWABLE 168 MG (420 MG), 300 MG (750 MG)... 133 ANTACID LIQUID... 97 ANTACID MAXIMUM STRENGTH... 97 ANTACID PLUS ANTI-GAS... 97 ANTACID REGULAR STRENGTH... 97 ANTACID WITH SIMETHICONE... 97 ANTACID (CALCIUM CARBONATE)... 133 ANTACID-ANTIGAS... 97 ANTACID-SIMETHICONE... 98 ANTI-DIARRHEAL (LOPERAMIDE) ORAL LIQUID 1 MG/5 ML... 95 ANTI-FUNGAL MICONAZOLE POWDER TOPICAL POWDER 2 %... 78 ANTI-ITCH (HC) TOPICAL CREAM... 80 ANTI-ITCH (HC) TOPICAL OINTMENT... 80 ANTIBIOTIC (NEOMY-BACIT- POLYM)... 77 ANTIBIOTIC-PAIN RELIEF (BACIT)... 77 ANTIFUNGAL MICONAZOLE CREAM... 78 ANTIFUNGAL (CLOTRIMAZOLE)... 78 ANTIFUNGAL (TOLNAFTATE) TOPICAL AEROSOL,SPRAY... 78 ANTIFUNGAL (TOLNAFTATE) TOPICAL CREAM... 78 AP-HIST DM... 122 APOKYN... 40 apraclonidine... 121 apri... 113 APRISO... 98 APRODINE... 122 APTIOM... 34 APTIVUS ORAL CAPSULE... 9 APTIVUS ORAL SOLUTION... 9 ARALAST NP... 84 aranelle (28)... 114 ARANESP (IN POLYSORBATE) INJECTION SOLUTION 100 MCG/ ML, 200 MCG/ML, 25 MCG/ML, 300 MCG/ML, 40 MCG/ML, 60 MCG/ML... 106 ARANESP (IN POLYSORBATE) INJECTION SYRINGE 10 MCG/0.4 ML, 200 MCG/0.4 ML, 40 MCG/ 0.4 ML... 106 ARANESP (IN POLYSORBATE) INJECTION SYRINGE 100 MCG/ 0.5 ML... 106 ARANESP (IN POLYSORBATE) INJECTION SYRINGE 150 MCG/ 0.3 ML, 60 MCG/0.3 ML... 106 ARANESP (IN POLYSORBATE) INJECTION SYRINGE 25 MCG/ 0.42 ML... 106 ARANESP (IN POLYSORBATE) INJECTION SYRINGE 300 MCG/ 0.6 ML... 106 (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全 天候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 148

ARANESP (IN POLYSORBATE) INJECTION SYRINGE 500 MCG/ ML... 106 arbinoxa... 122 ARCALYST... 106 aripiprazole oral solution... 51 aripiprazole oral tablet 10 mg... 51 aripiprazole oral tablet 15 mg... 51 aripiprazole oral tablet 2 mg... 51 aripiprazole oral tablet 20 mg, 30 mg... 51 aripiprazole oral tablet 5 mg... 51 aripiprazole oral tablet, disintegrating 10 mg... 51 aripiprazole oral tablet, disintegrating 15 mg... 51 ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 441 MG/1.6 ML... 51 ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 662 MG/2.4 ML... 51 ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 882 MG/3.2 ML... 51 ARRANON... 24 ARTIFICIAL TEARS (PF) OPHTHALMIC DROPPERETTE 0.1-0.3 %... 118 ARTIFICIAL TEARS (POLYVIN ALC)... 118 ARTIFICIAL TEARS(GLYCERIN- PEG)... 118 ARTIFICIAL TEARS(PG-HYPM- GLYC)... 118 ARTIFICIAL TEARS(PVALCH- POVID)... 118 ARZERRA... 24 ASACOL HD... 98 ascorbic acid (vitamin c) oral capsule, extended release... 140 ascorbic acid (vitamin c) oral tablet 1,000 mg... 140 ASPIR-LOW... 47 ASPIRIN LOW DOSE... 47 aspirin oral tablet... 47 ASPIRIN ORAL TABLET 325 MG... 47 aspirin oral tablet, chewable... 47 ASPIRIN ORAL TABLET,DELAYED RELEASE (DR/EC) 325 MG... 48 ASPIRIN ORAL TABLET,DELAYED RELEASE (DR/EC) 325 MG... 48 aspirin oral tablet,delayed release (dr/ec) 325 mg, 81 mg... 48 ASTAGRAF XL... 24 ASTEPRO NASAL SPRAY,NON- AEROSOL... 88 atenolol... 65 atenololchlorthalidone... 65 ATGAM... 107 ATHLETE'S FOOT AF... 79 ATHLETE'S FOOT (TERBINAFINE)... 78 ATHLETE'S FOOT (TOLNAFTATE)... 79 atorvastatin... 72 atovaquone... 16 atovaquone-proguanil oral tablet 250-100 mg... 16 ATRIPLA... 9 atropine injection syringe 0.05 mg/ml, 0.1 mg/ml... 95 atropine ophthalmic drops... 118 ATROVENT HFA... 129 AUBRA... 114 AVASTIN INTRAVENOUS SOLUTION 25 MG/ML... 24 AVASTIN INTRAVENOUS SOLUTION 25 MG/ML (16 ML)... 24 aviane... 114 AVODART... 132 AVONEX INTRAMUSCULAR PEN INJECTOR KIT... 106 AVONEX INTRAMUSCULAR SYRINGE... 106 AVONEX INTRAMUSCULAR SYRINGE KIT... 106 AVONEX (WITH ALBUMIN)... 106 AXIRON... 93 azacitidine... 24 AZACTAM... 17 AZACTAM IN DEXTROSE (ISO- OSM)... 17 AZASAN... 24 azathioprine... 24 azathioprine sodium... 24 azelastine nasal aerosol, spray... 88 azelastine ophthalmic... 118 AZILECT... 40 azithromycin intravenous recon soln 500 mg... 15 azithromycin intravenous recon soln 500 mg (2 mg/ ml)... 16 azithromycin oral suspension for reconstitution... 16 azithromycin oral tablet... 16 AZOPT... 120 azurette (28)... 114 B B-12 DOTS... 140 (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全 天候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 149

baciim... 17 bacitracin intramuscular... 17 bacitracin ophthalmic... 117 bacitracin topical ointment... 77 BACITRACIN TOPICAL PACKET... 77 BACITRACIN ZINC TOPICAL PACKET... 77 bacitracin-polymyxin b ophthalmic... 117 bacitracin-polymyxin b topical ointment... 78 bacitracin-polymyxin b topical packet... 78 BACITRAYCIN PLUS TOPICAL OINTMENT 500 UNIT/GRAM... 78 baclofen... 42 balsalazide... 98 balziva (28)... 114 BANOPHEN ALLERGY... 122 BANOPHEN ORAL CAPSULE 25 MG... 123 BANOPHEN ORAL CAPSULE 50 MG... 123 BANOPHEN ORAL LIQUID... 123 BANOPHEN ORAL TABLET... 123 BANZEL ORAL SUSPENSION... 34 BANZEL ORAL TABLET 200 MG... 35 BANZEL ORAL TABLET 400 MG... 35 BARACLUDE ORAL SOLUTION... 9 BCG VACCINE, LIVE (PF)... 108 BELEODAQ... 24 benazepril... 65 benazeprilhydrochlorothiazide... 65 BENDEKA... 24 BENLYSTA... 110 benzonatate oral capsule 100 mg, 200 mg... 123 benzoyl peroxide topical gel 10 %, 5 %... 76 benzphetamine oral tablet 50 mg... 84 benztropine oral... 40 BETA-HC... 80 betamethasone dipropionate... 80 betamethasone valerate topical cream... 80 betamethasone valerate topical lotion... 80 betamethasone valerate topical ointment... 81 betamethasone, augmented topical cream... 81 betamethasone, augmented topical lotion... 81 betamethasone, augmented topical ointment... 81 BETASERON SUBCUTANEOUS KIT... 107 BETATEMP... 48 betaxolol ophthalmic... 118 betaxolol oral... 65 bethanechol chloride... 132 bexarotene... 24 BEXSERO (PF)... 108 bicalutamide... 24 BICILLIN C-R INTRAMUSCULAR SYRINGE 1,200,000 UNIT/ 2 ML (600K/600K)... 20 BICNU... 25 BILTRICIDE... 17 BIOCOTRON... 123 BION TEARS (PF)... 118 BISA-LAX... 98 BISAC-EVAC... 98 bisacodyl oral... 98 bisacodyl rectal... 98 BISCOLAX... 98 BISMATROL ORAL SUSPENSION 262 MG/15 ML... 95 BISMATROL ORAL SUSPENSION 525 MG/15 ML... 95 BISMATROL ORAL TABLET, CHEWABLE... 95 BISMUTH... 95 BISMUTH MAXIMUM STRENGTH... 96 bisoprolol fumarate... 65 bisoprololhydrochlorothiazide... 65 bleo 15k... 25 bleomycin... 25 BLEPHAMIDE S.O.P.... 121 BLINCYTO... 25 BONIVA INTRAVENOUS... 110 BOOSTRIX TDAP... 108 BOSULIF ORAL TABLET 100 MG... 25 BOSULIF ORAL TABLET 500 MG... 25 BP... 76 briellyn... 114 BRILINTA... 70 brimonidine ophthalmic drops 0.2 %... 121 BRIVIACT INTRAVENOUS... 35 BRIVIACT ORAL SOLUTION... 35 BRIVIACT ORAL TABLET 10 MG... 35 BRIVIACT ORAL TABLET 100 MG, 75 MG... 35 BRIVIACT ORAL TABLET 25 MG... 35 BRIVIACT ORAL TABLET 50 MG... 35 bromocriptine... 40 (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全 天候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 150

brompheniraminphenylephrin-dm oral liquid 2-5-10 mg/5 ml... 123 budesonide inhalation suspension for nebulization 0.25 mg/2 ml, 0.5 mg/2 ml... 129 budesonide oral... 98 bumetanide... 65 BUPHENYL ORAL TABLET... 84 buprenorphine hcl injection solution... 43 buprenorphine hcl injection syringe... 43 buprenorphine hcl sublingual tablet 2 mg... 43 buprenorphine hcl sublingual tablet 8 mg... 43 buprenorphine-naloxone sublingual tablet 2-0.5 mg... 48 buprenorphine-naloxone sublingual tablet 8-2 mg... 48 bupropion hcl oral tablet 100 mg... 51 bupropion hcl oral tablet 75 mg... 51 bupropion hcl oral tablet extended release 100 mg... 51 bupropion hcl oral tablet extended release 150 mg, 200 mg... 51 bupropion hcl oral tablet extended release 24 hr 150 mg... 51 bupropion hcl oral tablet extended release 24 hr 300 mg... 52 bupropion hcl (smoking deter)... 87 buspirone... 52 BUSULFEX... 25 butalbital-acetaminop-cafcod oral capsule 50-325-40-30 mg... 43 butorphanol tartrate injection solution 1 mg/ ml... 48 butorphanol tartrate injection solution 2 mg/ ml... 48 butorphanol tartrate nasal... 48 BYDUREON... 90 BYETTA SUBCUTANEOUS PEN INJECTOR 10 MCG/DOSE(250 MCG/ML) 2.4 ML... 90 BYETTA SUBCUTANEOUS PEN INJECTOR 5 MCG/DOSE (250 MCG/ML) 1.2 ML... 90 C C-500 ORAL TABLET... 140 C-500 ORAL TABLET, CHEWABLE... 140 CA-D3-MAG OX-ZINC-COP-MANG- BOR ORAL TABLET,CHEWABLE 600 MG CALCIUM- 400 UNIT-40 MG... 140 cabergoline... 93 CABOMETYX ORAL TABLET 20 MG... 25 CABOMETYX ORAL TABLET 40 MG, 60 MG... 25 CAL-GEST ANTACID... 133 calamine... 75 CALAMINE-ZINC OXIDE TOPICAL LOTION 8-8 %... 75 CALCI-CHEW... 133 CALCIONATE... 133 calcipotriene scalp... 74 calcipotriene topical... 74 calcitonin (salmon)... 93 CALCITRATE... 133 calcitriol intravenous solution 1 mcg/ml... 93 calcitriol oral capsule... 93 CALCIUM 500... 133 CALCIUM 500 + D ORAL TABLET 500 MG(1,250MG) -200 UNIT... 133 CALCIUM 500 + D ORAL TABLET 500 MG(1,250MG) -400 UNIT... 133 CALCIUM 500 + D ORAL TABLET, CHEWABLE... 133 CALCIUM 500 + D (D3)... 133 CALCIUM 500 WITH D... 133 CALCIUM 600... 133 CALCIUM 600 + D(3) ORAL TABLET 600 MG(1,500MG) -200 UNIT, 600 MG(1,500MG) -400 UNIT... 133 CALCIUM 600 + MINERALS... 140 CALCIUM 600 WITH VITAMIN D3 ORAL TABLET... 133 calcium acetate oral capsule... 133 calcium acetate oral tablet 667 mg... 133 CALCIUM ANTACID ORAL TABLET,CHEWABLE 200 MG CALCIUM (500 MG)... 134 CALCIUM ANTACID ORAL TABLET,CHEWABLE 300 MG (750 MG), 400 MG (1,000 MG)... 134 CALCIUM ANTACID TROPICAL... 134 CALCIUM ANTACID ULTRA MAX ST... 134 calcium carbonate - d3 oral tablet 500 mg(1,250mg) -125 unit, 500 mg(1,250mg) -200 unit, 500 mg(1,250mg) -400 (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全 天候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 151

unit, 500mg (1,250mg) -600 unit... 134 calcium carbonate - d3 oral tablet 600 mg(1,500mg) -200 unit, 600 mg(1,500mg) -400 unit, 600 mg(1,500mg) -800 unit... 134 calcium carbonate - d3 oral tablet,chewable 500 mg(1, 250mg) -400 unit... 134 CALCIUM CARBONATE - D3 ORAL TABLET,CHEWABLE 500-100 MG- UNIT... 134 CALCIUM CARBONATE AND MAGNESIA ANTACID ORAL SUSPENSION 200-200-20 MG/5 ML, 400-400-40 MG/5 ML... 98 CALCIUM CARBONATE AND MAGNESIA ANTACID ORAL TABLET,CHEWABLE 700-300 MG... 98 CALCIUM CARBONATE ANTACID ORAL TABLET,CHEWABLE 400 MG (1,000 MG)... 134 CALCIUM CARBONATE ORAL SUSPENSION... 134 calcium carbonate oral tablet 500 mg calcium (1,250 mg), 600 mg (1,500 mg)... 134 calcium carbonate oral tablet,chewable 200 mg calcium (500 mg), 400 mg (1, 000 mg), 500 mg calcium (1, 250 mg)... 134 calcium carbonate-vit d3-min oral tablet... 140 CALCIUM CITRATE + D... 134 calcium citrate oral tablet 200 mg (950 mg)... 134 CALCIUM CITRATE ORAL TABLET 250 MG CALCIUM... 134 calcium citrate-vitamin d3 oral tablet 200 mg calcium - 250 unit, 250 mg calcium- 200 unit... 135 calcium citrate-vitamin d3 oral tablet 315-200 mg-unit, 315-250 mg-unit... 135 CALCIUM FOR WOMEN... 140 CALCIUM GLUCONATE ORAL TABLET 45 MG (500 MG)... 135 CALCIUM GLUCONATE ORAL TABLET 60 MG (650 MG)... 135 CALCIUM LACTATE ORAL TABLET 84 MG (648 MG)... 135 CALCIUM SOFT CHEW ORAL TABLET,CHEWABLE 500-100-40 MG-UNIT-MCG, 500-200-40 MG- UNIT-MCG... 140 CALCIUM WITH VITAMIN D... 135 calcium-magnesium-zinc oral tablet... 135 CALCIUM-MAGNESIUM-ZINC ORAL TABLET 333-133-5 MG... 135 calcium-vitamin d3-vitamin k oral tablet,chewable 500-200-40 mg-unit-mcg... 140 camila... 111 CANASA... 98 CANCIDAS... 8 candesartan oral tablet 16 mg, 4 mg, 8 mg... 65 candesartan oral tablet 32 mg... 65 candesartanhydrochlorothiazid oral tablet 16-12.5 mg... 65 candesartanhydrochlorothiazid oral tablet 32-12.5 mg, 32-25 mg... 65 CAPASTAT... 17 CAPEX... 81 CAPRELSA ORAL TABLET 100 MG... 25 CAPRELSA ORAL TABLET 300 MG... 25 captopril... 65 captoprilhydrochlorothiazide... 65 CARBAGLU... 84 carbamazepine oral capsule, er multiphase 12 hr... 35 carbamazepine oral suspension 100 mg/5 ml... 35 carbamazepine oral suspension 200 mg/10 ml... 35 carbamazepine oral tablet... 35 carbamazepine oral tablet extended release 12 hr 100 mg... 35 carbamazepine oral tablet extended release 12 hr 200 mg, 400 mg... 35 carbamazepine oral tablet, chewable... 35 carbidopa-levodopa... 40 carboplatin intravenous solution... 25 CARIMUNE NF NANOFILTERED INTRAVENOUS RECON SOLN 12 GRAM, 6 GRAM... 108 carteolol... 118 cartia xt... 65 carvedilol... 66 CAYSTON... 17 caziant (28)... 114 cefaclor oral capsule... 14 cefaclor oral suspension for reconstitution 125 mg/ 5 ml... 14 (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全 天候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 152

cefaclor oral suspension for reconstitution 250 mg/ 5 ml, 375 mg/5 ml... 14 cefaclor oral tablet extended release 12 hr... 14 cefadroxil oral capsule... 14 cefadroxil oral suspension for reconstitution 250 mg/ 5 ml, 500 mg/5 ml... 14 cefadroxil oral tablet... 14 cefazolin in dextrose (isoos) intravenous piggyback 1 gram/50 ml... 14 cefazolin injection recon soln 1 gram... 14 cefazolin injection recon soln 10 gram, 100 gram, 20 gram, 300 g... 14 cefazolin injection recon soln 500 mg... 14 cefazolin intravenous... 14 cefdinir... 14 cefepime... 14 cefoxitin in dextrose, isoosm... 14 cefoxitin intravenous recon soln 1 gram... 14 cefoxitin intravenous recon soln 10 gram, 2 gram... 15 cefpodoxime... 15 cefprozil... 15 ceftazidime injection recon soln 1 gram, 2 gram... 15 ceftazidime injection recon soln 6 gram... 15 ceftriaxone in dextrose,isoos... 15 ceftriaxone injection recon soln 1 gram, 2 gram, 250 mg, 500 mg... 15 ceftriaxone injection recon soln 10 gram... 15 ceftriaxone intravenous... 15 cefuroxime axetil oral tablet... 15 cefuroxime sodium intravenous vial injection recon soln 1.5 gram, 750 mg... 15 cefuroxime sodium intravenous vial intravenous recon soln 7.5 gram... 15 CELLCEPT INTRAVENOUS... 25 CELONTIN ORAL CAPSULE 300 MG... 35 cephalexin oral capsule 250 mg, 500 mg... 15 cephalexin oral suspension for reconstitution... 15 cephalexin oral tablet... 15 CERASPORT ORAL LIQUID... 135 CEREZYME INTRAVENOUS RECON SOLN 400 UNIT... 93 CERVARIX VACCINE (PF)... 108 cetirizine oral tablet... 123 cevimeline... 84 CHANTIX... 87 CHANTIX CONTINUING NTH BOX... 87 CHANTIX STARTING NTH BOX... 87 CHERATUSSIN AC... 123 chloramphenicol sod succinate... 17 chlorhexidine gluconate mucous membrane... 88 chloroquine phosphate oral... 17 chlorothiazide... 66 chlorpromazine... 52 chlorthalidone oral tablet 25 mg, 50 mg... 66 cholecalciferol (vitamin d3) oral capsule 1,000 unit, 5, 000 unit... 141 cholecalciferol (vitamin d3) oral capsule 2,000 unit, 400 unit... 141 cholecalciferol (vitamin d3) oral drops 400 unit/ml... 141 cholecalciferol (vitamin d3) oral tablet 1,000 unit, 5,000 unit... 141 cholecalciferol (vitamin d3) oral tablet 2,000 unit, 400 unit... 141 cholestyramine light... 72 cholestyramine (with sugar)... 72 ciclodan topical solution... 79 ciclopirox topical cream... 79 ciclopirox topical gel... 79 ciclopirox topical shampoo... 79 ciclopirox topical solution... 79 ciclopirox topical suspension... 79 cilostazol... 70 CINRYZE... 129 CIPRODEX... 88 ciprofloxacin er... 21 ciprofloxacin hcl ophthalmic... 117 ciprofloxacin hcl oral... 21 ciprofloxacin lactate intravenous solution 200 mg/20 ml... 21 (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全 天候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 153

ciprofloxacin lactate intravenous solution 400 mg/40 ml... 21 cisplatin... 25 citalopram oral solution... 52 citalopram oral tablet 10 mg... 52 citalopram oral tablet 20 mg... 52 citalopram oral tablet 40 mg... 52 CITRATE OF MAGNESIA... 98 CITROMA... 98 CITRUS CALCIUM ORAL TABLET 200 MG CALCIUM -250 UNIT... 135 CITRUS CALCIUM ORAL TABLET 315-250 MG-UNIT... 135 cladribine... 25 clarithromycin oral suspension for reconstitution... 16 clarithromycin oral tablet... 16 clarithromycin oral tablet extended release 24 hr... 16 CLASSIC PRENATAL... 141 CLEARLAX... 98 clemastine oral tablet 1.34 mg... 123 clemastine oral tablet 2.68 mg... 123 clindamycin hcl... 17 clindamycin phosphate injection... 17 clindamycin phosphate intravenous solution 300 mg/2 ml, 900 mg/6 ml... 17 clindamycin phosphate intravenous solution 600 mg/4 ml... 17 clindamycin phosphate topical... 76 clindamycin phosphate vaginal... 113 CLINIMIX 2.75%/D5W SULFIT FREE... 139 CLINIMIX 4.25%-D20W SULF- FREE... 139 CLINIMIX 4.25%-D25W SULF- FREE... 139 CLINIMIX 4.25%/D10W SULF FREE... 139 CLINIMIX 4.25%/D5W SULFIT FREE... 84 CLINIMIX 5%-D20W(SULFITE- FREE)... 139 CLINIMIX 5%/D15W SULFITE FREE... 139 CLINIMIX 5%/D25W SULFITE- FREE... 139 CLINIMIX E 2.75%/D10W SUL FREE... 84 CLINIMIX E 2.75%/D5W SULF FREE... 84 CLINIMIX E 4.25%/D25W SUL FREE... 139 CLINIMIX E 4.25%/D5W SULF FREE... 139 CLINIMIX E 5%/D15W SULFIT FREE... 139 CLINIMIX E 5%/D20W SULFIT FREE... 139 CLINIMIX E 5%/D25W SULFIT FREE... 139 CLINISOL SF 15 %... 139 clobetasol scalp... 81 clobetasol topical cream... 81 clobetasol topical gel... 81 clobetasol topical ointment... 81 clobetasol-emollient topical cream... 81 CLOLAR... 25 clomipramine... 52 clonazepam oral tablet 0.5 mg... 35 clonazepam oral tablet 1 mg... 35 clonazepam oral tablet 2 mg... 35 clonazepam oral tablet, disintegrating 0.125 mg... 35 clonazepam oral tablet, disintegrating 0.25 mg... 36 clonazepam oral tablet, disintegrating 0.5 mg... 36 clonazepam oral tablet, disintegrating 1 mg... 36 clonazepam oral tablet, disintegrating 2 mg... 36 clonidine hcl oral tablet... 66 clonidine transdermal patch... 66 clopidogrel oral tablet 300 mg... 70 clopidogrel oral tablet 75 mg... 70 clorazepate dipotassium... 52 CLOTRIMAZOLE 3 DAY... 113 CLOTRIMAZOLE AF... 79 CLOTRIMAZOLE ANTIFUNGAL... 79 clotrimazole mucous membrane... 8 clotrimazole topical... 79 clotrimazole vaginal cream... 113 CLOTRIMAZOLE-3... 113 CLOTRIMAZOLE-7... 113 (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全 天候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 154

clotrimazolebetamethasone... 79 clozapine oral tablet 100 mg... 52 clozapine oral tablet 200 mg... 52 clozapine oral tablet 25 mg... 52 clozapine oral tablet 50 mg... 52 clozapine oral tablet, disintegrating 100 mg... 52 clozapine oral tablet, disintegrating 12.5 mg... 52 clozapine oral tablet, disintegrating 150 mg... 52 clozapine oral tablet, disintegrating 200 mg... 52 clozapine oral tablet, disintegrating 25 mg... 52 COARTEM... 17 codeine-guaifenesin... 123 COL-RITE... 98 colchicine-probenecid... 110 COLCRYS... 110 COLD AND ALLERGY... 123 COLD AND ALLERGY PE... 123 colestipol... 73 colistin (colistimethate na)... 17 COLLYRIUM... 119 colocort... 98 COLY-MYCIN S... 88 COMBIGAN... 120 COMBIVENT RESPIMAT... 129 COMETRIQ ORAL CAPSULE 100 MG/DAY(80 MG X1-20 MG X1)... 25 COMETRIQ ORAL CAPSULE 140 MG/DAY(80 MG X1-20 MG X3)... 25 COMETRIQ ORAL CAPSULE 60 MG/DAY (20 MG X 3/DAY)... 25 COMFORT GEL... 98 COMFORT GEL EXTRA STRENGTH... 98 COMPLERA... 9 COMPLETE ALLERGY... 123 COMPLETE ALLERGY MEDICINE... 123 COMPLETE LICE TREATMENT... 83 compro... 98 CONDOMS, LATEX, LUBRICATED... 90 CONDOMS, LATEX, LUBRICATED DEVICE... 90 CONDOMS, LATEX, NON- LUBRICATED DEVICE... 90 constulose... 98 COPAXONE SUBCUTANEOUS SYRINGE 20 MG/ML... 41 COPAXONE SUBCUTANEOUS SYRINGE 40 MG/ML... 41 cormax scalp... 81 cortisone... 88 CORTISONE (HYDROCORTISONE) TOPICAL CREAM... 81 CORTIZONE-10 PLUS... 81 CORTIZONE-10 TOPICAL CREAM... 81 CORTIZONE-10 TOPICAL OINTMENT... 81 COTELLIC... 25 COUGH CONTROL DM ORAL LIQUID... 123 COUGH CONTROL (GUAIFENESIN)... 123 COUGH SYRUP... 123 CREON... 98 CRIXIVAN ORAL CAPSULE 200 MG... 9 CRIXIVAN ORAL CAPSULE 400 MG... 9 cromolyn inhalation... 129 cromolyn ophthalmic... 119 cryselle (28)... 114 CUBICIN... 17 cyanocobalamin (vitamin b- 12) injection... 141 cyanocobalamin (vitamin b- 12) oral tablet 1,000 mcg, 100 mcg, 500 mcg... 141 cyanocobalamin (vitamin b- 12) oral tablet extended release... 141 cyanocobalamin (vitamin b- 12) sublingual tablet 1,000 mcg... 141 cyanocobalamin (vitamin b- 12) sublingual tablet 2,500 mcg... 141 cyclafem 7/7/7 (28)... 114 cyclophosphamide oral capsule... 25 CYCLOSET... 90 cyclosporine intravenous... 25 cyclosporine modified... 25 cyclosporine oral capsule... 26 cyproheptadine oral tablet... 123 CYRAMZA INTRAVENOUS SOLUTION 10 MG/ML... 26 CYRAMZA INTRAVENOUS SOLUTION 10 MG/ML (50 ML)... 26 CYSTADANE... 98 CYSTAGON... 132 cytarabine... 26 cytarabine (pf) injection solution 100 mg/5 ml (20 mg/ (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全 天候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 155

ml), 2 gram/20 ml (100 mg/ ml)... 26 cytarabine (pf) injection solution 20 mg/ml... 26 D D-VI-SOL... 141 D-VITA... 141 d10 %-0.45 % sodium chloride... 84 d2.5 %-0.45 % sodium chloride... 84 D3-2000... 141 d5 % and 0.9 % sodium chloride... 85 d5 %-0.45 % sodium chloride... 85 dacarbazine... 26 DACOGEN... 26 DAILY PRENATAL... 141 DALIRESP... 129 danazol oral... 94 dantrolene... 42 DAPSONE... 17 DAPTACEL (DTAP PEDIATRIC) (PF)... 108 daptomycin... 17 DARAPRIM... 17 DARZALEX... 26 dasetta 7/7/7 (28)... 114 daunorubicin intravenous solution... 26 DAYHIST ALLERGY... 123 DEBLITANE... 112 decitabine... 26 DELTA D3... 141 DELYLA (28)... 114 DELZICOL ORAL CAPSULE (WITH DEL REL TABLETS)... 99 demeclocycline... 22 DEMSER... 66 DENAVIR... 80 DEPEN TITRATABS... 110 DEPO-PROVERA INTRAMUSCULAR SOLUTION 400 MG/ML... 112 DESCOVY... 9 DESENEX TOPICAL POWDER... 79 desipramine oral... 52 desmopressin injection... 94 desmopressin nasal aerosol, spray... 94 desmopressin nasal spray, non-aerosol... 94 desmopressin oral... 94 desog-e.estradiol/ e.estradiol... 114 desonide... 81 desoximetasone... 81 DESVENLAFAXINE FUMARATE ORAL TABLET EXTENDED RELEASE 24HR 100 MG... 52 DESVENLAFAXINE FUMARATE ORAL TABLET EXTENDED RELEASE 24HR 50 MG... 52 DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE 24 HR 100 MG... 53 DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE 24 HR 50 MG... 53 DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE 24HR 100 MG... 53 DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE 24HR 50 MG... 53 DEX4 GLUCOSE ORAL TABLET, CHEWABLE... 85 DEX4 GLUCOSE POUCH PACK... 85 DEX4 GLUCOSE QUICK DISSOLVE... 85 dexamethasone... 89 dexamethasone sodium phos (pf)... 89 dexamethasone sodium phosphate injection... 89 dexamethasone sodium phosphate ophthalmic... 121 DEXILANT... 105 dexrazoxane hcl intravenous recon soln 250 mg... 23 dexrazoxane hcl intravenous recon soln 500 mg... 23 dextroamphetamine oral capsule, extended release 10 mg, 5 mg... 53 dextroamphetamine oral capsule, extended release 15 mg... 53 dextroamphetamine oral tablet 10 mg... 53 dextroamphetamine oral tablet 5 mg... 53 dextroamphetamineamphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 5 mg, 7.5 mg... 53 dextroamphetamineamphetamine oral tablet 30 mg... 53 dextrose 10 % and 0.2 % nacl... 85 dextrose 10 % in water (d10w)... 85 dextrose 25 % in water (d25w)... 85 dextrose 30 % in water (d30w)... 85 dextrose 40 % in water (d40w)... 85 dextrose 5 % in water (d5w)... 85 (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全 天候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 156

dextrose 5 %-lactated ringers... 85 dextrose 5%-0.2 % sod chloride... 85 dextrose 5%-0.3 % sod.chloride... 85 dextrose 50 % in water (d50w) intravenous parenteral solution... 85 dextrose 50 % in water (d50w) intravenous syringe... 85 dextrose 70 % in water (d70w)... 85 dextrose oral gel... 85 dextrose with sodium chloride... 85 dextrose-kcl-nacl... 135 DIABETIC SILTUSSIN DAS- NA... 123 DIABETIC SILTUSSIN-DM... 123 DIABETIC TUSSIN DM ORAL LIQUID 10-100 MG/5 ML... 124 DIABETIC TUSSIN EX... 124 DIALYVITE 800... 141 DIALYVITE VITAMIN D... 141 DIARRHEA RELIEF (BISMUTH SUBS)... 96 diazepam injection solution... 53 diazepam injection syringe... 53 diazepam intensol... 53 diazepam oral concentrate... 53 diazepam oral solution 5 mg/ 5 ml (1 mg/ml)... 53 diazepam oral solution 5 mg/ 5 ml (1 mg/ml, 5 ml)... 53 diazepam oral tablet 10 mg... 53 diazepam oral tablet 2 mg... 53 diazepam oral tablet 5 mg... 54 diazepam rectal kit 12.5-15- 17.5-20 mg... 36 diazepam rectal kit 2.5 mg, 5-7.5-10 mg... 36 diclofenac potassium... 48 diclofenac sodium oral... 48 diclofenac sodium topical gel 3 %... 75 dicloxacillin... 20 dicyclomine oral capsule... 96 dicyclomine oral solution... 96 dicyclomine oral tablet... 96 didanosine oral capsule, delayed release(dr/ec) 125 mg... 9 didanosine oral capsule, delayed release(dr/ec) 200 mg... 10 didanosine oral capsule, delayed release(dr/ec) 250 mg, 400 mg... 10 DIFFERIN TOPICAL GEL 0.3 %... 76 DIFFERIN TOPICAL GEL WITH PUMP... 76 diflorasone... 81 diflunisal... 48 digox oral tablet 125 mcg... 69 digoxin injection solution... 69 digoxin oral solution 50 mcg/ ml... 69 digoxin oral tablet 125 mcg... 69 DILANTIN... 36 DILANTIN EXTENDED ORAL CAPSULES 100 MG... 36 DILANTIN INFATABS... 36 dilt-xr... 66 diltiazem hcl intravenous solution... 66 diltiazem hcl oral capsule, extended release 120 mg, 180 mg, 240 mg, 300 mg, 360 mg... 66 diltiazem hcl oral capsule, ext release degradable... 66 diltiazem hcl oral capsule, extended release 12 hr... 66 diltiazem hcl oral capsule, extended release 24hr... 66 diltiazem hcl oral tablet... 66 diltiazem hcl oral tablet extended release 24 hr... 66 DIOCTO ORAL LIQUID... 99 DIOCTO ORAL SYRUP... 99 DIOCTYL... 99 DIOTAME... 96 DIPENTUM... 99 DIPHEDRYL ALLERGY... 124 DIPHEDRYL ORAL CAPSULE... 124 DIPHEDRYL ORAL LIQUID... 124 DIPHEDRYL ORAL TABLET... 124 DIPHENHIST ORAL CAPSULE... 124 DIPHENHIST ORAL LIQUID... 124 DIPHENHIST ORAL TABLET 25 MG... 124 diphenhydramine hcl injection solution 50 mg/ ml... 124 diphenhydramine hcl injection syringe... 124 (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全 天候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 157

diphenhydramine hcl oral capsule... 124 diphenhydramine hcl oral elixir... 124 diphenhydramine hcl oral liquid... 124 diphenhydramine hcl oral syrup... 124 diphenhydramine hcl oral tablet 25 mg... 124 DIPHENHYDRAMINE ORAL CAPSULE 25 MG, 50 MG... 124 DIPHENHYDRAMINE ORAL ELIXIR 12.5 MG/5 ML... 124 DIPHENHYDRAMINE ORAL LIQUID 12.5 MG/5 ML... 124 DIPHENHYDRAMINE ORAL SYRUP 12.5 MG/5 ML... 124 diphenoxylateatropine... 96 disulfiram... 85 divalproex... 36 DOC-Q-LACE... 99 DOCEFREZ INTRAVENOUS RECON SOLN 20 MG... 26 docetaxel intravenous solution 10 mg/ml, 160 mg/16 ml (10 mg/ml), 160 mg/8 ml (20 mg/ml), 20 mg/2 ml (10 mg/ ml)... 26 docetaxel intravenous solution 20 mg/ml (1 ml), 80 mg/4 ml (20 mg/ml), 80 mg/8 ml (10 mg/ml)... 26 DOCU... 99 DOCUPRENE... 99 docusate calcium... 99 docusate sodium oral capsule 100 mg... 99 docusate sodium oral capsule 250 mg... 99 docusate sodium oral liquid... 99 docusate sodium oral tablet... 99 DOCUSIL... 99 dofetilide... 64 DOK ORAL CAPSULE 100 MG... 99 DOK ORAL CAPSULE 250 MG... 99 DOK ORAL TABLET... 99 donepezil oral tablet 10 mg... 41 donepezil oral tablet 5 mg... 41 donepezil oral tablet, disintegrating 10 mg... 41 donepezil oral tablet, disintegrating 5 mg... 41 dorzolamide... 120 dorzolamide-timolol... 120 DOUBLE ANTIBIOTIC... 78 doxazosin... 66 doxepin oral... 54 doxorubicin intravenous recon soln... 26 doxorubicin intravenous solution... 26 doxorubicin, pegliposomal... 26 DOXY-100... 22 doxycycline hyclate intravenous... 22 doxycycline hyclate oral capsule... 22 doxycycline hyclate oral tablet 100 mg, 20 mg... 22 doxycycline hyclate oral tablet 50 mg... 22 doxycycline hyclate oral tablet,delayed release (dr/ ec) 100 mg, 150 mg, 75 mg... 22 doxycycline monohydrate oral capsule... 22 doxycycline monohydrate oral tablet... 22 DRAMAMINE LESS DROWSY... 99 dronabinol... 99 drospirenone-ethinyl estradiol oral tablet 3-0.03 mg... 114 DROXIA... 26 DRY EYE RELIEF... 119 DSS... 99 DUCODYL... 99 DULCOLAX STOOL SOFTENER (DSS)... 99 DULERA... 129 duloxetine oral capsule, delayed release(dr/ec) 20 mg... 54 duloxetine oral capsule, delayed release(dr/ec) 30 mg... 54 duloxetine oral capsule, delayed release(dr/ec) 40 mg... 54 duloxetine oral capsule, delayed release(dr/ec) 60 mg... 54 duramorph (pf) injection solution 0.5 mg/ml... 43 duramorph (pf) injection solution 1 mg/ml... 43 DUREZOL... 121 dutasteride... 132 dutasteridetamsulosin... 132 E econazole topical... 79 (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全 天候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 158

ECONTRA EZ... 114 ECOTRIN LOW STRENGTH... 48 ECZEMA ANTI-ITCH... 81 ED A-HIST ORAL TABLET... 124 ED A-HIST PSE... 124 EDURANT... 10 EFFIENT... 70 ELAPRASE... 94 ELIDEL... 75 elinest... 114 ELIQUIS ORAL TABLET 2.5 MG... 70 ELIQUIS ORAL TABLET 5 MG... 70 ELITEK INTRAVENOUS RECON SOLN 1.5 MG... 23 elitek intravenous recon soln 7.5 mg... 23 ELLA... 114 EMCYT... 26 EMEND ORAL CAPSULE 125 MG... 99 EMEND ORAL CAPSULE 40 MG... 99 EMEND ORAL CAPSULE 80 MG... 99 EMEND ORAL CAPSULE,DOSE PACK... 100 EMEND ORAL SUSPENSION FOR RECONSTITUTION... 100 EMPLICITI... 26 EMSAM... 54 EMTRIVA ORAL CAPSULE... 10 EMTRIVA ORAL SOLUTION... 10 enalapril maleate... 66 enalaprilhydrochlorothiazide... 66 ENBREL SUBCUTANEOUS RECON SOLN... 110 ENBREL SUBCUTANEOUS SYRINGE 25 MG/0.5ML (0.51)... 110 ENBREL SUBCUTANEOUS SYRINGE 50 MG/ML (0.98 ML)... 110 ENBREL SURECLICK... 111 endocet oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg... 43 ENGERIX-B PEDIATRIC (PF)... 108 ENGERIX-B (PF)... 108 enoxaparin subcutaneous solution... 70 enoxaparin subcutaneous syringe 100 mg/ml, 150 mg/ ml... 70 enoxaparin subcutaneous syringe 120 mg/0.8 ml, 80 mg/ 0.8 ml... 70 enoxaparin subcutaneous syringe 30 mg/0.3 ml... 70 enoxaparin subcutaneous syringe 40 mg/0.4 ml... 70 enoxaparin subcutaneous syringe 60 mg/0.6 ml... 70 enpresse... 114 entacapone... 40 entecavir... 10 ENTERIC COATED ASPIRIN... 48 ENTRE-HIST PSE... 124 enulose... 100 EPCLUSA... 10 epinephrine injection syringe 0.1 mg/ml... 125 EPIPEN 2-PAK... 125 EPIPEN JR 2-PAK... 125 epirubicin intravenous solution 200 mg/100 ml... 27 epirubicin intravenous solution 50 mg/25 ml... 27 epitol... 36 EPIVIR HBV ORAL SOLUTION... 10 EPIVIR ORAL SOLUTION... 10 eplerenone... 66 eprosartan... 66 EPZICOM... 10 EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 100 MG... 36 EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 200 MG... 36 EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 300 MG... 36 ERAXIS(WATER DILUENT)... 8 ERBITUX... 27 ergocalciferol (vitamin d2) oral capsule... 142 ergocalciferol (vitamin d2) oral tablet 400 unit... 142 ergoloid... 54 ERGOMAR... 40 ERIVEDGE... 27 errin... 112 ERWINAZE... 27 ery pads... 76 ery-tab oral tablet,delayed release (dr/ec) 250 mg, 333 mg... 16 ERY-TAB ORAL TABLET,DELAYED RELEASE (DR/EC) 500 MG... 16 ERYTHROCIN INTRAVENOUS RECON SOLN 500 MG... 16 erythrocin (as stearate) oral tablet 250 mg... 16 erythromycin ethylsuccinate oral tablet... 16 erythromycin ophthalmic... 117 erythromycin oral tablet... 16 erythromycin with ethanol... 76 (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全 天候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 159

erythromycin-benzoyl peroxide... 76 ESBRIET... 129 escitalopram oxalate oral solution... 54 escitalopram oxalate oral tablet 10 mg... 54 escitalopram oxalate oral tablet 20 mg... 54 escitalopram oxalate oral tablet 5 mg... 54 ESTRACE VAGINAL... 112 estradiol oral... 112 estradiol transdermal patch weekly... 112 ESTRING... 112 ethambutol... 17 ethosuximide... 36 etodolac... 48 ETOPOPHOS... 27 etoposide intravenous... 27 EVOMELA... 27 EVOTAZ... 10 EXELON TRANSDERMAL... 41 exemestane... 27 EXJADE... 85 EXPECTORANT COUGH SYRUP... 125 EXPECTORANT ORAL LIQUID... 125 EYE DROP TEARS... 119 EYE IRRIGATING SOLUTION... 119 EYE ITCH RELIEF... 119 EYE STREAM... 119 EYE WASH... 119 EYE WASH STERILE... 119 EZFE 200... 142 F FABRAZYME... 94 FALLBACK SOLO... 114 falmina (28)... 114 famciclovir oral tablet 125 mg, 250 mg... 10 famciclovir oral tablet 500 mg... 10 famotidine intravenous... 105 famotidine oral suspension... 105 famotidine oral tablet 10 mg... 105 famotidine oral tablet 20 mg, 40 mg... 105 famotidine (pf)... 105 famotidine (pf)-nacl (isoos)... 105 FANAPT ORAL TABLET 1 MG... 54 FANAPT ORAL TABLET 10 MG... 54 FANAPT ORAL TABLET 12 MG... 54 FANAPT ORAL TABLET 2 MG... 54 FANAPT ORAL TABLET 4 MG... 54 FANAPT ORAL TABLET 6 MG... 54 FANAPT ORAL TABLET 8 MG... 54 FANAPT ORAL TABLETS,DOSE PACK... 54 FARESTON... 27 FARYDAK ORAL CAPSULE 10 MG... 27 FARYDAK ORAL CAPSULE 15 MG, 20 MG... 27 FASLODEX... 27 FAZACLO ORAL TABLET, DISINTEGRATING 100 MG... 54 FAZACLO ORAL TABLET, DISINTEGRATING 12.5 MG... 55 FAZACLO ORAL TABLET, DISINTEGRATING 25 MG... 55 felbamate... 36 felodipine oral er... 66 fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg... 73 fenofibrate nanocrystallized 48 mg, 145 mg... 73 fenofibrate oral tablet 160 mg, 54 mg... 73 fenoprofen oral tablet... 48 fentanyl citrate... 43 fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/ hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr... 44 FENTORA... 44 FEOSOL ORAL TABLET 325 MG (65 MG IRON)... 142 FERATE ORAL TABLET 240 MG (27 MG IRON)... 142 FEROSUL ORAL TABLET... 142 FERRETTS... 142 FERREX 150... 142 FERRIPROX ORAL SOLUTION... 85 FERRIPROX ORAL TABLET... 85 FERRO-TIME... 142 ferrous gluconate oral tablet 240 mg (27 mg iron)... 142 ferrous gluconate oral tablet 256 mg (28 mg iron)... 142 FERROUS GLUCONATE ORAL TABLET 324 MG (36 MG IRON), 324 MG (37.5 MG IRON), 324 MG (38 MG IRON)... 142 ferrous sulfate oral tablet 325 mg (65 mg iron)... 142 (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全 天候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 160

FERROUS SULFATE ORAL TABLET,DELAYED RELEASE (DR/EC) 324 MG (65 MG IRON)... 142 ferrous sulfate oral tablet, delayed release (dr/ec) 325 mg (65 mg iron)... 142 FERROUSUL... 142 FETZIMA ORAL CAPSULE,EXT REL 24HR DOSE PACK... 55 FETZIMA ORAL CAPSULE, EXTENDED RELEASE 24 HR 120 MG, 80 MG... 55 FETZIMA ORAL CAPSULE, EXTENDED RELEASE 24 HR 20 MG... 55 FETZIMA ORAL CAPSULE, EXTENDED RELEASE 24 HR 40 MG... 55 FEVER REDUCER AN PAIN RELIEVER ORAL SUSPENSION... 48 FEVERALL RECTAL SUPPOSITORY 650 MG... 48 finasteride oral tablet 5 mg... 132 FIRAZYR... 129 FIRMAGON KIT W DILUENT SYRINGE... 27 FLANAX ANTACID... 100 FLANAX (NAPROXEN)... 48 FLEBOGAMMA DIF... 108 flecainide... 64 FLEET GLYCERIN (ADULT)... 100 FLEET LAXATIVE... 100 FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCG/ ACTUATION... 129 FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 250 MCG/ ACTUATION, 50 MCG/ ACTUATION... 129 FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCG/ ACTUATION... 130 FLOVENT HFA INHALATION HFA AEROSOL INHALER 220 MCG/ ACTUATION... 130 FLOVENT HFA INHALATION HFA AEROSOL INHALER 44 MCG/ ACTUATION... 130 fluconazole... 8 fluconazole in dextrose(isoo)... 8 fluconazole in nacl (iso-osm) intravenous piggyback 100 mg/50 ml, 400 mg/200 ml... 8 fluconazole in nacl (iso-osm) intravenous piggyback 200 mg/100 ml... 8 flucytosine... 8 fludarabine intravenous recon soln... 27 fludarabine intravenous solution... 27 fludrocortisone... 89 flunisolide nasal spray,nonaerosol 25 mcg (0.025 %)... 130 fluocinolone... 81 fluocinolone acetonide oil... 88 fluocinolone and shower cap... 81 fluocinonide topical cream 0.05 %... 81 fluocinonide topical gel... 82 fluocinonide topical ointment... 82 fluocinonide topical solution... 82 fluocinonide-e topical cream 0.05 %... 82 fluorometholone... 121 fluorouracil intravenous... 27 fluorouracil topical cream 5 %... 75 fluoxetine oral capsule 10 mg... 55 fluoxetine oral capsule 20 mg... 55 fluoxetine oral capsule 40 mg... 55 fluoxetine oral solution... 55 fluoxetine oral tablet 10 mg... 55 fluoxetine oral tablet 20 mg... 55 fluphenazine decanoate... 55 fluphenazine hcl... 55 flurbiprofen... 48 flurbiprofen ophthalmic drops... 120 flutamide... 27 fluticasone nasal... 130 fluticasone topical cream... 82 fluticasone topical ointment... 82 fluvoxamine oral tablet 100 mg... 55 fluvoxamine oral tablet 25 mg... 55 fluvoxamine oral tablet 50 mg... 55 folic acid oral tablet 1 mg... 142 folic acid oral tablet 400 mcg, 800 mcg... 142 FOLOTYN... 27 (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全 天候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 161

fondaparinux subcutaneous syringe 10 mg/0.8 ml... 70 fondaparinux subcutaneous syringe 2.5 mg/0.5 ml... 70 fondaparinux subcutaneous syringe 5 mg/0.4 ml... 70 fondaparinux subcutaneous syringe 7.5 mg/0.6 ml... 70 FORADIL AEROLIZER... 130 FORTEO... 110 foscarnet... 10 fosinopril... 66 fosinoprilhydrochlorothiazide... 66 fosphenytoin... 36 FRAGMIN SUBCUTANEOUS SYRINGE 2,500 ANTI-XA UNIT/ 0.2 ML, 5,000 ANTI-XA UNIT/0.2 ML... 71 freamine iii 10 %... 140 FREESTYLE INSULINX STRIP... 90 FREESTYLE INSULINX TEST STRIPS... 90 FREESTYLE LANCETS... 90 FREESTYLE LITE STRIPS... 90 FREESTYLE TEST... 90 FULL SPECTRUM B-VITAMIN C... 142 FUNGOID-D... 79 furosemide injection solution... 67 furosemide oral solution 10 mg/ml, 40 mg/5 ml (8 mg/ ml)... 67 furosemide oral tablet... 67 FUSILEV... 23 FUZEON SUBCUTANEOUS RECON SOLN... 10 FYCOMPA ORAL SUSPENSION... 36 FYCOMPA ORAL TABLET 10 MG, 12 MG... 36 FYCOMPA ORAL TABLET 2 MG... 36 FYCOMPA ORAL TABLET 4 MG... 36 FYCOMPA ORAL TABLET 6 MG... 37 FYCOMPA ORAL TABLET 8 MG... 37 G G-TRON... 125 gabapentin oral capsule 100 mg... 37 gabapentin oral capsule 300 mg... 37 gabapentin oral capsule 400 mg... 37 gabapentin oral solution 250 mg/5 ml... 37 gabapentin oral solution 250 mg/5 ml (5 ml), 300 mg/6 ml (6 ml)... 37 gabapentin oral tablet 600 mg... 37 gabapentin oral tablet 800 mg... 37 GABITRIL ORAL TABLET 12 MG, 16 MG... 37 galantamine oral capsule,ext rel. pellets 24 hr... 41 galantamine oral solution... 41 galantamine oral tablet... 41 GAMASTAN S/D... 108 GAMMAGARD LIQUID... 108 GAMMAGARD S-D (IGA < 1 MCG/ ML)... 108 GAMUNEX-C... 108 ganciclovir sodium... 10 GARDASIL 9 (PF)... 108 GARDASIL (PF)... 108 GAS RELIEF 80... 100 GAS RELIEF ULTRA STRENGTH... 100 GATTEX 30-VIAL... 100 GATTEX ONE-VIAL... 100 GAUZE PADS 2 X 2... 90 GAVILAX ORAL POWDER... 100 gavilyte-c... 100 gavilyte-g... 100 gavilyte-n... 100 GAZYVA... 27 gemcitabine intravenous recon soln 1 gram, 200 mg... 27 gemcitabine intravenous recon soln 2 gram... 27 gemcitabine intravenous solution 1 gram/26.3 ml (38 mg/ml), 200 mg/5.26 ml (38 mg/ml)... 28 gemcitabine intravenous solution 2 gram/52.6 ml (38 mg/ml)... 28 gemfibrozil oral... 73 generlac... 100 gengraf oral capsule 100 mg, 25 mg... 28 gengraf oral capsule 50 mg... 28 gengraf oral solution... 28 GENOTROPIN... 107 GENOTROPIN MINIQUICK... 107 gentak ophthalmic ointment... 117 gentamicin injection... 17 gentamicin ophthalmic... 117 gentamicin sulfate (ped) (pf)... 17 gentamicin sulfate (pf) intravenous solution 100 mg/10 ml... 17 (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全 天候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 162

GENTAMICIN SULFATE (PF) INTRAVENOUS SOLUTION 60 MG/ 6 ML... 18 gentamicin sulfate (pf) intravenous solution 80 mg/ 8 ml... 18 gentamicin topical... 78 GENTLE LAXATIVE... 100 GENTLELAX... 100 GENVOYA... 10 GEODON INTRAMUSCULAR... 55 GERI-LANTA... 100 GERI-X ANTACID- ANTIGAS... 100 GERI-TUSSIN... 125 gildagia... 114 gildess 1.5/30 (21)... 114 GILENYA... 41 GILOTRIF... 28 GLATOPA... 41 GLEEVEC ORAL TABLET 100 MG... 28 GLEEVEC ORAL TABLET 400 MG... 28 GLEOSTINE... 28 glimepiride oral tablet 1 mg... 90 glimepiride oral tablet 2 mg... 90 glimepiride oral tablet 4 mg... 90 glipizide oral tablet 10 mg... 90 glipizide oral tablet 5 mg... 90 glipizide oral tablet extended release 24hr 10 mg... 90 glipizide oral tablet extended release 24hr 2.5 mg... 91 glipizide oral tablet extended release 24hr 5 mg... 91 glipizide-metformin oral tablet 2.5-250 mg... 91 glipizide-metformin oral tablet 2.5-500 mg, 5-500 mg... 91 GLUCAGEN HYPOKIT... 91 GLUCAGON EMERGENCY KIT (HUMAN)... 91 GLUCO BURST... 85 GLUCOSE GEL... 86 glucose oral tablet,chewable 4 gram... 86 GLUTOSE 15... 86 GLUTOSE 45... 86 glycerin (adult)... 100 GLYCOLAX ORAL POWDER... 100 glycopyrrolate oral... 96 GORMEL TEN... 75 griseofulvin microsize oral suspension... 8 griseofulvin ultramicrosize... 8 GUAIFENESIN AC... 125 guaifenesin oral liquid... 125 GUAIFENESIN-DM... 125 guanidine... 55 H HALAVEN... 28 halobetasol propionate... 82 HALOG... 82 haloperidol... 55 haloperidol decanoate... 55 haloperidol lactate... 56 HARVONI... 10 HAVRIX (PF) INTRAMUSCULAR SUSPENSION... 108 HAVRIX (PF) INTRAMUSCULAR SYRINGE 1,440 ELISA UNIT/ ML... 108 HAVRIX (PF) INTRAMUSCULAR SYRINGE 720 ELISA UNIT/0.5 ML... 108 HEADACHE RELIEF (ASA-ACET- CAF)... 48 HEALTHYLAX... 100 HEARTBURN ANTACID... 100 HEARTBURN PREVENTION... 105 HEARTBURN RELIEF... 100 HEARTBURN RELIEF (FATIDINE)... 105 HEARTBURN RELIEF (RANITIDINE)... 105 heather... 112 HEPARIN FLUSH... 71 heparin lock flush intravenous kit 100 unit/ ml... 71 heparin lock flush intravenous solution 10 unit/ml, 100 unit/ml... 71 heparin lock flush intravenous syringe 10 unit/ml... 71 HEPARIN LOCK FLUSH INTRAVENOUS SYRINGE 100 UNIT/ML... 71 HEPARIN LOCKFLUSH(PORCINE) (PF)... 71 heparin (porcine) in 5 % dex intravenous parenteral solution 12,500 unit/250 ml... 71 heparin (porcine) in 5 % dex intravenous parenteral solution 25,000 unit/250 ml (100 unit/ml), 25,000 unit/ 500 ml (50 unit/ml)... 71 (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全 天候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 163

heparin (porcine) in nacl (pf) intravenous parenteral solution 1,000 unit/500 ml, 2,000 unit/1,000 ml... 71 heparin (porcine) injection cartridge... 71 heparin (porcine) injection solution... 71 heparin, porcine (pf) injection solution... 72 heparin, porcine (pf) intravenous solution 100 unit/ml (1 ml)... 72 HEPARIN, PORCINE (PF) INTRAVENOUS SYRINGE 1 UNIT/ ML... 72 heparin, porcine (pf) intravenous syringe 10 unit/ml, 100 unit/ml... 72 HEPARIN(PORCINE) IN 0.45% NACL INTRAVENOUS PARENTERAL SOLUTION 12,500 UNIT/250 ML... 71 heparin(porcine) in 0.45% nacl intravenous parenteral solution 25,000 unit/250 ml, 25,000 unit/500 ml... 72 HEPATAMINE 8%... 140 HERCEPTIN... 28 HETLIOZ... 56 HEXALEN... 28 HI-CAL PLUS VIT D... 135 HIBERIX (PF)... 108 HIGH POTENCY IRON... 142 HUMATROPE INJECTION CARTRIDGE 12 MG (36 UNIT), 24 MG (72 UNIT)... 107 HUMIRA PEDIATRIC CROHN'S START SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML... 111 HUMIRA PEDIATRIC CROHN'S START SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML (6 PACK)... 111 HUMIRA PEN... 111 HUMIRA PEN CROHN'S-UC-HS START... 111 HUMIRA PEN PSORIASIS- UVEITIS... 111 HUMIRA SUBCUTANEOUS SYRINGE KIT 10 MG/0.2 ML, 20 MG/0.4 ML... 111 HUMIRA SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML... 111 hydralazine... 67 hydrochlorothiazide... 67 hydrocodone-acetaminophen oral solution 10-325 mg/15 ml(15 ml), 2.5-167 mg/5 ml, 5-163 mg/7.5ml(7.5ml)... 44 hydrocodone-acetaminophen oral solution 7.5-325 mg/15 ml... 44 hydrocodone-acetaminophen oral tablet 10-300 mg, 5-300 mg, 7.5-300 mg... 44 hydrocodone-acetaminophen oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg... 44 hydrocodonechlorpheniramine... 125 hydrocodone-homatropine oral syrup 5-1.5 mg/5 ml... 125 HYDROCODONE-HOMATROPINE ORAL SYRUP 5-1.5 MG/5 ML (5 ML)... 125 hydrocodone-homatropine oral tablet... 125 hydrocodone-ibuprofen oral tablet 7.5-200 mg... 44 hydrocortisone acetate topical... 82 hydrocortisone oral... 89 HYDROCORTISONE PLUS... 82 hydrocortisone rectal cream 2.5 %... 100 hydrocortisone rectal enema... 100 hydrocortisone topical cream 0.5 %... 82 hydrocortisone topical cream 1 %, 2.5 %... 82 hydrocortisone topical lotion 1 %... 82 hydrocortisone topical lotion 2.5 %... 82 hydrocortisone topical ointment 0.5 %... 82 hydrocortisone topical ointment 1 %, 2.5 %... 82 hydrocortisone valerate... 82 hydrocortisone-acetic acid... 88 hydrocortisone-min oil-wht pet... 82 HYDROCREAM... 82 HYDROMET... 125 hydromorphone oral tablet 2 mg, 4 mg... 44 hydromorphone oral tablet 8 mg... 44 HYDROSKIN TOPICAL LOTION... 82 hydroxychloroquine oral... 18 hydroxyprogesterone caproate... 112 hydroxyurea... 28 I I-PRIN... 49 (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全 天候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 164

ibandronate intravenous... 110 ibandronate oral... 110 IBRANCE... 28 IBUPROFEN IB ORAL TABLET... 49 ibuprofen oral capsule... 49 ibuprofen oral suspension... 49 ibuprofen oral tablet 200 mg... 49 ibuprofen oral tablet 400 mg, 600 mg, 800 mg... 49 ICLUSIG ORAL TABLET 15 MG... 28 ICLUSIG ORAL TABLET 45 MG... 28 idarubicin... 28 IFEREX 150... 142 ifosfamide intravenous recon soln... 28 ifosfamide intravenous solution... 28 ILARIS (PF)... 107 ILEVRO... 120 imatinib oral tablet 100 mg... 28 imatinib oral tablet 400 mg... 28 IMBRUVICA... 28 imipenem-cilastatin... 18 imipramine hcl... 56 imiquimod... 75 IVAX RABIES VACCINE (PF)... 108 INCRELEX... 86 indapamide... 67 INFANRIX (DTAP) (PF) INTRAMUSCULAR SUSPENSION... 108 INLYTA ORAL TABLET 1 MG... 28 INLYTA ORAL TABLET 5 MG... 28 INSTA-GLUCOSE... 86 insulin pen needle... 91 INSULIN SYRINGE (DISP) U-100 0.3 ML, 1 ML, 1/2 ML... 91 INTELENCE ORAL TABLET 100 MG... 10 INTELENCE ORAL TABLET 200 MG... 10 INTELENCE ORAL TABLET 25 MG... 10 intralipid intravenous emulsion 20 %... 140 INTRON A INJECTION... 107 INTUNIV ER... 56 INVANZ INJECTION... 18 INVEGA ORAL TABLET EXTENDED RELEASE 24HR 1.5 MG... 56 INVEGA ORAL TABLET EXTENDED RELEASE 24HR 3 MG... 56 INVEGA ORAL TABLET EXTENDED RELEASE 24HR 6 MG... 56 INVEGA ORAL TABLET EXTENDED RELEASE 24HR 9 MG... 56 INVEGA SUSTENNA... 56 INVEGA TRINZA INTRAMUSCULAR SYRINGE 273 MG/0.875 ML... 56 INVEGA TRINZA INTRAMUSCULAR SYRINGE 410 MG/1.315 ML... 56 INVEGA TRINZA INTRAMUSCULAR SYRINGE 546 MG/1.75 ML... 56 INVEGA TRINZA INTRAMUSCULAR SYRINGE 819 MG/2.625 ML... 56 INVIRASE ORAL CAPSULE... 10 INVIRASE ORAL TABLET... 10 INVOKANA ORAL TABLET 100 MG... 91 INVOKANA ORAL TABLET 300 MG... 91 INZO ANTIFUNGAL... 79 IOPHEN C-NR... 125 IOPHEN DM-NR... 125 IOPHEN-NR... 125 IPOL INJECTION SUSPENSION... 108 ipratropium bromide inhalation... 130 ipratropium bromide nasal... 88 ipratropium-albuterol... 130 irbesartan... 67 IRESSA... 28 irinotecan intravenous solution 100 mg/5 ml, 40 mg/ 2 ml... 29 irinotecan intravenous solution 500 mg/25 ml... 29 IRON HIGH POTENCY... 143 IRON ORAL TABLET 325 MG (65 MG IRON)... 143 IRON (DRIED)... 143 IRON (FERROUS SULFATE)... 143 ISENTRESS ORAL POWDER IN PACKET... 10 ISENTRESS ORAL TABLET... 10 ISENTRESS ORAL TABLET, CHEWABLE 100 MG... 11 ISENTRESS ORAL TABLET, CHEWABLE 25 MG... 11 isoniazid oral... 18 isosorbide dinitrate oral... 74 isosorbide mononitrate... 74 ISTODAX... 29 ITCHY EYE DROPS... 119 itraconazole... 8 IXEMPRA... 29 IXIARO (PF)... 108 (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全 天候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 165

J JAKAFI ORAL TABLET 10 MG... 29 JAKAFI ORAL TABLET 15 MG... 29 JAKAFI ORAL TABLET 20 MG... 29 JAKAFI ORAL TABLET 25 MG... 29 JAKAFI ORAL TABLET 5 MG... 29 JALYN... 132 jantoven... 72 JANUMET... 91 JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 100-1,000 MG... 91 JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 50-1,000 MG, 50-500 MG... 91 JANUVIA ORAL TABLET 100 MG... 91 JANUVIA ORAL TABLET 25 MG... 91 JANUVIA ORAL TABLET 50 MG... 91 JARDIANCE... 91 jencycla... 112 JEVTANA... 29 JOCK ITCH... 79 JOCK ITCH (CLOTRIMAZOLE)... 79 JOCK ITCH (TERBINAFINE)... 79 jolessa... 114 jolivette... 112 junel 1.5/30 (21)... 114 junel 1/20 (21)... 114 junel fe 1.5/30 (28)... 114 junel fe 1/20 (28)... 114 JUNEL FE 24... 114 JUXTAPID... 73 K K-PEC ANTIDIARRHEAL (BISM SUB)... 96 KADCYLA... 29 KALETRA ORAL SOLUTION... 11 KALETRA ORAL TABLET 100-25 MG... 11 KALETRA ORAL TABLET 200-50 MG... 11 KALYDECO ORAL TABLET... 130 KAO-TIN (BISMUTH SUBSALICYLAT)... 96 KAO-TIN (DOCUSATE CALCIUM)... 100 KAOPECTATE EX STR (BISMUTH SS)... 96 KAOPECTATE (BISMUTH SUBSALICY)... 96 kariva (28)... 115 kelnor 1/35 (28)... 115 KEPIVANCE... 23 ketoconazole oral... 8 ketoconazole topical... 79 ketorolac ophthalmic... 120 KETOTIFEN FUM 0.025% EYE DROPS... 119 ketotifen fumarate... 119 KEYTRUDA... 29 KHEDEZLA ORAL TABLET EXTENDED RELEASE 24HR 100 MG... 56 KHEDEZLA ORAL TABLET EXTENDED RELEASE 24HR 50 MG... 56 KINERET... 111 kionex (with sorbitol)... 86 KLOR-CON 10... 135 KLOR-CON 8... 135 klor-con m10... 135 KLOR-CON M15... 135 KLOR-CON M20... 135 KORLYM... 94 KPN... 143 kurvelo... 115 KUVAN ORAL TABLET, SOLUBLE... 94 KYNAMRO... 73 L labetalol intravenous solution... 67 labetalol oral... 67 lactated ringers intravenous... 135 lactated ringers irrigation... 84 lactulose... 101 LAMISIL AT TOPICAL CREAM... 79 lamivudine oral solution... 11 lamivudine oral tablet 100 mg... 11 lamivudine oral tablet 150 mg... 11 lamivudine oral tablet 300 mg... 11 lamivudine-zidovudine... 11 lamotrigine oral tablet... 37 lamotrigine oral tablet, chewable dispersible... 37 LANOXIN ORAL TABLET 125 MCG, 62.5 MCG... 69 lansoprazole oral capsule, delayed release(dr/ ec)... 105 LANTUS... 91 LANTUS SOLOSTAR... 91 LARIN 1.5/30 (21)... 115 LARIN FE 1/20 (28)... 115 latanoprost... 120 LATUDA ORAL TABLET 120 MG... 56 LATUDA ORAL TABLET 20 MG... 56 (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全 天候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 166

LATUDA ORAL TABLET 40 MG... 56 LATUDA ORAL TABLET 60 MG... 56 LATUDA ORAL TABLET 80 MG... 56 LAXA CLEAR... 101 LAXATIVE PEG 3350 ORAL POWDER... 101 LAXATIVE (BISACODYL) ORAL TABLET,DELAYED RELEASE (DR/EC)... 101 LAXATIVE (BISACODYL) RECTAL... 101 LAZANDA NASAL SPRAY,NON- AEROSOL 100 MCG/SPRAY, 400 MCG/SPRAY... 44 LAZANDA NASAL SPRAY,NON- AEROSOL 300 MCG/SPRAY... 44 leflunomide... 111 LENVIMA ORAL CAPSULE 10 MG/ DAY (10 MG X 1/DAY)... 29 LENVIMA ORAL CAPSULE 14 MG/ DAY(10 MG X 1-4 MG X 1), 20 MG/DAY (10 MG X 2)... 29 LENVIMA ORAL CAPSULE 18 MG/ DAY (10 MG X 1-4 MG X2)... 29 LENVIMA ORAL CAPSULE 24 MG/ DAY(10 MG X 2-4 MG X 1)... 29 LENVIMA ORAL CAPSULE 8 MG/ DAY (4 MG X 2), 8 MG/DAY (4 MG X 2) (60 PACK)... 29 lessina... 115 LETAIRIS... 130 letrozole... 29 leucovorin calcium injection recon soln 100 mg, 200 mg, 350 mg, 50 mg... 23 leucovorin calcium injection recon soln 500 mg... 23 leucovorin calcium oral... 24 LEUKERAN... 29 LEUKINE INJECTION RECON SOLN... 107 leuprolide subcutaneous kit... 29 levalbuterol hcl inhalation solution for nebulization 0.31 mg/3 ml, 1.25 mg/0.5 ml, 1.25 mg/3 ml... 130 levalbuterol hcl inhalation solution for nebulization 0.63 mg/3 ml... 130 LEVEMIR... 91 LEVEMIR FLEXTOUCH... 92 levetiracetam intravenous... 37 levetiracetam oral solution 100 mg/ml... 37 levetiracetam oral solution 500 mg/5 ml (5 ml)... 37 levetiracetam oral tablet... 37 levetiracetam oral tablet extended release 24 hr 500 mg... 37 levetiracetam oral tablet extended release 24 hr 750 mg... 37 levobunolol ophthalmic drops 0.5 %... 118 levocarnitine oral tablet... 86 levocarnitine (with sugar)... 86 levocetirizine oral tablet... 125 levofloxacin intravenous... 21 levofloxacin oral... 21 levoleucovorin calcium intravenous recon soln... 24 levonest (28)... 115 levonorg-eth estrad triphasic... 115 levonorgestrel oral tablet 1.5 mg... 115 levonorgestrel-ethinyl estrad oral tablet 0.1-20 mgmcg, 0.15-0.03 mg... 115 levonorgestrel-ethinyl estrad oral tablets,dose pack,3 month... 115 levorphanol tartrate... 44 levothyroxine oral... 95 levoxyl oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg... 95 LEXIVA ORAL SUSPENSION... 11 LEXIVA ORAL TABLET... 11 LICE BEDDING SPRAY... 83 LICE COMPLETE KIT 1-2-3... 83 LICE CREAM RINSE... 83 LICE KILLING... 83 LICE KILLING (PERMETHRIN)... 83 LICE PYRINYL SHAMPOO... 83 LICE SOLUTION... 83 LICE TREATMENT TOPICAL LIQUID 1 %... 83 LICE TREATMENT TOPICAL SHAMPOO... 83 LICE TREATMENT (PERMETHRIN)... 83 lidocaine hcl injection solution 10 mg/ml (1 %), 20 mg/ml (2 %)... 77 lidocaine hcl injection solution 5 mg/ml (0.5 %)... 77 lidocaine hcl laryngotracheal... 77 lidocaine hcl mucous membrane... 77 (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全 天候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 167

lidocaine hcl urethral... 77 lidocaine topical adhesive patch,medicated... 77 lidocaine topical ointment... 77 lidocaine viscous... 77 lidocaine (pf) injection solution 10 mg/ml (1 %), 20 mg/ml (2 %), 40 mg/ml (4 %), 5 mg/ml (0.5 %)... 77 lidocaine (pf) injection solution 15 mg/ml (1.5 %)... 77 lidocaine (pf) intravenous solution... 64 lidocaine (pf) intravenous syringe 100 mg/5 ml (2 %)... 64 lidocaine-prilocaine topical cream... 77 lindane topical shampoo... 83 linezolid oral suspension for reconstitution... 18 linezolid oral tablet... 18 LINZESS... 101 liothyronine oral... 95 LIQUID ANTACID... 101 LIQUITEARS... 119 lisinopril... 67 lisinoprilhydrochlorothiazide... 67 lithium carbonate... 57 lithium citrate oral solution 8 meq/5 ml... 57 LOHIST-DM... 125 LOKARA... 82 LONSURF... 30 loperamide oral capsule... 96 loperamide oral liquid 1 mg/ 5 ml... 96 LORADAMED... 125 loratadine oral tablet... 125 loratadine oral tablet, disintegrating... 125 LORAZEPAM INTENSOL... 57 lorazepam oral tablet... 57 LORCET HD... 44 LORCET PLUS ORAL TABLET 7.5-325 MG... 44 LORCET (HYDROCODONE)... 44 LORTAB 10-325... 44 LORTAB 5-325... 44 LORTAB 7.5-325... 44 losartan oral tablet 100 mg... 67 losartan oral tablet 25 mg, 50 mg... 67 losartanhydrochlorothiazide... 67 LOTRIMIN AF TOPICAL CREAM... 79 LOTRIMIN AF TOPICAL POWDER... 79 lovastatin oral tablet 10 mg, 20 mg... 73 lovastatin oral tablet 40 mg... 73 low-ogestrel (28)... 115 loxapine succinate... 57 LUBRICANT EYE DROPS... 119 LUBRICANT EYE DROPS (GLYC- PG)... 119 LUBRICANT EYE (PG-PEG 400)... 119 LUBRICANT REDNESS RELIEVER OPHTHALMIC DROPS 0.03-0.5 %... 121 LUBRICATING PLUS... 119 LUMIGAN OPHTHALMIC DROPS 0.01 %... 120 LUNESTA... 57 LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 3.75 MG... 30 LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 7.5 MG... 30 LUPRON DEPOT (3 NTH) INTRAMUSCULAR SYRINGE KIT 22.5 MG... 30 lutera (28)... 115 LYNPARZA... 30 LYRICA ORAL CAPSULE 100 MG... 37 LYRICA ORAL CAPSULE 150 MG... 37 LYRICA ORAL CAPSULE 200 MG... 37 LYRICA ORAL CAPSULE 225 MG, 300 MG... 37 LYRICA ORAL CAPSULE 25 MG... 38 LYRICA ORAL CAPSULE 50 MG... 38 LYRICA ORAL CAPSULE 75 MG... 38 LYRICA ORAL SOLUTION... 38 LYSODREN... 30 lyza... 112 M M-CLEAR WC... 126 M-M-R II (PF)... 108 MAALOX MAXIMUM STRENGTH... 101 MACRODANTIN ORAL CAPSULE 25 MG, 50 MG... 22 MAG-AL PLUS... 101 MAG-AL PLUS EXTRA STRENGTH... 101 magnesium citrate oral solution... 101 MAGNESIUM OXIDE ORAL CAPSULE 500 MG... 136 (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全 天候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 168

magnesium sulfate in water intravenous parenteral solution... 136 magnesium sulfate in water intravenous piggyback 2 gram/50 ml (4 %), 4 gram/50 ml (8 %)... 136 magnesium sulfate in water intravenous piggyback 4 gram/100 ml (4 %)... 136 magnesium sulfate injection solution... 136 magnesium sulfate injection syringe... 136 MAPAP EXTRA STRENGTH... 49 maprotiline oral tablet 25 mg... 57 maprotiline oral tablet 50 mg... 57 maprotiline oral tablet 75 mg... 57 marlissa... 115 MARPLAN... 57 MARQIBO... 30 MASANTI DOUBLE STRENGTH... 101 MASOPHEN ORAL TABLET 500 MG... 49 MATULANE... 30 matzim la... 67 MAXIMUM REDNESS RELIEF... 121 meclizine oral tablet 12.5 mg, 25 mg... 101 meclizine oral tablet, chewable... 101 meclofenamate oral... 49 MEDI-MECLIZINE... 101 MEDIPROXEN... 49 MEDIWASH... 119 MEDIWASH EYE IRRIGANT... 119 medroxyprogesterone intramuscular... 112 medroxyprogesterone oral... 112 mefloquine... 18 megestrol oral suspension 400 mg/10 ml (10 ml), 800 mg/ 20 ml (20 ml)... 30 megestrol oral suspension 400 mg/10 ml (40 mg/ml)... 30 megestrol oral tablet... 30 MEKINIST ORAL TABLET 0.5 MG... 30 MEKINIST ORAL TABLET 2 MG... 30 meloxicam oral suspension... 49 meloxicam oral tablet... 49 melphalan hcl... 30 memantine oral solution... 42 memantine oral tablet 10 mg... 42 memantine oral tablet 5 mg... 42 MENACTRA (PF) INTRAMUSCULAR SOLUTION... 109 MENEST... 112 MENOMUNE - A/C/Y/W- 135... 109 MENOMUNE - A/C/Y/W-135 (PF)... 109 MENSTRUAL RELIEF... 49 MENVEO A-C-Y-W-135-DIP (PF)... 109 MEPHYTON... 72 mercaptopurine... 30 meropenem... 18 MESALAMINE ORAL... 101 mesalamine rectal... 101 mesalamine with cleansing wipe... 101 mesna... 24 MESNEX ORAL... 24 MESTINON ORAL SYRUP... 42 MESTINON TIMESPAN... 42 METADATE ER... 57 metaproterenol... 130 metformin oral tablet 1,000 mg... 92 metformin oral tablet 500 mg... 92 metformin oral tablet 850 mg... 92 metformin oral tablet extended release 24 hr 500 mg... 92 metformin oral tablet extended release 24 hr 750 mg... 92 metformin oral tablet extended release 24hr 1,000 mg... 92 methadone injection... 44 methadone intensol... 44 methadone oral concentrate... 45 methadone oral solution 10 mg/5 ml... 45 methadone oral solution 5 mg/5 ml... 45 methadone oral tablet 10 mg... 45 methadone oral tablet 5 mg... 45 methadose oral concentrate... 45 methazolamide oral... 120 methenamine hippurate... 22 methimazole oral tablet 10 mg, 5 mg... 89 methotrexate sodium... 30 (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全 天候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 169

methotrexate sodium (pf) injection recon soln... 30 methotrexate sodium (pf) injection solution... 30 methoxsalen rapid... 75 methyclothiazide... 67 methyldopa... 67 methyldopahydrochlorothiazide... 67 methyldopate... 67 methylphenidate oral capsule, er biphasic 30-70 30 mg... 57 methylphenidate oral capsule, er biphasic 30-70 40 mg... 57 methylphenidate oral capsule,er biphasic 50-50 30 mg... 57 methylphenidate oral capsule,er biphasic 50-50 40 mg... 57 methylphenidate oral tablet... 57 methylphenidate oral tablet extended release... 57 methylphenidate oral tablet extended release 24hr 18 mg... 57 methylprednisolone acetate... 89 methylprednisolone oral tablets... 89 methylprednisolone sodium succ injection recon soln 125 mg, 40 mg... 89 methylprednisolone sodium succ intravenous... 89 metipranolol... 118 metoclopramide hcl injection solution... 101 metoclopramide hcl injection syringe... 101 metoclopramide hcl oral solution... 101 metoclopramide hcl oral tablet... 101 metolazone... 67 metoprolol succinate... 67 metoprolol tahydrochlorothiaz... 67 metoprolol tartrate intravenous solution... 67 metoprolol tartrate intravenous syringe... 68 metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg... 68 metro i.v.... 18 metronidazole in nacl (isoos)... 18 metronidazole oral... 18 metronidazole topical cream... 76 metronidazole topical gel 0.75 %... 76 metronidazole topical lotion... 76 metronidazole vaginal... 113 mexiletine... 64 MI-ACID GAS RELIEF... 101 MIACALCIN INJECTION... 94 MICATIN... 79 MICONAZOLE 3 DAY VAGINAL CREAM... 113 MICONAZOLE 7... 113 miconazole nitrate topical cream... 79 miconazole nitrate vaginal comb pack,prefill appl, cream... 113 miconazole nitrate vaginal cream... 113 miconazole nitrate vaginal suppository... 113 MICONAZOLE-3 VAGINAL KIT... 113 miconazole-3 vaginal suppository... 113 MICONAZORB AF... 79 MICRO-GUARD... 80 MICROGESTIN 1.5/30 (21)... 115 MICROGESTIN 1/20 (21)... 115 MICROGESTIN FE 1.5/30 (28)... 115 MICROGESTIN FE 1/20 (28)... 115 midodrine... 86 MIGRAINE FORMULA... 49 MIGRAINE RELIEF... 49 MIGRANAL... 40 MILK OF MAGNESIA... 101 MILK OF MAGNESIA CONCENTRATED... 101 MINERAL OIL EXTRA HEAVY... 102 MINERAL OIL HEAVY ORAL... 102 MINERAL OIL LAXATIVE... 102 mineral oil oral... 102 mineral oil rectal... 102 minocycline oral capsule... 22 minocycline oral tablet... 22 minoxidil oral... 68 MINTOX... 102 MINTOX MAXIMUM STRENGTH... 102 MINTOX PLUS... 102 MIRALAX ORAL POWDER IN PACKET... 102 MIRCETTE (28)... 115 mirtazapine oral tablet 15 mg... 57 (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全 天候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 170

mirtazapine oral tablet 30 mg... 57 mirtazapine oral tablet 45 mg... 58 mirtazapine oral tablet 7.5 mg... 58 mirtazapine oral tablet, disintegrating 15 mg... 58 mirtazapine oral tablet, disintegrating 30 mg... 58 mirtazapine oral tablet, disintegrating 45 mg... 58 misoprostol... 105 mitomycin... 30 mitoxantrone... 30 modafinil oral tablet 100 mg... 58 modafinil oral tablet 200 mg... 58 DERIBA... 11 ISTURE DROPS... 119 molindone... 58 mometasone topical... 82 mono-linyah... 115 NOJECT PREFILL (PF)... 72 mononessa (28)... 115 montelukast... 130 morgidox oral capsule 100 mg... 22 morgidox oral capsule 50 mg... 22 morphine concentrate oral solution... 45 morphine intravenous cartridge 2 mg/ml... 45 RPHINE INTRAVENOUS CARTRIDGE 8 MG/ML... 45 morphine intravenous solution 10 mg/ml, 50 mg/ ml... 45 morphine intravenous solution 100 mg/4 ml, 25 mg/ ml, 250 mg/10 ml... 45 RPHINE INTRAVENOUS SOLUTION 4 MG/ML, 8 MG/ ML... 45 morphine intravenous syringe 2 mg/ml, 4 mg/ml... 45 morphine oral capsule, er multiphase 24 hr 30 mg, 60 mg... 45 morphine oral capsule, extend.release pellets 100 mg, 20 mg, 30 mg, 50 mg, 60 mg, 80 mg... 46 morphine oral solution 10 mg/5 ml... 46 morphine oral solution 20 mg/5 ml (4 mg/ml)... 46 morphine oral tablet 15 mg... 46 morphine oral tablet 30 mg... 46 morphine oral tablet extended release 100 mg, 15 mg, 30 mg, 60 mg... 46 morphine oral tablet extended release 200 mg... 46 morphine (pf) injection solution 0.5 mg/ml... 45 morphine (pf) injection solution 1 mg/ml... 45 morphine (pf) intravenous patient control.analgesia soln 150 mg/30 ml... 45 morphine (pf) intravenous patient control.analgesia soln 30 mg/30 ml... 45 TION RELIEF (MECLIZINE)... 102 TION SICKNESS RELIEF (MECLIZ)... 102 TION SICKNESS (MECLIZINE)... 102 VIPREP... 102 ZOBIL... 107 MULTAQ... 64 mupirocin topical ointment... 78 MUSTARGEN... 30 MY WAY... 115 MYCOBUTIN... 18 mycophenolate mofetil... 30 mycophenolate sodium... 31 MYFERON 150... 143 MYOZYME... 94 MYRBETRIQ... 131 MYTAB GAS... 102 MYTAB GAS MAXIMUM STRENGTH... 102 myzilra... 115 N nabumetone... 49 nadolol... 68 nadololbendroflumethiazide... 68 nafcillin injection recon soln 1 gram, 10 gram... 20 nafcillin injection recon soln 2 gram... 20 nafcillin intravenous recon soln 2 gram... 20 NAGLAZYME... 94 nalbuphine injection solution 10 mg/ml... 49 nalbuphine injection solution 20 mg/ml... 49 naloxone... 49 naltrexone oral... 49 NAMENDA ORAL SOLUTION... 42 NAMENDA ORAL TABLET 10 MG... 42 (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全 天候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 171

NAMENDA ORAL TABLET 5 MG... 42 NAMENDA TITRATION PAK... 42 NAMENDA XR ORAL CAP, SPRINKLE,ER 24HR DOSE PACK... 42 NAMENDA XR ORAL CAPSULE, SPRINKLE,ER 24HR... 42 naproxen... 49 naproxen sodium oral capsule... 49 naproxen sodium oral tablet 220 mg... 49 naproxen sodium oral tablet 275 mg, 550 mg... 49 NARCAN... 50 NASAL DECONGESTANT (PSEUDOEPH) ORAL LIQUID... 126 NASAL DECONGESTANT (PSEUDOEPH) ORAL TABLET... 126 NASAL DECONGESTANT (PSEUDOEPH) ORAL TABLET EXTENDED RELEASE... 126 NASAL MIST... 88 NATACYN... 117 nateglinide oral tablet 120 mg... 92 nateglinide oral tablet 60 mg... 92 NATPARA... 94 NATURAL TEARS (PF)... 119 NEBUPENT... 18 necon 0.5/35 (28)... 115 necon 1/35 (28)... 116 necon 10/11 (28)... 116 necon 7/7/7 (28)... 116 needles, insulin disp., safety... 92 nefazodone oral tablet 100 mg... 58 nefazodone oral tablet 150 mg... 58 nefazodone oral tablet 200 mg... 58 nefazodone oral tablet 250 mg... 58 nefazodone oral tablet 50 mg... 58 neo-polycin... 117 neo-polycin hc... 120 neomycin... 18 neomycin-bacitracin-polyhc... 121 neomycin-bacitracinpolymyxin... 117 neomycin-polymyxin b gu... 84 neomycin-polymyxin b- dexameth... 121 neomycin-polymyxingramicidin... 117 neomycin-polymyxin-hc ophthalmic... 121 neomycin-polymyxin-hc otic... 88 NEOSPORIN ANTI-ITCH... 82 NEOSPORIN PLUS PAINRELIEF (BAC)... 78 NEULASTA SUBCUTANEOUS SYRINGE... 107 NEUPOGEN... 107 NEUPRO... 40 NEVANAC... 120 nevirapine oral suspension... 11 nevirapine oral tablet... 11 nevirapine oral tablet extended release 24 hr 100 mg... 11 nevirapine oral tablet extended release 24 hr 400 mg... 11 NEXAVAR... 31 NEXT CHOICE ONE DOSE... 116 niacin oral capsule, extended release 250 mg, 500 mg... 73 niacin oral tablet 100 mg, 50 mg, 500 mg... 73 NIACIN ORAL TABLET 250 MG... 73 niacin oral tablet extended release 24 hr 1,000 mg, 750 mg... 73 niacin oral tablet extended release 24 hr 500 mg... 73 niacin oral tablet extended release 250 mg, 750 mg... 73 NIACOR... 73 NIASPAN EXTENDED-RELEASE ORAL TABLET EXTENDED RELEASE 24 HR 1,000 MG, 750 MG... 73 NIASPAN EXTENDED-RELEASE ORAL TABLET EXTENDED RELEASE 24 HR 500 MG... 73 nicardipine oral... 68 NICORELIEF... 87 NICOTINE TRANSDERMAL... 87 nicotine transdermal system transdermal patch 24 hour 14 mg/24 hr, 21 mg/24 hr, 7 mg/24 hr... 87 nicotine transdermal system transdermal patch, td daily, sequential 21-14-7 mg/24 hr... 87 nicotine (polacrilex)... 87 NICOTROL NS... 87 nifedical xl... 68 nifedipine oral tablet extended release... 68 nifedipine oral tablet extended release 24hr... 68 (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全 天候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 172

NIGHTIME SLEEP... 126 NIGHTTIME SLEEP AID (DIPHEN) ORAL CAPSULE 50 MG... 126 NIGHTTIME SLEEP AID (DIPHEN) ORAL TABLET... 126 NILANDRON... 31 NINLARO... 31 NIPENT... 31 nitro-bid... 74 nitroglycerin intravenous... 74 nitroglycerin sublingual... 74 nitroglycerin transdermal patch 24 hour... 74 NITROSTAT... 74 NOBLE FORMULA HC TOPICAL CREAM... 82 NON-ASPIRIN ORAL SUSPENSION... 50 NON-DROWSY ALLERGY... 126 nora-be... 112 NORCO... 46 NORDITROPIN FLEXPRO SUBCUTANEOUS PEN INJECTOR 10 MG/1.5 ML (6.7 MG/ML), 15 MG/1.5 ML (10 MG/ML), 5 MG/ 1.5 ML (3.3 MG/ML)... 107 norethindrone acetate... 112 norethindrone (contraceptive)... 112 norethindrone-e.estradioliron... 116 norgestimate-ethinyl estradiol oral tablet 0.18/ 0.215/0.25 mg-35 mcg (28), 0.25-35 mg-mcg... 116 NORLYROC... 112 NORSOL-M IN 5 % DEXTROSE... 140 NORSOL-R... 136 NORSOL-R IN 5 % DEXTROSE... 136 NORSOL-R PH 7.4... 140 nortrel 0.5/35 (28)... 116 nortrel 1/35 (21)... 116 nortrel 1/35 (28)... 116 nortrel 7/7/7 (28)... 116 nortriptyline... 58 NORVIR ORAL CAPSULE... 11 NORVIR ORAL SOLUTION... 11 NORVIR ORAL TABLET... 11 NOVOLIN 70/30... 92 NOVOLIN N... 92 NOVOLIN R... 92 NOVOLOG... 92 NOVOLOG FLEXPEN... 92 NOVOLOG MIX 70-30... 92 NOVOLOG MIX 70-30 FLEXPEN... 92 NOVOLOG PENFILL... 92 NOXAFIL ORAL SUSPENSION... 8 NUEDEXTA... 42 NULOJIX... 31 NUPLAZID... 58 NUVARING... 113 nyamyc... 80 nystatin oral suspension... 8 nystatin oral tablet... 8 nystatin topical... 80 nystatin-triamcinolone... 80 nystop... 80 O ocella... 116 octreotide acetate... 31 OCUSOFT IRRIGATING OPHTH SOLN... 119 ODEFSEY... 11 ODOMZO... 31 ODOR CONTROL FOOT- SNEAKER... 80 ofloxacin ophthalmic... 117 ofloxacin oral tablet 400 mg... 21 ofloxacin otic... 88 ogestrel (28)... 116 olanzapine intramuscular... 58 olanzapine oral tablet 10 mg... 58 olanzapine oral tablet 15 mg... 58 olanzapine oral tablet 2.5 mg... 58 olanzapine oral tablet 20 mg... 58 olanzapine oral tablet 5 mg... 58 olanzapine oral tablet 7.5 mg... 58 olanzapine oral tablet, disintegrating 10 mg... 58 olanzapine oral tablet, disintegrating 15 mg... 58 olanzapine oral tablet, disintegrating 20 mg... 59 olanzapine oral tablet, disintegrating 5 mg... 59 olanzapine-fluoxetine oral capsule 12-25 mg, 12-50 mg, 6-50 mg... 59 olanzapine-fluoxetine oral capsule 3-25 mg, 6-25 mg... 59 olopatadine ophthalmic... 119 OLYSIO... 11 omega-3 acid ethyl esters... 73 omeprazole oral capsule, delayed release(dr/ ec)... 105 OMEPRAZOLE ORAL TABLET, DELAYED RELEASE (DR/ EC)... 105 (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全 天候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 173

ONCASPAR... 31 ondansetron hcl intravenous... 102 ondansetron hcl oral solution... 102 ondansetron hcl oral tablet 24 mg... 102 ondansetron hcl oral tablet 4 mg, 8 mg... 102 ondansetron hcl (pf) injection solution... 102 ondansetron hcl (pf) injection syringe... 102 ondansetron odt... 102 ONE DAILY PRENATAL ORAL COMBO PACK 28-800-440 MG- MCG-MG... 143 ONFI ORAL SUSPENSION... 38 ONFI ORAL TABLET 10 MG... 38 ONFI ORAL TABLET 20 MG... 38 OPCICON ONE-STEP... 116 OPDIVO... 31 ORAL SALINE LAXATIVE ORAL LIQUID... 102 oralone... 88 ORAP... 59 ORENCIA... 111 ORENCIA CLICKJECT... 111 ORENCIA (WITH MALTOSE)... 111 ORFADIN ORAL CAPSULE 10 MG, 2 MG, 5 MG... 86 ORFADIN ORAL CAPSULE 20 MG... 86 ORFADIN ORAL SUSPENSION... 86 orsythia... 116 oxacillin injection recon soln 1 gram, 2 gram... 20 oxacillin injection recon soln 10 gram... 20 oxacillin intravenous recon soln 1 gram... 20 oxacillin intravenous recon soln 2 gram... 20 oxaliplatin intravenous recon soln 100 mg... 31 oxaliplatin intravenous recon soln 50 mg... 31 oxaliplatin intravenous solution... 31 oxandrolone oral tablet 10 mg... 94 oxandrolone oral tablet 2.5 mg... 94 oxaprozin... 50 oxcarbazepine oral tablet... 38 OXSORALEN... 76 OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR 150 MG... 38 OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR 300 MG... 38 OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR 600 MG... 38 oxybutynin chloride oral syrup... 131 oxybutynin chloride oral tablet... 131 oxybutynin chloride oral tablet extended release 24hr 10 mg, 15 mg... 132 oxybutynin chloride oral tablet extended release 24hr 5 mg... 132 oxycodone oral capsule... 46 oxycodone oral concentrate... 46 oxycodone oral tablet 10 mg, 5 mg... 46 oxycodone oral tablet 15 mg... 46 oxycodone oral tablet 20 mg, 30 mg... 46 oxycodone-acetaminophen oral solution... 46 oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg... 46 oxycodone-aspirin... 46 OYSCO 500/D ORAL TABLET... 136 OYSCO D... 136 OYSCO-500... 136 OYST-CAL-500... 136 OYSTER SHELL + D3... 136 OYSTER SHELL CALCIUM... 136 OYSTER SHELL CALCIUM 500... 136 OYSTER SHELL CALCIUM-VIT D2 ORAL TABLET 250 (625)-125 MG-UNIT... 143 OYSTER SHELL CALCIUM-VIT D3... 136 OYSTERCAL-D... 136 P pacerone oral tablet 100 mg, 200 mg, 400 mg... 64 paclitaxel... 31 PAIN AND FEVER ORAL TABLET 500 MG... 50 PAIN RELIEF EXTRA STRENGTH... 50 PAIN RELIEF ORAL TABLET... 50 PAIN RELIEF (ACETAMIN-ASP- CAF)... 50 PAIN RELIEVER EXTRA STRENGTH... 50 PAIN RELIEVER ORAL CAPSULE... 50 (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全 天候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 174

PAIN RELIEVER ORAL TABLET 500 MG... 50 PAIN RELIEVER PLUS... 50 PAIN RELIEVER (ACETAM- ASPIRIN)... 50 PAIN-OFF... 50 paliperidone oral tablet extended release 24hr 1.5 mg... 59 paliperidone oral tablet extended release 24hr 3 mg... 59 paliperidone oral tablet extended release 24hr 6 mg... 59 paliperidone oral tablet extended release 24hr 9 mg... 59 pamidronate... 94 PAMPRIN MAX... 50 PANCREAZE... 102 PANRETIN... 76 pantoprazole... 105 paroex oral rinse... 88 paromomycin... 18 paroxetine hcl oral tablet 10 mg... 59 paroxetine hcl oral tablet 20 mg... 59 paroxetine hcl oral tablet 30 mg... 59 paroxetine hcl oral tablet 40 mg... 59 paroxetine hcl oral tablet extended release 24 hr 12.5 mg... 59 paroxetine hcl oral tablet extended release 24 hr 25 mg... 59 paroxetine hcl oral tablet extended release 24 hr 37.5 mg... 59 PASER... 18 PATADAY... 119 PATANOL... 119 PAXIL ORAL SUSPENSION... 59 PAZEO... 119 PEDVAX HIB (PF)... 109 peg 3350-electrolytes oral recon soln 236-22.74-6.74-5.86 gram... 102 peg 3350-electrolytes oral recon soln 240-22.72-6.72-5.84 gram... 103 peg-electrolyte soln... 103 PEGANONE... 38 PEGINTRON... 107 PEGINTRON REDIPEN... 107 PENICILLIN G POT IN DEXTROSE INTRAVENOUS PIGGYBACK 1 MILLION UNIT/50 ML... 20 PENICILLIN G POT IN DEXTROSE INTRAVENOUS PIGGYBACK 2 MILLION UNIT/50 ML, 3 MILLION UNIT/50 ML... 20 penicillin g potassium injection recon soln 20 million unit... 21 penicillin g potassium injection recon soln 5 million unit... 21 penicillin g procaine intramuscular syringe 1.2 million unit/2 ml... 21 penicillin g procaine intramuscular syringe 600, 000 unit/ml... 21 penicillin g sodium... 21 penicillin v potassium... 21 PENTACEL ACTHIB COMPONENT (PF)... 109 PENTAM... 18 PENTASA... 103 pentoxifylline... 72 PEPCID AC ORAL TABLET 20 MG... 105 PEPTIC RELIEF... 96 PEPTO-BISL ORAL TABLET, CHEWABLE... 96 PEPTO-BISL TO-GO... 96 periogard... 88 PERJETA... 31 permethrin topical cream... 83 permethrin topical liquid... 84 perphenazine... 59 PERSA-GEL... 76 PHARBETOL ORAL TABLET 500 MG... 50 phenadoz... 126 phenelzine... 60 phenobarbital oral elixir... 38 phenobarbital oral tablet 100 mg... 38 phenobarbital oral tablet 15 mg... 38 phenobarbital oral tablet 16.2 mg... 38 phenobarbital oral tablet 30 mg... 38 phenobarbital oral tablet 32.4 mg... 38 phenobarbital oral tablet 60 mg... 38 phenobarbital oral tablet 64.8 mg... 38 phenobarbital oral tablet 97.2 mg... 38 phentermine... 84 PHENYLEPHRINE HCL/ DIPHENHYDRAMINE HCL... 126 phenytoin oral suspension 100 mg/4 ml... 38 (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全 天候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 175

phenytoin oral suspension 125 mg/5 ml... 38 phenytoin oral tablet, chewable... 38 phenytoin sodium extended... 38 phenytoin sodium intravenous solution... 39 philith... 116 PHOSPHATE LAXATIVE ORAL LIQUID... 103 PHOSPHOLINE IODIDE... 118 PICATO... 76 pilocarpine hcl oral... 86 PIMTREA (28)... 116 pindolol... 68 PINK BISMUTH MAXIMUM STRENGTH... 96 PINK BISMUTH ORAL SUSPENSION... 96 PINK BISMUTH ORAL TABLET... 96 PINK BISMUTH ORAL TABLET, CHEWABLE... 96 pioglitazone oral tablet 15 mg... 92 pioglitazone oral tablet 30 mg... 92 pioglitazone oral tablet 45 mg... 92 pioglitazone-metformin... 92 piperacillintazobactam... 21 pirmella... 116 piroxicam... 50 PLASMA-LYTE 148... 140 PLASMA-LYTE-56 IN 5 % DEXTROSE... 140 podofilox... 76 POLY BACITRACIN... 78 POLY-IRON... 143 POLY-VITA... 143 POLY-VITAMIN... 143 polycin... 117 polyethylene glycol 3350 oral powder... 103 polyethylene glycol 3350 oral powder in packet... 103 polymyxin b sulftrimethoprim... 118 polysaccharide iron complex... 143 polyvinyl alcohol... 120 POMALYST ORAL CAPSULE 1 MG... 31 POMALYST ORAL CAPSULE 2 MG... 31 POMALYST ORAL CAPSULE 3 MG, 4 MG... 31 portia... 116 PORTRAZZA... 31 potassium chlorid-d5-0.45%nacl intravenous parenteral solution 10 meq/ l, 30 meq/l, 40 meq/l... 136 potassium chlorid-d5-0.45%nacl intravenous parenteral solution 20 meq/ l... 136 potassium chloride in 0.9%nacl intravenous parenteral solution 20 meq/ l... 137 potassium chloride in 5 % dex intravenous parenteral solution 20 meq/l, 40 meq/ l... 137 potassium chloride in 5 % dex intravenous parenteral solution 30 meq/l... 137 potassium chloride in lr-d5 intravenous parenteral solution 20 meq/l... 137 potassium chloride in lr-d5 intravenous parenteral solution 40 meq/l... 137 potassium chloride intravenous piggyback 10 meq/100 ml, 20 meq/100 ml, 20 meq/50 ml, 40 meq/100 ml... 137 potassium chloride intravenous piggyback 10 meq/50 ml... 137 potassium chloride intravenous piggyback 30 meq/100 ml... 137 potassium chloride intravenous solution... 137 potassium chloride oral capsule, extended release... 137 potassium chloride oral tablet extended release... 137 potassium chloride oral tablet,er particles/ crystals... 137 potassium chloride-0.45 % nacl... 137 potassium chloride-d5-0.2%nacl intravenous parenteral solution 20 meq/ l... 138 potassium chloride-d5-0.2%nacl intravenous parenteral solution 40 meq/ l... 138 potassium chloride-d5-0.3%nacl intravenous parenteral solution 20 meq/ l... 138 potassium chloride-d5-0.9%nacl intravenous (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全 天候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 176

parenteral solution 20 meq/ l... 138 potassium chloride-d5-0.9%nacl intravenous parenteral solution 40 meq/ l... 138 potassium citrate oral tablet extended release 10 meq (1,080 mg), 5 meq (540 mg)... 132 POTIGA ORAL TABLET 200 MG, 300 MG, 400 MG... 39 POTIGA ORAL TABLET 50 MG... 39 POWDERLAX... 103 PRADAXA ORAL CAPSULE 110 MG... 72 PRADAXA ORAL CAPSULE 150 MG, 75 MG... 72 PRALUENT PEN... 74 PRALUENT SYRINGE... 74 pramipexole oral tablet... 40 pravastatin... 74 prazosin oral... 68 prednisolone acetate... 121 prednisolone oral solution 15 mg/5 ml... 89 prednisolone sodium phosphate ophthalmic... 121 prednisolone sodium phosphate oral solution 15 mg/5 ml (3 mg/ml), 5 mg base/ 5 ml (6.7 mg/5 ml)... 89 prednisolone sodium phosphate oral tablet, disintegrating... 89 prednisone intensol... 89 prednisone oral... 89 PREMARIN... 112 PREMPHASE... 112 PREMPRO... 112 PRENATAL FORMULA ORAL TABLET 28 MG IRON- 800 MCG... 143 PRENATAL ONE DAILY... 143 PRENATAL TABLET... 143 PRENATAL VITAMIN ORAL CAPSULE 13.5-0.4 MG... 143 prenatal vitamin oral tablet... 143 PRENATAL VITAMIN ORAL TABLET, 27-0.8 MG, 28 MG IRON- 800 MCG... 143 PRENATAL VITAMIN ORAL TABLET 27 MG IRON- 800 MCG... 143 prenatal vitamin oral tablet 28 mg iron- 800 mcg... 143 prevalite... 74 previfem... 116 PREZCOBIX... 11 PREZISTA ORAL SUSPENSION... 12 PREZISTA ORAL TABLET 150 MG... 12 PREZISTA ORAL TABLET 600 MG, 800 MG... 12 PREZISTA ORAL TABLET 75 MG... 12 PRIFTIN... 18 PRIMAQUINE... 18 primidone... 39 PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 100 MG... 60 PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 25 MG... 60 PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 50 MG... 60 PROAIR HFA... 130 PROAIR RESPICLICK... 130 probenecid... 110 procainamide injection solution 100 mg/ml... 64 procainamide injection solution 500 mg/ml... 64 prochlorperazine edisylate injection solution 10 mg/2 ml (5 mg/ml)... 103 prochlorperazine maleate oral tablet 10 mg, 5 mg... 103 prochlorperazine maleate rectal... 103 PROCRIT... 107 procto-pak... 103 proctosol hc... 103 proctozone-hc... 103 PROGLYCEM... 92 PROGRAF INTRAVENOUS... 31 PROLEUKIN... 107 PROLIA... 110 PROMACTA ORAL TABLET 12.5 MG, 25 MG, 75 MG... 72 PROMACTA ORAL TABLET 50 MG... 72 promethazine oral tablet... 126 PROMETHAZINE VC- CODEINE... 126 promethazine-codeine... 126 promethazine-dm... 126 promethazine-phenylephcodeine... 126 promethegan rectal suppository 12.5 mg... 126 PROLAXIN... 103 propafenone oral tablet... 64 propranolol intravenous... 68 propranolol oral... 68 propranololhydrochlorothiazid... 68 (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全 天候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 177

propylthiouracil... 89 PROQUAD (PF)... 109 PROTONIX INTRAVENOUS... 105 PROTOPIC... 76 protriptyline... 60 PROVIL... 50 PSEUDOEPHEDRINE 120 MG ER... 126 pseudoephedrine hcl oral liquid... 126 pseudoephedrine hcl oral tablet 30 mg... 126 pseudoephedrine hcl oral tablet 60 mg... 126 pseudoephedrine hcl oral tablet extended release... 126 PSEUDOEPHEDRINE HCL/ CHLORPHENIRAMINE MALEATE ORAL TABLET 4-10 MG, 4-60 MG... 127 PSEUDOEPHEDRINE HCL/ CHLORPHENIRAMINE MALEATE TABLET... 127 PSEUDOEPHEDRINE HCL/ TRIPROLIDINE HCL ORAL TABLET... 127 PULZYME... 130 PURELAX... 103 PURIXAN... 31 pyrazinamide... 18 pyridostigmine bromide... 42 pyridoxine (vitamin b6) oral tablet 100 mg, 25 mg, 50 mg... 144 Q Q-DRYL ORAL CAPSULE... 127 Q-DRYL ORAL LIQUID... 127 Q-PAP EXTRA STRENGTH... 50 Q-PAP ORAL TABLET 500 MG... 50 Q-TUSSIN... 127 QUADRACEL (PF)... 109 quetiapine oral tablet 100 mg... 60 quetiapine oral tablet 200 mg... 60 quetiapine oral tablet 25 mg... 60 quetiapine oral tablet 300 mg... 60 quetiapine oral tablet 400 mg... 60 quetiapine oral tablet 50 mg... 60 quinapril... 68 quinaprilhydrochlorothiazide... 68 quinidine gluconate oral... 64 quinidine sulfate oral tablet... 64 quinine sulfate... 18 QUIT 2... 87 QUIT 4 BUCCAL GUM... 87 QVAR INHALATION AEROSOL 40 MCG/ACTUATION... 130 QVAR INHALATION AEROSOL 80 MCG/ACTUATION... 130 R RABAVERT (PF)... 109 raloxifene... 110 ramipril... 68 RANEXA... 74 ranitidine hcl oral syrup... 106 ranitidine hcl oral tablet 150 mg, 300 mg... 106 ranitidine hcl oral tablet 75 mg... 106 RAPAMUNE... 31 RAVICTI... 86 READY-TO-USE ENEMA (MIN OIL)... 103 REBIF REBIDOSE... 107 REBIF TITRATION PACK... 107 REBIF (WITH ALBUMIN)... 107 reclipsen (28)... 116 RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION... 109 RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 10 MCG/ML... 109 RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 5 MCG/0.5 ML... 109 RECORT PLUS... 82 REDNESS RELIEVER LUBRICANT... 121 RELCOF C... 127 RELENZA DISKHALER... 12 RELISTOR SUBCUTANEOUS SOLUTION... 103 REMICADE... 103 RENA-VITE... 144 RENAGEL... 86 RENVELA ORAL POWDER IN PACKET 0.8 GRAM... 86 RENVELA ORAL POWDER IN PACKET 2.4 GRAM... 86 RENVELA ORAL TABLET... 86 repaglinide oral tablet 0.5 mg... 92 repaglinide oral tablet 1 mg... 92 repaglinide oral tablet 2 mg... 93 REPATHA PUSHTRONEX... 74 REPATHA SURECLICK... 74 REPATHA SYRINGE... 74 RESCRIPTOR ORAL TABLET... 12 RESCRIPTOR ORAL TABLET, DISPERSIBLE... 12 (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全 天候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 178

REST SIMPLY NIGHTTIME SLEEP... 127 RESTASIS... 120 RESTFULLY SLEEP... 127 RETROVIR INTRAVENOUS... 12 REVIVE PLUS... 120 REVLIMID ORAL CAPSULE 10 MG... 31 REVLIMID ORAL CAPSULE 15 MG, 2.5 MG, 20 MG, 25 MG... 32 REVLIMID ORAL CAPSULE 5 MG... 32 REXULTI ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG... 60 REXULTI ORAL TABLET 3 MG, 4 MG... 60 REYATAZ ORAL CAPSULE 150 MG, 200 MG... 12 REYATAZ ORAL CAPSULE 300 MG... 12 REYATAZ ORAL POWDER IN PACKET... 12 RI-GEL... 103 RI-GEL II... 103 RI-X... 103 RI-TUSSIN... 127 ribasphere oral capsule... 12 ribasphere oral tablet 200 mg... 12 ribavirin oral capsule... 12 ribavirin oral tablet 200 mg... 12 RID COMPLETE LICE ELIM KIT TOPICAL... 84 RIDAURA... 111 rifampin... 18 RIFATER... 18 riluzole... 86 rimantadine... 12 ringers intravenous... 138 ringers irrigation... 84 RINGWORM... 80 RISACAL-D... 144 RISPERDAL CONSTA INTRAMUSCULAR SYRINGE 12.5 MG/2 ML, 25 MG/2 ML, 37.5 MG/ 2 ML... 60 RISPERDAL CONSTA INTRAMUSCULAR SYRINGE 50 MG/2 ML... 60 risperidone oral solution... 60 risperidone oral tablet 0.25 mg... 60 risperidone oral tablet 0.5 mg... 60 risperidone oral tablet 1 mg... 60 risperidone oral tablet 2 mg... 60 risperidone oral tablet 3 mg... 60 risperidone oral tablet 4 mg... 60 risperidone oral tablet, disintegrating 0.25 mg... 61 risperidone oral tablet, disintegrating 0.5 mg... 61 risperidone oral tablet, disintegrating 1 mg... 61 risperidone oral tablet, disintegrating 2 mg... 61 risperidone oral tablet, disintegrating 3 mg... 61 risperidone oral tablet, disintegrating 4 mg... 61 RITUXAN... 32 rivastigmine... 42 rivastigmine tartrate... 42 rizatriptan... 40 ROBAFEN... 127 ROBAFEN DM COUGH... 127 ropinirole oral tablet... 40 rosadan topical cream... 76 ROTARIX... 109 ROTATEQ VACCINE... 109 roweepra... 39 ROZEREM... 61 RYDEX... 127 S SABRIL... 39 SALICYLIC ACID TOPICAL LIQUID 3 %... 75 SANDIMMUNE ORAL SOLUTION... 32 SANI-SUPP (ADULT)... 103 SANTYL... 83 SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 10 MG... 61 SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 2.5 MG... 61 SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 5 MG... 61 SAVELLA ORAL TABLET 100 MG... 111 SAVELLA ORAL TABLET 12.5 MG... 111 SAVELLA ORAL TABLET 25 MG... 111 SAVELLA ORAL TABLET 50 MG... 111 SAVELLA ORAL TABLETS,DOSE PACK... 111 SCALP RELIEF HYDROCORTISONE TOPICAL LIQUID 3 %... 75 SCALP RELIEF HYDROCORTISONE TOPICAL SOLUTION 1 %... 83 SCALPICIN ANTI-ITCH... 83 SCOT-TUSSIN EXPECTORANT... 127 SECURA ANTIFUNGAL... 80 (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全 天候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 179

SECURA ANTIFUNGAL EXTRA THICK... 80 selegiline hcl... 40 selenium sulfide topical lotion... 74 SELZENTRY... 12 SENSIPAR ORAL TABLET 30 MG, 60 MG... 94 SENSIPAR ORAL TABLET 90 MG... 94 SEREVENT DISKUS... 130 SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 150 MG... 61 SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 200 MG... 61 SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 300 MG... 61 SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 400 MG... 61 SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 50 MG... 61 sertraline oral concentrate... 62 sertraline oral tablet 100 mg... 62 sertraline oral tablet 25 mg... 62 sertraline oral tablet 50 mg... 62 SHAROBEL... 112 SIGNIFOR... 32 SILACE ORAL LIQUID... 103 SILACE ORAL SYRUP... 104 SILADRYL SA... 127 sildenafil oral... 130 SILTUSSIN DM DAS... 127 SILTUSSIN SA... 127 silver sulfadiazine... 75 SIMETHICONE ORAL CAPSULE 125 MG, 180 MG... 104 simethicone oral capsule 180 mg... 104 simethicone oral tablet, chewable... 104 SIMETHICONE ORAL TABLET, CHEWABLE 125 MG... 104 SIMETHICONE ORAL TABLET, CHEWABLE 125 MG, 80 MG... 104 SIMULECT INTRAVENOUS RECON SOLN 10 MG... 32 SIMULECT INTRAVENOUS RECON SOLN 20 MG... 32 simvastatin... 74 SINUS 12 HOUR... 127 SINUS AND ALLERGY PE... 127 SINUS-ALLERGY (PHENYLEPHRINE)... 127 sirolimus... 32 SIRTURO... 19 SKIN TREATMENT... 76 SLEEP AID MAX STR (DIPHENHYDR)... 128 SLEEP AID (DIPHENHYDRAMINE) ORAL CAPSULE 50 MG... 127 SLEEP AID (DIPHENHYDRAMINE) ORAL TABLET... 128 SLEEP AID (DOXYLAMINE)... 62 SLEEP TABLET (DIPHENHYDRAMINE)... 128 SLEEP-TABS... 128 SLOW RELEASE IRON ORAL TABLET EXTENDED RELEASE 160 MG (50 MG IRON), 250 MG (50 MG IRON), 47.5 MG IRON... 144 SOTH ANTACID... 138 SOTHLAX... 104 sodium chloride 0.45 % intravenous parenteral solution... 138 sodium chloride 0.45 % intravenous piggyback... 138 sodium chloride 0.9 % intravenous... 86 sodium chloride 3 %... 138 sodium chloride 5 %... 138 sodium chloride inhalation solution for nebulization 0.9 %, 3 %... 131 sodium chloride intravenous parenteral solution 2.5 meq/ ml... 138 sodium chloride intravenous parenteral solution 4 meq/ ml... 138 sodium chloride irrigation... 86 sodium fluoride oral tablet... 144 sodium fluoride oral tablet, chewable 1 mg fluoride (2.2 mg)... 144 sodium polystyrene sulfonate oral powder... 86 sodium polystyrene sulfonate oral suspension... 86 sodium polystyrene sulfonate rectal enema 30 gram/120 ml... 87 SODIUM POLYSTYRENE SULFONATE RECTAL ENEMA 50 GRAM/200 ML... 87 sodium polystyrene (sorb free)... 86 SOF-LAX... 104 SOLTAX... 32 SOMATULINE DEPOT... 32 (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全 天候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 180

SOMAVERT SUBCUTANEOUS RECON SOLN 10 MG, 15 MG, 20 MG... 94 SOMAVERT SUBCUTANEOUS RECON SOLN 25 MG, 30 MG... 94 SOOTHE REGULAR STRENGTH... 96 SOOTHE (BISMUTH SUBSALICYLATE)... 96 SOOTHING CARE (HYDROCORTISONE)... 83 SORIATANE ORAL CAPSULE 10 MG, 17.5 MG, 25 MG... 75 sorine oral tablet 120 mg, 160 mg, 80 mg... 64 sorine oral tablet 240 mg... 64 sotalol af... 64 sotalol oral... 64 SOVALDI... 12 SPIRIVA RESPIMAT... 131 SPIRIVA WITH HANDIHALER... 131 spironolactonhydrochlorothiaz... 68 spironolactone... 68 sprintec (28)... 116 SPRITAM ORAL TABLET FOR SUSPENSION 1,000 MG, 250 MG, 500 MG... 39 SPRITAM ORAL TABLET FOR SUSPENSION 750 MG... 39 SPRYCEL... 32 sps (with sorbitol) oral... 87 sps (with sorbitol) rectal... 87 sronyx... 116 ssd... 75 stavudine oral capsule 15 mg, 20 mg... 12 stavudine oral capsule 30 mg, 40 mg... 12 stavudine oral recon soln... 12 STERILE EYE DROPS OPHTHALMIC DROPS 0.012-0.2 %, 0.03-0.5 %... 122 STERILE EYE WASH... 120 STERILE SALINE NASAL... 88 STIMATE... 94 STIVARGA... 32 STOMACH RELIEF... 96 STOMACH RELIEF MAX STRENGTH... 96 STOMACH RELIEF ORIGINAL... 96 STOOL SOFTENER ORAL CAPSULE 100 MG, 240 MG, 250 MG... 104 STOOL SOFTENER ORAL CAPSULE 50 MG... 104 STOOL SOFTENER ORAL LIQUID... 104 STOOL SOFTENER ORAL SYRUP... 104 STOOL SOFTENER ORAL TABLET... 104 STOP LICE... 84 STOP SKING AID... 87 STRATTERA ORAL CAPSULE 10 MG, 18 MG, 25 MG, 40 MG... 62 STRATTERA ORAL CAPSULE 100 MG, 60 MG, 80 MG... 62 STRAWBERRY C... 144 STREPTOMYCIN INTRAMUSCULAR... 19 STRIBILD... 12 STROMECTOL... 19 SUBSYS... 46 sucralfate oral tablet... 106 SUDOGEST... 128 SUDOGEST 12-HOUR... 128 SUDOGEST COLD AND ALLERGY... 128 SUDOGEST SINUS AND ALLERGY... 128 sulfacetamide sodium ophthalmic drops... 121 sulfacetamide sodium (acne)... 78 sulfacetamideprednisolone... 121 sulfadiazine oral... 22 sulfamethoxazoletrimethoprim... 22 SULFAMYLON... 78 sulfasalazine... 104 sulindac oral... 50 sumatriptan succinate oral... 40 sumatriptan succinate subcutaneous cartridge... 40 sumatriptan succinate subcutaneous pen injector 4 mg/0.5 ml, 6 mg/0.5 ml... 40 sumatriptan succinate subcutaneous pen injector 6 mg/0.5 ml (autoinjector)... 41 sumatriptan succinate subcutaneous solution... 41 sumatriptan succinate subcutaneous syringe 6 mg/ 0.5 ml... 41 SUPER CALCIUM... 138 SUPER PAIN RELIEF... 50 SUPHEDRIN... 128 SUPHEDRIN 12 HOUR... 128 SUPHEDRINE... 128 SUPHEDRINE 12 HOUR... 128 SUPHEDRINE PE COLD AND ALLERGY... 128 (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全 天候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 181

SUPHEDRINE PE SINUS ANDALLERGY... 128 SUPPOSITORY ADULT... 104 SUPREP BOWEL PREP KIT... 104 SURFAK... 104 SURNTIL... 62 SUSTIVA ORAL CAPSULE 200 MG... 12 SUSTIVA ORAL CAPSULE 50 MG... 12 SUSTIVA ORAL TABLET... 12 SUTENT ORAL CAPSULE 12.5 MG... 32 SUTENT ORAL CAPSULE 25 MG, 37.5 MG, 50 MG... 32 syeda... 116 SYLATRON... 107 SYMBICORT... 131 SYMLINPEN 120... 93 SYMLINPEN 60... 93 SYNAGIS... 12 SYNAREL... 94 SYNERCID... 19 SYNRIBO... 32 SYNTHROID... 95 SYPRINE... 87 T TABLOID... 32 tacrolimus oral... 32 TAFINLAR... 32 TAGRISSO ORAL TABLET 40 MG... 32 TAGRISSO ORAL TABLET 80 MG... 32 TAKE ACTION... 116 TAMIFLU... 12 tamoxifen... 32 tamsulosin... 132 TARCEVA ORAL TABLET 100 MG, 150 MG... 32 TARCEVA ORAL TABLET 25 MG... 32 TARGRETIN ORAL... 32 TARGRETIN TOPICAL... 33 TARINA FE 1/20 (28)... 116 TASIGNA... 33 TAZORAC... 77 taztia xt... 68 TEARS AGAIN (PVA)... 120 TEARS NATURALE FREE (PF)... 120 TECENTRIQ... 33 TECHNIVIE... 13 TEFLARO... 15 telmisartan oral tablet 20 mg, 40 mg... 68 telmisartan oral tablet 80 mg... 68 temazepam oral capsule 15 mg, 22.5 mg, 30 mg... 62 terazosin... 68 terbinafine hcl oral... 8 terbinafine hcl topical... 80 terbutaline oral... 131 terbutaline subcutaneous... 131 terconazole... 113 TESTIM... 94 testosterone cypionate... 94 testosterone enanthate... 94 tetanus,diphtheria tox ped (pf)... 109 TETANUS-DIPHTHERIA TOXOIDS- TD... 109 tetrabenazine oral tablet 12.5 mg... 42 tetrabenazine oral tablet 25 mg... 42 tetracycline... 22 THALOMID ORAL CAPSULE 100 MG, 50 MG... 33 THALOMID ORAL CAPSULE 150 MG, 200 MG... 33 THE MAGIC BULLET... 104 theophylline oral tablet extended release 12 hr... 131 theophylline oral tablet extended release 24 hr... 131 THERA-D... 144 thermazene... 75 thiamine hcl (vitamin b1) oral tablet 100 mg, 250 mg, 50 mg... 144 thiamine mononitrate (vit b1)... 144 thioridazine... 62 thiotepa... 33 thiothixene... 62 THYGLOBULIN... 109 tiagabine... 39 TICE BCG... 109 TIKOSYN... 64 timolol maleate ophthalmic... 118 timolol maleate oral... 68 TINACTIN TOPICAL AEROSOL POWDER... 80 TIVICAY ORAL TABLET 10 MG, 25 MG... 13 TIVICAY ORAL TABLET 50 MG... 13 tizanidine oral tablet... 42 TOBI... 19 tobramycin... 118 tobramycin sulfate injection recon soln... 19 tobramycin sulfate injection solution... 19 tobramycin-dexamethasone opthalmic suspension... 121 tolcapone... 40 (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全 天候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 182

tolmetin... 50 tolnaftate topical aerosol powder... 80 tolnaftate topical cream... 80 tolterodine oral capsule, extended release 24hr... 132 tolterodine oral tablet... 132 topiramate oral capsule, sprinkle... 39 topiramate oral tablet 100 mg... 39 topiramate oral tablet 200 mg... 39 topiramate oral tablet 25 mg... 39 topiramate oral tablet 50 mg... 39 toposar... 33 topotecan intravenous recon soln... 33 topotecan intravenous solution... 33 TORISEL... 33 torsemide oral... 69 TOUJEO SOLOSTAR... 93 TOVIAZ... 132 TPN ELECTROLYTES... 138 TRACLEER... 131 tramadol oral tablet... 50 tramadolacetaminophen... 50 trandolapril... 69 tranexamic acid intravenous... 72 tranexamic acid oral... 113 TRANSDERM-SCOP... 104 tranylcypromine... 62 travasol 10 %... 140 TRAVATAN Z... 120 TRAVEL SICKNESS (MECLIZINE)... 104 travoprost (benzalkonium)... 120 trazodone... 62 TREANDA INTRAVENOUS RECON SOLN... 33 TRECATOR... 19 TRELSTAR DEPOT... 33 TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION... 33 TRELSTAR INTRAMUSCULAR SYRINGE 11.25 MG/2 ML, 3.75 MG/2 ML... 33 TRELSTAR INTRAMUSCULAR SYRINGE 22.5 MG/2 ML... 33 TRELSTAR LA... 33 tretinoin topical cream... 77 tretinoin topical gel 0.01 %, 0.025 %... 77 tretinoin (chemotherapy)... 33 TREXALL... 33 TRI-BIOZENE... 78 tri-estarylla... 116 tri-linyah... 117 tri-previfem (28)... 117 tri-sprintec (28)... 117 triamcinolone acetonide dental... 88 triamcinolone acetonide injection suspension 10 mg/ ml... 89 triamcinolone acetonide injection suspension 40 mg/ ml... 89 triamcinolone acetonide topical cream... 83 triamcinolone acetonide topical lotion... 83 triamcinolone acetonide topical ointment 0.025 %, 0.1 %, 0.5 %... 83 triamterenehydrochlorothiazid oral capsule 37.5-25 mg... 69 triamterenehydrochlorothiazid oral tablet... 69 trianex... 83 triderm topical cream... 83 trifluoperazine... 62 trifluridine... 118 trihexyphenidyl... 40 TRILEPTAL ORAL SUSPENSION... 39 trimethoprim... 22 trinessa (28)... 117 trintellix oral tablet 10 mg... 62 trintellix oral tablet 20 mg... 62 trintellix oral tablet 5 mg... 62 TRIPLE ANTIBIOTIC PLUS... 78 TRIPLE ANTIBIOTIC TOPICAL OINTMENT... 78 TRIPLE ANTIBIOTIC TOPICAL OINTMENT IN PACKET... 78 TRIPLE ANTIBIOTIC (PRAM) EXTRA... 78 TRIPLE ANTIBIOTIC-PAIN RELIEF... 78 TRISENOX... 33 TRIUMEQ... 13 trivora (28)... 117 TRIZIVIR... 13 TROPHAMINE 10 %... 140 TROPHAMINE 6%... 140 TRUMENBA... 109 (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全 天候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 183

TRUVADA ORAL TABLET 100-150 MG, 133-200 MG, 167-250 MG... 13 TRUVADA ORAL TABLET 200-300 MG... 13 TUDORZA PRESSAIR INHALATION AEROSOL POWDR BREATH ACTIVATED 400 MCG/ ACTUATION... 131 TUDORZA PRESSAIR INHALATION AEROSOL POWDR BREATH ACTIVATED 400 MCG/ ACTUATION (30 ACTUAT)... 131 TUMS ULTRA ORAL TABLET, CHEWABLE 400 MG (1,000 MG)... 138 TUSNEL DIABETIC... 128 TUSSI PRES-B ORAL LIQUID 4-10-20 MG/5 ML... 128 TUSSIGON... 128 TUSSIN CHEST CONGESTION... 128 TUSSIN COUGH-CHEST CONGESTION... 128 TUSSIN DM COUGH AND CHEST ORAL LIQUID 10-100 MG/5 ML... 128 TUSSIN DM ORAL LIQUID... 128 TUSSIN EXPECTORANT... 128 TUSSIN HONEY... 128 TUSSIN ORAL LIQUID... 128 TWINRIX (PF)... 109 TYBOST... 13 TYGACIL... 19 TYKERB... 33 TYPHIM VI INTRAMUSCULAR SOLUTION... 109 TYPHIM VI INTRAMUSCULAR SYRINGE... 109 TYSABRI... 42 TYZEKA... 13 TYZINE NASAL DROPS 0.05 %... 88 U ULTRA FRESH... 120 ULTRA SLEEP (DOXYLAMINE SUCC)... 62 ULTRA STRENGTH ANTACID... 139 ULTRA STRENGTH CALCIUM ANTACID... 139 UNITHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG... 95 UNITUXIN... 33 urea topical cream 10 %, 20 %... 76 urea topical lotion 10 %... 76 UREACIN-20... 76 URINARY PAIN RELIEF ORAL TABLET 95 MG... 132 URINARY TRACT... 132 ursodiol... 104 UVADEX... 76 V VAGIFEM... 112 VAGINAL CONTRACEPTIVE FOAM... 113 VAGISTAT-3... 113 valacyclovir... 13 VALCHLOR... 76 valganciclovir oral tablet... 13 valproate sodium... 39 valproic acid... 39 valproic acid (as sodium salt) oral solution 250 mg/5 ml... 39 valproic acid (as sodium salt) oral solution 250 mg/5 ml (5 ml), 500 mg/10 ml (10 ml)... 39 valsartan oral tablet 160 mg... 69 valsartan oral tablet 320 mg... 69 valsartan oral tablet 40 mg, 80 mg... 69 valsartanhydrochlorothiazide... 69 VALU-DRYL ALLERGY ORAL CAPSULE... 128 vancomycin in 0.9% sodium cl intravenous piggyback 1 gram/200 ml... 22 VANCOMYCIN IN 0.9% SODIUM CL INTRAVENOUS PIGGYBACK 500 MG/100 ML, 750 MG/150 ML... 23 vancomycin in dextrose 5 % intravenous piggyback 1 gram/200 ml... 23 VANCOMYCIN IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK 500 MG/100 ML, 750 MG/150 ML... 23 vancomycin intravenous recon soln 1,000 mg, 10 gram, 500 mg, 750 mg... 23 vancomycin intravenous recon soln 5 gram... 23 vancomycin oral capsule 125 mg... 23 vancomycin oral capsule 250 mg... 23 VAQTA (PF)... 109 VARIVAX (PF)... 110 VARIZIG... 110 VECAMYL... 74 VECTIBIX... 33 VECTICAL... 75 VELCADE... 33 (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全 天候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 184

velivet triphasic regimen (28)... 117 VENCLEXTA ORAL TABLET 10 MG... 34 VENCLEXTA ORAL TABLET 100 MG... 34 VENCLEXTA ORAL TABLET 50 MG... 34 VENCLEXTA STARTING PACK... 34 venlafaxine oral capsule, extended release 24hr 150 mg... 62 venlafaxine oral capsule, extended release 24hr 37.5 mg... 62 venlafaxine oral capsule, extended release 24hr 75 mg... 62 venlafaxine oral tablet 100 mg... 62 venlafaxine oral tablet 25 mg... 62 venlafaxine oral tablet 37.5 mg... 63 venlafaxine oral tablet 50 mg... 63 venlafaxine oral tablet 75 mg... 63 venlafaxine oral tablet extended release 24hr 150 mg... 63 venlafaxine oral tablet extended release 24hr 37.5 mg... 63 venlafaxine oral tablet extended release 24hr 75 mg... 63 VENTAVIS... 131 VENTOLIN HFA... 131 verapamil intravenous solution... 69 verapamil oral capsule, 24 hr er pellet ct... 69 verapamil oral capsule,ext rel. pellets 24 hr... 69 verapamil oral tablet... 69 verapamil oral tablet extended release 120 mg (24 hours)... 69 verapamil oral tablet extended release 120 mg, 180 mg, 240 mg... 69 VERSACLOZ... 63 VESICARE... 132 vicodin... 46 vicodin es... 46 vicodin hp... 46 VICTOZA 2-PAK... 93 VICTOZA 3-PAK... 93 VIDEX 2 GRAM PEDIATRIC... 13 VIDEX 4 GRAM PEDIATRIC... 13 VIEKIRA PAK... 13 VIEKIRA XR... 13 VIGAX... 118 VIIBRYD ORAL TABLET 10 MG... 63 VIIBRYD ORAL TABLET 20 MG... 63 VIIBRYD ORAL TABLET 40 MG... 63 VIMPAT INTRAVENOUS... 39 VIMPAT ORAL SOLUTION... 39 VIMPAT ORAL TABLET 100 MG... 40 VIMPAT ORAL TABLET 150 MG... 40 VIMPAT ORAL TABLET 200 MG... 40 VIMPAT ORAL TABLET 50 MG... 40 vinblastine intravenous solution... 34 VINCASAR PFS INTRAVENOUS SOLUTION 1 MG/ML... 34 vincasar pfs intravenous solution 2 mg/2 ml... 34 vincristine... 34 vinorelbine... 34 viorele (28)... 117 VIRACEPT ORAL TABLET 250 MG... 13 VIRACEPT ORAL TABLET 625 MG... 13 VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 HR 100 MG... 13 VIRAZOLE... 13 VIREAD ORAL POWDER... 13 VIREAD ORAL TABLET... 13 VIRTUSSIN AC... 129 VITAMIN A PALMITATE ORAL CAPSULE... 144 VITAMIN A PALMITATE ORAL TABLET 10,000 UNIT... 144 vitamin a palmitate oral tablet 15,000 unit... 144 VITAMIN B-1... 144 VITAMIN B-1 (NONITRATE)... 144 VITAMIN B-12 ORAL TABLET 1, 000 MCG, 100 MCG, 250 MCG, 500 MCG... 144 VITAMIN B-12 ORAL TABLET EXTENDED RELEASE 1,000 MCG... 144 VITAMIN B-12 ORAL TABLET EXTENDED RELEASE 2,000 MCG... 144 VITAMIN B-12 SUBLINGUAL TABLET 2,500 MCG... 144 VITAMIN B-2... 145 VITAMIN B-6 ORAL TABLET 100 MG, 25 MG, 50 MG... 145 (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全 天候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 185

VITAMIN C ORAL CAPSULE, EXTENDED RELEASE... 145 VITAMIN C ORAL TABLET 1,000 MG, 250 MG, 500 MG... 145 VITAMIN C ORAL TABLET, CHEWABLE 250 MG, 500 MG... 145 VITAMIN C WITH ROSE HIPS ORAL TABLET... 145 VITAMIN D2... 145 VITAMIN D3 ORAL CAPSULE 1, 000 UNIT, 2,000 UNIT, 400 UNIT... 145 VITAMIN D3 ORAL TABLET 1,000 UNIT, 2,000 UNIT, 400 UNIT... 145 VITAMIN D3 ORAL TABLET 5,000 UNIT... 145 vitamin e oral capsule 1,000 unit, 200 unit, 400 unit... 145 vitamin e oral capsule 100 unit... 145 VITAMIN E (DL, ACETATE) ORAL CAPSULE 100 UNIT... 145 VITEKTA... 13 VIVELLE-DOT... 112 VOLTAREN TOPICAL GEL 1 %... 50 voriconazole intravenous... 9 voriconazole oral suspension for reconstitution... 9 voriconazole oral tablet 200 mg... 9 voriconazole oral tablet 50 mg... 9 VOSPIRE ER... 131 VOTRIENT... 34 VPRIV... 94 VRAYLAR ORAL CAPSULE... 63 VRAYLAR ORAL CAPSULE,DOSE PACK... 63 VYFEMLA (28)... 117 W warfarin... 72 water for irrigation, sterile... 87 WELCHOL... 74 WOMAN'S LAXATIVE ORAL TABLET,DELAYED RELEASE (DR/EC)... 104 WOMEN'S GENTLE LAXATIVE (BISAC)... 104 WOMEN'S LAXATIVE (BISACODYL) ORAL TABLET, DELAYED RELEASE (DR/ EC)... 105 X XALKORI... 34 XARELTO ORAL TABLET 10 MG, 20 MG... 72 XARELTO ORAL TABLET 15 MG... 72 XARELTO ORAL TABLETS,DOSE PACK... 72 XENAZINE ORAL TABLET 12.5 MG... 42 XENAZINE ORAL TABLET 25 MG... 42 XGEVA... 24 XIFAXAN ORAL TABLET 550 MG... 19 XODOL 10/300... 46 XODOL 5/300... 46 XODOL 7.5/300... 47 XOLAIR... 131 XTANDI... 34 XYREM... 63 Y YERVOY... 34 YF-VAX (PF)... 110 YONDELIS... 34 Z zafirlukast... 131 zaleplon oral capsule 10 mg... 63 zaleplon oral capsule 5 mg... 63 ZALTRAP... 34 ZANOSAR... 34 zarah... 117 ZAVESCA... 95 ZEASORB (MICONAZOLE)... 80 ZELBORAF... 34 ZEMAIRA... 87 zenchent (28)... 117 zenzedi oral tablet 10 mg... 63 zenzedi oral tablet 5 mg... 63 ZEPATIER... 13 ZETIA... 74 ZIAGEN ORAL SOLUTION... 13 zidovudine oral capsule... 14 zidovudine oral syrup... 14 zidovudine oral tablet... 14 ziprasidone hcl oral capsule 20 mg... 63 ziprasidone hcl oral capsule 40 mg... 63 ziprasidone hcl oral capsule 60 mg, 80 mg... 63 ZIRGAN... 118 zoledronic acid intravenous recon soln 4 mg... 95 zoledronic acid intravenous solution 4 mg/5 ml... 95 ZOLINZA... 34 zolmitriptan... 41 ZOMETA INTRAVENOUS SOLUTION 4 MG/100 ML... 95 ZOMIG NASAL... 41 zonisamide... 40 (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全 天候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 186

ZORTRESS... 34 ZOSTAVAX (PF)... 110 ZOSYN IN DEXTROSE (ISO-OSM) INTRAVENOUS PIGGYBACK 2.25 GRAM/50 ML... 21 ZOSYN IN DEXTROSE (ISO-OSM) INTRAVENOUS PIGGYBACK 3.375 GRAM/50 ML, 4.5 GRAM/100 ML... 21 zovia 1/35e (28)... 117 zovia 1/50e (28)... 117 ZYDELIG... 34 ZYKADIA... 34 ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 210 MG, 405 MG... 63 ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 300 MG... 64 ZYTIGA... 34 ZYVOX INTRAVENOUS PARENTERAL SOLUTION 200 MG/ 100 ML... 19 ZYVOX INTRAVENOUS PARENTERAL SOLUTION 600 MG/ 300 ML... 19 ZYVOX ORAL SUSPENSION FOR RECONSTITUTION... 19 (TTY 711) 致電 CareMore Cal MediConnect Plan 非工作時間訊息服務每週 7 天,24 小時全 天候提供 ( 包括假日 ) 此為免費電話 如需了解更多資訊, 請瀏覽網站 duals.caremore.com 187

如果您有任何疑問, 請致電 CareMore Cal MediConnect Plan 會員服務部, 電話號碼 1-888-350-3447 (TTY 711), 太平洋時間週一至週五上午 8 點至下午 8 點 如需更多資訊, 請瀏覽網站 duals.caremore.com 給付藥物清單 和 / 或網路內藥房和醫療服務提供者可能於全年內隨時變動 在我們做的改變對您造成影 響之前, 我們會向您寄送通知 福利 和 / 或共付費用可能於每年 1 月 1 日進行變動 您可以隨時查詢 CareMore Cal MediConnect Plan 最新的給付藥物清單, 請上網至網站 duals.caremore.com 或致電 1-888-350-3447 (TTY 711). 條件及限制可能適用 有關更多資訊, 請致電 CareMore Cal MediConnect Plan 會員服務部, 或查閱 CareMore Cal MediConnect Plan 會員手冊 處方藥物的共付費用可能會根據您所取得的 Extra Help( 額外補助 ) 等級而有所不同 請聯絡本計劃以 取得更多詳情 CareMore Cal MediConnect Plan (Medicare-Medicaid Plan) 是一個同時與 Medicare 和 Medi-Cal 訂立合 約的醫療保健計劃, 從而為參保人提供這兩個計劃的福利 CareMore 代表 CareMore 的附屬公司負責執 行合約 CareMore 為 CareMore Health System 的註冊商標 H6629_16_25137_T_001_CT CMS Approved 08/26/2015 處方藥物 ID: 16405 版本.. 22 發佈時間 1/1/2016 CCADMKT-0003-15.05.15