Formulary (List of Covered Drugs) Formulario (Lista de ... plan...This formulary was updated on...

This formulary was updated on 03242020 For more recent information or other questions please contact Vitality Health Plan of California Member Service at 1-866-333-3530 or for TTYTDD users 711 8 am to 8 pm seven days a week from October 1 through March 31 and 8 am to 8 pm Monday to Friday from April 1 through September 30 or visit wwwvitalityhpnet

Este formulario se actualizoacute el 03242020 Para obtener informacioacuten maacutes reciente o si tiene cualquier otra pregunta comuniacutequese con el Servicio para los miembros de Vitality Health Plan of California al 1-866-333-3530 Los usuarios de TTYTDD deben llamar al 711 Desde el 1ordm de octubre hasta el 31 de marzo el horario de atencioacuten es de 800 a m a 800 p m los siete diacuteas de la semana y desde el 1ordm de abril hasta el 30 de septiembre el horario de atencioacuten es de 800 a m a 800 p m de lunes a viernes Tambieacuten puede visitar wwwvitalityhpnet 本處方藥一覽表更新於 2020 年 3 月 24 日如需最新資訊或有其他問題請聯絡 Vitality Health Plan of California 會員服務部電話1-866-333-3530聽障人士可致電 71110 月 1 日至 3 月 31 日期間辦公時間為每週七天上午 8 點至晚上 8 點4 月 1 日至 9 月 30 日期間辦公時間為週一至週五上午 8 點至晚上 8 點或者瀏覽 wwwvitalityhpnet 이 처방집은 2020 년 3월 24일에 업데이트되었습니다 더욱 최근의 정보를 원하시거나 기타 궁금한 사항이 있으시면 Vitality Health Plan of California 가입자 서비스부에 1-866-333-3530번으로 TTYTDD사용자는 711번으로 10월 1일부터 3월 31일까지는 주 7일 오전 8시-오후 8시 중에 그리고 4월 1일부터 9월 30일까지는 월요일-금요일 오전 8시-오후 8시 중에 전화해 주십시오 또는 wwwvitalityhpnet을 언제든 방문하실 수 있습니다 Danh mục thuốc nagravey được cập nhật vagraveo ngagravey 03242020 Để biết thocircng tin gần đacircy hoặc coacute thắc mắc gigrave khaacutec xin vui lograveng gọi cho Vitality Health Plan of California theo số 1-866-333-3530 hoặc với người dugraveng TTYTDD 711 8 giờ saacuteng đến 8 giờ tối bảy ngagravey mỗi tuần từ ngagravey 1 thaacuteng 10 đến ngagravey 31 thaacuteng 3 vagrave từ 8 giờ saacuteng đến 8 giờ tối Thứ Hai đến Thứ Saacuteu từ ngagravey 1 thaacuteng 4 đến ngagravey 30 thaacuteng 9 hoặc truy cập wwwvitalityhpnet H1426_345ENG_C 08122019 H1426_345SPA_C 08122019 H1426_345CHI_C 08122019 H1426_345KOR_C 08122019 H1426_345VIE_C 08122019

Plus (HMO) 2020

Formulary (List of Covered Drugs)

Formulario (Lista de medicamentos cubiertos) 處處方方藥藥一一覽覽表表（（承承保保藥藥物物清清單單））

처처방방집집(보보장장 약약 목목록록) Danh Mục Thuốc (Danh saacutech Thuốc được Bảo hiểm)

Formulary ID 00020576 Version 10 Identificacioacuten del formulario 00020576 versioacuten 10 藥物表 ID 00020576版本 10 처방집 ID 00020576 버전 10 ID Danh mục thuốc 00020576 Phiecircn bản 10 This formulary was updated on 03242020 For more recent information or other questions please contact Vitality Health Plan of California Member Service at 1-866-333-3530 or for TTYTDD users 711 8 am to 8 pm seven days a week from October 1 through March 31 and 8 am to 8 pm Monday to Friday from April 1 through September 30 or visit wwwvitalityhpnet

Este formulario se actualizoacute el 03242020 Para obtener informacioacuten maacutes reciente o si tiene cualquier otra pregunta comuniacutequese con el Servicio para los miembros de Vitality Health Plan of California al 1-866-333-3530 Los usuarios de TTYTDD deben llamar al 711 Desde el 1ordm de octubre hasta el 31 de marzo el horario de atencioacuten es de 800 a m a 800 p m los siete diacuteas de la semana y desde el 1ordm de abril hasta el 30 de septiembre el horario de atencioacuten es de 800 a m a 800 p m de lunes a viernes Tambieacuten puede visitar wwwvitalityhpnet 本處方藥一覽表更新於 2020 年 3 月 24 日如需最新資訊或有其他問題請聯絡 Vitality Health Plan of California 會員服務部電話1-866-333-3530聽障人士可致電 71110 月 1 日至 3 月 31 日期間辦公時間為每週七天上午 8 點至晚上 8 點4 月 1 日至 9 月 30 日期間辦公時間為週一至週五上午 8 點至晚上 8 點或者瀏覽 wwwvitalityhpnet 이 처방집은 2020년 3월 24일에 업데이트되었습니다 더욱 최근의 정보를 원하시거나 기타 궁금한 사항이 있으시면 Vitality Health Plan of California 가입자 서비스부에 1-866-333-3530번으로 TTYTDD사용자는 711번으로 10월 1일부터 3월 31일까지는 주 7일 오전 8시-오후 8시 중에 그리고 4월 1일부터 9월 30일까지는 월요일-금요일 오전 8시-오후 8시 중에 전화해 주십시오 또는 wwwvitalityhpnet을 언제든 방문하실 수 있습니다 Danh mục thuốc nagravey được cập nhật vagraveo ngagravey 03242020 Để biết thocircng tin gần đacircy hoặc coacute thắc mắc gigrave khaacutec xin vui lograveng gọi cho Vitality Health Plan of California theo số 1-866-333-3530 hoặc với người dugraveng TTYTDD 711 8 giờ saacuteng đến 8 giờ tối bảy ngagravey mỗi tuần từ ngagravey 1 thaacuteng 10 đến ngagravey 31 thaacuteng 3 vagrave từ 8 giờ saacuteng đến 8 giờ tối Thứ Hai đến Thứ Saacuteu từ ngagravey 1 thaacuteng 4 đến ngagravey 30 thaacuteng 9 hoặc truy cập wwwvitalityhpnet H1426_345ENG_C 08122019 H1426_345SPA_C 08122019 H1426_345CHI_C 08122019 H1426_345KOR_C 08122019 H1426_345VIE_C 08122019

PLEASE READ THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN LEA ESTE DOCUMENTO QUE CONTIENE INFORMACIOacuteN SOBRE

LOS MEDICAMENTOS QUE CUBRIMOS EN ESTE PLAN 請閱讀本文件包含有關本計劃承保藥物的資訊

내용을 확인하시기 바랍니다 이 문서에는 이 플랜에서 보장하는 약에 관한 정보가 들어 있습니다 XIN ĐỌC TAgraveI LIỆU NAgraveY COacute THOcircNG TIN VỀ CAacuteC THUỐC ĐƯỢC CHUacuteNG TOcircI BẢO HIỂM

II-1

Table of Contents Proficiency of Language Assistance Services are Availablehelliphelliphelliphelliphelliphelliphelliphellip Page II-3 Discrimination is Against the Lawhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip Page II-5 Introduction in Englishhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip Page II-10 Introduction in Spanishhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip Page II-19 Introduction in Chinesehelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip Page II-28 Introduction in Koreanhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip Page II-36 Introduction in Vietnamesehelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip Page II-45 List of Covered Drugshelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip Indexhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip Page I-1 Iacutendice Tiene a su disposicioacuten servicios profesionales de asistencia linguumliacutesticahelliphelliphellip Paacutegina II-3 La discriminacioacuten es ilegalhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip Paacutegina II-6 Introduccioacuten en ingleacuteshelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip Paacutegina II-10 Introduccioacuten en espantildeolhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip Paacutegina II-19 Introduccioacuten en chinohelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip Paacutegina II-28 Introduccioacuten en coreanohelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip Paacutegina II-36 Introduccioacuten en vietnamitahelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip Paacutegina II-45 Lista de medicamentos cubiertoshelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip Paacutegina 1 Iacutendicehelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip Paacutegina I-1

II-2

目錄

提供語言協助服務helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip 頁碼 II-3 歧視屬於違法helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip 頁碼 II-7 英文說明helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip 頁碼 II-10 西班牙文說明helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip 頁碼 II-19 中文說明helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip 頁碼 II-28 韓文說明helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip 頁碼 II-36 越南文說明helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip 頁碼 II-45 承保藥物清單helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip 頁碼 1 索引helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip 頁碼 I-1 목차 언어 지원 서비스를 이용하실 수 있습니다helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip 페이지 II-3 차별은 법으로 금지되어 있습니다helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip 페이지 II-8 소개 (영어)helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip 페이지 II-10 소개 (스페인어)helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip 페이지 II-19 소개 (중국어)helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip 페이지 II-28 소개 (한국어)helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip 페이지 II-36 소개 (베트남어)helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip 페이지 II-45 보장 약 목록helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip 페이지 1 색인helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip 페이지 I-1 Mục lục Dịch vụ Hỗ trợ Thagravenh thạo Ngocircn ngữ coacute sẵnhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip Trang II-3 Phacircn biệt đối xử lagrave việc bất hợp phaacutephelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip Trang II-8 Giới thiệu bằng Tiếng Anhhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip Trang II-10 Giới thiệu bằng Tiếng Tacircy Ban Nhahelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip Trang II-19 Giới thiệu bằng Tiếng Trunghelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip Trang II-28 Giới thiệu bằng Tiếng Hagravenhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip Trang II-36 Giới thiệu bằng Tiếng Việthelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip Trang II-45 Danh saacutech Thuốc được Bảo hiểmhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip Trang 1 Chỉ mụchelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip Trang I-1

II-3

Proficiency of Language Assistance Services are Available Hours 8 am to 8 pm seven days a week from October 1 through March 31 and Monday to Friday from April 1 through September 30

Tiene a su disposicioacuten servicios profesionales de asistencia linguumliacutestica Horario de 800 a m a 800 p m los siete diacuteas de la semana desde 1 de octubre hasta el 31 de marzo y de lunes a viernes desde el 1 de abril hasta el 30 de septiembre

提供語言協助服務服務時間10 月 1 日至 3 月 31 日期間每週七天上午 8 點至晚上 8 點4 月 1 日至 9 月 30 日期間週一至週五上午 8 點至晚上 8 點

언어 지원 서비스를 이용하실 수 있습니다 시간 10월 1일부터 3월 31일까지는 주 7일 오전 8시부터 오후 8시 사이에 4월 1일부터 9월 30일까지는 월요일-금요일 같은 시간대에 이용할 수 있습니다

Dịch vụ Hỗ trợ Thagravenh thạo Ngocircn ngữ coacute sẵn Thời gian 800 saacuteng đến 800 tối bảy ngagraveytuần từ ngagravey 1 thaacuteng 10 đến ngagravey 31 thaacuteng 3 vagrave Thứ Hai đến Thứ Saacuteu từ ngagravey 1 thaacuteng 4 đến ngagravey 30 thaacuteng 9

ATTENTION If you speak English language assistance services free of charge are available to you Call 1-866-333-3530 (TTYTDD 711)

ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten servicios gratuitos de asistencia linguumliacutestica Llame al 1-866-333-3530 (TTYTDD 711)

注意如果您使用繁體中文您可以免費獲得語言援助服務請致電 1-866-333-3530（TTYTDD711） CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ trợ ngocircn ngữ miễn phiacute dagravenh cho bạn Gọi số 1-866-333-3530 (TTYTDD 711)

PAUNAWA Kung nagsasalita ka ng Tagalog maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad Tumawag sa 1-866-333-3530 (TTYTDD 711)

주의 한국어를 사용하시는 경우 언어 지원 서비스를 무료로 이용하실 수 있습니다 1-866-333-3530 (TTYTDD 711) 번으로 전화해 주십시오

ՈՒՇԱԴՐՈՒԹՅՈՒՆ Եթե խոսում եք հայերեն ապա ձեզ անվճար կարող են տրամադրվել լեզվական աջակցության ծառայություններ Զանգահարեք 1-866-333-3530 (TTYTDD (հեռատիպ) 711)

با باشدی م فراھم شمای برا گانیرا بصورتی زبان لاتیتسھ دیکنی م گفتگو فارسی زبان بھ اگر توجھ1-866-333-3530 (TTYTDD 711) دیریبگ تماس

ВНИМАНИЕ Если вы говорите на русском языке то вам доступны бесплатные услуги перевода Звоните 1-866-333-3530 (телетайп 711)

II-4

注意事項日本語を話される場合無料の言語支援をご利用いただけます1-866-333-3530（TTYTDD 711）までお電話にてご連絡ください

-866-1خدمات المساعدة اللغوية تتوافر لك بالمجان اتصل برقم ملحوظة إذا كنت تتحدث اذكر اللغة فإن )711(رقم هاتف الصم والبكم 333-3530

ਿਧਆਨ ਿਦਓ ਜ ਤਸੀ ਪਜਾਬੀ ਬਲਦ ਹ ਤਾ ਭਾਸ਼ਾ ਿਵਚ ਸਹਾਇਤਾ ਸਵਾ ਤਹਾਡ ਲਈ ਮਫਤ ਉਪਲਬਧ ਹ 1-866-333-3530 (TTYTDD 711) ਤ ਕਾਲ ਕਰ

របយត េបើសនអកនយ ែខរ េសជនយែផក េយមនគតឈ ល គចនសបបេរ អក ចរ ទរសព 1-866-333-3530 (TTYTDD 711)

LUS CEEV Yog tias koj hais lus Hmoob cov kev pab txog lus muaj kev pab dawb rau koj Hu rau 1-866-333-3530 (TTYTDD 711)

ान द यिद आप िहदी बोलत ह तो आपक िलए म म भाषा सहायता सवाए उपल ह 1-866-333-3530 (TTYTDD 711) पर कॉल कर

เรยน ถาคณพดภาษาไทยคณสามารถใชบรการชวยเหลอทางภาษาไดฟร โทร 1-866-333-3530 (TTYTDD 711)

II-5

Discrimination is Against the Law Vitality Health Plan of California complies with applicable Federal civil rights laws and does not discriminate on the basis of race ethnicity national origin religion gender sex age mental or physical disability health status receipt of health care claims experience medical history genetic information evidence of insurability or geographic location Vitality Health Plan of California does not exclude people or treat them differently because of race ethnicity national origin religion gender sex age mental or physical disability health status receipt of health care claims experience medical history genetic information evidence of insurability or geographic location Vitality Health Plan of California bull Provides free aids and services to people with disabilities to communicate effectively with us such as

o Qualified sign language interpreters o Written information in other formats (large print audio accessible electronic formats other formats)

bull Provides free language services to people whose primary language is not English such as o Qualified interpreters o Information written in other languages

If you need these services contact Vitality Member Service Department at 1-866-333-3530 (TTYTDD 711) to help you Hours are 8 am to 8 pm seven days a week from October 1 through March 31 and Monday to Friday from April 1 through September 30 You can also ask for a Civil Rights Coordinator who works for Vitality Health Plan of California If you believe that Vitality Health Plan of California has failed to provide these services or discriminated in another way based on race color national origin age disability or sex you can file a grievance with Vitality Health Plan of California Member Services Department (Complaints) 18000 Studebaker Road Suite 960 Cerritos CA 90703 1-866-333-3530 (TTYTDD 711) FAX 1-866-207-6539 You can file a grievance in person or by mail fax or email If you need help filing a grievance a Vitality Civil Rights Coordinator is available to help you You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal available at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at US Department of Health and Human Services 200 Independence Avenue SW Room 509F HHH Building Washington DC 20201 1-800-368-1019 800-537-7697 (TDD) Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml

II-6

La discriminacioacuten es ilegal Vitality Health Plan of California cumple con todas las leyes federales de derechos civiles aplicables y no discrimina por cuestiones de raza origen eacutetnico nacionalidad religioacuten geacutenero sexo edad discapacidad fiacutesica o mental estado de salud recepcioacuten de atencioacuten meacutedica experiencia en reclamaciones historia cliacutenica informacioacuten geneacutetica evidencia de asegurabilidad o ubicacioacuten geograacutefica Vitality Health Plan of California no excluye a las personas ni las trata diferente por cuestiones de raza origen eacutetnico nacionalidad religioacuten geacutenero sexo edad discapacidad fiacutesica o mental estado de salud recepcioacuten de atencioacuten meacutedica experiencia en reclamaciones historia cliacutenica informacioacuten geneacutetica evidencia de asegurabilidad o ubicacioacuten geograacutefica Vitality Health Plan of California bull Proporciona asistencia y servicios gratuitos a personas con discapacidades para que puedan

comunicarse con nosotros de manera eficaz Estos servicios incluyen lo siguiente o Inteacuterpretes calificados de lenguaje de sentildeas o Informacioacuten escrita en otros formatos (letra grande audio formatos electroacutenicos accesibles otros

formatos) bull Proporciona servicios gratuitos de idiomas a personas cuyo idioma principal no es el ingleacutes Estos

servicios incluyen lo siguiente o Inteacuterpretes calificados o Informacioacuten escrita en otros idiomas

Si necesita estos servicios comuniacutequese con el Departamento de Servicios para los Miembros de Vitality al 1-866-333-3530 (TTY TTY 711) para recibir ayuda El horario es de 800 a m a 800 p m los siete diacuteas de la semana desde el 1 de octubre hasta el 31 de marzo y de lunes a viernes desde el 1 de abril hasta el 30 de septiembre Tambieacuten puede solicitar la asistencia del coordinador de derechos civiles que trabaja para Vitality Health Plan of California Si considera que Vitality Health Plan of California no proporcionoacute estos servicios o lo discriminoacute de alguna otra manera por motivos de raza color nacionalidad edad discapacidad o sexo puede presentar un reclamo a Vitality Health Plan of California Member Services Department (Complaints) 18000 Studebaker Road Suite 960 Cerritos CA 90703 1-866-333-3530 (TTYTDD 711) FAX 1-866-207-6539 Puede presentar un reclamo en persona o por correo fax o correo electroacutenico Si necesita ayuda para presentar un reclamo el coordinador de derechos civiles de Vitality estaacute disponible para ayudarle Tambieacuten puede presentar un reclamo de derechos civiles ante la Oficina de Derechos Civiles del Departamento de Salud y Servicios Humanos de los Estados Unidos por viacutea electroacutenica a traveacutes del Portal de Reclamos de la Oficina de Derechos Civiles disponible en httpsocrportalhhsgovocrportallobbyjsf o por correo o teleacutefono a la siguiente direccioacuten US Department of Health and Human Services 200 Independence Avenue SW Room 509F HHH Building Washington DC 20201 1-800-368-1019 800-537-7697 (TDD) Los formularios de reclamo estaacuten disponibles en httpwwwhhsgovocrofficefileindexhtml

II-7

歧視屬於違法 Vitality Health Plan of California 遵循適用的聯邦民權法不會因種族族群原國籍宗教性別認同性

別年齡身心殘障健康狀況接受醫療護理情況索賠經歷病史基因資訊可保性證明或地理位置

而歧視任何人Vitality Health Plan of California 不會因種族族群原國籍宗教性別認同性別年

齡身心殘障健康狀況接受醫療護理情況索賠經歷病史基因資訊可保性證明或地理位置而拒絕

或差別對待任何人 Vitality Health Plan of California 承諾 bull 向殘障人士提供免費協助和服務幫助他們與我們進行有效溝通比如

o 合格的手語翻譯員 o 其他格式（大字印刷音訊無障礙電子格式其他格式）的書面資訊

bull 向母語並非英語的人士提供免費語言服務比如 o 合格的翻譯員 o 用其他語言書寫的資訊

如果您需要這些服務請致電 1-866-333-3530（聽障語障專線711）聯絡 Vitality 會員服務部獲取協助

服務時間為 10 月 1 日至 3 月 31 日期間每週七天上午 8 點至晚上 8 點4 月 1 日至 9 月 30 日期間週一至週五上午 8 點至晚上 8 點您也可以要求 Vitality Health Plan of California 的民權協調員為您服務如果您認為 Vitality Health Plan of California 因種族膚色原國籍年齡殘障或性別而未能提供這些服務

或在其他方面存在歧視行為您可向以下人員提出申訴 Vitality Health Plan of California Member Services Department (Complaints) 18000 Studebaker Road Suite 960 Cerritos CA 90703 1-866-333-3530（聽障語障專線711）傳真1-866-207-6539 您可以親自或以郵寄傳真或電子郵件的方式提出申訴如果您在提出申訴時需要幫助Vitality 民權協調員

可向您提供幫助您還可透過民權辦公室投訴入口網站 httpsocrportalhhsgovocrportallobbyjsf 以電子形式向美國衛生與公

眾服務部民權辦公室提出民權投訴或者透過郵件或電話進行此投訴 US Department of Health and Human Services 200 Independence Avenue SW Room 509F HHH Building Washington DC 20201 1-800-368-1019800-537-7697（語障專線）投訴表格可在 httpwwwhhsgovocrofficefileindexhtml 取得

II-8

차별은 법으로 금지되어 있습니다 Vitality Health Plan of California는 적용되는 연방 민권법을 준수하며 인종 민족성 출신 국가 종교 성별 연령 정신 또는 신체적 장애 건강 상태 의료 기록 청구 이력 병력 유전자 정보 보험 가입에 대한 증거 또는 지리적 위치 등을 바탕으로 차별을 하지 않습니다 Vitality Health Plan of California는 인종 민족성 출신 국가 종교 성별 연령 정신 또는 신체적 장애 건강 상태 의료 기록 청구 이력 병력 유전자 정보 보험 가입에 대한 증거 또는 지리적 위치를 이유로 사람들을 배제시키거나 다르게 대우하지 않습니다 Vitality Health Plan of California는 bull 효과적으로 의사소통을 하기 위해 장애인들에게 무료로 다음과 같은 지원과 서비스를 제공합니다

o 유자격 수화 통역사 o 다른 형식의(대형 활자 오디오 이용 가능한 전자 형식 기타 형식) 문서 정보

bull 주로 사용하는 언어가 영어가 아닌 사람들에게는 다음과 같은 무료 언어 서비스를 제공합니다 o 유자격 통역사 o 다른 언어로 작성된 정보

이러한 서비스가 필요하시면 Vitality 가입자 서비스부에 1-866-333-3530(TTYTDD 711)번으로 연락해 주십시오 10월 1일부터 3월 31일까지는 주 7일 오전 8시부터 오후 8시 사이에 4월 1일부터 9월 30일까지는 월요일-금요일 같은 시간대에 이용할 수 있습니다 또한 Vitality Health Plan of California 소속 민권 담당자(Civil Rights Coordinator)와의 통화를 요청하실 수 있습니다 Vitality Health Plan of California가 이러한 서비스를 제공하지 못했거나 인종 피부색 출신 국가 나이 장애 여부 또는 성별에 의해 다른 방식으로 차별을 했다고 생각하시면 다음으로 불만을 제기하실 수 있습니다 Vitality Health Plan of California Member Services Department (Complaints) 18000 Studebaker Road Suite 960 Cerritos CA 90703 1-866-333-3530 (TTYTDD 711) 팩스 1-866-207-6539 직접 또는 우편 팩스 이메일로 불만을 제기하실 수 있습니다 불만 제기 접수와 관련된 도움이 필요하시면 Vitality 민권 담당자가 도와드릴 수 있습니다 또한 미국 보건복지부(US Department of Health and Human Services) 민권사무국(Office for Civil Rights)에 온라인으로 민권국 불만 제기 포털(httpsocrportalhhsgovocrportallobbyjsf)을 통해 민권 관련 불만 사항을 접수하시거나 우편 또는 전화로 접수하실 수 있습니다 연락처 US Department of Health and Human Services 200 Independence Avenue SW Room 509F HHH Building Washington DC 20201 1-800-368-1019 800-537-7697 (TDD) 불만사항 접수 양식은 httpwwwhhsgovocrofficefileindexhtml에서 구하실 수 있습니다

II-9

Phacircn biệt đối xử lagrave việc bất hợp phaacutep Vitality Health Plan of California tuacircn thủ luật phaacutep về quyền cocircng dacircn hiện hagravenh của Liecircn bang vagrave khocircng phacircn biệt đối xử theo chủng tộc dacircn tộc nguồn gốc quốc gia tocircn giaacuteo giới tiacutenh tigravenh dục tuổi taacutec khuyết tật về tinh thần hay thể chất tigravenh trạng sức khỏe nhận dịch vụ chăm soacutec sức khỏe lịch sử khiếu nại tiền sử bệnh lyacute thocircng tin di truyền bằng chứng về khả năng coacute thể bảo hiểm hoặc vị triacute địa lyacute Vitality Health Plan of California khocircng loại trừ mọi người hoặc đối xử với họ khaacutec vigrave chủng tộc dacircn tộc nguồn gốc quốc gia tocircn giaacuteo giới tiacutenh tigravenh dục tuổi taacutec khuyết tật về tinh thần hay thể chất tigravenh trạng sức khỏe nhận dịch vụ chăm soacutec sức khỏe lịch sử khiếu nại tiền sử bệnh lyacute thocircng tin di truyền bằng chứng về khả năng coacute thể bảo hiểm hoặc vị triacute địa lyacute Vitality Health Plan of California bull Cung cấp caacutec dịch vụ vagrave hỗ trợ miễn phiacute cho những người khuyết tật để giao tiếp hiệu quả với chuacuteng

tocirci chẳng hạn o Thocircng dịch viecircn ngocircn ngữ tiacuten hiệu đủ trigravenh độ o Thocircng tin bằng văn bản bằng caacutec định dạng khaacutec (chữ in lớn acircm thanh định dạng điện tử coacute thể

truy cập caacutec định dạng khaacutec) bull Cung cấp dịch vụ ngocircn ngữ miễn phiacute cho những người coacute ngocircn ngữ chiacutenh khocircng phải Tiếng Anh như

o Thocircng dịch viecircn đủ trigravenh độ o Thocircng tin bằng văn bản dưới dạng caacutec ngocircn ngữ khaacutec

Nếu quyacute vị cần caacutec dịch vụ nagravey liecircn lạc với Ban Dịch vụ Hội viecircn của Vitality theo số 1-866-333-3530 (TTYTDD 711) để giuacutep quyacute vị Giờ lagrave từ 800 saacuteng đến 800 tối bảy ngagraveytuần từ ngagravey 1 thaacuteng 10 đến ngagravey 31 thaacuteng 3 vagrave Thứ Hai đến Thứ Saacuteu từ ngagravey 1 thaacuteng 4 đến ngagravey 30 thaacuteng 9 Quyacute vị cũng coacute thể yecircu cầu Điều phối viecircn Dacircn quyền lagravem việc cho Vitality Health Plan of California Nếu quyacute vị nghĩ rằng Vitality Health Plan of California đatilde khocircng cung cấp những dịch vụ nagravey hoặc phacircn biệt đối xử theo một caacutech khaacutec dựa trecircn chủng tộc magraveu da nguồn gốc quốc gia độ tuổi khuyết tật hoặc giới tiacutenh quyacute vị coacute thể khiếu nại với Vitality Health Plan of California Member Services Department (Complaints) 18000 Studebaker Road Suite 960 Cerritos CA 90703 1-866-333-3530 (TTYTDD 711) FAX 1-866-207-6539 Quyacute vị coacute thể nộp đơn khiếu nại trực tiếp hoặc qua thư fax hoặc email Nếu bạn cần giuacutep đỡ để khiếu nại Điều phối viecircn Dacircn quyền của Vitality luocircn sẵn sagraveng giuacutep đỡ quyacute vị Quyacute vị coacute thể gửi khiếu nại về quyền cocircng dacircn đến Bộ Y tế vagrave Dịch vụ Nhacircn sinh Hoa Kỳ (US Department of Health and Human Services) Văn phograveng Quyền Cocircng dacircn (Office for Civil Rights) theo higravenh thức điện tử thocircng qua Cổng Thocircng tin về Khiếu nại của Văn phograveng Quyền Cocircng dacircn tại địa chỉ httpsocrportalhhsgovocrportallobbyjsf hoặc gửi qua bưu điện hoặc gọi điện theo số Bộ Y tế vagrave Dịch vụ Nhacircn sinh Hoa Kỳ 200 Independence Avenue SW Room 509F HHH Building Washington DC 20201 1-800-368-1019 800-537-7697 (TDD) Mẫu khiếu nại coacute tại httpwwwhhsgovocrofficefileindexhtml

II-10

Note to existing members This formulary has changed since last year Please review this document to make sure that it still contains the drugs you take When this drug list (formulary) refers to ldquowerdquo ldquousrdquo or ldquoourrdquo it means Vitality Health Plan of California When it refers to ldquoplanrdquo or ldquoour planrdquo it means Plus (HMO) This document includes list of the drugs (formulary) for our plan which is current as of 03242020 For an updated formulary please contact us Our contact information along with the date we last updated the formulary appears on the front and back cover pages You must generally use network pharmacies to use your prescription drug benefit Benefits formulary pharmacy network andor copaymentscoinsurance may change on January 1 2020 and from time to time during the year What is the Vitality Health Plan of California Formulary A formulary is a list of covered drugs selected by Vitality Health Plan of California in consultation with a team of health care providers which represents the prescription therapies believed to be a necessary part of a quality treatment program Vitality Health Plan of California will generally cover the drugs listed in our formulary as long as the drug is medically necessary the prescription is filled at a Vitality Health Plan of California network pharmacy and other plan rules are followed For more information on how to fill your prescriptions please review your Evidence of Coverage Can the Formulary (drug list) change Most changes in drug coverage happen on January 1 but we may add or remove drugs on the Drug List during the year move them to different cost-sharing tiers or add new restrictions We must follow Medicare rules in making these changes Changes that can affect you this year In the below cases you will be affected by coverage changes during the year bull New generic drugs We may immediately remove a brand name drug on our Drug List if we are

replacing it with a new generic drug that will appear on the same or lower cost sharing tier and with the same or fewer restrictions Also when adding the new generic drug we may decide to keep the brand name drug on our Drug List but immediately move it to a different cost-sharing tier or add new restrictions If you are currently taking that brand name drug we may not tell you in advance before we make that change but we will later provide you with information about the specific change(s) we have made

o If we make such a change you or your prescriber can ask us to make an exception and continue to cover the brand name drug for you The notice we provide you will also include information on how to request an exception and you can also find information in the section below entitled ldquoHow do I request an exception to the Vitality Heath Plan of Californiarsquos Formularyrdquo

bull Drugs removed from the market If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drugrsquos manufacturer removes the drug from the market we will immediately remove the drug from our formulary and provide notice to members who take the drug

II-11

bull Other changes We may make other changes that affect members currently taking a drug For instance we may add a new generic drug to replace a brand name drug currently on the formulary or add new restrictions to the brand name drug or move it to a different cost-sharing tier Or we may make changes based on new clinical guidelines If we remove drugs from our formulary add prior authorization quantity limits andor step therapy restrictions on a drug or move a drug to a higher cost-sharing tier we must notify affected members of the change at least 30 days before the change becomes effective or at the time the member requests a refill of the drug at which time the member will receive a 30-day supply of the drug

o If we make these other changes you or your prescriber can ask us to make an exception and continue to cover the brand name drug for you The notice we provide you will also include information on how to request an exception and you can also find information in the section below entitled ldquoHow do I request an exception to the Vitality Health Plan of Californiarsquos Formularyrdquo

Changes that will not affect you if you are currently taking the drug Generally if you are taking a drug on our 2020 formulary that was covered at the beginning of the year we will not discontinue or reduce coverage of the drug during the 2020 coverage year except as described above This means these drugs will remain available at the same cost-sharing and with no new restrictions for those members taking them for the remainder of the coverage year

The enclosed formulary is current as of 03242020 To get updated information about the drugs covered by Vitality Health Plan of California please contact us Our contact information appears on the front and back cover pages Every month Vitality Health Plan of California mails you a report called the ldquoExplanation of Benefitsrdquo or ldquoEOBrdquo The EOB tells you the total amount you have spent on your prescription drugs and the total amount we have paid for each of your prescription drugs during the month Along with your EOB we will send you a ldquoFormulary Change Noticerdquo if there have been any recent changes to our formulary In addition all formulary changes will be included on the monthly updated formulary available on our web site at wwwvitalityhpnet How do I use the Formulary There are two ways to find your drug within the formulary Medical Condition The formulary begins on page 1 The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat For example drugs used to treat a heart condition are listed under the category Cardiovascular Agents If you know what your drug is used for look for the category name in the list that begins on page 3 Then look under the category name for your drug Alphabetical Listing If you are not sure what category to look under you should look for your drug in the Index that begins on page I-1 The Index provides an alphabetical list of all of the drugs included in this document Both brand name drugs and generic drugs are listed in the Index Look in the Index and find your drug Next to your drug you will see the page number where you can find coverage information Turn to the page listed in the Index and find the name of your drug in the first column of the list

II-12

What are generic drugs Vitality Health Plan of California covers both brand name drugs and generic drugs A generic drug is approved by the FDA as having the same active ingredient as the brand name drug Generally generic drugs cost less than brand name drugs Are there any restrictions on my coverage Some covered drugs may have additional requirements or limits on coverage These requirements and limits may include bull Prior Authorization Vitality Health Plan of California requires you or your physician to get prior

authorization for certain drugs This means that you will need to get approval from Vitality Health Plan of California before you fill your prescriptions If you donrsquot get approval Vitality Health Plan of California may not cover the drug

bull Quantity Limits For certain drugs Vitality Health Plan of California limits the amount of the drug that Vitality Health Plan of California will cover For example Vitality Health Plan of California provides 30 tablets per prescription for Rabeprazole oral tablet This may be in addition to a standard one-month or three-month supply

bull Step Therapy In some cases Vitality Health Plan of California requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition For example if Drug A and Drug B both treat your medical condition Vitality Health Plan of California may not cover Drug B unless you try Drug A first If Drug A does not work for you Vitality Health Plan of California will then cover Drug B

You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 3 You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site We have posted on line a document that explains our prior authorization and step therapy restrictions You may also ask us to send you a copy Our contact information along with the date we last updated the formulary appears on the front and back cover pages You can ask Vitality Health Plan of California to make an exception to these restrictions or limits or for a list of other similar drugs that may treat your health condition See the section ldquoHow do I request an exception to the Vitality Health Plan of Californiarsquos formularyrdquo on page II-14 for information about how to request an exception

II-13

What are over-the counter (OTC) drugs OTC drugs are non-prescription drugs that are not normally covered by a Medicare Prescription Drug Plan Vitality Health Plan of California pays for certain OTC drugs DRUG NAME STRENGTH DOSAGE FORM CETIRIZINE HCL 5 MG5 ML SOLUTION CETIRIZINE HCL 1 MGML SOLUTION CETIRIZINE HCL 5 MG TAB CHEW CETIRIZINE HCL 10 MG TAB CHEW CETIRIZINE HCL 5 MG TABLET CETIRIZINE HCL 10 MG TABLET CETIRIZINE HCLPSEUDOEPHEDRINE 5 MG-120MG TAB ER 12H FEXOFENADINE HCL 30 MG5 ML ORAL SUSP FEXOFENADINE HCL 30 MG TAB RAPDIS FEXOFENADINE HCL 60 MG TABLET FEXOFENADINE HCL 180 MG TABLET FEXOFENADINEPSEUDOEPHEDRINE 60MG-120MG TAB ER 12H FEXOFENADINEPSEUDOEPHEDRINE 180MG-240MG TAB ER 24H KETOTIFEN FUMARATE 003 DROPS LEVOCETIRIZINE DIHYDROCHLORIDE 5 MG TABLET LORATADINE 5 MG5 ML SOLUTION LORATADINE 5 MG TAB CHEW LORATADINE 10 MG TAB RAPDIS LORATADINE 10 MG TABLET LORATADINEPSEUDOEPHEDRINE 5 MG-120MG TAB ER 12H LORATADINEPSEUDOEPHEDRINE 10MG-240MG TAB ER 24H PHENYLEPHRINEDMACETAMINOPGG 5-325-200 TABLET

Vitality Health Plan of California will provide these OTC drugs at no cost to you The cost to Vitality Health Plan of California of these OTC drugs will not count toward your total Part D drug costs (that is the cost of the OTC drugs does not count for the coverage gap) What if my drug is not on the Formulary If your drug is not included in this formulary (list of covered drugs) you should first contact Member Services and ask if your drug is covered If you learn that Vitality Health Plan of California does not cover your drug you have two options

bull You can ask Member Services for a list of similar drugs that are covered by Vitality Health Plan of California When you receive the list show it to your doctor and ask him or her to prescribe a similar drug that is covered by Vitality Health Plan of California

II-14

bull You can ask Vitality Health Plan of California to make an exception and cover your drug See below for information about how to request an exception

How do I request an exception to the Vitality Health Plan of Californiarsquos Formulary You can ask Vitality Health Plan of California to make an exception to our coverage rules There are several types of exceptions that you can ask us to make

bull You can ask us to cover a drug even if it is not on our formulary If approved this drug will be covered at a pre-determined cost-sharing level and you would not be able to ask us to provide the drug at a lower cost-sharing level

bull You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier If approved this would lower the amount you must pay for your drug

bull You can ask us to waive coverage restrictions or limits on your drug For example for certain drugs Vitality Health Plan of California limits the amount of the drug that we will cover If your drug has a quantity limit you can ask us to waive the limit and cover a greater amount

Generally Vitality Health Plan of California will only approve your request for an exception if the alternative drugs included on the planrsquos formulary the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition andor would cause you to have adverse medical effects You should contact us to ask us for an initial coverage decision for a formulary or utilization restriction exception When you request a formulary or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request Generally we must make our decision within 72 hours of getting your prescriberrsquos supporting statement You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision If your request to expedite is granted we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber What do I do before I can talk to my doctor about changing my drugs or requesting an exception As a new or continuing member in our plan you may be taking drugs that are not on our formulary Or you may be taking a drug that is on our formulary but your ability to get it is limited For example you may need a prior authorization from us before you can fill your prescription You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take While you talk to your doctor to determine the right course of action for you we may cover your drug in certain cases during the first 90 days you are a member of our plan For each of your drugs that is not on our formulary or if your ability to get your drugs is limited we will cover a temporary 30-day supply If your prescription is written for fewer days wersquoll allow refills to provide up to a maximum 30-day supply of medication After your first 30-day supply we will not pay for these drugs even if you have been a member of the plan less than 90 days

II-15

If you are a resident of a long-term care facility and you need a drug that is not on our formulary or if your ability to get your drugs is limited but you are past the first 90 days of membership in our plan we will cover a 31-day emergency supply of that drug while you pursue a formulary exception In circumstances where a beneficiary is changing from one treatment setting to another Vitality Health Plan will ensure a fast process for approving non-formulary Part D drugs This process shall also apply to formulary Part D drugs that require prior authorization or step-therapy Examples of level of care changes are beneficiaries who are discharged from a hospital to a home beneficiaries who end their skilled nursing facility Medicare Part A stay and who need to revert to their Part D plan formulary beneficiaries who end a long-term care facility stay and return to the community and beneficiaries who are discharged from psychiatric hospitals with medication regimens that are highly individualized Vitality Health Plans contracted pharmacies can insert an industry standard submission code at the point of sale to override the formulary restrictions Vitality Health Plans contracted PBMrsquos (MedImpact) after hours service will provide pharmacies with access to representatives who can override pharmacy claims processing issues This access will allow pharmacies the ability to override claims at the point-of-sale and ensure beneficiaries receive reliable access to medications For more information For more detailed information about your Vitality Health Plan of California prescription drug coverage please review your Evidence of Coverage and other plan materials If you have questions about Vitality Health Plan of California please contact us Our contact information along with the date we last updated the formulary appears on the front and back cover pages If you have general questions about Medicare prescription drug coverage please call Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day7 days a week TTYTDD users should call 1-877-486-2048 Or visit httpwwwmedicaregov Vitality Health Plan of California Formulary The formulary that begins on the next page provides coverage information about the drugs covered by Vitality Health Plan of California If you have trouble finding your drug in the list turn to the Index that begins on page I-1 The first column of the chart lists the drug name Brand name drugs are capitalized (eg ELIQUIS) and generic drugs are listed in lower-case italics (eg simvastatin) The information in the RequirementsLimits column tells you if Vitality Health Plan of California has any special requirements for coverage of your drug

II-16

Abbreviation Description Explanation

PA Prior Authorization Restriction

You (or your physician) are required to get prior authorization from Vitality Health Plan before you fill your prescription for this drug Without prior approval Vitality Health Plan may not cover this drug

PA BvD

Prior Authorization Restriction for Part B vs Part D Determination

This drug may be eligible for payment under Medicare Part B or Part D You (or your physician) are required to get prior authorization from Vitality Health Plan to determine that this drug is covered under Medicare Part D before you fill your prescription for this drug Without prior approval Vitality Health Plan may not cover this drug

PA-HRM

Prior Authorization Restriction for High Risk Medications

This drug has been deemed by CMS to be potentially harmful and therefore a High Risk Medication for Medicare beneficiaries 65 years or older Members age 65 yrs or older are required to get prior authorization from Vitality Health Plan before you fill your prescription for this drug Without prior approval Vitality Health Plan may not cover this drug

PA NSO Prior Authorization Restriction for New Starts Only

If you are a new member or if you have not taken this drug before you (or your physician) are required to get prior authorization from Vitality Health Plan before you fill your prescription for this drug Without prior approval Vitality Health Plan may not cover this drug

PA NSO-HRM

Prior Authorization Restriction for High Risk Medications and for New Starts Only


QL Quantity Limit Restriction

Vitality Health Plan limits the amount of this drug that is covered per prescription or within a specific time frame

ST Step Therapy Restriction

Before Vitality Health Plan will provide coverage for this drug you must first try another drug(s) to treat your medical condition This drug may only be covered if the other drug(s) does not work for you

EX Excluded Part D Drug

This prescription drug is not normally covered in a Medicare Prescription Drug Plan The amount you pay when you fill a prescription for this drug does not count towards your total drug costs (that is the amount you pay does not help you qualify for catastrophic coverage) In addition if you are receiving extra help to pay for your prescriptions you will not get any extra help to pay for this drug

LA Limited Access Drug

This prescription may be available only at certain pharmacies For more information consult your Pharmacy Directory or call Member Services at 888-254-9907 TTYTDD users should call 888-254-9907

II-17


GC Gap Coverage We provide coverage of this prescription drug in the coverage gap Please refer to our Evidence of Coverage for more information about this coverage

NDS Non-Extended Days Supply

You may be able to receive greater than a 1- month supply of most of the drugs on your formulary via mail order or retail at a reduced cost share Drugs not available for extended days supply (greater than 1-month supply) via your mail order or retail pharmacy benefit are noted with ldquoNDSrdquo in the RequirementsLimits column of your formulary

HI Home Infusion Drug

This prescription drug may be covered under our medical benefit For more information call

AGE Age limit Restriction This prescription drug will be limited to certain age groups

CB Capped Benefit This drug has a maximum benefit This prescription drug is not normally covered in a Medicare Prescription Drug Plan The amount you pay when you fill a prescription for this drug does not count towards your total drug costs (that is the amount you pay does not help you qualify for catastrophic coverage) In addition if you are receiving extra help to pay for your prescriptions you will not get any extra help to pay for this drug Drug Name Drug Tier RequirementsLimits

sildenafil oral tablet 100 mg (Viagra) 2 Quantity Limits (maximum 6 tablets per 30 days)



II-18

CopaymentsCoinsurance for members of Plus (HMO) in San Joaquin and Santa Clara Counties

Tier Description CopaymentCoinsurance

30 day supply 90 day supply Tier 1 Preferred Generic $0 $0 Tier 2 Generic 25 25 Tier 3 Preferred Brand 25 25 Tier 4 Non-Preferred Drug 25 25 Tier 5 Specialty Tier 25 Not Applicable Tier 6 Vaccines $0 Not Applicable

II-19

Nota para los miembros actuales Este formulario ha cambiado desde el antildeo pasado Revise este documento para asegurarse de que auacuten contiene los medicamentos que toma Cuando esta lista de medicamentos (formulario) dice ldquonosotrosrdquo ldquonosrdquo o ldquonuestroardquo hace referencia a Vitality Health Plan of California Cuando dice ldquoplanrdquo o ldquonuestro planrdquo hace referencia a Plus (HMO) Este documento incluye la lista de medicamentos (formulario) de nuestro plan que estaacute vigente desde el 03242020 Para obtener el formulario actualizado comuniacutequese con nosotros Nuestra informacioacuten de contacto junto con la fecha de la uacuteltima actualizacioacuten del formulario aparece en las paacuteginas de la portada y la portada posterior En general debe utilizar las farmacias de la red para usar su beneficio de medicamentos con receta Los beneficios el formulario la red de farmacias o los copagoscoseguros pueden cambiar el 1 de enero de 2020 y ocasionalmente durante el antildeo iquestQueacute es el formulario de Vitality Health Plan of California El formulario es una lista de medicamentos cubiertos seleccionados por Vitality Health Plan of California con la colaboracioacuten de un equipo de proveedores de atencioacuten meacutedica que representa los tratamientos recetados que se cree que son parte necesaria de un programa de tratamiento de calidad Por lo general Vitality Health Plan of California cubriraacute los medicamentos incluidos en el formulario siempre y cuando el medicamento sea necesario por motivos meacutedicos se abastezca la receta en una farmacia de la red de Vitality Health Plan of California y se cumpla con otras normas del plan Para obtener maacutes informacioacuten sobre coacutemo abastecer una receta consulte su Evidencia de cobertura iquestPuede cambiar el formulario (la lista de medicamentos) La mayoriacutea de los cambios en la cobertura para medicamentos ocurren el 1 de enero pero podemos agregar o eliminar medicamentos de la Lista de medicamentos durante el antildeo moverlos a un nivel de costo compartido diferente o agregar nuevas restricciones Debemos seguir las reglas de Medicare al hacer estos cambios Cambios que pueden afectarlo este antildeo En los casos a continuacioacuten usted se veraacute afectado por los cambios de cobertura durante el antildeo bull Nuevos medicamentos geneacutericos Podemos eliminar de inmediato un medicamento de marca en

nuestra Lista de medicamentos si lo reemplazamos con un nuevo medicamento geneacuterico que apareceraacute en el mismo nivel de costo compartido o uno menor y con las mismas restricciones o menos Ademaacutes al agregar el nuevo medicamento geneacuterico podemos decidir mantener el medicamento de marca en nuestra Lista de medicamentos pero moverlo inmediatamente a un nivel de costo compartido diferente o agregar nuevas restricciones Si actualmente estaacute tomando ese medicamento de marca es posible que no le informemos con anticipacioacuten antes de hacer ese cambio pero luego le brindaremos informacioacuten sobre los cambios especiacuteficos que hemos realizado

o Si hacemos dicho cambio usted o el emisor de la receta pueden solicitarnos que hagamos una excepcioacuten y sigamos cubriendo el medicamento de marca para usted El aviso que le proporcionamos tambieacuten incluiraacute informacioacuten sobre coacutemo solicitar una excepcioacuten Tambieacuten puede encontrar informacioacuten en la seccioacuten a continuacioacuten titulada ldquoiquestCoacutemo solicito una excepcioacuten al formulario de Vitality Health Plan of Californiardquo

II-20

bull Medicamentos retirados del mercado Si la Administracioacuten de Alimentos y Medicamentos (FDA) considera que un medicamento de nuestro formulario no es seguro o si el fabricante del medicamento lo retira del mercado inmediatamente lo eliminaremos de nuestro formulario y les proporcionaremos un aviso a los miembros que lo toman

bull Otros cambios Es posible que hagamos otros cambios que afecten a los miembros que actualmente

toman un medicamento Por ejemplo podemos agregar un nuevo medicamento geneacuterico para reemplazar un medicamento de marca actualmente incluido en el formulario agregar nuevas restricciones al medicamento de marca o moverlo a un nivel de costo compartido diferente O podemos hacer cambios basadosen nuevas pautas cliacutenicas Si eliminamos medicamentos de nuestro formulario agregamos autorizaciones previas liacutemites de cantidad o restricciones de terapia escalonada en relacioacuten con un medicamento o si pasamos un medicamento a un nivel de costo compartido superior debemos notificar sobre el cambio a los miembros afectados al menos 30 diacuteas antes de que el cambio entre en vigencia o cuando el miembro solicite un reabastecimiento del medicamento momento en el cual el miembro recibiraacute un suministro del medicamento para 30 diacuteas

o Si hacemos estos otros cambios usted o el emisor de la receta pueden solicitarnos que hagamos una excepcioacuten y sigamos cubriendo el medicamento de marca para usted El aviso que le proporcionamos tambieacuten incluiraacute informacioacuten sobre coacutemo solicitar una excepcioacuten Tambieacuten puede encontrar informacioacuten en la seccioacuten a continuacioacuten titulada ldquoiquestCoacutemo solicito una excepcioacuten al formulario de Vitality Health Plan of Californiardquo

Cambios que no lo afectaraacuten si actualmente estaacute tomando un medicamento Por lo general si toma un medicamento que se encuentra en nuestro formulario de 2020 y que estaba cubierto al comienzo del antildeo no discontinuaremos ni reduciremos la cobertura del medicamento durante el antildeo de cobertura 2020 excepto lo descrito anteriormente Esto significa que estos medicamentos continuaraacuten estando disponibles al mismo costo compartido y sin nuevas restricciones para aquellos miembros que lo tomen por el resto del antildeo de cobertura

El formulario adjunto estaacute vigente desde el 03242020 Para obtener informacioacuten actualizada sobre los medicamentos cubiertos por Vitality Health Plan of California poacutengase en contacto con nosotros Nuestra informacioacuten de contacto aparece en las paacuteginas de la portada y la portada posterior Todos los meses Vitality Health Plan of California le enviacutea por correo un informe que se denomina la ldquoExplicacioacuten de beneficiosrdquo o ldquoEOBrdquo La EOB le informa el monto total que gastoacute en sus medicamentos con receta y el monto total que nosotros pagamos por cada uno de sus medicamentos con receta durante el mes Junto con su EOB le enviaremos un ldquoAviso de cambios del formulariordquo en caso de que haya habido cambios recientes en este Ademaacutes todos los cambios en el formulario se incluiraacuten en el formulario actualizado mensualmente que se encuentra disponible en nuestra paacutegina web en wwwvitalityhpnet iquestCoacutemo utilizo el formulario Hay dos formas para encontrar un medicamento dentro del formulario Afeccioacuten El formulario comienza en la paacutegina 1 Los medicamentos en este formulario estaacuten agrupados en categoriacuteas seguacuten el tipo de afecciones que traten Por ejemplo los medicamentos utilizados para tratar una enfermedad cardiacuteaca estaacuten incluidos en la categoriacutea Agentes cardiovasculares Si usted sabe para queacute se utiliza el medicamento busque el nombre de la categoriacutea en la lista que comienza en la paacutegina 3 Luego busque su medicamento bajo el nombre de esa categoriacutea

II-21

Listado alfabeacutetico Si no estaacute seguro de la categoriacutea donde debe buscar busque su medicamento en el Iacutendice que comienza en la paacutegina I-1 El Iacutendice proporciona un listado alfabeacutetico de todos los medicamentos incluidos en este documento Tanto los medicamentos de marca como los geneacutericos se encuentran en el Iacutendice Consulte el Iacutendice y busque su medicamento Junto al medicamento veraacute el nuacutemero de paacutegina donde puede encontrar la informacioacuten de cobertura Vaya a la paacutegina que aparece en el Iacutendice y busque el nombre de su medicamento en la primera columna de la lista iquestQueacute son los medicamentos geneacutericos Vitality Health Plan of California cubre tanto los medicamentos de marca como los geneacutericos Un medicamento geneacuterico estaacute aprobado por la FDA ya que se considera que tiene el mismo ingrediente activo que el medicamento de marca En general los medicamentos geneacutericos cuestan menos que los de marca iquestHay alguna restriccioacuten en mi cobertura Algunos medicamentos cubiertos pueden tener requisitos adicionales o liacutemites en la cobertura Estos requisitos y liacutemites pueden incluir lo siguiente bull Autorizacioacuten previa Vitality Health Plan of California exige que usted o su meacutedico obtengan una

autorizacioacuten previa para determinados medicamentos Esto significa que debe contar con la aprobacioacuten de Vitality Health Plan of California antes de abastecer sus recetas Si no obtiene la autorizacioacuten es posible que Vitality Health Plan of California no cubra el medicamento

bull Liacutemites de cantidad Para determinados medicamentos Vitality Health Plan of California limita la cantidad del medicamento que cubriraacute Vitality Health Plan of California Por ejemplo Vitality Health Plan of California suministra 30 comprimidos por receta de rabeprazol en comprimidos por viacutea oral Esto puede ser complementario a un suministro estaacutendar para un mes o tres meses

bull Terapia escalonada En algunos casos Vitality Health Plan of California requiere que usted primero pruebe determinados medicamentos para tratar su afeccioacuten antes de que cubramos otro medicamento para esa afeccioacuten Por ejemplo si el medicamento A y el medicamento B tratan su afeccioacuten es posible que Vitality Health Plan of California no cubra el medicamento B a menos que usted pruebe primero el medicamento A Si el medicamento A no funciona para usted entonces Vitality Health Plan of California cubriraacute el medicamento B

Puede averiguar si su medicamento tiene requisitos adicionales o liacutemites consultando el formulario que comienza en la paacutegina 3 Tambieacuten puede obtener maacutes informacioacuten sobre las restricciones que se aplican a medicamentos cubiertos especiacuteficos ingresando en nuestra paacutegina web Hemos publicado un documento en liacutenea que explica nuestra autorizacioacuten previa y las restricciones de terapia escalonada Tambieacuten puede pedirnos que le enviemos una copia Nuestra informacioacuten de contacto junto con la fecha de la uacuteltima actualizacioacuten del formulario aparece en las paacuteginas de la portada y la portada posterior Puede pedirle a Vitality Health Plan of California que haga una excepcioacuten a estas restricciones o liacutemites o puede solicitarle una lista de otros medicamentos similares que puedan tratar su afeccioacuten Consulte la seccioacuten ldquoiquestCoacutemo solicito una excepcioacuten al formulario de Vitality Health Plan of Californiardquo en la paacutegina II-23 para obtener informacioacuten sobre coacutemo solicitar una excepcioacuten

II-22

iquestQueacute son los medicamentos de venta libre (OTC) Los medicamentos de venta libre son medicamentos sin receta que por lo general no cubre un plan de medicamentos con receta de Medicare Vitality Health Plan of California cubre determinados medicamentos de venta libre NOMBRE DEL MEDICAMENTO CONCENTRACIOacuteN PRESENTACIOacuteN CETIRIZINE HCL 5 mg5 ml SOLUCIOacuteN CETIRIZINE HCL 1 mgml SOLUCIOacuteN CETIRIZINE HCL 5 mg COMP MASTICABLE CETIRIZINE HCL 10 mg COMP MASTICABLE CETIRIZINE HCL 5 mg COMPRIMIDO CETIRIZINE HCL 10 mg COMPRIMIDO CETIRIZINE HCLPSEUDOEPHEDRINE 5 mg-120 mg COMP LIB PROL 12H FEXOFENADINE HCL 30 mg5 ml SUSP ORAL FEXOFENADINE HCL 30 mg COMP DIS RAacuteP FEXOFENADINE HCL 60 mg COMPRIMIDO FEXOFENADINE HCL 180 mg COMPRIMIDO FEXOFENADINEPSEUDOEPHEDRINE 60 mg-120 mg COMP LIB PROL 12H FEXOFENADINEPSEUDOEPHEDRINE 180 mg-240 mg COMP LIB PROL 24H KETOTIFEN FUMARATE 003 GOTAS LEVOCETIRIZINE DIHYDROCHLORIDE 5 mg COMPRIMIDO LORATADINE 5 mg5 ml SOLUCIOacuteN LORATADINE 5 mg COMP MASTICABLE LORATADINE 10 mg COMP DIS RAacuteP LORATADINE 10 mg COMPRIMIDO LORATADINEPSEUDOEPHEDRINE 5 mg-120 mg COMP LIB PROL 12H LORATADINEPSEUDOEPHEDRINE 10 mg-240 mg COMP LIB PROL 24H PHENYLEPHRINEDMACETAMINOPGG 5-325-200 COMPRIMIDO

Vitality Health Plan of California le proporcionaraacute estos medicamentos de venta libre sin costo El costo de estos medicamentos de venta libre para Vitality Health Plan of California no se tiene en cuenta para los costos totales de los medicamentos de la Parte D (es decir el costo de los medicamentos de venta libre no se tiene en cuenta para la etapa del periodo sin cobertura)

II-23

iquestQueacute sucede si mi medicamento no estaacute incluido en el formulario Si su medicamento no estaacute incluido en este formulario (lista de medicamentos cubiertos) primero debe comunicarse con el Departamento de Servicios para los miembros y consultar si su medicamento estaacute cubierto Si resulta que Vitality Health Plan of California no cubre su medicamento tiene dos opciones

bull Puede pedirle al Departamento de Servicios para los miembros una lista de medicamentos similares cubiertos por Vitality Health Plan of California Al recibir la lista mueacutestresela a su meacutedico y piacutedale que le recete un medicamento similar cubierto por Vitality Health Plan of California

bull Puede pedirle a Vitality Health Plan of California que haga una excepcioacuten y cubra su medicamento Consulte la informacioacuten debajo sobre coacutemo solicitar una excepcioacuten

iquestCoacutemo solicito una excepcioacuten al formulario de Vitality Health Plan of California Puede solicitar a Vitality Health Plan of California que haga una excepcioacuten a las reglas de cobertura Existen varios tipos de excepciones que puede solicitarnos

bull Puede solicitarnos que cubramos un medicamento incluso si este no se encuentra en nuestro formulario Si se aprueba el medicamento estaraacute cubierto a un nivel de costo compartido determinado previamente y no podraacute solicitar que se proporcione a un nivel de costo compartido menor

bull Puede solicitarnos que cubramos un medicamento del formulario a un nivel de costo compartido menor si este medicamento no estaacute en el nivel de medicamentos especializados Si se aprueba esto reduciriacutea el monto que usted debe pagar por su medicamento

bull Puede solicitarnos que no se apliquen restricciones o liacutemites de cobertura en su medicamento Por ejemplo para un determinado medicamento Vitality Health Plan of California limita la cantidad del medicamento que cubriremos Si su medicamento tiene un liacutemite de cantidad puede solicitarnos que no apliquemos el liacutemite y que cubramos una cantidad mayor

Generalmente Vitality Health Plan of California solo aprobaraacute su solicitud de excepcioacuten si los medicamentos alternativos incluidos en el formulario del plan el medicamento de costo compartido menor o las restricciones de utilizacioacuten adicionales no fueran tan eficaces para tratar su afeccioacuten o pudieran causarle efectos meacutedicos adversos Debe comunicarse con nosotros para solicitar una decisioacuten de cobertura inicial para una excepcioacuten al formulario o a una restriccioacuten de utilizacioacuten Cuando solicite una excepcioacuten al formulario o a las restricciones de utilizacioacuten debe presentar una declaracioacuten del emisor de la receta o de su meacutedico que respalde su solicitud Por lo general debemos tomar una decisioacuten en un plazo de 72 horas despueacutes de obtener la declaracioacuten de respaldo del emisor de la receta Puede solicitar una excepcioacuten acelerada (raacutepida) si usted o su meacutedico consideran que esperar hasta 72 horas para obtener una decisioacuten podriacutea dantildear gravemente su salud Si se le concede la solicitud acelerada debemos tomar una decisioacuten antes de las 24 horas despueacutes de obtener una declaracioacuten de respaldo de su meacutedico o de otro emisor de la receta

II-24

iquestQueacute debo hacer antes de poder hablar con mi meacutedico sobre cambiar mis medicamentos o solicitar una excepcioacuten Como miembro nuevo o que continuacutea en nuestro plan es posible que tome medicamentos que no se encuentren en nuestro formulario Tambieacuten puede suceder que el medicamento se encuentre en nuestro formulario pero su capacidad de obtenerlo sea limitada Por ejemplo es posible que necesite nuestra autorizacioacuten previa antes de poder abastecer su receta Debe consultar con su meacutedico para decidir si debe comenzar a tomar un medicamento apropiado que cubramos o solicitar una excepcioacuten al formulario para que cubramos el medicamento que toma Mientras usted consulta con su meacutedico para determinar la accioacuten maacutes apropiada podemos cubrir su medicamento en ciertos casos durante los primeros 90 diacuteas como miembro de nuestro plan Para cada uno de sus medicamentos que no se encuentre en nuestro formulario o si su capacidad de obtenerlos es limitada cubriremos un suministro temporal para 30 diacuteas Si su receta estaacute indicada para menos diacuteas permitiremos reabastecimientos hasta llegar a un suministro maacuteximo para 30 diacuteas del medicamento Luego del primer suministro para 30 diacuteas no pagaremos esos medicamentos incluso si hace menos de 90 diacuteas que es miembro del plan Si usted es residente de un centro de atencioacuten a largo plazo y necesita un medicamento que no se encuentra en nuestro formulario o si su capacidad de obtenerlo es limitada pero ya pasaron los primeros 90 diacuteas como miembro de nuestro plan cubriremos un suministro de emergencia para 31 diacuteas de ese medicamento mientras usted intenta conseguir una excepcioacuten al formulario En circunstancias en las que un beneficiario cambie de entorno de tratamiento Vitality Health Plan garantizaraacute un proceso raacutepido para la aprobacioacuten de medicamentos de la Parte D que no figuren en el formulario Este proceso tambieacuten se aplica a los medicamentos de la Parte D del formulario que requieren autorizacioacuten previa o terapia escalonada Algunos ejemplos de cambios en el nivel de atencioacuten son los siguientes beneficiarios que reciben el alta de un hospital y son trasladados a su hogar beneficiarios que finalizan su estadiacutea en un centro de atencioacuten de enfermeriacutea especializada (SNF) de la Parte A de Medicare y que necesitan cambiar al formulario del plan de la Parte D beneficiarios que finalizan su estadiacutea en un centro de atencioacuten a largo plazo y regresan a la comunidad y beneficiarios que reciben el alta de hospitales psiquiaacutetricos con regiacutemenes de medicamentos altamente individualizados Las farmacias contratadas por Vitality Health Plans pueden ingresar un coacutedigo de presentacioacuten estaacutendar de la industria en el punto de venta para anular las restricciones en el formulario El servicio fuera del horario de atencioacuten del administrador de beneficios de farmacia (PBM) MedImpact contratado por Vitality Health Plans les brinda a las farmacias acceso a representantes que pueden resolver los problemas de procesamiento de las reclamaciones de farmacia Este acceso les permitiraacute a las farmacias la posibilidad de anular las reclamaciones en el punto de venta y garantizar que los beneficiarios reciban acceso confiable a los medicamentos

II-25

Para obtener maacutes informacioacuten Para obtener informacioacuten maacutes detallada sobre su cobertura para medicamentos con receta de Vitality Health Plan of California revise su Evidencia de cobertura y otros materiales del plan Si tiene preguntas sobre Vitality Health Plan of California comuniacutequese con nosotros Nuestra informacioacuten de contacto junto con la fecha de la uacuteltima actualizacioacuten del formulario aparece en las paacuteginas de la portada y la portada posterior Si tiene alguna pregunta general sobre la cobertura para medicamentos con receta de Medicare llame a Medicare al 1-800-MEDICARE (1-800-633-4227) durante las 24 horas del diacutea los 7 diacuteas de la semana Los usuarios de TTYTDD deben llamar al 1-877-486-2048 O bien visite httpwwwmedicaregov Formulario de Vitality Health Plan of California El formulario que comienza en la paacutegina siguiente brinda informacioacuten sobre la cobertura de los medicamentos que cubre Vitality Health Plan of California Si tiene alguna dificultad para encontrar en la lista el medicamento que toma consulte el Iacutendice que comienza en la paacutegina I-1 En la primera columna de esta tabla se indica el nombre del medicamento Los medicamentos de marca aparecen en letra mayuacutescula (por ejemplo ELIQUIS) y los medicamentos geneacutericos aparecen en letra minuacutescula y cursiva (por ejemplo simvastatina) La informacioacuten en la columna RequisitosLiacutemites le indica si Vitality Health Plan of California tiene alguacuten requisito especial para la cobertura de su medicamento Abreviatura Descripcioacuten Explicacioacuten

PA Restriccioacuten de autorizacioacuten previa

Usted (o su meacutedico) debe obtener autorizacioacuten previa de Vitality Health Plan antes de abastecer la receta para este medicamento Sin la aprobacioacuten previa es posible que Vitality Health Plan no cubra este medicamento

PA BvD

Restriccioacuten de autorizacioacuten previa para determinacioacuten de Parte B frente a Parte D

Este medicamento podriacutea ser elegible para pagarse seguacuten la Parte B o la Parte D de Medicare Usted (o su meacutedico) debe obtener autorizacioacuten previa de Vitality Health Plan a fin de determinar si este medicamento estaacute cubierto en virtud de la Parte D de Medicare antes de abastecer la receta para este medicamento Sin la aprobacioacuten previa es posible que Vitality Health Plan no cubra este medicamento

PA-HRM

Restriccioacuten de autorizacioacuten previa para medicamentos de alto riesgo

Los Centros de Servicios de Medicare y Medicaid (Centers for Medicare and Medicaid Services CMS) han considerado que este medicamento es potencialmente dantildeino por lo que es un medicamento de alto riesgo para los beneficiarios de Medicare de 65 antildeos o maacutes Los miembros de 65 antildeos o maacutes deben obtener autorizacioacuten previa de Vitality Health Plan antes de abastecer la receta para este medicamento Sin la aprobacioacuten previa es posible que Vitality Health Plan no cubra este medicamento

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Abreviatura Descripcioacuten Explicacioacuten

PA NSO

Restriccioacuten de autorizacioacuten previa para nuevos comienzos uacutenicamente

Si usted es un miembro nuevo o si no ha tomado este medicamento antes usted (o su meacutedico) debe obtener autorizacioacuten previa de Vitality Health Plan antes de abastecer la receta para este medicamento Sin la aprobacioacuten previa es posible que Vitality Health Plan no cubra este medicamento

PA NSO-HRM

Restriccioacuten de autorizacioacuten previa para medicamentos de alto riesgo y nuevos comienzos uacutenicamente


QL Restriccioacuten de liacutemite de cantidad

Vitality Health Plan limita la cantidad de este medicamento que se cubre por receta o en un plazo especiacutefico

ST Restriccioacuten de terapia escalonada

Antes de que Vitality Health Plan brinde cobertura para este medicamento usted deberaacute probar otro u otros medicamentos para tratar su afeccioacuten Es posible que este medicamento esteacute cubierto uacutenicamente si los otros medicamentos no funcionaron en su caso

EX Medicamento excluido de la Parte D

Este medicamento con receta generalmente no estaacute cubierto en un plan de medicamentos con receta de Medicare El monto que paga cuando abastece una receta no se tiene en cuenta en sus costos totales de medicamentos (es decir el monto que usted paga no le ayuda a reunir los requisitos para la cobertura en caso de cataacutestrofe) Ademaacutes si recibe ayuda adicional para pagar sus medicamentos con receta no recibiraacute ninguna ayuda adicional para pagar este medicamento

LA Medicamento de acceso limitado

Este medicamento con receta puede estar disponible solo en ciertas farmacias Para obtener maacutes informacioacuten consulte su Directorio de farmacias o llame a Servicios para los miembros al 888-254-9907 Los usuarios de TTYTDD deben llamar al 888-254-9907

GC Periodo sin cobertura

Brindamos cobertura para este medicamento con receta durante la etapa del periodo sin cobertura Consulte la Evidencia de cobertura para obtener maacutes informacioacuten sobre esta cobertura

NDS Suministro de diacuteas sin posibilidad de extensioacuten

Es posible que reciba un suministro para maacutes de 1 mes de la mayoriacutea de los medicamentos que figuran en su formulario a traveacutes de un pedido por correo o en un minorista por un costo compartido menor Los medicamentos que no estaacuten disponibles para suministro de diacuteas con posibilidad de extensioacuten (suministro para maacutes de 1 mes) a traveacutes del beneficio de pedido por correo o de farmacia minorista se indican con la sigla ldquoNDSrdquo en la columna RequisitosLiacutemites del formulario

HI Medicamento de infusioacuten en el hogar

Este medicamento con receta puede estar cubierto por nuestro beneficio meacutedico Para obtener maacutes informacioacuten comuniacutequese por teleacutefono

AGE Restriccioacuten de liacutemite de edad

Este medicamento con receta se limitaraacute para determinados grupos etarios

CB Liacutemite de beneficio Este medicamento tiene un beneficio maacuteximo

II-27

Este medicamento con receta generalmente no estaacute cubierto en un plan de medicamentos con receta de Medicare El monto que paga cuando abastece una receta no se tiene en cuenta en sus costos totales de medicamentos (es decir el monto que usted paga no le ayuda a reunir los requisitos para la cobertura en caso de cataacutestrofe) Ademaacutes si recibe ayuda adicional para pagar sus medicamentos con receta no recibiraacute ninguna ayuda adicional para pagar este medicamento Nombre del medicamento Nivel del

medicamento RequisitosLiacutemites

sildenafil comprimidos por viacutea oral 100 mg (Viagra)

2 Liacutemites de cantidad (maacuteximo de 6 comprimidos cada 30 diacuteas)





CopagosCoseguros para los miembros de Plus (HMO) en los condados de San Joaquin y Santa Clara

Nivel Descripcioacuten CopagoCoseguro

Suministro para 30 diacuteas Suministro para 90 diacuteas Nivel 1 Medicamento geneacuterico preferido $0 $0 Nivel 2 Medicamento geneacuterico 25 25 Nivel 3 Medicamento de marca preferido 25 25 Nivel 4 Medicamento no preferido 25 25 Nivel 5 Medicamento especializado 25 Not Applicable Nivel 6 Vacunas $0 Not Applicable

II-28

現有會員請注意本處方藥一覽表自去年已變更請閱讀本文件確保本處方藥一覽表仍然包含您使用的藥物本藥物清單（處方藥一覽表）中凡提述「我們」或「我們的」時均指 Vitality Health Plan of California而「計劃」或「我們的計劃」指代 Plus (HMO) 本文件載有我們計劃截至 2020 年 3 月 24 日的藥物清單（處方藥一覽表）如需獲取最新的處方藥一覽表請聯絡我們我們的聯絡資訊連同最後更新處方藥一覽表的日期載於封面和封底一般情況下您必須使用網絡內藥房才能享受處方藥福利自 2020 年 1 月 1 日起和在該年內福利處方藥一覽表藥房網絡和或共付額共同保險可能會不時有所調整什麼是 Vitality Health Plan of California 處方藥一覽表處方藥一覽表是 Vitality Health Plan of California 透過諮詢醫療提供者團隊所選出的受保藥物清單是高品質治療計劃中不可或缺的處方藥治療只要具有醫療必要性且於 Vitality Health Plan of California 網絡內藥房配藥並遵守其他計劃規定Vitality Health Plan of California 通常會承保列於我們處方藥一覽表中的藥物要瞭解有關如何按您的處方配藥的更多資訊請查閱您的「承保範圍說明書」處方藥一覽表（藥物清單）是否會變更大多數藥物的承保範圍在 1 月 1 日作出更改但是我們可能會在一年之中添加或刪除藥物清單上的藥物更改分攤費用等級或增設限制這些更改必須跟隨 Medicare 的既有規定今年可能會影響到您的變更在下列情況中您將受到當年承保範圍更改的影響 bull 新的普通藥如果我們計劃用新的普通藥取代某一品牌藥而且這種普通藥出現在相同或更低

的分攤費用等級上並具有相同或更少的限制我們可能會立即將該品牌藥從藥物清單上移除另外在加入新普通藥時我們可能會決定將該品牌藥保留在藥物清單上但會立即將其移至其他分攤費用等級或增設限制如果您正在使用該品牌藥在作出更改前我們可能不會提前告知您但是之後我們會向您提供有關我們所作的具體更改的資訊

o 如果我們作出更改您或您的處方醫生可以要求我們作出例外處理並繼續為您承保該品

牌藥我們向您發送的通知將詳細介紹如何申請例外處理您也可以在後文的「如何申

請 Vitality Health Plan of California 的處方藥一覽表例外處理」章節中查看更多資訊

bull 藥物退出市場若美國食品及藥物管理局認為我們處方藥一覽表上的某種藥物不安全或藥物製造商從市場中撤除該藥物我們會立即從我們的處方藥一覽表上刪除該藥物並向使用該藥物的會員發出通知

bull 其他更改我們可能會作出影響目前正在使用藥物的會員的其他更改例如我們可能會添加一種新的普通藥以取代處方藥一覽表上現有的品牌藥或對品牌藥添加新的限制條件或是將

II-29

其移至其他費用分攤等級我們也可能會根據新的臨床指南作出更改如果我們從處方藥一覽表中移除了某些藥物對某個藥物新增了事先授權數量限制和或階段療法限制或提高某個藥物的費用分攤等級則我們必須在該更改生效前至少 30 天或在會員要求再次配藥時向受影響的會員發出通知（該名會員將收到 30 天份的藥物）

o 如果我們作出其他更改您或您的處方醫生可以要求我們作出例外處理並繼續為您承保

該品牌藥我們向您發送的通知將詳細介紹如何申請例外處理您也可以在後文的「如

何申請 Vitality Health Plan of California 的處方藥一覽表例外處理」章節中查看更多資

訊如果您正在使用該藥物這些變更將不會對您產生影響一般而言若您正在使用年初享受承保的 2020 年處方藥一覽表上的藥物我們不會在 2020 年承保年度中終止或減少此藥物的承保除非出現上文所述情況換言之在承保年度的剩餘時間內此藥物將以相同的分攤費用向使用此藥物的會員提供且不設新的限制

本文件隨附的處方藥一覽表最後更新於 2020 年 3 月 24 日如需獲得有關 Vitality Health Plan of California 承保藥物的最新資訊請聯絡我們我們的聯絡資訊在封面和封底頁均有提供 Vitality Health Plan of California 每個月都會向您郵寄一份名為「福利說明」（簡稱「EOB」）的報告福利說明可告訴您當月您已花費在處方藥上的總金額以及我們已為您每份處方藥支付的總金額如果處方藥一覽表近期有所更改我們會連同福利說明向您寄送一份「處方藥一覽表更改通知」此外所有的處方藥一覽表更改將包含在處方藥一覽表的每月更新中詳見我們的網站 wwwvitalityhpnet 如何使用處方藥一覽表有兩種方法在處方藥一覽表中查找您所需的藥物病症處方藥一覽表從第 1 頁開始本處方藥一覽表中的藥物按照所治療的病症類型分類例如用來治療心臟病的藥物列在「心血管藥物」類別若您瞭解藥物的用途您可在從第 3 頁開始的清單中查找類別名稱然後在此類別名稱下查找所需的藥物按字母順序排列的清單如果您不確定要尋找什麼類別您可以利用自第 I-1 頁開始的索引來尋找您的藥物該索引提供一份按字母順序排列的清單其中有本文件包含的所有藥物品牌藥和普通藥均列在該索引中請在該索引中查找所需的藥物在藥物旁邊您將看到載有承保資訊的頁碼轉到該索引中所列的頁碼在清單的第一欄即可找到所需的藥物名稱

II-30

什麼是普通藥 Vitality Health Plan of California 同時承保品牌藥和普通藥普通藥是一種由 FDA 核准具有與品牌藥相同活性成分的藥物通常普通藥的費用較品牌藥低我的承保範圍是否有任何限制某些承保藥物可能有其他要求或承保範圍限制這些要求和限制可能包括 bull 事先授權對於某些藥物Vitality Health Plan of California 要求您或您的醫生取得事先授權

這表示您將需要在配藥前取得 Vitality Health Plan of California 的核准如果您未取得核准Vitality Health Plan of California 可能不會承保該藥物

bull 數量限制對於某些藥物Vitality Health Plan of California 限制了 Vitality Health Plan of California 承保的藥物數量例如對於 Rabeprazole 口服藥片Vitality Health Plan of California 會為每份處方提供 30 片這可以另外附加在標準的一個月或三個月的藥量上

bull 階段療法某些情況下Vitality Health Plan of California 會要求您先嘗試使用某些藥物治療您的病症才會承保您使用另外一種藥物例如假設藥物 A 和藥物 B 都能治療您的病症則在您嘗試使用藥物 A 前Vitality Health Plan of California 可能不會承保藥物 B藥物 A 對您無效時Vitality Health Plan of California 才會承保藥物 B

您可以透過第 3 頁開始的處方藥一覽表查詢您的藥物是否有額外的要求或限制您也可以前往我們的網站進一步瞭解關於特定承保藥物限制的資訊我們已在線上刊載文件說明我們事先授權和階段療法的限制您也可以要求我們寄一份給您我們的聯絡資訊連同最後更新處方藥一覽表的日期載於封面和封底您可以要求 Vitality Health Plan of California 對此類限制或使用上限作出例外處理或索取可能治療您的病症的其他相似藥物清單請參見第 II-32 頁的「如何申請 Vitality Health Plan of California 處方藥一覽表例外處理」章節瞭解有關例外處理申請方式的資訊

II-31

什麼是非處方 (OTC) 藥非處方藥是指無需醫生處方即可獲取的藥物通常不受 Medicare 處方藥計劃承保Vitality Health Plan of California 會為某些非處方藥承保藥物名稱規格藥物劑型 CETIRIZINE HCL 5 MG5 ML 溶液 CETIRIZINE HCL 1 MGML 溶液 CETIRIZINE HCL 5 MG 咀嚼片 CETIRIZINE HCL 10 MG 咀嚼片 CETIRIZINE HCL 5 MG 片劑 CETIRIZINE HCL 10 MG 片劑 CETIRIZINE HCLPSEUDOEPHEDRINE 5 MG-120MG 12 小時緩釋片 FEXOFENADINE HCL 30 MG5 ML 口服混懸液 FEXOFENADINE HCL 30 MG 速溶片 FEXOFENADINE HCL 60 MG 片劑 FEXOFENADINE HCL 180 MG 片劑 FEXOFENADINEPSEUDOEPHEDRINE 60MG-120MG 12 小時緩釋片 FEXOFENADINEPSEUDOEPHEDRINE 180MG-240MG 24 小時緩釋片 KETOTIFEN FUMARATE 003 滴劑 LEVOCETIRIZINE DIHYDROCHLORIDE 5 MG 片劑 LORATADINE 5 MG5 ML 溶液 LORATADINE 5 MG 咀嚼片 LORATADINE 10 MG 速溶片 LORATADINE 10 MG 片劑 LORATADINEPSEUDOEPHEDRINE 5 MG-120MG 12 小時緩釋片 LORATADINEPSEUDOEPHEDRINE 10MG-240MG 24 小時緩釋片 PHENYLEPHRINEDMACETAMINOPGG 5-325-200 片劑

Vitality Health Plan of California 將免費為您提供這些非處方藥Vitality Health Plan of California 為這些非處方藥支付的費用將不計入您的 D 部分藥物總費用（即非處方藥的費用不計入達到承保範圍缺口的金額）若處方藥一覽表沒有列出我的藥物該怎麼辦若您的藥物不在此處方藥一覽表（承保藥物清單）上那麼您首先應該聯絡會員服務部詢問您的藥物是否在承保範圍內如果您得知 Vitality Health Plan of California 並未承保您的藥物則您有兩種選擇

bull 向會員服務部索要一份由 Vitality Health Plan of California 承保的相似藥物清單收到該清單後請拿給您的醫生看並要求醫生開處由 Vitality Health Plan of California 承保的相似藥物

bull 您可以要求 Vitality Health Plan of California 作出例外處理並承保您的藥物請查看以下關於如何申請例外處理的資訊

II-32

如何申請 Vitality Health Plan of California 處方藥一覽表例外處理您可以要求 Vitality Health Plan of California 對我們的承保規則作出例外處理您可以向我們提出數種例外處理申請

bull 您可以要求我們承保一種藥物即使它不在我們的處方藥一覽表上如獲批准此藥物將按預定分攤費用等級獲得承保且您不得要求我們以更低的分攤費用等級提供此藥物

bull 如果此藥物在處方藥一覽表上且不屬特殊藥物您可要求我們按更低的分攤費用等級承保此藥如獲批准這會減少您必須為藥物支付的金額

bull 您可以要求我們撤銷對您的藥物的承保限制例如對於某些藥物Vitality Health Plan of California 限制了藥物的承保數量若您的藥物有數量限制您可以要求我們撤銷限制並承保更多數量

通常只有在替代藥物處於計劃的處方藥一覽表上時或是較低分攤費用的藥物或額外的使用限制對於治療您的病症無法達到相同的效果時和或可能造成副作用時Vitality Health Plan of California 才會批准您的例外處理申請您應當聯絡我們要求我們做出針對處方藥一覽表或使用限制例外處理的初始承保決定在提出針對處方藥一覽表或使用限制例外處理申請時您應提交一份處方醫生或醫生的聲明以支持您的申請通常我們在收到處方醫生的支持聲明後必須在 72 小時內做出決定若您或您的醫生認為等候 72 小時再做出決定會對您的健康造成嚴重傷害您可以申請加急（快速）例外處理如果您的加急申請獲得批准我們在收到您的醫生或其他處方醫生的支持聲明後必須在 24 小時內為您做出決定在向醫生提出變更藥物請求或提交例外處理申請之前我應該做什麼作為我們計劃的新老會員您可能正在使用我們處方藥一覽表上沒有的藥物或者您正在使用一種在我們處方藥一覽表上的藥物但您獲取該藥物的能力受到限制例如您在配藥前可能要獲得我們的事先授權您應當先和您的醫生談談以決定您是否應該換用我們承保的適當藥物或提出處方藥一覽表例外處理申請以使我們承保您使用的藥物在您與醫生討論以確定何種措施適合您時我們會在您成為計劃會員後的前 90 天內針對某些情況為您的藥物提供承保對於您使用的不在處方藥一覽表上的每種藥物或因受限而難以足量獲取的藥物我們將為您承保 30 天的藥量如果為您開具的處方上藥物供應天數較少我們將允許補充藥物以提供最多 30 天份的供藥在最初的 30 天供藥後即使您成為計劃會員的天數還不足 90 天我們將不再為這些藥物付費如果您居住在長期護理機構且處方藥一覽表沒有列出您所需的藥物或您獲取藥物時受到限制但您成為我們計劃的會員已超過 90 天則在您尋求處方藥一覽表例外處理時我們將會對該藥物承保 31 天份的緊急供藥如果受益人從一種治療環境轉至另一種環境Vitality Health Plan 將確保遵循快速程序以核准不在處方藥一覽表中的 D 部分藥物此程序還適用於要求事先授權或階段療法的處方藥一覽表 D 部分藥物護理等級變更的示例有受益人出院回家受益人結束專業護理機構 Medicare A 部分住院並且需要恢復使用 D 部分的計劃處方藥一覽表的藥物受益人結束長期護理機構住院返回社區中以及受益人從精神病院出院並且使用高度個人化的藥物治療方案

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與 Vitality Health Plan 簽有合約的藥房可在銷售點添加行業標準提交代碼以免除處方藥一覽表上的限制與 Vitality Health Plan 簽有合約的 PBM（藥房福利管理公司MedImpact）的非工作時間服務會為藥房提供代表的聯絡方式該代表能夠解決藥房索賠處理問題這項服務能讓藥房能在銷售點解決索賠問題確保受益人獲得可靠的藥物補給瞭解更多資訊如需瞭解更多關於 Vitality Health Plan of California 處方藥承保的詳細資訊請查看您的「承保範圍說明書」及其他計劃資料如果您對 Vitality Health Plan of California 有任何疑問請聯絡我們我們的聯絡資訊連同最後更新處方藥一覽表的日期載於封面和封底若您對 Medicare 處方藥承保範圍有任何疑問請致電 Medicare電話1-800-MEDICARE (1-800-633-4227)（全天候開通）聽障語障人士可致電 1-877-486-2048或瀏覽 httpwwwmedicaregov Vitality Health Plan of California 處方藥一覽表從下一頁開始的處方藥一覽表介紹了 Vitality Health Plan of California 承保藥物的承保資訊若您在清單中尋找藥物時遇到困難請閱讀從第 I-1 頁開始的索引表格的第一欄列出了藥物名稱品牌藥用大寫字母表示（例如 ELIQUIS）普通藥則用小寫斜體字母表示（例如 simvastatin）要求限制欄中的資訊說明了 Vitality Health Plan of California 在承保您的藥物時是否有任何特殊要求縮寫描述說明

PA 事先授權限制您（或您的醫生）必須先獲得 Vitality Health Plan 的事先授權才可以配取該處方藥若無事先授權Vitality Health Plan 不會承保該藥物

PA BvD B 部分和 D 部分裁決的事先授權限制

此藥物可能享有 Medicare B 部分或 D 部分承保您（或您的醫生）必須先獲得 Vitality Health Plan 的事先授權以裁決 Medicare D 部分是否承保此藥物才可以配取該處方藥若無事先授權Vitality Health Plan 不會承保該藥物

PA-HRM 高風險藥物的事先授權限制

CMS 認為該藥物有潛在危害因此將它歸為 Medicare 65 歲或以上受益人的高風險藥物65 歲或以上的會員必須先獲得 Vitality Health Plan 的事先授權才可以配取該處方藥若無事先授權Vitality Health Plan 不會承保該藥物

PA NSO 新會員特有的事先授權限制

如果您是新會員或您從未服用過此藥物則您（或您的醫生）必須先獲得 Vitality Health Plan 的事先授權才可以配取該處方藥若無事先授權Vitality Health Plan 不會承保該藥物

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縮寫描述說明

PA NSO-HRM

高風險藥物和新會員特有的事先授權限制


QL 數量限制 Vitality Health Plan 限制了每份處方或指定時期內承保的藥物數量

ST 階段療法限制 Vitality Health Plan 為該藥物提供承保前您必須先嘗試用其他藥物來治療您的病症該藥物只有在其他藥物對您無效的情況下才能獲得承保

EX 被排除的 D 部分藥物

本處方藥物通常不由 Medicare 處方藥計劃承保您在配取此藥物時所支付的金額不計入您的藥物花費總額（這表示您所支付的金額無法幫您取得災難承保資格）此外若您有接受額外補助以支付您的處方藥費用您將無法為該藥物取得任何額外補助

LA 具有取藥限制的藥物

本處方藥可能僅在某些藥房提供如需更多資訊請查看藥房目錄或致電我們的會員服務部電話888-254-9907聽障語障人士可致電 888-254-9907

GC 缺口承保我們為該處方藥提供承保缺口期間的承保關於此承保範圍的資訊請參閱「承保範圍說明書」

NDS 不延長天數的供藥

您可以透過郵購或零售藥房以優惠價格獲得處方藥一覽表上的大多數藥物且配取的藥量可大於 1 個月份量如果藥物不能透過郵購或零售藥房福利享有延長天數供藥（超過 1 個月的份量）在處方藥一覽表的要求限制欄中將註明「NDS」

HI 居家輸液藥物該處方藥可能受我們的醫療福利承保如需更多資訊請致電

AGE 年齡限制該處方藥只面向某些年齡群體

CB 福利限制該藥物具有最高福利限制

本處方藥物通常不由 Medicare 處方藥計劃承保您在配取此藥物時所支付的金額不計入您的藥物花費總額（這表示您所支付的金額無法幫您取得災難承保資）此外若您有接受額外補助以支付您的處方藥費用您將無法為該藥物取得任何額外補助藥物名稱藥物等級要求限制

sildenafil oral tablet 100 mg (Viagra) 2 數量限制（每 30 天最多 6 片）



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San Joaquin 郡 Santa Clara 郡 Plus (HMO) 會員的共付額共同保險

等級描述共付額共同保險

30 天份的藥量 90 天份的藥量第 1 級首選普通藥 $0 $0 第 2 級普通藥 25 25 第 3 級首選品牌藥 25 25 第 4 級非首選藥物 25 25 第 5 級特殊級藥 25 不適用第 6 級疫苗 $0 不適用

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기존 가입자 참고 사항 이 처방집은 작년 이후 변경되었습니다 쓰시는 약이 처방집에 계속 포함된 상태인지 확인하기 위해 본 문서를 검토해 주십시오 이 의약품 목록(처방집)에서 저희 또는 당사라고 칭할 때 그것은 Vitality Health Plan of California를 의미합니다 플랜 또는 저희 플랜이라고 칭하는 것은 Plus (HMO) 를 의미합니다 이 문서는 2020년 3월 24일 현재 최신인 의약품 목록(처방집)을 포함합니다 업데이트된 처방집을 원하시면 저희에게 문의해 주십시오 처방집이 마지막으로 업데이트되었던 날짜와 함께 저희의 연락처 정보가 앞표지와 뒤표지에 표시됩니다 처방약 혜택을 이용하시려면 일반적으로 네트워크 약국을 이용하셔야 합니다 혜택 처방집 약국 네트워크 및또는 자기부담금공동보험액은 2020년 1월 1일 수요일 그리고 연중에 수시로 변경될 수 있습니다 Vitality Health Plan of California 처방집이란 무엇입니까 처방집(formulary)은 Vitality Health Plan of California가 의료제공자 팀과 협의해 선택한 보장약 목록으로서 양질의 치료 프로그램에서 필수적인 부분으로 여겨지는 처방약 치료법을 나타냅니다 Vitality Health Plan of California는 해당 의약품이 의학적으로 필요하고 가입자가 Vitality Health Plan of California 네트워크 약국에서 처방약을 조제하고 기타 플랜 규칙을 준수하는 이상 일반적으로 처방집에 수록된 의약품을 보장합니다 처방약 조제에 관한 세부 정보가 궁금하시면 보장범위 증명(Evidence of Coverage EOC)을 검토해 주십시오 처방집(의약품 목록)은 변경될 수 있습니까 대부분의 약 보장에 대한 변경은 1월 1일에 적용되지만 연중에도 의약품 목록에 약을 추가 또는 제거하거나 다른 비용 분담 단계로 약을 옮기거나 새로운 제한을 추가할 수 있습니다 이러한 변경시 메디케어 규칙을 반드시 따라야만 합니다 올해에 가입자에게 영향을 줄 수 있는 변경 사항 다음의 경우 가입자는 해당 연도에 보장 변경의 영향을 받게 됩니다 bull 새로운 복제 약 동일하거나 더 낮은 비용 분담 단계에 동일한 제한 또는 더 적은 제한으로 나타날 새로운 복제약으로 대체하는 경우 당사는 의약품 목록에 있는 브랜드 약을 즉시 제거할 수 있습니다 또한 새로운 복제약을 추가할 때 의약품 목록에 브랜드 약을 그대로 둘 수 있지만 이 브랜드 약을 다른 비용 분담 단계로 즉시 이동하거나 새로운 제한사항을 추가할 수 있습니다 만약 귀하가 현재 그 브랜드 약을 복용하고 있다면 변경 전에 미리 귀하에게 고지되지 않을 수도 있지만 나중에 귀하께 당사가 만든 구체적인 변경에 대한 정보를 제공할 것입니다

o 그러한 변경이 있을 때 가입자나 담당 처방의는 플랜에 예외 적용을 요구하거나 가입자에 대해 브랜드 약을 계속 보장해줄 것을 요구할 수 있습니다 귀하께 제공하는 통지서에는 예외를 요청하는 방법에 대한 정보도 포함되어 있으며 Vitality Health Plan of California의 처방집에 대한 예외는 어떻게 요청하나요라는 제목의 섹션에서도 정보를 확인할 수 있습니다

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bull 의약품이 시장에서 없어지는 경우 식품의약국이 처방집의 의약품이 안전하지 않다고 여기거나 의약품의 제조사가 시장에서 의약품을 철수하는 경우 저희는 처방집에서 해당 의약품을 즉시 제외하고 해당 의약품을 복용 중인 가입자에게 관련 안내를 합니다

bull 기타 변경사항 저희는 현재 특정 의약품을 복용하는 가입자에게 영향을 줄 수 있는 기타 변경 조치를 취할 수 있습니다 예를 들어 현재 처방집에 있는 브랜드 약을 대체할 새로운 복제약을 추가하거나 브랜드 약에 새로운 제한 사항을 추가하거나 브랜드 약을 다른 비용 분담 단계로 변경할 수 있습니다 또는 새로운 임상 지침을 근거로 변경을 할 수도 있습니다 저희가 처방집에서 의약품을 없애거나 사전 승인 요건을 추가하거나 의약품의 분량 제한 및또는 단계적 치료 제한 요건을 추가하거나 의약품을 상위의 비용 분담액 군으로 이동하는 경우 변경 사항이 발효되기 최소 30일전 또는 가입자가 해당 의약품의 리필을 요청하는 시점에 해당 변경으로 영향을 받게 되는 가입자에게 통지해드리며 이때 해당 의약품 30일분을 받게 됩니다


현재 약을 복용하는 경우 귀하에게 영향을 주지 않는 변경 사항입니다 일반적으로 연초에 보장되었던 2020년 처방집의 의약품을 복용하고 계신 경우 저희는 2020년 보장연도 동안 해당 의약품 보장을 중단하거나 줄이지 않습니다 즉 해당 의약품을 복용하시는 가입자는 남은 보장연도 동안 동일한 비용 분담액으로 해당 약을 계속 이용하실 수 있습니다

동봉된 처방집은 2020년 3월 24일 현재 최신입니다 Vitality Health Plan of California가 보장하는 의약품에 대한 최신 정보를 원하시면 저희에게 연락해 주십시오 저희 연락처 정보는 앞표지와 뒤표지에 나와 있습니다 매월 Vitality Health Plan of California에서 가입자에게 ldquo혜택 설명서rdquo 또는 ldquoEOBrdquo라고 하는 보고서를 우편으로 보내드립니다 혜택 설명서는 해당 월에 가입자가 처방약에 지불한 총 금액과 가입자의 처방약 각각에 대해 당사가 지불한 총 금액을 알려줍니다 당사의 처방집에 최근 변경이 있는 경우에는 혜택 설명서와 함께 ldquo처방집 변경 사항 통지rdquo를 보내드립니다 또한 처방집의 모든 변경 사항은 웹 사이트 wwwvitalityhpnet에 매월 업데이트되어 게시되는 처방집에 수록될 것입니다 처방집은 어떻게 사용합니까 처방집 안에서 의약품을 찾는 두 가지 방법이 있습니다 의학적 증상 처방집은 1페이지에서 시작됩니다 본 처방집의 의약품은 치료를 위해 사용되는 질환 종류에 따라 범주별로 분류됩니다 예컨대 심장 질환의 치료에 사용되는 의약품은 심혈관계 약제 아래에 수록됩니다 귀하의 의약품이 어디에 사용되는지 알고 있다면 3페이지에서 시작되는 목록에서 범주명을 찾으십시오 그 다음 범주명 아래에서 귀하의 의약품이 있는지 찾아보십시오 알파벳 순서의 목록 찾아야 할 하위 범주가 확실치 않다면 I-1페이지에서 시작되는 색인에서 의약품이 있는지 찾으셔야 합니다 색인은 이 문서에 포함된 모든 의약품들의 알파벳순 목록을 제공합니다 브랜드 약과 복제약 모두 색인에 기재되어 있습니다 색인을 살펴보고 의약품을 찾으십시오 의약품 이름 옆에 페이지 번호가 있고 그 페이지에서 보장 정보를 찾을 수 있습니다 색인에 기재된 페이지로 가서 목록의 첫 번째 열에서 약품 명을 찾으십시오

II-38

복제약이란 무엇인가요 Vitality Health Plan of California는 브랜드 약과 복제약 모두를 보장합니다 복제약은 FDA가 브랜드 약과 동일한 활성 성분을 가졌다고 승인한 것입니다 일반적으로 복제약은 브랜드 약보다 가격이 낮습니다 제 보장에 어떤 제약이 있습니까 일부 보장약에는 추가 요건이 있거나 보장 제한이 있습니다 이러한 요건 및 제한에는 다음 사항이 포함될 수 있습니다 bull 사전 허가 Vitality Health Plan of California에서 귀하나 귀하의 의사가 특정 의약품에 대해 사전 허가를 받도록 규정합니다 이는 처방약을 조제 받기 전 Vitality Health Plan of California로부터 승인을 받으셔야 한다는 의미입니다 승인을 얻지 못하면 Vitality Health Plan of California는 약 비용을 보장하지 않을 수 있습니다

bull 분량 제한 특정 의약품의 경우 Vitality Health Plan of California는 Vitality Health Plan of California가 보장하게 될 의약품의 양을 제한합니다 예를 들어 Vitality Health Plan of California는 Rabeprazole 경구약을 처방전당 30정을 제공합니다 이것은 기본적인 한달분 또는 석달분에 추가될 수 있습니다

bull 단계적 치료법 경우에 따라 Vitality Health Plan of California에서 해당 질환에 대해 다른 약을 보장해드리기 전에 귀하의 질환을 치료하는 특정 약을 먼저 써보셔야 합니다 예를 들어 A약과 B약 모두가 귀하의 의학적 증상을 치료하는 경우 Vitality Health Plan of California는 귀하가 A약을 먼저 써보기 전까지는 B약을 보장하지 않을 수 있습니다 A약이 효과가 없는 경우 Vitality Health Plan of California는 B약을 보장하게 됩니다

귀하의 의약품에 어떤 추가 요건이 있는지 또는 제약이 있는지에 대해서는 3페이지에서 시작되는 처방집을 찾아보시면 확인하실 수 있습니다 또한 보장되는 특정한 의약품에 해당되는 제약 사항에 대한 세부 정보는 저희 웹사이트를 방문하시면 확인하실 수 있습니다 사전 허가와 단계적 치료법 제한에 대해 설명한 온라인 문서를 게시해 두었습니다 귀하께서는 저희에게 사본을 보내달라고 요청하실 수도 있습니다 처방집이 마지막으로 업데이트되었던 날짜와 함께 저희의 연락처 정보가 앞표지와 뒤표지에 표시됩니다 Vitality Health Plan of California에 이러한 제약 사항 또는 제한의 예외를 요청하시거나 귀하의 질환을 치료할 수 있는 기타 유사한 의약품 목록을 요청하실 수 있습니다 예외 요청 방법에 대한 정보는 II-40 페이지의 ldquoVitality Health Plan of California의 처방집에 대한 예외는 어떻게 요청하나요rdquo 절을 참조하십시오

II-39

비처방(OTC) 의약품이란 무엇인가요 OTC 약은 Medicare 처방약 플랜에서 일반적으로 보장하지 않는 비처방약입니다 Vitality Health Plan of California는 특정 OTC 약에 대한 비용을 지불합니다 약 이름 강도 투여 형태 CETIRIZINE HCL 5 MG5 ML 용액 CETIRIZINE HCL 1 MGML 용액 CETIRIZINE HCL 5 MG 씹어먹는 정제 CETIRIZINE HCL 10 MG 씹어먹는 정제 CETIRIZINE HCL 5 MG 정제 CETIRIZINE HCL 10 MG 정제 CETIRIZINE HCLPSEUDOEPHEDRINE 5 MG-120MG 정제 ER 12H FEXOFENADINE HCL 30 MG5 ML 경구 현탁액 FEXOFENADINE HCL 30 MG 정제 RAPDIS FEXOFENADINE HCL 60 MG 정제 FEXOFENADINE HCL 180 MG 정제 FEXOFENADINEPSEUDOEPHEDRINE 60MG-120MG 정제 ER 12H FEXOFENADINEPSEUDOEPHEDRINE 180MG-240MG 정제 ER 24H KETOTIFEN FUMARATE 003 드롭스 LEVOCETIRIZINE DIHYDROCHLORIDE 5 MG 정제 LORATADINE 5 MG5 ML 용액 LORATADINE 5 MG 씹어먹는 정제 LORATADINE 10 MG 정제 RAPDIS LORATADINE 10 MG 정제 LORATADINEPSEUDOEPHEDRINE 5 MG-120MG 정제 ER 12H LORATADINEPSEUDOEPHEDRINE 10MG-240MG 정제 ER 24H PHENYLEPHRINEDMACETAMINOPGG 5-325-200 정제

Vitality Health Plan of California는 이러한 OTC 약을 가입자의 비용 부담없이 제공해드립니다 Vitality Health Plan of California에서 부담하는 이러한 OTC 약의 비용은 귀하의 총 파트 D 약 비용에 산정되지 않습니다 (즉 OTC 약 비용은 보장 공백에 대해 누적되지 않음) 제 약이 처방집에 없으면 어떻게 하나요 귀하의 의약품이 본 처방집(보장 약 목록)에 포함되어 있지 않은 경우 먼저 가입자 서비스부에 연락해 귀하의 약이 보장되는지 문의하셔야 합니다 Vitality Health Plan of California가 귀하의 약을 보장하지 않는다는 것을 아셨다면 두 가지 선택권이 있습니다

II-40

bull 가입자 서비스부에 Vitality Health Plan of California가 보장하는 유사한 의약품 목록을 요청하실 수 있습니다 이 목록을 받으시면 담당 의사에게 보여주시고Vitality Health Plan of California가 보장하는 유사한 의약품을 처방하도록 요청하십시오

bull 해당 약을 보장해달라는 예외를 적용해 달라고 Vitality Health Plan of California에 요청할 수 있습니다 예외 요청 방법에 관한 정보는 아래를 참조하십시오

Vitality Health Plan of California의 처방집에 대한 예외는 어떻게 요청하나요 보장 규칙에 예외를 적용해 달라고 Vitality Health Plan of California에 요청할 수 있습니다 요청하실 수 있는 몇 가지 유형의 예외가 있습니다

bull 약이 처방집에 없는 경우라도 의약품 보장을 요청하실 수 있습니다 승인을 받으면 이 의약품은 사전에 결정된 비용 분담액 수준으로 보장되어 더 낮은 비용 분담 수준으로 의약품을 제공하라고 요청하실 수 없을 것입니다

bull 이 의약품이 특수 분류에 없다면 처방집 약을 더 낮은 비용 분담 수준으로 보장하도록 요청하실 수 있습니다 승인된다면 이러한 요청으로 귀하가 의약품에 지불해야 하는 금액이 낮춰질 것입니다

bull 저희에게 보장 제약이나 귀하의 의약품에 대한 제한을 면제하도록 요청하실 수 있습니다 예컨대 특정 의약품의 경우 Vitality Health Plan of California에서는 보장할 의약품의 양을 제한합니다 귀하의 의약품에 분량 제한이 있다면 저희에게 제한 철회와 더 많은 분량에 대한 보장을 요청하실 수 있습니다

일반적으로 Vitality Health Plan of California의 처방집에 포함된 대안적 의약품 더 낮은 비용 분담액의 의약품 또는 의약품 사용에 관한 추가적 제한이 질환을 치료하는 데 있어 그만큼 효과적이지 않을 수 있거나 귀하에게 부정적인 의학적 효과를 야기할 수 있다면 예외 요청을 승인할 것입니다 저희에게 연락해 처방집에 대한 초기 보장 결정을 요청하시거나 의약품 사용 제한 예외를 요청하셔야 합니다 처방집이나 의약품 사용 제한 예외를 요청하실 때 그러한 요청을 뒷받침하는 처방자나 의사의 진술서를 제출하셔야 합니다 일반적으로 저희는 처방자의 근거 진술서를 획득한 지 72시간 내에 결정을 내려야 합니다 귀하 또는 담당 의사가 결정에 대해 72시간까지 기다리는 것이 귀하의 건강을 심각하게 해칠 수 있을 것으로 믿는 경우 귀하는 신속(빠른) 예외를 요청할 수 있습니다 귀하의 신속 요청이 허가되는 경우 저희는 담당 의사나 다른 처방자의 근거 진술서를 획득한 지 늦어도 24시간 내에 귀하에게 결정 내용을 전달해야 합니다 저의 약을 변경하거나 예외를 요청하는 문제에 대해 의사와 상의하기 전 저는 어떻게 대처하나요 저희 플랜의 신규 또는 기존 가입자로서 귀하는 처방집에 없는 의약품을 복용하고 계실 수도 있습니다 또는 처방집에 있으나 이용에 제약이 있는 약을 복용하고 계실 수도 있습니다 예컨대 처방전을 조제 받기 전 저희로부터 사전 허가를 받으셔야 하는 경우입니다 귀하께서는 보장이 되는 적절한 약으로 전환을 요청해야 하는지 아니면 복용하시는 약을 저희가 보장해주도록 처방집 예외 요청을 해야 하는지 담당 의사와 상의하셔야 합니다 어떤 조치가 올바른지 담당 의사와 상의하시는 동안 귀하께서 저희 플랜 가입 후 최초 90일 동안은 경우에 따라 귀하의 약을 보장해드립니다

II-41

저희 처방집에 없는 의약품이거나 수령할 수 있는 의약품이 제한적일 경우 임시로 30일분을 보장할 것입니다 처방전이 그보다 적은 기간에 대해 작성된 경우 최대 30일치 약을 제공하기 위해 여러 차례 리필을 허락할 것입니다 최초 30일분이 제공된 후에는 귀하가 90일이 안 된 플랜 가입자라도 이러한 의약품에 대해 저희가 더 이상 비용 지불을 하지 않습니다 장기 치료 시설에 거주하고 있는 가입자로서 처방집에 없는 의약품이 필요하시거나 의약품 이용에 제약이 있지만 플랜에 가입한 지 90일이 지난 상태에서 처방집 예외를 요청하시는 경우라면 저희는 31일분의 의약품 응급 공급분을 보장합니다 수혜자가 치료 환경을 바꾸는 경우 Vitality Health Plan은 처방집에 없는 파트 D 약을 신속히 승인할 수 있도록 할 것입니다 사전 허가나 단계적 치료법이 필요한 처방집 파트 D 약에도 이 절차를 적용합니다 치료 수준 변경의 예 병원에서 집으로 퇴원한 수혜자 전문 요양 시설 Medicare 파트 A 이용 체류가 종료되고 파트 D 플랜 처방집으로 복귀해야 하는 수혜자 장기 치료 시설 체류가 종료되고 지역으로 돌아오는 수혜자 고도로 개별화된 약물 요법을 하는 정신병원에서 퇴원한 수혜자 Vitality Health Plans 제휴 약국은 처방집 제한사항을 우선하기 위해 판매처에서 업계 표준 제출 코드를 삽입할 수 있습니다 Vitality Health Plans와 제휴한 PBM(MedImpact)의 영업 시간 이후 서비스는 약국이 약국 청구 처리 문제를 결정할 수 있는 담당자를 이용할 수 있도록 합니다 이를 통해 약국은 판매처에서 청구건에 대해 최종 결정을 할 수 있으며 가입자가 의약품을 신뢰하고 이용할 수 있도록 할 것입니다 자세한 정보 Vitality Health Plan of California 처방약 보장에 관한 더욱 세부적인 정보가 궁금하시면 보장범위 증명과 기타 플랜 자료를 검토해 주십시오 Vitality Health Plan of California에 대한 질문은 저희에게 문의해 주십시오 처방집이 마지막으로 업데이트되었던 날짜와 함께 저희의 연락처 정보가 앞표지와 뒤표지에 표시됩니다 Medicare 처방약 보장에 관한 일반적인 궁금증은 Medicare 전화 1-800-MEDICARE (1-800-633-4227)번으로 주 7일 하루 24시간 언제든 연락해 주십시오 TTYTDD 이용자는 1-877-486-2048번으로 전화해 주십시오 또는 httpwwwmedicaregov를 방문해 주십시오 Vitality Health Plan of California 처방집 다음 페이지에서 시작되는 처방집에는 Vitality Health Plan of California가 보장하는 일부 의약품에 대한 보장 정보가 제공됩니다 이 목록에서 의약품을 찾는 데 어려움이 있는 경우 I-1 페이지부터 시작되는 색인을 참조하시기 바랍니다 표의 첫 번째 열에 의약품 이름이 나와 있습니다 브랜드 약은 대문자로 되어 있고(예 ELIQUIS) 복제약은 소문자 기울임꼴로 되어 있습니다(예 simvastatin) 요건제한 열에 나와 있는 정보는 Vitality Health Plan of California에서 의약품 보장에 특별한 요건을 두는지를 알려줍니다

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약어 설명 설명

PA 사전 승인 제한 사항

가입자는 이 의약품에 대한 처방 조제를 받기 전에 Vitality Health Plan으로부터 사전 승인을 받아야 합니다 사전 승인을 얻지 못하면 Vitality Health Plan은 이 의약품 비용을 보장하지 않을 수 있습니다

PA BvD

파트 B 및 파트 D 결정에 대한 사전 승인 제한 사항

이 의약품은 상황에 따라 Medicare 파트 B 또는 D에서 보장될 수 있습니다 가입자(또는 주치의)는 이 의약품에 대한 처방 조제를 받기 전에 Vitality Health Plan으로부터 사전 허가를 받아야 합니다 사전 승인을 얻지 못하면 Vitality Health Plan은 이 의약품 비용을 보장하지 않을 수 있습니다

PA-HRM 고위험 약에 대한 사전 승인 제한 사항

이 의약품은 CMS가 잠정적 위험이 있는 것으로 판단했으며 65세 이상의 Medicare 수혜자에게 고위험 의약품으로 간주했습니다 65세 이상의 가입자는 이 의약품에 대한 처방 조제를 받기 전에 Vitality Health Plan으로부터 사전 승인을 받아야 합니다 사전 승인을 얻지 못하면 Vitality Health Plan은 이 의약품 비용을 보장하지 않을 수 있습니다

PA NSO 신규 이용에 대한 사전 승인 제한 사항

신규 가입자이거나 이 의약품을 복용한 적이 없다면 가입자(또는 담당 의사)는 처방약을 조제하기 전에 Vitality Health Plan의 사전 승인을 받아야 합니다 사전 승인을 얻지 못하면 Vitality Health Plan은 이 의약품 비용을 보장하지 않을 수 있습니다

PA NSO-HRM

고위험 약 및 신규 이용에 대한 사전 승인 제한 사항


QL 수량 제한 사항 Vitality Health Plan은 처방전으로 보장되는 이 의약품의 양 또는 기한을 제한합니다

ST 단계적 치료법 제한 사항

Vitality Health Plan이 이 의약품에 대해 보장을 제공하기 전에 가입자는 질병 치료를 위해 다른 약을 먼저 사용해보아야 합니다 다른 약이 효능이 없는 경우에만 이 약이 보장됩니다

EX 제외된 Medicare 파트 D 약

이 처방약은 일반적으로 Medicare 처방약 플랜으로 보장되지 않습니다 이 처방약을 조제할 때 가입자가 지불하는 금액은 총 의약품 비용에 포함되지 않습니다(즉 지불하는 금액은 재해성 보장에 포함되지 않음) 또한 처방약 비용을 지불하기 위해 추가 지원을 받고 있다면 이 약 비용을 위해 추가 지원을 받지 못합니다

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LA 이용이 제한적인 의약품

이 처방약은 특정 약국에서만 구할 수 있습니다 보다 자세한 정보는 약국 명부를 참조하시거나 가입자 서비스부에 1-888-254-9907번으로 문의해 주십시오 TTYTDD 사용자는 888-254-9907번으로 전화하셔야 합니다

GC 보장 공백 보장 보장 공백 중에 이 처방약의 보장을 제공해드립니다 본 보장에 대한 자세한 정보는 보장범위 증명을 참조해 주십시오

NDS 비장기간 조제

처방집에 있는 대부분의 약은 1개월분 이상을 할인된 공동 분담액으로 소매 약국에서 또는 우편 주문을 통해 수령할 수 있습니다 우편 주문 또는 소매 약국 혜택을 통한 장기 공급(1개월 이상 공급)에 해당되지 않는 약은 처방집의 요구 사항제한 열에 NDS으로 표시됩니다

HI 가정 주입 의약품 이 처방약은 당사의 의료 혜택으로 보장을 받을 수 있습니다 자세한 정보는 전화로 문의하십시오

AGE 연령 제한 사항 이 처방약은 특정 연령 그룹으로 제한됩니다

CB 혜택 한도 이 의약품에는 최대 혜택 한도가 있습니다

이 처방약은 일반적으로 Medicare 처방약 플랜으로 보장되지 않습니다 이 처방약을 조제할 때 가입자가 지불하는 금액은 총 의약품 비용에 포함되지 않습니다(즉 지불하는 금액은 재해성 보장에 포함되지 않음) 또한 처방약 비용을 지불하기 위해 추가 지원을 받고 있다면 이 약 비용을 위해 추가 지원을 받지 못합니다 의약품 이름 의약품 단계 요건제한 사항

sildenafil 경구 정제 100mg(Viagra) 2 수량 한도(30일마다 최대 6정)

sildenafil 경구 정제 50 mg(Viagra) 2 수량 한도(30일마다 최대 6정)


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San Joaquin 카운티의 Santa Clara 카운티의 Plus (HMO) 가입자의 자기부담금공동보험액

단계 설명 자기부담금공동보험액

30일치 90일치 1단계 우선적 복제약 $0 $0 2단계 복제약 25 25 3단계 우선적 브랜드 약 25 25 4단계 비 우선적 약 25 25 5단계 특수 단계 25 해당 안 됨 6단계 백신 $0 해당 안 됨

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Hội viecircn hiện tại xin lưu yacute Danh mục thuốc nagravey đatilde được thay đổi từ năm ngoaacutei Xin xem lại tagravei liệu nagravey để bảo đảm noacute vẫn chứa caacutec thuốc magrave quyacute vị sử dụng Khi danh saacutech thuốc (danh mục thuốc) nagravey noacutei về ldquochuacuteng tocircirdquo ldquocho chuacuteng tocircirdquo hoặc ldquocủa chuacuteng tocircirdquo noacute coacute nghĩa lagrave Vitality Health Plan of California Khi đề cập ldquochương trigravenhrdquo hoặc ldquochương trigravenh của chuacuteng tocircirdquo coacute nghĩa lagrave chương trigravenh Plus (HMO) Tagravei liệu nagravey bao gồm một phần danh saacutech thuốc (danh mục) trong chương trigravenh của chuacuteng tocirci được cập nhật kể từ ngagravey 03242020 Để coacute được danh mục thuốc mới nhất xin quyacute vị liecircn lạc với chuacuteng tocirci Thocircng tin liecircn lạc của chuacuteng tocirci cugraveng với ngagravey cập nhật cuối cugraveng của danh mục thuốc coacute in tại bigravea trước vagrave bigravea sau Thocircng thường quyacute vị phải sử dụng caacutec nhagrave thuốc trong mạng lưới để sử dụng quyền lợi thuốc theo toa của quyacute vị Caacutec quyền lợi danh saacutech thuốc nhagrave thuốc trong mạng lưới vagravehoặc tiền đồng trảđồng bảo hiểm coacute thể thay đổi vagraveo ngagravey 1 thaacuteng 1 năm 2020 vagrave thay đổi theo thời gian trong năm Danh mục thuốc của Vitality Health Plan of California lagrave gigrave Danh mục Thuốc lagrave danh saacutech caacutec thuốc được bảo hiểm do Vitality Health Plan of California lựa chọn cugraveng với sự cố vấn của caacutec nhagrave cung cấp dịch vụ chăm soacutec sức khỏe noacute thể hiện caacutec liệu phaacutep chỉ định được tin lagrave một bộ phận cần thiết của chương trigravenh điều trị coacute chất lượng Noacutei chung Vitality Health Plan of California sẽ bảo hiểm cho caacutec thuốc trong danh mục của chuacuteng tocirci với điều kiện thuốc đoacute lagrave cần thiết về mặt y tế được mua tại nhagrave thuốc trong mạng lưới của Vitality Health Plan of California vagrave phugrave hợp với caacutec quy định khaacutec của chương trigravenh Để biết thecircm về caacutech mua thuốc toa xin xem Chứng từ Bảo hiểm của quyacute vị Danh mục Thuốc (danh saacutech thuốc) coacute thể thay đổi khocircng Hầu hết caacutec thay đổi về bảo hiểm thuốc diễn ra vagraveo ngagravey 1 thaacuteng 1 nhưng chuacuteng tocirci coacute thể thecircm hoặc bớt thuốc khỏi Danh saacutech Thuốc trong năm coacute thể chuyển sang bậc chia sẻ chi phiacute khaacutec hoặc thecircm giới hạn mới Chuacuteng tocirci phatildei tuacircn thủ luật lệ của Medicare về những thay đổi nagravey Caacutec thay đổi coacute thể ảnh hưởng đến quyacute vị trong năm nay Trong caacutec trường hợp becircn dưới caacutec thay đổi về bảo hiểm sẽ ảnh hưởng đến quyacute vị trong năm bull Thuốc gốc mới Chuacuteng tocirci coacute thể ngay lập tức loại bỏ một thuốc chiacutenh hiệu trong Danh saacutech Thuốc

của chuacuteng tocirci nếu chuacuteng tocirci thay thế thuốc đoacute bằng một loại thuốc gốc mới sẽ xuất hiện với cugraveng một bậc chia sẻ chi phiacute hoặc bậc chia sẻ thấp hơn vagrave với cugraveng mức hạn chế hoặc hạn chế iacutet hơn Ngoagravei ra khi thecircm thuốc gốc mới chuacuteng tocirci coacute thể quyết định giữ thuốc chiacutenh hiệu trong Danh saacutech Thuốc của chuacuteng tocirci nhưng ngay lập tức chuyển thuốc đoacute sang một bậc chia sẻ chi phiacute khaacutec hoặc thecircm caacutec hạn chế mới Nếu quyacute vị hiện đang dugraveng thuốc chiacutenh hiệu chuacuteng tocirci khocircng thể cho quyacute vị biết trước khi chuacuteng tocirci thực hiện thay đổi nhưng chuacuteng tocirci sẽ cung cấp cho quyacute vị thocircng tin về (caacutec) thay đổi cụ thể magrave chuacuteng tocirci đatilde thực hiện sau nagravey

o Nếu chuacuteng tocirci thực hiện một thay đổi như vậy quyacute vị hoặc baacutec sĩ kecirc đơn của quyacute vị coacute thể yecircu cầu chuacuteng tocirci tạo một ngoại lệ vagrave tiếp tục bảo hiểm thuốc chiacutenh hiệu đoacute cho quyacute vị Thocircng baacuteo chuacuteng tocirci cung cấp cho quyacute vị cũng sẽ bao gồm thocircng tin về caacutech yecircu cầu ngoại lệ vagrave quyacute vị cũng coacute thể tigravem thocircng tin trong phần becircn dưới coacute tiecircu đề ldquoLagravem caacutech nagraveo để yecircu cầu ngoại lệ cho Danh mục Thuốc của Vitality Heath Plan of Californiarsquos Formularyrdquo

II-46

bull Thuốc bị thu hồi khỏi thị trường Nếu Cơ quan Thực vagrave Dược phẩm (Food and Drug Administration) thấy một loại thuốc trong danh mục của chuacuteng tocirci lagrave khocircng an toagraven hoặc nhagrave sản xuất thu hồi thuốc khỏi thị trường chuacuteng tocirci sẽ lập tức loại thuốc đoacute ra khỏi danh mục của chuacuteng tocirci vagrave thocircng baacuteo cho hội viecircn dugraveng thuốc đoacute biết

bull Caacutec thay đổi khaacutec Chuacuteng tocirci coacute thể thực hiện caacutec thay đổi khaacutec ảnh hưởng đến caacutec hội viecircn hiện đang

dugraveng thuốc Viacute dụ chuacuteng tocirci coacute thể thecircm một loại thuốc gốc mới để thay thế thuốc chiacutenh hiệu hiện coacute trong danh mục thuốc hoặc thecircm caacutec hạn chế mới đối với thuốc chiacutenh hiệu hoặc chuyển thuốc sang một bậc chia sẻ chi phiacute khaacutec Hoặc chuacuteng tocirci coacute thể thực hiện caacutec thay đỏi dựa trecircn caacutec hướng dẫn lacircm sagraveng mới Nếu chuacuteng tocirci loại bỏ caacutec thuốc khỏi danh mục thecircm vagraveo yecircu cầu xin pheacutep trước giới hạn số lượng vagravehoặc giới hạn loại thuốc cho việc trị liệu theo từng giai đoạn hoặc chuyển thuốc sang bậc chia sẻ cao hơn chuacuteng tocirci phải thocircng baacuteo tất cả caacutec thay đổi nagravey cho những hội viecircn hiện đang sử dụng caacutec loại thuốc đoacute iacutet nhất 30 ngagravey trước ngagravey thay đổi coacute hiệu lực hoặc vagraveo luacutec hội viecircn yecircu cầu được mua thecircm thuốc đoacute luacutec đoacute hội viecircn sẽ nhận được thuốc cho 30 ngagravey

o Nếu chuacuteng tocirci đưa ra caacutec thay đổi khaacutec quyacute vị hoặc baacutec sĩ kecirc đơn của quyacute vị coacute thể yecircu cầu chuacuteng tocirci tạo một ngoại lệ vagrave tiếp tục bảo hiểm thuốc chiacutenh hiệu đoacute cho quyacute vị Thocircng baacuteo chuacuteng tocirci cung cấp cho quyacute vị cũng sẽ bao gồm thocircng tin về caacutech yecircu cầu ngoại lệ vagrave quyacute vị cũng coacute thể tigravem thocircng tin trong phần becircn dưới coacute tiecircu đề ldquoLagravem caacutech nagraveo để yecircu cầu ngoại lệ cho Danh mục Thuốc của Vitality Health Plan of Californiardquo

Caacutec thay đổi sẽ khocircng ảnh hưởng đến quyacute vị nếu quyacute vị hiện đang dugraveng thuốc Thocircng thường nếu quyacute vị đang dugraveng một loại thuốc trong danh mục thuốc 2020 được bảo hiểm vagraveo đầu năm chuacuteng tocirci sẽ khocircng giảm hoặc hủy liecircn tục của loại thuốc đoacute trong thời gian bảo hiểm của năm 2020 trừ khi được mocirc tả becircn trecircn Điều nagravey coacute nghĩa lagrave caacutec thuốc đoacute sẽ vẫn được cung cấp ở cugraveng mức chia sẻ chi phiacute vagrave khocircng coacute giới hạn mới cho những hội viecircn đang dugraveng chuacuteng cho phần cograven lại của năm bảo hiểm

Kegravem theo đacircy lagrave danh mục kể từ ngagravey 24 thaacuteng 3 năm 2020 Để nhận thocircng tin cập nhật về thuốc được Vitality Health Plan of California bảo hiểm vui lograveng liecircn hệ với chuacuteng tocirci Thocircng tin liecircn lạc của chuacuteng tocirci coacute ghi tại caacutec trang của bigravea trước vagrave bigravea sau Hagraveng thaacuteng Vitality Health Plan of California sẽ gửi qua bưu điện cho quyacute vị một baacuteo caacuteo gọi lagrave tờ ldquoGiải thiacutech Quyền lợirdquo hay ldquoEOBrdquo EOB cho quyacute vị biết tổng số tiền quyacute vị đatilde chi cho thuốc toa của quyacute vị vagrave tổng số tiền chuacuteng tocirci đatilde trả cho mỗi loại thuốc toa của quyacute vị trong thaacuteng đoacute Cugraveng với EOB chuacuteng tocirci sẽ gửi cho quyacute vị Thocircng baacuteo Thay đổi Danh mục Thuốc (ldquoFormulary Change Noticerdquo) nếu mới coacute thay đổi nagraveo được thực hiện cho danh mục thuốc của chuacuteng tocirci Ngoagravei ra tất cả caacutec thay đổi về danh mục thuốc cũng sẽ được cập nhật hagraveng thaacuteng trecircn trang mạng của chuacuteng tocirci tại wwwvitalityhpnet Tocirci sử dụng Danh mục Thuốc như thế nagraveo Coacute hai caacutech để tigravem thuốc của quyacute vị trong danh mục Theo Bệnh Danh saacutech thuốc bắt đầu trecircn trang 1 Thuốc trong danh mục nagravey được nhoacutem thagravenh nhoacutem theo loại bệnh magrave chuacuteng được dugraveng để điều trị Viacute dụ thuốc điều trị bệnh tim được đặt dưới phacircn loại ldquoThuốc điều trị tim mạchrdquo Nếu biết thuốc của migravenh sử dụng cho bệnh gigrave tigravem tecircn phacircn loại trong danh saacutech bắt đầu ở trang 3 Rồi tigravem tiếp thuốc của quyacute vị ở trong nhoacutem bệnh nagravey

II-47

Theo vần abc Nếu quyacute vị khocircng chắc chắn phacircn loại nagraveo để tigravem quyacute vị necircn tigravem tecircn thuốc của migravenh trong Bảng danh mục bắt đầu ở trang I-1 Bảng chuacute dẫn nagravey liệt kecirc theo bảng chữ caacutei tất cả caacutec loại thuốc coacute trong tagravei liệu nagravey Cả thuốc chiacutenh hiệu vagrave thuốc gốc đều được liệt kecirc trong Bảng chuacute dẫn nagravey Xem trong Bảng chuacute dẫn để tigravem thuốc của quyacute vị Becircn cạnh tecircn thuốc quyacute vị sẽ nhigraven thấy số trang nơi quyacute vị coacute thể tigravem thấy thocircng tin bảo hiểm Lật sang trang được liệt kecirc trong Bảng chuacute dẫn vagrave tigravem tecircn thuốc của quyacute vị ở cột đầu tiecircn trong danh saacutech Thuốc gốc lagrave gigrave Vitality Health Plan of California bảo hiểm cho cả thuốc chiacutenh hiệu vagrave thuốc gốc Thuốc gốc theo phecirc chuẩn của FDA lagrave thuốc coacute cugraveng thagravenh phần hoạt chất với thuốc chiacutenh hiệu Thuốc gốc thường rẻ hơn thuốc chiacutenh hiệu Coacute hạn chế nagraveo về việc bảo hiểm cho tocirci khocircng Một số thuốc được bảo hiểm coacute thể coacute thecircm caacutec yecircu cầu hoặc giới hạn về bảo hiểm Caacutec yecircu cầu hoặc giới hạn nagravey coacute thể bao gồm bull Xin pheacutep trước Vitality Health Plan of California yecircu cầu quyacute vị hoặc baacutec sĩ quyacute vị phải xin pheacutep

trước đối với một số thuốc nagraveo đoacute Điều đoacute coacute nghĩa lagrave quyacute vị phải được Vitality Health Plan of California chấp thuận trước rồi mới được mua thuốc Nếu khocircng coacute sự chấp thuận nagravey Vitality Health Plan of California sẽ khocircng bảo hiểm thuốc cho quyacute vị

bull Giới hạn Số lượng Với một số thuốc nagraveo đoacute Vitality Health Plan of California coacute giới hạn số lượng thuốc magrave Vitality Health Plan of California sẽ đagravei thọ Viacute dụ Vitality Health Plan of California cung cấp 30 viecircnđơn thuốc đối với thuốc uống Rabeprazole Đacircy coacute thể lagrave một giới hạn khaacutec ngoagravei quy định về lượng cấp một thaacuteng hoặc ba thaacuteng thocircng thường

bull Liệu phaacutep bước Trong một số trường hợp Vitality Health Plan of California yecircu cầu quyacute vị phải thử dugraveng những loại thuốc nagraveo đoacute trước để trị bệnh cho quyacute vị rồi mới đagravei thọ cho một loại thuốc khaacutec trị bệnh đoacute Viacute dụ như Thuốc A vagrave Thuốc B đều trị bệnh của quyacute vị Vitality Health Plan of California coacute thể sẽ khocircng đagravei thọ cho Thuốc B nếu quyacute vị khocircng thử dugraveng Thuốc A trước Nếu Thuốc A khocircng trị được bệnh cho quyacute vị Vitality Health Plan of California sẽ đagravei thọ cho Thuốc B

Quyacute vị coacute thể tigravem hiểu xem thuốc của migravenh coacute thecircm những yecircu cầu hoặc giới hạn khaacutec bằng caacutech tigravem trong danh mục bắt đầu ở trang 3 Quyacute vị cũng coacute thể tigravem xem thecircm về caacutec hạn chế được aacutep dụng cho thuốc được bảo hiểm cụ thể bằng caacutech xem trecircn trang mạng của chuacuteng tocirci Chuacuteng tocirci đatilde đưa lecircn trang mạng một tagravei liệu giải thiacutech caacutec hạn chế của chuacuteng tocirci về việc xin pheacutep trước vagrave liệu phaacutep bước Quyacute vị cũng coacute thể yecircu cầu chuacuteng tocirci gửi cho quyacute vị một bản Thocircng tin liecircn lạc của chuacuteng tocirci cugraveng với ngagravey cập nhật cuối cugraveng của danh mục thuốc coacute in tại bigravea trước vagrave bigravea sau Quyacute vị coacute thể yecircu cầu Vitality Health Plan of California cho quyacute vị hưởng ngoại lệ đối với caacutec hạn chế hoặc giới hạn nagravey hoặc cho quyacute vị được sử dụng một danh saacutech caacutec thuốc khaacutec tương tự coacute thể trị được bệnh của quyacute vị Xin quyacute vị xem mục ldquoTocirci xin hưởng ngoại lệ đối với danh mục thuốc của Vitality Health Plan of California bằng caacutech nagraveordquo trecircn trang II-49 để biết caacutech xin hưởng ngoại lệ

II-48

Thuốc khocircng cần toa (OTC) lagrave gigrave Thuốc OTC lagrave thuốc khi mua khocircng cần phải coacute toa baacutec sĩ magrave thường Chương trigravenh Thuốc toa Medicare khocircng đagravei thọ Vitality Health Plan of California thanh toaacuten cho một số thuốc OTC nhất định TEcircN THUỐC HAgraveM LƯỢNG DẠNG BAgraveO CHẾ CETIRIZINE HCL 5 MG5 ML DUNG DỊCH CETIRIZINE HCL 1 MGML DUNG DỊCH CETIRIZINE HCL 5 MG VIEcircN NEacuteN NHAI CETIRIZINE HCL 10 MG VIEcircN NEacuteN NHAI CETIRIZINE HCL 5 MG VIEcircN NEacuteN CETIRIZINE HCL 10 MG VIEcircN NEacuteN CETIRIZINE HCLPSEUDOEPHEDRINE 5 MG-120MG VIEcircN NEacuteN ER 12H FEXOFENADINE HCL 30 MG5 ML HỖN DỊCH UỐNG FEXOFENADINE HCL 30 MG VỈ THUỐC FEXOFENADINE HCL 60 MG VIEcircN NEacuteN FEXOFENADINE HCL 180 MG VIEcircN NEacuteN FEXOFENADINEPSEUDOEPHEDRINE 60MG-120MG VIEcircN NEacuteN ER 12H FEXOFENADINEPSEUDOEPHEDRINE 180MG-240MG VIEcircN NEacuteN ER 24H KETOTIFEN FUMARATE 003 NHỎ LEVOCETIRIZINE DIHYDROCHLORIDE 5 MG VIEcircN NEacuteN LORATADINE 5 MG5 ML DUNG DỊCH LORATADINE 5 MG VIEcircN NEacuteN NHAI LORATADINE 10 MG VỈ THUỐC LORATADINE 10 MG VIEcircN NEacuteN LORATADINEPSEUDOEPHEDRINE 5 MG-120MG VIEcircN NEacuteN ER 12H LORATADINEPSEUDOEPHEDRINE 10MG-240MG VIEcircN NEacuteN ER 24H PHENYLEPHRINEDMACETAMINOPGG 5-325-200 VIEcircN NEacuteN

Vitality Health Plan of California sẽ cung cấp miễn phiacute cho quyacute vị caacutec thuốc OTC nagravey Chi phiacute magrave Vitality Health Plan of California chi trả cho caacutec thuốc OTC nagravey sẽ khocircng được tiacutenh vagraveo tổng chi phiacute thuốc Phần D của quyacute vị (tức lagrave chi phiacute thuốc OTC nagravey khocircng dugraveng để tiacutenh giai đoạn khocircng được trả bảo hiểm)

II-49

Điều gigrave xảy ra nếu thuốc của tocirci khocircng coacute trong Danh saacutech Thuốc Nếu thuốc của quyacute vị khocircng coacute trong danh mục nagravey (danh saacutech thuốc được bảo hiểm) trước tiecircn quyacute vị cần liecircn hệ với Ban Dịch vụ Hội viecircn để hỏi xem thuốc của migravenh coacute được bảo hiểm khocircng Nếu Vitality Health Plan of California khocircng đagravei thọ cho thuốc của quyacute vị quyacute vị coacute hai lựa chọn

bull Quyacute vị coacute thể đề nghị Ban Dịch vụ Hội viecircn cung cấp một danh saacutech thuốc tương tự được Vitality Health Plan of California đagravei thọ Khi nhận được danh saacutech đoacute quyacute vị hatildey đưa cho baacutec sĩ của quyacute vị xem vagrave đề nghị họ kecirc cho quyacute vị một loại thuốc tương tự được Vitality Health Plan of California đagravei thọ

bull Quyacute vị coacute thể đề nghị Vitality Health Plan of California cho quyacute vị hưởng ngoại lệ lagrave đagravei thọ cho thuốc của quyacute vị Xem dưới đacircy để biết caacutech xin hưởng ngoại lệ

Tocirci xin hưởng ngoại lệ đối với danh mục thuốc của Vitality Health Plan of California bằng caacutech nagraveo Quyacute vị coacute thể đề nghị Vitality Health Plan of California cho quyacute vị hưởng ngoại lệ đối với caacutec quy định về đagravei thọ của chuacuteng tocirci Coacute nhiều loại ngoại lệ magrave quyacute vị coacute thể xin chuacuteng tocirci cho hưởng

bull Quyacute vị coacute thể yecircu cầu chuacuteng tocirci bảo hiểm cho một loại thuốc ngay cả khi noacute khocircng nằm trong danh mục thuốc Nếu được chấp thuận thuốc đoacute sẽ được bảo hiểm với mức chia sẻ chi phiacute được xaacutec định trước vagrave quyacute vị sẽ khocircng thể yecircu cầu chuacuteng tocirci cung cấp thuốc đoacute cho quyacute vị với mức chia sẻ chi phiacute thấp hơn

bull Quyacute vị coacute thể yecircu cầu chuacuteng tocirci bảo hiểm cho một loại thuốc nằm trong danh mục với mức chia sẻ chi phiacute thấp hơn nếu thuốc đoacute khocircng nằm trong bậc thuốc đặc trị Nếu được chấp thuận số tiền quyacute vị phải trả cho thuốc của quyacute vị sẽ iacutet hơn

bull Quyacute vị coacute thể yecircu cầu chuacuteng tocirci bỏ hạn chế hoặc giới hạn bảo hiểm cho thuốc của quyacute vị Viacute dụ như với một số thuốc nhất định Vitality Health Plan of California coacute giới hạn số lượng thuốc magrave chuacuteng tocirci sẽ đagravei thọ Nếu thuốc của quyacute vị coacute giới hạn về số lượng quyacute vị coacute thể xin chuacuteng tocirci bỏ giới hạn đoacute magrave bảo hiểm cho quyacute vị số lượng thuốc lớn hơn

Noacutei chung Vitality Health Plan of California sẽ chỉ chấp thuận yecircu cầu hưởng ngoại lệ của quyacute vị nếu thuốc thay thế coacute trong danh mục thuốc của chương trigravenh thuốc coacute mức chia sẻ chi phiacute thấp hơn hoặc khi caacutec hạn chế về việc sử dụng khaacutec sẽ khocircng coacute hiệu quả trong việc trị bệnh cho quyacute vị vagravehoặc sẽ gacircy cho quyacute vị caacutec taacutec dụng bất lợi về mặt y tế Quyacute vị necircn liecircn lạc với chuacuteng tocirci để đề nghị chuacuteng tocirci ra quyết định đagravei thọ lần đầu cho quyacute vị được hưởng ngoại lệ đối với caacutec hạn chế về danh mục thuốc sử dụng Khi quyacute vị yecircu cầu trường hợp ngoại lệ về danh mục hoặc về giới hạn sử dụng quyacute vị necircn gửi thecircm hồ sơ hỗ trợ yecircu cầu từ baacutec sĩ kecirc toa hoặc baacutec sĩ Noacutei chung chuacuteng tocirci phải ra quyết định trong vograveng 72 giờ kể từ khi nhận được giấy xaacutec nhận ủng hộ của người kecirc thuốc cho quyacute vị Quyacute vị coacute thể xin hưởng ngoại lệ xuacutec tiến (nhanh) nếu quyacute vị hoặc baacutec sĩ của quyacute vị tin rằng sức khỏe của quyacute vị coacute thể bị tổn hại nghiecircm trọng khi phải chờ đợi đến 72 giờ để ra quyết định Nếu yecircu cầu xuacutec tiến của quyacute vị được chấp nhận chuacuteng tocirci phải ra quyết định cho quyacute vị trong khocircng quaacute 24 giờ sau khi chuacuteng tocirci nhận được giấy xaacutec nhận ủng hộ của baacutec sĩ hay người kecirc thuốc cho quyacute vị

II-50

Tocirci sẽ được đối xử ra sao khi chưa bagraven được với baacutec sĩ để đổi thuốc hay xin hưởng ngoại lệ Dugrave lagrave hội viecircn mới hay cũ của chương trigravenh thuốc magrave quyacute vị đang dugraveng cũng coacute thể khocircng coacute trong danh mục của chuacuteng tocirci Hoặc thuốc magrave quyacute vị đang dugraveng coacute thể coacute trong danh mục của chuacuteng tocirci nhưng quyacute vị iacutet coacute khả năng được nhận thuốc đoacute Viacute dụ như quyacute vị coacute thể phải xin pheacutep chuacuteng tocirci trước thigrave mới được mua thuốc toa của quyacute vị Quyacute vị necircn noacutei chuyện với baacutec sĩ của quyacute vị để quyết định xem quyacute vị coacute necircn đổi sang dugraveng một loại thuốc phugrave hợp được chuacuteng tocirci bảo hiểm hoặc xin hưởng ngoại lệ danh mục thuốc hay khocircng để chuacuteng tocirci sẽ bảo hiểm cho thuốc quyacute vị dugraveng Trong khi quyacute vị trao đổi với baacutec sĩ của migravenh để xaacutec định caacutech lagravem đuacuteng đắn cho migravenh chuacuteng tocirci coacute thể bảo hiểm cho thuốc của quyacute vị trong một số trường hợp nhất định trong vograveng 90 ngagravey đầu sau khi quyacute vị trở thagravenh hội viecircn của chương trigravenh Đối với mỗi loại thuốc của quyacute vị khocircng nằm trong danh mục hoặc số lượng thuốc bị giới hạn chuacuteng tocirci sẽ bảo hiểm một số lượng tạm thời cho 30 ngagravey Nếu toa thuốc của quyacute vị được kecirc cho số ngagravey iacutet hơn chuacuteng tocirci sẽ cho pheacutep mua tiếp để coacute được lượng cấp tối đa 30 ngagravey của thuốc đoacute Sau khi bảo hiểm cho 30 ngagravey đầu tiecircn chuacuteng tocirci sẽ khocircng chi trả cho những loại thuốc nagravey nữa ngay cả khi quyacute vị lagrave hội viecircn của chuacuteng tocirci iacutet hơn 90 ngagravey Nếu quyacute vị lagrave một người cư truacute tại một cơ sở chăm soacutec lacircu dagravei vagrave quyacute vị cần những loại thuốc khocircng nằm trong danh mục hoặc nếu khả năng lấy được thuốc của quyacute vị bị giới hạn nhưng quyacute vị đatilde lagrave hội viecircn của chuacuteng tocirci hơn 90 ngagravey chuacuteng tocirci sẽ bảo hiểm một số lượng khẩn cấp cho 31 ngagravey trong thời gian quyacute vị yecircu cầu trường hợp ngoại lệ về danh mục Trong trường hợp người coacute bảo hiểm của chương trigravenh sẽ chuyển từ cơ sở điều trị nagravey sang cơ sở khaacutec Vitality Health Plan of California sẽ bảo đảm sử dụng quy trigravenh chấp thuận nhanh cho caacutec thuốc Phần D khocircng coacute trong danh mục Thủ tục nagravey cũng được aacutep dụng cho caacutec loại thuốc Phần D coacute trong danh saacutech thuốc cần phải xin pheacutep trước hoặc phải thực hiện liệu phaacutep bước Viacute dụ về caacutec mức độ thay đổi trong việc chăm soacutec gồm coacute người coacute bảo hiểm của chương trigravenh được xuất viện về nhagrave người coacute bảo hiểm của chương trigravenh khocircng cograven ở tại cơ sở điều dưỡng theo Medicare Phần A vagrave cần chuyển về danh saacutech thuốc phần D người coacute bảo hiểm của chương trigravenh khocircng cograven ở tại cơ sở chăm soacutec lacircu dagravei vagrave trở về cộng đồng vagrave người coacute bảo hiểm của chương trigravenh lagrave người xuất viện từ bệnh viện tacircm thần coacute phaacutec đồ thuốc coacute tiacutenh caacute nhacircn cao Caacutec nhagrave thuốc coacute hợp đồng Vitality Health Plans coacute thể nhập matilde đệ trigravenh tiecircu chuẩn của ngagravenh tại điểm baacuten hagraveng để hủy bỏ caacutec hạn chế về danh mục thuốc Dịch vụ sau giờ lagravem việc (MedImpact) của PMB coacute hợp đồng với Vitality Health Plans sẽ cung cấp cho caacutec nhagrave thuốc tiếp xuacutec với những đại diện coacute thể giải quyết caacutec vấn đề trong việc xử lyacute yecircu cầu của nhagrave thuốc Việc tiếp xuacutec nagravey sẽ cho pheacutep nhagrave thuốc giải quyết được caacutec yecircu cầu về cấp thuốc ngay tại điểm baacuten hagraveng vagrave bảo đảm người coacute bảo hiểm của chương trigravenh coacute thể nhận được thuốc theo caacutech thức đaacuteng tin cậy Để tigravem hiểu thecircm Để biết chi tiết hơn về việc Vitality Health Plan of California đagravei thọ cho thuốc toa của quyacute vị xin xem Chứng từ Bảo hiểm của quyacute vị vagrave caacutec tagravei liệu khaacutec của chương trigravenh Nếu quyacute vị coacute thắc mắc về Vitality Health Plan of California xin liecircn lạc với chuacuteng tocirci Thocircng tin liecircn lạc của chuacuteng tocirci cugraveng với ngagravey cập nhật cuối cugraveng của danh mục thuốc coacute in tại bigravea trước vagrave bigravea sau Nếu quyacute vị coacute caacutec thắc mắc chung về việc bảo hiểm thuốc toa Medicare xin gọi Medicare theo số 1-800-MEDICARE (1-800-633-4227) 24 giờ mỗi ngagravey7 mỗi tuần Người dugraveng TTYTDD vui lograveng gọi 1-877-486-2048 Hoặc vagraveo httpwwwmedicaregov

II-51

Danh mục Thuốc của Vitality Health Plan of California Danh mục thuốc bắt đầu từ trang kế tiếp coacute thocircng tin về việc đagravei thọ cho một số loại thuốc được Vitality Health Plan of California đagravei thọ Nếu quyacute vị coacute những trở ngại trong việc tigravem thuốc của migravenh trong danh saacutech xin mở Bảng mục lục bắt đầu từ trang I-1 Cột thứ nhất của bảng nagravey lagrave tecircn thuốc Caacutec thuốc thương hiệu được viết hoa (viacute dụ ELIQUIS) vagrave caacutec thuốc gốc được viết thường in nghiecircng (viacute dụ simvastatin) Thocircng tin trong cột Yecircu cầuGiới hạn cho quyacute vị biết Vitality Health Plan of California coacute yecircu cầu đặc biệt nagraveo về việc đagravei thọ cho thuốc của quyacute vị hay khocircng Viết tắt Mocirc tả Giải thiacutech

PA Hạn chế về Xin pheacutep Trước

Quyacute vị (hoặc baacutec sĩ của quyacute vị) bắt buộc phải xin Vitality Health Plan of California cho pheacutep trước khi quyacute vị mua thuốc toa của quyacute vị Nếu khocircng được chấp thuận trước Vitality Health Plan of California coacute thể sẽ khocircng đagravei thọ cho thuốc nagravey

PA BvD

Hạn chế về Xin pheacutep Trước để Xaacutec định của Phần B so với Phần D

Thuốc nagravey coacute thể đủ tiecircu chuẩn để được đagravei thọ theo Medicare Phần B hoặc Phần D Quyacute vị (hoặc baacutec sĩ của quyacute vị) cần phải xin Vitality Health Plan of California cho pheacutep trước để xaacutec định thuốc nagravey sẽ được đagravei thọ theo Medicare Phần D trước khi quyacute vị mua thuốc toa của migravenh Nếu khocircng được chấp thuận trước Vitality Health Plan of California coacute thể sẽ khocircng đagravei thọ cho thuốc nagravey

PA-HRM

Hạn chế về Xin pheacutep Trước đối với Thuốc coacute Nguy cơ cao

Thuốc nagravey được CMS coi lagrave nguy hiểm tiềm tagraveng vagrave do đoacute lagrave Loại thuốc Rủi ro Cao đối với người thụ hưởng Medicare từ 65 tuổi trở lecircn Caacutec hội viecircn từ 65 tuổi trở lecircn phải xin Vitality Health Plan of California cho pheacutep trước khi quyacute vị mua thuốc toa của quyacute vị Nếu khocircng được chấp thuận trước Vitality Health Plan of California coacute thể sẽ khocircng đagravei thọ cho thuốc nagravey

PA NSO

Hạn chế về Xin pheacutep Trước chỉ đối với Lần bắt đầu Mới

Nếu quyacute vị lagrave hội viecircn mới hoặc nếu quy vị chưa dugraveng loại thuốc nagravey trước đacircy quyacute vị (hoặc baacutec sĩ của quyacute vị) phải xin Vitality Health Plan of California cho pheacutep trước khi quyacute vị mua thuốc toa của quyacute vị Nếu khocircng được chấp thuận trước Vitality Health Plan of California coacute thể sẽ khocircng đagravei thọ cho thuốc nagravey

PA NSO-HRM

Hạn chế về Xin pheacutep Trước đối với Thuốc Nguy cơ cao vagrave Chỉ đối với Lần bắt đầu Mới


QL Hạn chế về Giới hạn Số lượng

Vitality Health Plan giới hạn số lượng thuốc nagravey được bảo hiểm trecircn mỗi đơn hoặc trong khoảng thời gian cụ thể

II-52

Viết tắt Mocirc tả Giải thiacutech

ST Hạn chế về Trị liệu theo từng Giai đoạn

Trước khi Vitality Health Plan of California đagravei thọ cho thuốc nagravey quyacute vị phải dugraveng thử (những) loại thuốc khaacutec để điều cho bệnh trạng của migravenh Thuốc nagravey chỉ coacute thể được đagravei thọ nếu (những) thuốc khaacutec khocircng coacute hiệu quả với quyacute vị

EX Thuốc Phần D Khocircng được bảo hiểm

Thocircng thường thuốc kecirc đơn nagravey khocircng được bảo hiểm trong Chương trigravenh Thuốc kecirc đơn của Medicare Số tiền quyacute vị phải thanh toaacuten khi mua thuốc theo đơn nagravey khocircng được tiacutenh vagraveo tổng chi phiacute thuốc của quyacute vị (coacute nghĩa lagrave số tiền quyacute vị thanh toaacuten khocircng giuacutep quyacute vị đủ điều kiện hưởng bảo hiểm tai họa) Ngoagravei ra nếu quyacute vị đang nhận trợ cấp đặc biệt cho thuốc kecirc đơn của migravenh quyacute vị sẽ khocircng được nhận bất kỳ trợ cấp đặc biệt nagraveo để thanh toaacuten cho thuốc nagravey

LA Thuốc được Phacircn phối Giới hạn

Đơn thuốc nagravey coacute thể chỉ sẵn coacute ở một số nhagrave thuốc nhất định Để biết thocircng tin chi tiết vui lograveng xem Danh bạ Nhagrave thuốc hoặc gọi cho Phograveng Dịch vụ Hội viecircn tại số 888-254-9907 Người dugraveng TTYTDD vui lograveng gọi 888-254-9907

GC Giai đoạn Khocircng được Bảo hiểm

Chuacuteng tocirci cung cấp bảo hiểm cho loại thuốc theo toa nagravey trong giai đoạn khocircng được bảo hiểm Xin tham khảo Chứng từ Bảo hiểm để biết thecircm về việc bảo hiểm nagravey

NDS Lượng cấp Theo Ngagravey Khocircng Keacuteo dagravei

Quyacute vị coacute thể nhận được nhiều hơn lượng thuốc 1 thaacuteng của hầu hết thuốc trong danh mục thuốc qua đặt hagraveng qua thư hoặc baacuten lẻ theo mức chia sẻ chi phiacute được giảm bớt Thuốc khocircng coacute cho lượng thuốc theo ngagravey gia hạn (lớn hơn lượng thuốc 1 thaacuteng) qua quyền lợi đặt hagraveng qua thư hoặc nhagrave thuốc baacuten lẻ được ghi ldquoNDSrdquo trong cột Yecircu cầuGiới hạn của danh mục thuốc

HI Thuốc Truyền tại Nhagrave thuốc

Thuốc theo toa nagravey coacute thể được bao trả theo quyền lợi y tế của chuacuteng tocirci Để biết thecircm thocircng tin gọi

TUỔI Giới hạn Tuổi taacutec Thuốc theo toa nagravey sẽ chỉ được cung cấp cho caacutec nhoacutem tuổi cụ thể

CB Quyền lợi Tối đa Thuốc nagravey coacute mức quyền lợi tối đa

II-53

Thocircng thường thuốc kecirc đơn nagravey khocircng được bảo hiểm trong Chương trigravenh Thuốc kecirc đơn của Medicare Số tiền quyacute vị phải thanh toaacuten khi mua thuốc theo đơn nagravey khocircng được tiacutenh vagraveo tổng chi phiacute thuốc của quyacute vị (coacute nghĩa lagrave số tiền quyacute vị thanh toaacuten khocircng giuacutep quyacute vị đủ điều kiện hưởng bảo hiểm tai họa) Ngoagravei ra nếu quyacute vị đang nhận trợ cấp đặc biệt cho thuốc kecirc đơn của migravenh quyacute vị sẽ khocircng được nhận bất kỳ trợ cấp đặc biệt nagraveo để thanh toaacuten cho thuốc nagravey Tecircn thuốc Bậc Thuốc Yecircu cầuGiới hạn

viecircn uống sildenafil 100 mg (Viagra) 2 Giới hạn Số lượng (tối đa 6 viecircn cứ 30 ngagravey)



Tiền đồng trảĐồng bảo hiểm đối với caacutec hội viecircn của Plus (HMO) tại Quận San Joaquin vagrave Quận Santa Clara

Bậc Mocirc tả Tiền đồng trảĐồng bảo hiểm

với lượng cấp 30 ngagravey với lượng cấp 90 ngagravey Bậc 1 Thuốc gốc được Ưu tiecircn $0 $0 Bậc 2 Thuốc gốc 25 25 Bậc 3 Thuốc Chiacutenh hiệu được Ưu tiecircn 25 25 Bậc 4 Thuốc Khocircng được Ưu tiecircn 25 25 Bậc 5 Bậc Đặc trị 25 Khocircng aacutep dụng Bậc 6 Caacutec loại vắc-xin $0 Khocircng aacutep dụng

Table of Contents

Analgesics3Anesthetics 10Anti-AddictionSubstance Abuse Treatment Agents 11Antianxiety Agents 12Antibacterials 14Anticancer Agents 22Anticholinergic Agents 37Anticonvulsants37Antidementia Agents 42Antidepressants 42Antidiabetic Agents 46Antifungals51Antigout Agents 53Antihistamines53Anti-Infectives (Skin And Mucous Membrane)54Antimigraine Agents54Antimycobacterials55Antinausea Agents56Antiparasite Agents 58Antiparkinsonian Agents59Antipsychotic Agents61Antivirals (Systemic)66Blood ProductsModifiersVolume Expanders 73Caloric Agents77Cardiovascular Agents 81Central Nervous System Agents 93Contraceptives98Dental And Oral Agents 105Dermatological Agents 106Devices 111Enzyme ReplacementModifiers 112Eye Ear Nose Throat Agents 114Gastrointestinal Agents 118Genitourinary Agents 123Heavy Metal Antagonists 124Hormonal Agents StimulantReplacementModifying124

1

Immunological Agents132Inflammatory Bowel Disease Agents 142Irrigating Solutions143Metabolic Bone Disease Agents144Miscellaneous Therapeutic Agents146Ophthalmic Agents 148Replacement Preparations 150Respiratory Tract Agents 152Skeletal Muscle Relaxants 157Sleep Disorder Agents 157Vasodilating Agents158Vitamins And Minerals159

2

Drug Name Drug Tier RequirementsLimits

AnalgesicsAnalgesics Miscellaneousacetaminophen-codeine oral solution120-12 mg5 ml

1 GC NEDS QL (4500 per 30 days)

acetaminophen-codeine oral tablet300-15 mg

2 NEDS QL (360 per 30 days)


(Tylenol-Codeine 3) 2 NEDS QL (360 per 30 days)



ascomp with codeine oral capsule30-50-325-40 mg

4 PA-HRM NEDS QL (180 per 30 days) AGE (Max 64 Years)

buprenorphine hcl injection solution03 mgml

(Buprenex) 2

buprenorphine hcl injection syringe03 mgml

2

buprenorphine transdermal patch weekly 10 mcghour 15 mcghour 20 mcghour 5 mcghour 75 mcghour

(Butrans) 4 NEDS QL (4 per 28 days)

butalbital compound wcodeine oral capsule 30-50-325-40 mg


butalbital-acetaminop-caf-cod oral capsule 50-300-40-30 mg

(Fioricet with Codeine) 4 PA-HRM NEDS QL (180 per 30 days) AGE (Max 64 Years)



butalbital-acetaminophen oral tablet50-325 mg

(Tencon) 2 PA-HRM QL (180 per 30 days) AGE (Max 64 Years)

butalbital-acetaminophen-caff oral capsule 50-325-40 mg

(Zebutal) 4 PA-HRM QL (180 per 30 days) AGE (Max 64 Years)

butalbital-acetaminophen-caff oral tablet 50-325-40 mg

(Esgic) 2 PA-HRM QL (180 per 30 days) AGE (Max 64 Years)

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document

3


butalbital-aspirin-caffeine oral capsule 50-325-40 mg

(Fiorinal) 2 PA-HRM QL (180 per 30 days) AGE (Max 64 Years)

butalbital-aspirin-caffeine oral tablet 50-325-40 mg

2 PA-HRM QL (180 per 30 days) AGE (Max 64 Years)

butorphanol tartrate nasal spraynon-aerosol 10 mgml


capacet oral capsule 50-325-40 mg 4 PA-HRM QL (180 per 30 days) AGE (Max 64 Years)

codeine sulfate oral tablet 15 mg 30 mg 60 mg


endocet oral tablet 10-325 mg 2 NEDS QL (180 per 30 days)

endocet oral tablet 25-325 mg 5-325 mg



fentanyl citrate buccal lozenge on a handle 1200 mcg 1600 mcg 200 mcg 400 mcg 600 mcg 800 mcg

(Actiq) 5 PA NEDS QL (120 per 30 days)

fentanyl transdermal patch 72 hour100 mcghr 12 mcghr 25 mcghr 50 mcghr 75 mcghr

(Duragesic) 2 NEDS QL (10 per 30 days)

hydrocodone-acetaminophen oral solution 75-325 mg15 ml


hydrocodone-acetaminophen oral tablet 10-300 mg

(Vicodin HP) 4 NEDS QL (180 per 30 days)


(Lorcet HD) 2 NEDS QL (180 per 30 days)






(Lorcet (hydrocodone)) 2 NEDS QL (240 per 30 days)




(Lorcet Plus) 2 NEDS QL (180 per 30 days)


4


hydrocodone-ibuprofen oral tablet10-200 mg

(Ibudone) 4 NEDS QL (150 per 30 days)

hydrocodone-ibuprofen oral tablet 5-200 mg




hydromorphone (pf) injection solution 10 (mgml) (5 ml) 10 mgml

2

hydromorphone oral liquid 1 mgml (Dilaudid) 2 NEDS QL (1200 per 30 days)

hydromorphone oral tablet 2 mg 4 mg 8 mg

(Dilaudid) 2 NEDS QL (180 per 30 days)

LAZANDA NASAL SPRAYNON-AEROSOL 100 MCGSPRAY 300 MCGSPRAY 400 MCGSPRAY

5 PA NEDS QL (30 per 30 days)

lorcet (hydrocodone) oral tablet 5-325 mg


lorcet hd oral tablet 10-325 mg 2 NEDS QL (180 per 30 days)

lorcet plus oral tablet 75-325 mg 2 NEDS QL (180 per 30 days)

methadone injection solution 10 mgml

2

methadone oral solution 10 mg5 ml 2 NEDS QL (600 per 30 days)


methadone oral tablet 10 mg (Dolophine) 2 NEDS QL (120 per 30 days)


methadose oral tabletsoluble 40 mg 2 NEDS QL (30 per 30 days)

morphine concentrate oral solution100 mg5 ml (20 mgml)


MORPHINE INJECTION SYRINGE 10 MGML

4

morphine intravenous solution 10 mgml 4 mgml 8 mgml

2


5


morphine oral solution 10 mg5 ml 2 NEDS QL (700 per 30 days)

morphine oral solution 20 mg5 ml (4 mgml)


MORPHINE ORAL TABLET 15 MG




morphine oral tablet extended release 100 mg 200 mg 60 mg

(MS Contin) 2 NEDS QL (60 per 30 days)

morphine oral tablet extended release 15 mg 30 mg


NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HR 100 MG 150 MG 200 MG 250 MG 50 MG


NUCYNTA ORAL TABLET 100 MG 50 MG 75 MG


oxycodone oral capsule 5 mg 4 NEDS QL (180 per 30 days)

oxycodone oral concentrate 20 mgml


oxycodone oral solution 5 mg5 ml 4 NEDS QL (1300 per 30 days)

oxycodone oral tablet 10 mg 2 NEDS QL (180 per 30 days)

oxycodone oral tablet 15 mg 30 mg (Roxicodone) 2 NEDS QL (120 per 30 days)


oxycodone oral tablet 5 mg (Roxicodone) 2 NEDS QL (180 per 30 days)

oxycodone oral tabletoral onlyextrel12 hr 10 mg 15 mg 20 mg 30 mg 40 mg 60 mg 80 mg

(OxyContin) 3 NEDS QL (60 per 30 days)

oxycodone-acetaminophen oral tablet 10-325 mg

(Endocet) 2 NEDS QL (180 per 30 days)

oxycodone-acetaminophen oral tablet 25-325 mg 5-325 mg





6


oxycodone-aspirin oral tablet48355-325 mg


OXYCONTIN ORAL TABLETORAL ONLYEXTREL12 HR 10 MG 15 MG 20 MG 30 MG 40 MG 60 MG 80 MG


oxymorphone oral tablet 10 mg (Opana) 4 NEDS QL (120 per 30 days)


oxymorphone oral tablet extended release 12 hr 10 mg 15 mg 20 mg 30 mg 40 mg 5 mg 75 mg


tencon oral tablet 50-325 mg 2 PA-HRM QL (180 per 30 days) AGE (Max 64 Years)

tramadol oral tablet 50 mg (Ultram) 1 GC NEDS QL (240 per 30 days)

tramadol-acetaminophen oral tablet375-325 mg

(Ultracet) 2 NEDS QL (300 per 30 days)

vicodin es oral tablet 75-300 mg 4 NEDS QL (180 per 30 days)

vicodin hp oral tablet 10-300 mg 4 NEDS QL (180 per 30 days)

vicodin oral tablet 5-300 mg 4 NEDS QL (240 per 30 days)

XTAMPZA ER ORAL CAPSPRINKLER12HR(DONT CRUSH) 135 MG 18 MG 9 MG


XTAMPZA ER ORAL CAPSPRINKLER12HR(DONT CRUSH) 27 MG




zebutal oral capsule 50-325-40 mg 4 PA-HRM QL (180 per 30 days) AGE (Max 64 Years)


7


Nonsteroidal Anti-Inflammatory AgentsCALDOLOR INTRAVENOUS RECON SOLN 800 MG8 ML (100 MGML)

4

celecoxib oral capsule 100 mg 200 mg 50 mg

(Celebrex) 2 QL (60 per 30 days)

celecoxib oral capsule 400 mg (Celebrex) 4 QL (60 per 30 days)

diclofenac epolamine transdermal patch 12 hour 13

(Flector) 4 PA

diclofenac potassium oral tablet 50 mg

2

diclofenac sodium oral tablet extended release 24 hr 100 mg

(Voltaren-XR) 2

diclofenac sodium oral tabletdelayed release (drec) 25 mg 50 mg 75 mg

2

diclofenac sodium topical drops 15

2 QL (300 per 30 days)

diclofenac sodium topical gel 1 (Voltaren) 2

diclofenac sodium topical gel 3 (Solaraze) 4 PA QL (100 per 28 days)

diclofenac-misoprostol oral tabletirdelayed relbiphasic 50-200 mg-mcg

(Arthrotec 50) 4


(Arthrotec 75) 4

diflunisal oral tablet 500 mg 2

DUEXIS ORAL TABLET 800-266 MG


etodolac oral capsule 200 mg 300 mg

4

etodolac oral tablet 400 mg (Lodine) 4

etodolac oral tablet 500 mg 4

fenoprofen oral tablet 600 mg (Nalfon) 4

flurbiprofen oral tablet 100 mg 50 mg

2

ibu oral tablet 400 mg 600 mg 800 mg

1 GC


8


ibuprofen oral suspension 100 mg5 ml

(Childrens Advil) 2

ibuprofen oral tablet 400 mg 600 mg 800 mg

(IBU) 1 GC

indomethacin oral capsule 25 mg 1 PA-HRM GC QL (240 per 30 days) AGE (Max 64 Years)


indomethacin oral capsule extended release 75 mg


ketoprofen oral capsule 25 mg 50 mg 75 mg

4

ketoprofen oral capsuleext rel pellets 24 hr 200 mg

4

ketorolac injection cartridge 15 mgml




ketorolac injection solution 15 mgml


ketorolac injection solution 30 mgml (1 ml)


ketorolac injection syringe 15 mgml 2 PA-HRM QL (40 per 30 days) AGE (Max 64 Years)


ketorolac intramuscular cartridge 60 mg2 ml


ketorolac intramuscular solution 60 mg2 ml



9


ketorolac intramuscular syringe 60 mg2 ml


ketorolac oral tablet 10 mg 2 PA-HRM QL (20 per 30 days) AGE (Max 64 Years)

mefenamic acid oral capsule 250 mg 4

meloxicam oral tablet 15 mg 75 mg (Mobic) 1 GC

nabumetone oral tablet 500 mg 750 mg

2

naproxen oral tablet 250 mg 375 mg

1 GC

naproxen oral tablet 500 mg (Naprosyn) 1 GC

naproxen oral tabletdelayed release (drec) 375 mg 500 mg

(EC-Naprosyn) 2

PENNSAID TOPICAL SOLUTION IN METERED-DOSE PUMP 20 MGGRAM ACTUATION(2 )


piroxicam oral capsule 10 mg 20 mg

(Feldene) 4

sulindac oral tablet 150 mg 200 mg 2

tolmetin oral capsule 400 mg 4

tolmetin oral tablet 200 mg 600 mg 4

VIMOVO ORAL TABLETIRDELAYED RELBIPHASIC 375-20 MG 500-20 MG


VOLTAREN TOPICAL GEL 1 2

AnestheticsLocal Anestheticsglydo mucous membrane jelly in applicator 2


lidocaine (pf) injection solution 10 mgml (1 ) 15 mgml (15 ) 20 mgml (2 ) 5 mgml (05 )

(Xylocaine-MPF) 1 GC

lidocaine (pf) injection solution 40 mgml (4 )

1 GC

lidocaine (pf) intravenous solution20 mgml (2 )

(Xylocaine (Cardiac) (PF))

1 GC


10


lidocaine hcl injection solution 10 mgml (1 ) 20 mgml (2 ) 5 mgml (05 )

(Xylocaine) 1 GC

lidocaine hcl mucous membrane jelly2


lidocaine hcl mucous membrane solution 4 (40 mgml)

2

lidocaine topical adhesive patchmedicated 5

(Lidoderm) 2 PA QL (90 per 30 days)

lidocaine topical ointment 5 2 PA QL (90 per 30 days)

lidocaine viscous mucous membrane solution 2

2

lidocaine-prilocaine topical cream25-25

4 PA QL (30 per 30 days)

ZTLIDO TOPICAL ADHESIVE PATCHMEDICATED 18


Anti-AddictionSubstance Abuse Treatment AgentsAnti-AddictionSubstance Abuse Treatment Agentsacamprosate oral tabletdelayed release (drec) 333 mg

2

buprenorphine hcl sublingual tablet2 mg 8 mg


buprenorphine-naloxone sublingual film 12-3 mg 8-2 mg

(Suboxone) 4 QL (60 per 30 days)



buprenorphine-naloxone sublingual tablet 2-05 mg 8-2 mg


bupropion hcl (smoking deter) oral tablet extended release 12 hr 150 mg

2

CHANTIX CONTINUING MONTH BOX ORAL TABLET 1 MG

3 QL (336 per 365 days)

CHANTIX ORAL TABLET 05 MG 1 MG

3 QL (336 per 365 days)

CHANTIX STARTING MONTH BOX ORAL TABLETSDOSE PACK 05 MG (11)- 1 MG (42)

3


11


disulfiram oral tablet 250 mg 500 mg

(Antabuse) 2

LUCEMYRA ORAL TABLET 018 MG


naloxone injection solution 04 mgml

2

naloxone injection syringe 04 mgml 1 mgml

2

naltrexone oral tablet 50 mg 2

NARCAN NASAL SPRAYNON-AEROSOL 4 MGACTUATION


NICOTROL INHALATION CARTRIDGE 10 MG

4 QL (1008 per 90 days)

SUBLOCADE SUBCUTANEOUS SOLUTION EXTENDED REL SYRINGE 100 MG05 ML 300 MG15 ML

5 NEDS

ZUBSOLV SUBLINGUAL TABLET 07-018 MG 14-036 MG 114-29 MG 29-071 MG 57-14 MG


ZUBSOLV SUBLINGUAL TABLET 86-21 MG


Antianxiety AgentsBenzodiazepinesalprazolam oral tablet 025 mg 05 mg 1 mg

(Xanax) 1 GC NEDS QL (120 per 30 days)

alprazolam oral tablet 2 mg (Xanax) 1 GC NEDS QL (150 per 30 days)

alprazolam oral tablet extended release 24 hr 05 mg 1 mg 2 mg

(Xanax XR) 2 NEDS QL (120 per 30 days)

alprazolam oral tablet extended release 24 hr 3 mg


buspirone oral tablet 10 mg 15 mg 30 mg 5 mg 75 mg

2

chlordiazepoxide hcl oral capsule 10 mg 25 mg 5 mg


clonazepam oral tablet 05 mg 1 mg (Klonopin) 1 GC NEDS QL (90 per 30 days)


12


clonazepam oral tablet 2 mg (Klonopin) 1 GC NEDS QL (300 per 30 days)

clonazepam oral tabletdisintegrating 0125 mg 025 mg 05 mg 1 mg


clonazepam oral tabletdisintegrating 2 mg


clorazepate dipotassium oral tablet15 mg 375 mg


clorazepate dipotassium oral tablet75 mg

(Tranxene T-Tab) 2 NEDS QL (180 per 30 days)

diazepam 5 mgml oral conc 5 mgml 2 NEDS QL (1200 per 30 days)

diazepam injection solution 5 mgml 2 QL (10 per 28 days)

diazepam injection syringe 5 mgml 2 QL (10 per 28 days)

diazepam oral concentrate 5 mgml (Diazepam Intensol) 2 NEDS QL (1200 per 30 days)

diazepam oral solution 5 mg5 ml (1 mgml)


diazepam oral tablet 10 mg 2 mg 5 mg

(Valium) 1 GC NEDS QL (120 per 30 days)

estazolam oral tablet 1 mg 2 NEDS QL (60 per 30 days)


flurazepam oral capsule 15 mg 2 NEDS QL (60 per 30 days)


lorazepam injection solution 2 mgml 4 mgml

(Ativan) 1 GC QL (2 per 30 days)

lorazepam injection syringe 2 mgml 4 mgml


lorazepam oral concentrate 2 mgml (Lorazepam Intensol) 2 NEDS QL (150 per 30 days)

lorazepam oral tablet 05 mg 1 mg (Ativan) 1 GC NEDS QL (90 per 30 days)

lorazepam oral tablet 2 mg (Ativan) 1 GC NEDS QL (150 per 30 days)

midazolam oral syrup 2 mgml 2 NEDS QL (10 per 30 days)


13


oxazepam oral capsule 10 mg 15 mg 30 mg


temazepam oral capsule 15 mg 30 mg

(Restoril) 1 GC NEDS QL (30 per 30 days)

triazolam oral tablet 0125 mg 2 NEDS QL (120 per 30 days)

triazolam oral tablet 025 mg (Halcion) 2 NEDS QL (60 per 30 days)

AntibacterialsAminoglycosidesBETHKIS INHALATION SOLUTION FOR NEBULIZATION 300 MG4 ML

5 PA BvD NEDS

gentamicin injection solution 20 mg2 ml 40 mgml

2

gentamicin sulfate (ped) (pf) injection solution 20 mg2 ml

2

gentamicin sulfate (pf) intravenous solution 100 mg10 ml 60 mg6 ml 80 mg8 ml

2

neomycin oral tablet 500 mg 1 GC

streptomycin intramuscular recon soln 1 gram

4

TOBI PODHALER INHALATION CAPSULE WINHALATION DEVICE 28 MG


tobramycin in 0225 nacl inhalation solution for nebulization300 mg5 ml

(Tobi) 5 PA BvD NEDS

tobramycin sulfate injection solution40 mgml

4

Antibacterials Miscellaneousbaciim intramuscular recon soln50000 unit

2

bacitracin intramuscular recon soln50000 unit

4

chloramphenicol sod succinate intravenous recon soln 1 gram

2

clindamycin 75 mg5 ml soln 75 mg5 ml

(Clindamycin Pediatric)

4


14


clindamycin hcl oral capsule 150 mg 300 mg 75 mg

(Cleocin HCl) 1 GC

clindamycin in 5 dextrose intravenous piggyback 300 mg50 ml 600 mg50 ml 900 mg50 ml

2

clindamycin pediatric oral recon soln 75 mg5 ml

4

clindamycin phosphate injection solution 150 (mgml) (6 ml)

2

clindamycin phosphate injection solution 150 mgml

(Cleocin) 2

clindamycin phosphate intravenous solution 600 mg4 ml

(Cleocin) 2

colistin (colistimethate na) injection recon soln 150 mg

(Coly-Mycin M Parenteral)

5 PA BvD NEDS

daptomycin intravenous recon soln500 mg

(Cubicin) 5 NEDS

FIRVANQ ORAL RECON SOLN 25 MGML 50 MGML

4

linezolid 600 mg300 ml-09 nacl600 mg300 ml

5 NEDS

linezolid in dextrose 5 intravenous piggyback 600 mg300 ml

(Zyvox) 5 NEDS

linezolid oral suspension for reconstitution 100 mg5 ml

(Zyvox) 5 NEDS

linezolid oral tablet 600 mg (Zyvox) 2

methenamine hippurate oral tablet 1 gram

(Hiprex) 2

metronidazole in nacl (iso-os) intravenous piggyback 500 mg100 ml

(Metro IV) 2

metronidazole oral tablet 250 mg 500 mg

(Flagyl) 1 GC

nitrofurantoin macrocrystal oral capsule 100 mg 50 mg

(Macrodantin) 2 QL (120 per 30 days)

nitrofurantoin macrocrystal oral capsule 25 mg


nitrofurantoin monohydm-cryst oral capsule 100 mg

(Macrobid) 2 QL (60 per 30 days)

polymyxin b sulfate injection recon soln 500000 unit

2


15


SYNERCID INTRAVENOUS RECON SOLN 500 MG

5 NEDS

trimethoprim oral tablet 100 mg 1 GC

vancomycin intravenous recon soln1000 mg 125 gram 10 gram 5 gram 500 mg 750 mg

2

vancomycin oral capsule 125 mg 250 mg

(Vancocin) 4

XIFAXAN ORAL TABLET 200 MG



5 PA NEDS

Cephalosporinscefaclor oral capsule 250 mg 500 mg

2

cefaclor oral suspension for reconstitution 125 mg5 ml 250 mg5 ml 375 mg5 ml

4

cefaclor oral tablet extended release 12 hr 500 mg

4

cefadroxil oral capsule 500 mg 2

cefadroxil oral suspension for reconstitution 250 mg5 ml 500 mg5 ml

2

cefadroxil oral tablet 1 gram 4

cefazolin injection recon soln 1 gram 10 gram 500 mg

2

cefdinir oral capsule 300 mg 2

cefdinir oral suspension for reconstitution 125 mg5 ml 250 mg5 ml

2

cefditoren pivoxil oral tablet 200 mg 4

cefditoren pivoxil oral tablet 400 mg (Spectracef) 4

cefepime injection recon soln 1 gram 2 gram

(Maxipime) 2

cefixime oral capsule 400 mg (Suprax) 2

cefixime oral suspension for reconstitution 100 mg5 ml 200 mg5 ml

(Suprax) 4

cefotaxime injection recon soln 1 gram

2


16


cefoxitin intravenous recon soln 1 gram 10 gram 2 gram

4

cefpodoxime oral suspension for reconstitution 100 mg5 ml 50 mg5 ml

2

cefpodoxime oral tablet 100 mg 200 mg

2

cefprozil oral suspension for reconstitution 125 mg5 ml 250 mg5 ml

2

cefprozil oral tablet 250 mg 500 mg 2

ceftazidime injection recon soln 1 gram 2 gram 6 gram

(Tazicef) 2

ceftriaxone injection recon soln 1 gram 10 gram 2 gram 250 mg 500 mg

2

cefuroxime axetil oral tablet 250 mg 500 mg

2

cefuroxime sodium injection recon soln 750 mg

2

cefuroxime sodium intravenous recon soln 15 gram 75 gram

2

cephalexin oral capsule 250 mg 500 mg

(Keflex) 1 GC

cephalexin oral capsule 750 mg (Keflex) 4

cephalexin oral suspension for reconstitution 125 mg5 ml 250 mg5 ml

2

cephalexin oral tablet 250 mg 500 mg

2

TEFLARO INTRAVENOUS RECON SOLN 400 MG 600 MG

5 NEDS

Macrolidesazithromycin intravenous recon soln500 mg

(Zithromax) 2

azithromycin oral packet 1 gram (Zithromax) 4

azithromycin oral suspension for reconstitution 100 mg5 ml

(Zithromax) 4


(Zithromax) 2


17


azithromycin oral tablet 250 mg (6 pack) 500 mg (3 pack) 600 mg

1 GC

azithromycin oral tablet 250 mg 500 mg

(Zithromax) 1 GC

clarithromycin oral suspension for reconstitution 125 mg5 ml 250 mg5 ml

2

clarithromycin oral tablet 250 mg 500 mg

2

clarithromycin oral tablet extended release 24 hr 500 mg

4

DIFICID ORAL TABLET 200 MG

5 ST NEDS QL (20 per 10 days)

erythromycin ethylsuccinate oral suspension for reconstitution 200 mg5 ml

(EES Granules) 4


(EryPed 400) 4

erythromycin oral tablet 250 mg 500 mg

2

Miscellaneous B-Lactam Antibioticsaztreonam injection recon soln 1 gram 2 gram

(Azactam) 2

CAYSTON INHALATION SOLUTION FOR NEBULIZATION 75 MGML

5 PA LA NEDS

ertapenem injection recon soln 1 gram

(Invanz) 4

imipenem-cilastatin intravenous recon soln 250 mg

2


(Primaxin IV) 2

meropenem intravenous recon soln 1 gram

(Merrem) 4

meropenem intravenous recon soln500 mg

(Merrem) 4

meropenem-09 nacl 500 mg50500 mg50 ml

4


18


Penicillinsamoxicillin oral capsule 250 mg 500 mg

1 GC

amoxicillin oral suspension for reconstitution 125 mg5 ml 200 mg5 ml 250 mg5 ml 400 mg5 ml

1 GC

amoxicillin oral tablet 500 mg 875 mg

1 GC

amoxicillin oral tabletchewable 125 mg 250 mg

1 GC

amoxicillin-pot clavulanate oral suspension for reconstitution 200-285 mg5 ml 400-57 mg5 ml

2

amoxicillin-pot clavulanate oral suspension for reconstitution 250-625 mg5 ml

(Augmentin) 4


(Augmentin ES-600) 2

amoxicillin-pot clavulanate oral tablet 250-125 mg

4

amoxicillin-pot clavulanate oral tablet 500-125 mg 875-125 mg

(Augmentin) 1 GC

amoxicillin-pot clavulanate oral tablet extended release 12 hr 1000-625 mg

(Augmentin XR) 4

amoxicillin-pot clavulanate oral tabletchewable 200-285 mg 400-57 mg

2

ampicillin oral capsule 250 mg 500 mg

2

ampicillin sodium injection recon soln 1 gram 10 gram 125 mg 2 gram 250 mg 500 mg

2

ampicillin-sulbactam injection recon soln 15 gram 15 gram 3 gram

(Unasyn) 2

BICILLIN L-A INTRAMUSCULAR SYRINGE 1200000 UNIT2 ML 2400000 UNIT4 ML 600000 UNITML

4


19


dicloxacillin oral capsule 250 mg 500 mg

2

nafcillin 1 gm 50 ml inj 1 gram50 ml

2

nafcillin injection recon soln 1 gram 2

nafcillin injection recon soln 10 gram

5 NEDS


penicillin g potassium injection recon soln 20 million unit

(Pfizerpen-G) 4

penicillin g procaine intramuscular syringe 12 million unit2 ml 600000 unitml

2

penicillin v potassium oral recon soln125 mg5 ml 250 mg5 ml

2

penicillin v potassium oral tablet 250 mg 500 mg

1 GC

pfizerpen-g injection recon soln 20 million unit

4

piperacillin-tazobactam intravenous recon soln 225 gram 3375 gram 45 gram

(Zosyn) 2 PA BvD

piperacillin-tazobactam intravenous recon soln 405 gram

(Zosyn) 4 PA BvD

QuinolonesBAXDELA ORAL TABLET 450 MG


ciprofloxacin (mixture) oral tablet er multiphase 24 hr 1000 mg 500 mg

2

ciprofloxacin hcl oral tablet 100 mg 2

ciprofloxacin hcl oral tablet 250 mg 500 mg

(Cipro) 1 GC

ciprofloxacin hcl oral tablet 750 mg 1 GC

ciprofloxacin in 5 dextrose intravenous piggyback 200 mg100 ml 400 mg200 ml

2

ciprofloxacin oral suspensionmicrocapsule recon 250 mg5 ml 500 mg5 ml

(Cipro) 2


20


levofloxacin in d5w intravenous piggyback 250 mg50 ml 500 mg100 ml 750 mg150 ml

2

levofloxacin intravenous solution 25 mgml

4

levofloxacin oral solution 250 mg10 ml

4

levofloxacin oral tablet 250 mg 1 GC

levofloxacin oral tablet 500 mg 750 mg

(Levaquin) 1 GC

moxifloxacin oral tablet 400 mg 2Sulfonamidessulfadiazine oral tablet 500 mg 2

sulfamethoxazole-trimethoprim intravenous solution 400-80 mg5 ml

2

sulfamethoxazole-trimethoprim oral suspension 200-40 mg5 ml

(Sulfatrim) 2

sulfamethoxazole-trimethoprim oral tablet 400-80 mg

(Bactrim) 1 GC


(Bactrim DS) 1 GC

sulfatrim oral suspension 200-40 mg5 ml

4

Tetracyclinesdemeclocycline oral tablet 150 mg 300 mg

4

doxy-100 intravenous recon soln 100 mg

2

doxycycline hyclate intravenous recon soln 100 mg

(Doxy-100) 2

doxycycline hyclate oral capsule 100 mg 50 mg

(Morgidox) 2

doxycycline hyclate oral tablet 100 mg 20 mg

2

doxycycline hyclate oral tabletdelayed release (drec) 100 mg 150 mg 75 mg

4

doxycycline hyclate oral tabletdelayed release (drec) 200 mg 50 mg

(Doryx) 4


21


doxycycline monohydrate oral capsule 100 mg

(Mondoxyne NL) 2


4


(Monodox) 2


(Mondoxyne NL) 4

doxycycline monohydrate oral suspension for reconstitution 25 mg5 ml

(Vibramycin) 2

doxycycline monohydrate oral tablet100 mg

(Avidoxy) 2

doxycycline monohydrate oral tablet150 mg 75 mg

4


2

minocycline oral capsule 100 mg 75 mg

2

minocycline oral capsule 50 mg (Minocin) 2

minocycline oral tablet 100 mg 50 mg 75 mg

4

mondoxyne nl oral capsule 100 mg 50 mg

2

mondoxyne nl oral capsule 75 mg 4

okebo oral capsule 75 mg 4

soloxide oral tabletdelayed release (drec) 150 mg

4

tetracycline oral capsule 250 mg 500 mg

2

tigecycline intravenous recon soln 50 mg

(Tygacil) 5 NEDS

Anticancer AgentsAnticancer AgentsABRAXANE INTRAVENOUS SUSPENSION FOR RECONSTITUTION 100 MG

5 NEDS

ADCETRIS INTRAVENOUS RECON SOLN 50 MG

5 PA NSO NEDS


22


adriamycin intravenous solution 10 mg5 ml 2 mgml 20 mg10 ml 50 mg25 ml

2 PA BvD

adrucil intravenous solution 25 gram50 ml 500 mg10 ml

2 PA BvD

AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION 2 MG 3 MG 5 MG

5 PA NSO NEDS QL (112 per 28 days)

AFINITOR ORAL TABLET 10 MG


AFINITOR ORAL TABLET 25 MG 5 MG 75 MG


ALECENSA ORAL CAPSULE 150 MG


ALIMTA INTRAVENOUS RECON SOLN 100 MG 500 MG

5 NEDS

ALIQOPA INTRAVENOUS RECON SOLN 60 MG


ALUNBRIG ORAL TABLET 180 MG 90 MG


ALUNBRIG ORAL TABLET 30 MG


ALUNBRIG ORAL TABLETSDOSE PACK 90 MG (7)- 180 MG (23)

5 PA NSO NEDS

anastrozole oral tablet 1 mg (Arimidex) 1 GC

arsenic trioxide intravenous solution1 mgml

5 NEDS


(Trisenox) 5 NEDS

AVASTIN INTRAVENOUS SOLUTION 25 MGML

5 PA NSO NEDS

AYVAKIT ORAL TABLET 100 MG 200 MG 300 MG


azacitidine injection recon soln 100 mg

(Vidaza) 5 NEDS

BALVERSA ORAL TABLET 3 MG





23




BAVENCIO INTRAVENOUS SOLUTION 20 MGML

5 PA NSO NEDS

BELEODAQ INTRAVENOUS RECON SOLN 500 MG

5 PA NSO NEDS

BENDEKA INTRAVENOUS SOLUTION 25 MGML

5 PA NSO NEDS

BESPONSA INTRAVENOUS RECON SOLN 09 MG (025 MGML INITIAL)

5 PA NSO NEDS

bexarotene oral capsule 75 mg (Targretin) 5 PA NSO NEDS QL (420 per 30 days)

bicalutamide oral tablet 50 mg (Casodex) 2

bleomycin injection recon soln 15 unit 30 unit

2

BLINCYTO INTRAVENOUS KIT 35 MCG

5 PA NSO NEDS

BORTEZOMIB INTRAVENOUS RECON SOLN 35 MG

5 PA NSO NEDS

BOSULIF ORAL TABLET 100 MG


BOSULIF ORAL TABLET 400 MG 500 MG


BRAFTOVI ORAL CAPSULE 50 MG




BRUKINSA ORAL CAPSULE 80 MG

5 PA NSO NEDS

CABOMETYX ORAL TABLET 20 MG 60 MG


CABOMETYX ORAL TABLET 40 MG


CALQUENCE ORAL CAPSULE 100 MG


CAPRELSA ORAL TABLET 100 MG





24


carboplatin intravenous solution 10 mgml

(Paraplatin) 2

cladribine intravenous solution 10 mg10 ml

2 PA BvD

clofarabine intravenous solution 20 mg20 ml

(Clolar) 5 NEDS

COMETRIQ ORAL CAPSULE 100 MGDAY(80 MG X1-20 MG X1) 140 MGDAY(80 MG X1-20 MG X3) 60 MGDAY (20 MG X 3DAY)


COPIKTRA ORAL CAPSULE 15 MG 25 MG


COTELLIC ORAL TABLET 20 MG

5 PA NSO LA NEDS QL (63 per 28 days)

cyclophosphamide intravenous recon soln 1 gram 2 gram 500 mg

5 PA BvD NEDS

CYCLOPHOSPHAMIDE ORAL CAPSULE 25 MG 50 MG

2 PA BvD ST

CYRAMZA INTRAVENOUS SOLUTION 10 MGML

5 PA NSO NEDS

DARZALEX INTRAVENOUS SOLUTION 20 MGML

5 PA NSO LA NEDS

DAURISMO ORAL TABLET 100 MG




decitabine intravenous recon soln 50 mg

(Dacogen) 5 NEDS

docetaxel intravenous solution 20 mg2 ml (10 mgml) 20 mgml 80 mg8 ml (10 mgml)

5 NEDS

docetaxel intravenous solution 20 mgml (1 ml) 80 mg4 ml (20 mgml)

(Taxotere) 5 NEDS

doxorubicin intravenous solution 10 mg5 ml 2 mgml 20 mg10 ml 50 mg25 ml

(Adriamycin) 2 PA BvD

doxorubicin peg-liposomal intravenous suspension 2 mgml

(Doxil) 5 PA BvD NEDS


25


DROXIA ORAL CAPSULE 200 MG 300 MG 400 MG

4

ELIGARD (3 MONTH) SUBCUTANEOUS SYRINGE 225 MG

4


4


4

ELIGARD SUBCUTANEOUS SYRINGE 75 MG (1 MONTH)

4

EMCYT ORAL CAPSULE 140 MG

5 NEDS

EMPLICITI INTRAVENOUS RECON SOLN 300 MG 400 MG

5 PA NSO NEDS

ENHERTU INTRAVENOUS RECON SOLN 100 MG

5 PA NSO NEDS

ERIVEDGE ORAL CAPSULE 150 MG


ERLEADA ORAL TABLET 60 MG


erlotinib oral tablet 100 mg 25 mg (Tarceva) 5 PA NSO NEDS QL (60 per 30 days)

erlotinib oral tablet 150 mg (Tarceva) 5 PA NSO NEDS QL (90 per 30 days)

ETOPOPHOS INTRAVENOUS RECON SOLN 100 MG

4

etoposide intravenous solution 20 mgml

(Toposar) 2

exemestane oral tablet 25 mg (Aromasin) 4

FARYDAK ORAL CAPSULE 10 MG 15 MG 20 MG

5 PA NSO NEDS

floxuridine injection recon soln 05 gram

2 PA BvD

fluorouracil intravenous solution 1 gram20 ml 5 gram100 ml

2 PA BvD

fluorouracil intravenous solution 500 mg10 ml

(Adrucil) 2 PA BvD

flutamide oral capsule 125 mg 2


26


fulvestrant intramuscular syringe250 mg5 ml

(Faslodex) 5 NEDS

GAZYVA INTRAVENOUS SOLUTION 1000 MG40 ML

5 PA NSO NEDS

gemcitabine intravenous recon soln 1 gram 200 mg

2

gemcitabine intravenous recon soln 2 gram

5 NEDS

gemcitabine intravenous solution 1 gram263 ml (38 mgml) 2 gram526 ml (38 mgml) 200 mg526 ml (38 mgml)

5 NEDS

GILOTRIF ORAL TABLET 20 MG 30 MG 40 MG


GLEOSTINE ORAL CAPSULE 10 MG 40 MG 5 MG

4

GLEOSTINE ORAL CAPSULE 100 MG

5 NEDS

HERCEPTIN HYLECTA SUBCUTANEOUS SOLUTION 600 MG-10000 UNIT5 ML


HERCEPTIN INTRAVENOUS RECON SOLN 150 MG 440 MG

5 PA NSO NEDS

hydroxyurea oral capsule 500 mg (Hydrea) 2

IBRANCE ORAL CAPSULE 100 MG 125 MG 75 MG


ICLUSIG ORAL TABLET 15 MG




IDHIFA ORAL TABLET 100 MG 50 MG


ifosfamide intravenous recon soln 1 gram

(Ifex) 2

ifosfamide intravenous solution 1 gram20 ml 3 gram60 ml

2

ifosfamide-mesna intravenous kit 1-1 gram 3000-1000 mg

4

imatinib oral tablet 100 mg (Gleevec) 2 PA NSO QL (90 per 30 days)


27



IMBRUVICA ORAL CAPSULE 140 MG




IMBRUVICA ORAL TABLET 140 MG 280 MG 420 MG 560 MG


IMFINZI INTRAVENOUS SOLUTION 50 MGML

5 PA NSO NEDS

IMLYGIC INJECTION SUSPENSION 10EXP6 (1 MILLION) PFUML




INFUGEM INTRAVENOUS PIGGYBACK 1200 MG120 ML (10 MGML) 1300 MG130 ML (10 MGML) 1400 MG140 ML (10 MGML) 1500 MG150 ML (10 MGML) 1600 MG160 ML (10 MGML) 1700 MG170 ML (10 MGML) 1800 MG180 ML (10 MGML) 1900 MG190 ML (10 MGML) 2000 MG200 ML (10 MGML) 2200 MG220 ML (10 MGML)

5 NEDS

INLYTA ORAL TABLET 1 MG 5 PA NSO NEDS QL (180 per 30 days)


INREBIC ORAL CAPSULE 100 MG


IRESSA ORAL TABLET 250 MG 5 PA NSO NEDS QL (60 per 30 days)

irinotecan intravenous solution 100 mg5 ml 300 mg15 ml 40 mg2 ml

(Camptosar) 2

irinotecan intravenous solution 500 mg25 ml

2


28


IXEMPRA INTRAVENOUS RECON SOLN 15 MG 45 MG

5 NEDS

JAKAFI ORAL TABLET 10 MG 15 MG 20 MG 25 MG 5 MG


KANJINTI INTRAVENOUS RECON SOLN 150 MG 420 MG

5 PA NSO NEDS

KEYTRUDA INTRAVENOUS SOLUTION 25 MGML


KISQALI FEMARA CO-PACK ORAL TABLET 200 MGDAY(200 MG X 1)-25 MG






KISQALI ORAL TABLET 200 MGDAY (200 MG X 1)






KYPROLIS INTRAVENOUS RECON SOLN 10 MG 30 MG 60 MG

5 PA NSO NEDS

LENVIMA ORAL CAPSULE 10 MGDAY (10 MG X 1) 12 MGDAY (4 MG X 3) 14 MGDAY(10 MG X 1-4 MG X 1) 18 MGDAY (10 MG X 1-4 MG X2) 20 MGDAY (10 MG X 2) 24 MGDAY(10 MG X 2-4 MG X 1) 4 MG 8 MGDAY (4 MG X 2)

5 PA NSO NEDS

letrozole oral tablet 25 mg (Femara) 2

LEUKERAN ORAL TABLET 2 MG

4

leuprolide subcutaneous kit 1 mg02 ml

2

LIBTAYO INTRAVENOUS SOLUTION 50 MGML



29


LONSURF ORAL TABLET 15-614 MG




LORBRENA ORAL TABLET 100 MG




LUMOXITI INTRAVENOUS RECON SOLN 1 MG

5 PA NSO NEDS

LUPRON DEPOT (3 MONTH) INTRAMUSCULAR SYRINGE KIT 225 MG

5 NEDS


5 NEDS


5 NEDS

LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 375 MG

5 NEDS

LYNPARZA ORAL TABLET 100 MG 150 MG


LYSODREN ORAL TABLET 500 MG

5 NEDS

MARQIBO INTRAVENOUS KIT 5 MG31 ML(016 MGML) FINAL

5 PA NSO NEDS

MATULANE ORAL CAPSULE 50 MG

5 NEDS

megestrol oral tablet 20 mg 40 mg 2 PA NSO-HRM AGE (Max 64 Years)

MEKINIST ORAL TABLET 05 MG




MEKTOVI ORAL TABLET 15 MG


melphalan hcl intravenous recon soln50 mg

(Alkeran (as HCl)) 5 NEDS


30


mercaptopurine oral tablet 50 mg 2

methotrexate sodium (pf) injection recon soln 1 gram

2 PA BvD

methotrexate sodium (pf) injection solution 25 mgml

2 PA BvD

methotrexate sodium injection solution 25 mgml

2 PA BvD

methotrexate sodium oral tablet 25 mg

2 PA BvD ST

mitoxantrone intravenous concentrate 2 mgml

2

MYLOTARG INTRAVENOUS RECON SOLN 45 MG (1 MGML INITIAL CONC)

5 PA NSO NEDS

NERLYNX ORAL TABLET 40 MG


NEXAVAR ORAL TABLET 200 MG


nilutamide oral tablet 150 mg (Nilandron) 5 NEDS

NINLARO ORAL CAPSULE 23 MG 3 MG 4 MG


NUBEQA ORAL TABLET 300 MG


ODOMZO ORAL CAPSULE 200 MG

5 PA NSO LA NEDS

OGIVRI INTRAVENOUS RECON SOLN 150 MG 420 MG

5 PA NSO NEDS

ONCASPAR INJECTION SOLUTION 750 UNITML

5 PA NSO NEDS

ONIVYDE INTRAVENOUS DISPERSION 43 MGML

5 NEDS

OPDIVO INTRAVENOUS SOLUTION 100 MG10 ML 240 MG24 ML 40 MG4 ML

5 PA NSO NEDS

oxaliplatin intravenous recon soln100 mg 50 mg

2

oxaliplatin intravenous solution 100 mg20 ml 50 mg10 ml (5 mgml)

2

paclitaxel intravenous concentrate 6 mgml

2 PA BvD


31


PADCEV INTRAVENOUS RECON SOLN 20 MG 30 MG

5 PA NSO NEDS

PERJETA INTRAVENOUS SOLUTION 420 MG14 ML (30 MGML)

5 PA NSO NEDS

PIQRAY ORAL TABLET 200 MGDAY (200 MG X 1)


PIQRAY ORAL TABLET 250 MGDAY (200 MG X1-50 MG X1) 300 MGDAY (150 MG X 2)


POLIVY INTRAVENOUS RECON SOLN 140 MG

5 PA NSO NEDS

POMALYST ORAL CAPSULE 1 MG 2 MG 3 MG 4 MG


PORTRAZZA INTRAVENOUS SOLUTION 800 MG50 ML (16 MGML)


PROLEUKIN INTRAVENOUS RECON SOLN 22 MILLION UNIT

5 NEDS

PURIXAN ORAL SUSPENSION 20 MGML

5 NEDS

REVLIMID ORAL CAPSULE 10 MG 15 MG 25 MG 20 MG 25 MG 5 MG


RITUXAN HYCELA SUBCUTANEOUS SOLUTION 1400 MG117 ML (120 MGML) 1600 MG134 ML (120 MGML)

5 PA NSO NEDS

RITUXAN INTRAVENOUS CONCENTRATE 10 MGML

5 PA NSO NEDS

ROZLYTREK ORAL CAPSULE 100 MG




RUBRACA ORAL TABLET 200 MG 250 MG 300 MG


RUXIENCE INTRAVENOUS CONCENTRATE 10 MGML

5 PA NSO NEDS

RYDAPT ORAL CAPSULE 25 MG



32


SOLTAMOX ORAL SOLUTION 10 MG5 ML

5 NEDS

SPRYCEL ORAL TABLET 100 MG 140 MG 50 MG 70 MG 80 MG


SPRYCEL ORAL TABLET 20 MG


STIVARGA ORAL TABLET 40 MG


SUTENT ORAL CAPSULE 125 MG 25 MG 375 MG 50 MG


SYLVANT INTRAVENOUS RECON SOLN 100 MG 400 MG

5 PA NSO NEDS

SYNRIBO SUBCUTANEOUS RECON SOLN 35 MG

5 PA NSO NEDS

TABLOID ORAL TABLET 40 MG

4

TAFINLAR ORAL CAPSULE 50 MG 75 MG


TAGRISSO ORAL TABLET 40 MG 80 MG


TALZENNA ORAL CAPSULE 025 MG




tamoxifen oral tablet 10 mg 20 mg 2

TARGRETIN TOPICAL GEL 1


TASIGNA ORAL CAPSULE 150 MG 200 MG


TASIGNA ORAL CAPSULE 50 MG


TAZVERIK ORAL TABLET 200 MG


TECENTRIQ INTRAVENOUS SOLUTION 1200 MG20 ML (60 MGML) 840 MG14 ML (60 MGML)

5 PA NSO NEDS

TEMODAR INTRAVENOUS RECON SOLN 100 MG

5 PA NSO NEDS


33


temsirolimus intravenous recon soln30 mg3 ml (10 mgml) (first)

(Torisel) 5 PA BvD NEDS QL (4 per 28 days)

thiotepa injection recon soln 15 mg (Tepadina) 5 NEDS

TIBSOVO ORAL TABLET 250 MG


toposar intravenous solution 20 mgml

2

topotecan intravenous recon soln 4 mg

(Hycamtin) 5 NEDS

topotecan intravenous solution 4 mg4 ml (1 mgml)

5 NEDS

toremifene oral tablet 60 mg (Fareston) 5 NEDS

TRAZIMERA INTRAVENOUS RECON SOLN 420 MG

5 PA NSO NEDS

TREANDA INTRAVENOUS RECON SOLN 100 MG 25 MG

5 PA NSO NEDS

TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 1125 MG






tretinoin (chemotherapy) oral capsule 10 mg

5 NEDS

TRUXIMA INTRAVENOUS CONCENTRATE 10 MGML

5 PA NSO NEDS

TURALIO ORAL CAPSULE 200 MG


TYKERB ORAL TABLET 250 MG

5 PA NSO NEDS

UNITUXIN INTRAVENOUS SOLUTION 35 MGML

5 PA NSO NEDS

valrubicin intravesical solution 40 mgml

(Valstar) 5 NEDS


34


VECTIBIX INTRAVENOUS SOLUTION 100 MG5 ML (20 MGML) 400 MG20 ML (20 MGML)

5 PA NSO NEDS

VELCADE INJECTION RECON SOLN 35 MG

5 PA NSO NEDS

VENCLEXTA ORAL TABLET 10 MG

3 PA NSO LA QL (60 per 30 days)





VENCLEXTA STARTING PACK ORAL TABLETSDOSE PACK 10 MG-50 MG- 100 MG

5 PA NSO LA NEDS

VERZENIO ORAL TABLET 100 MG 150 MG 200 MG 50 MG


vinblastine intravenous solution 1 mgml

2 PA BvD

vincasar pfs intravenous solution 1 mgml 2 mg2 ml

2 PA BvD

vincristine intravenous solution 1 mgml 2 mg2 ml

(Vincasar PFS) 2 PA BvD

vinorelbine intravenous solution 10 mgml 50 mg5 ml

(Navelbine) 2

VITRAKVI ORAL CAPSULE 100 MG




VITRAKVI ORAL SOLUTION 20 MGML


VIZIMPRO ORAL TABLET 15 MG 30 MG 45 MG


VOTRIENT ORAL TABLET 200 MG


VYXEOS INTRAVENOUS RECON SOLN 44-100 MG

5 PA BvD NEDS

XALKORI ORAL CAPSULE 200 MG 250 MG


XATMEP ORAL SOLUTION 25 MGML

4 PA BvD ST


35


XOSPATA ORAL TABLET 40 MG


XPOVIO ORAL TABLET 100 MGWEEK (20 MG X 5)








XTANDI ORAL CAPSULE 40 MG


YERVOY INTRAVENOUS SOLUTION 200 MG40 ML (5 MGML) 50 MG10 ML (5 MGML)

5 PA NSO NEDS

YONDELIS INTRAVENOUS RECON SOLN 1 MG

5 PA NSO NEDS

YONSA ORAL TABLET 125 MG 5 PA NSO NEDS QL (120 per 30 days)

ZALTRAP INTRAVENOUS SOLUTION 100 MG4 ML (25 MGML) 200 MG8 ML (25 MGML)

5 PA NSO NEDS

ZEJULA ORAL CAPSULE 100 MG


ZELBORAF ORAL TABLET 240 MG


ZIRABEV INTRAVENOUS SOLUTION 25 MGML

5 PA NSO NEDS

ZOLADEX SUBCUTANEOUS IMPLANT 108 MG




ZOLINZA ORAL CAPSULE 100 MG

5 NEDS

ZYDELIG ORAL TABLET 100 MG 150 MG


ZYKADIA ORAL CAPSULE 150 MG



36


ZYKADIA ORAL TABLET 150 MG


ZYTIGA ORAL TABLET 250 MG 500 MG


Anticholinergic AgentsAntimuscarinicsAntispasmodicsatropine injection syringe 005 mgml 01 mgml

4

AnticonvulsantsAnticonvulsantsAPTIOM ORAL TABLET 200 MG 400 MG


APTIOM ORAL TABLET 600 MG 800 MG


BANZEL ORAL SUSPENSION 40 MGML

5 NEDS

BANZEL ORAL TABLET 200 MG 400 MG

5 NEDS

BRIVIACT INTRAVENOUS SOLUTION 50 MG5 ML


BRIVIACT ORAL SOLUTION 10 MGML


BRIVIACT ORAL TABLET 10 MG 100 MG 25 MG 50 MG 75 MG


carbamazepine oral capsule er multiphase 12 hr 100 mg 200 mg 300 mg

(Carbatrol) 2

carbamazepine oral suspension 100 mg5 ml

(Tegretol) 2

carbamazepine oral tablet 200 mg (Epitol) 2

carbamazepine oral tablet extended release 12 hr 100 mg 200 mg 400 mg

(Tegretol XR) 2

carbamazepine oral tabletchewable100 mg

2

CELONTIN ORAL CAPSULE 300 MG

4

clobazam oral suspension 25 mgml (Onfi) 2 PA NSO QL (480 per 30 days)


37


clobazam oral tablet 10 mg 20 mg (Onfi) 2 PA NSO QL (60 per 30 days)

DIASTAT ACUDIAL RECTAL KIT 125-15-175-20 MG 5-75-10 MG

4

DIASTAT RECTAL KIT 25 MG 4

diazepam rectal kit 125-15-175-20 mg 5-75-10 mg

(Diastat AcuDial) 4

diazepam rectal kit 25 mg (Diastat) 4

divalproex oral capsule delayed rel sprinkle 125 mg

(Depakote Sprinkles) 2

divalproex oral tablet extended release 24 hr 250 mg 500 mg

(Depakote ER) 2

divalproex oral tabletdelayed release (drec) 125 mg 250 mg 500 mg

(Depakote) 2

EPIDIOLEX ORAL SOLUTION 100 MGML

5 PA NSO NEDS

epitol oral tablet 200 mg 2

ethosuximide oral capsule 250 mg (Zarontin) 2

ethosuximide oral solution 250 mg5 ml

(Zarontin) 2

felbamate oral suspension 600 mg5 ml

(Felbatol) 4

felbamate oral tablet 400 mg 600 mg

(Felbatol) 4

fosphenytoin injection solution 100 mg pe2 ml 500 mg pe10 ml

(Cerebyx) 2

FYCOMPA ORAL SUSPENSION 05 MGML


FYCOMPA ORAL TABLET 10 MG 12 MG 8 MG


FYCOMPA ORAL TABLET 2 MG


FYCOMPA ORAL TABLET 4 MG 6 MG


gabapentin oral capsule 100 mg 300 mg

(Neurontin) 1 GC QL (360 per 30 days)

gabapentin oral capsule 400 mg (Neurontin) 1 GC QL (270 per 30 days)


38


gabapentin oral solution 250 mg5 ml

(Neurontin) 2 QL (2160 per 30 days)

gabapentin oral tablet 600 mg (Neurontin) 2 QL (180 per 30 days)


GRALISE 30-DAY STARTER PACK ORAL TABLET EXTENDED RELEASE 24 HR 300 MG (9)- 600 MG (69)

4 ST

GRALISE ORAL TABLET EXTENDED RELEASE 24 HR 300 MG 600 MG

4 ST QL (90 per 30 days)

lamotrigine oral tablet 100 mg 150 mg 200 mg 25 mg

(Subvenite) 1 GC

lamotrigine oral tablet disintegrating dose pk 25 mg (21) -50 mg (7)

(Lamictal ODT Starter (Blue))

4

lamotrigine oral tablet disintegrating dose pk 25 mg(14)-50 mg (14)-100 mg (7)

(Lamictal ODT Starter (Orange))

4


(Lamictal ODT Starter (Green))

4

lamotrigine oral tablet extended release 24hr 100 mg 200 mg 25 mg 250 mg 300 mg 50 mg

(Lamictal XR) 4

lamotrigine oral tablet chewable dispersible 25 mg 5 mg

(Lamictal) 2

lamotrigine oral tabletdisintegrating 100 mg 200 mg 25 mg 50 mg

(Lamictal ODT) 4

levetiracetam intravenous solution500 mg5 ml

(Keppra) 2

levetiracetam oral solution 100 mgml

(Keppra) 2

levetiracetam oral tablet 1000 mg 250 mg 500 mg 750 mg

(Keppra) 2

levetiracetam oral tablet extended release 24 hr 500 mg 750 mg

(Keppra XR) 2

NAYZILAM NASAL SPRAYNON-AEROSOL 5 MGSPRAY (01 ML)



39


oxcarbazepine oral suspension 300 mg5 ml (60 mgml)

(Trileptal) 2

oxcarbazepine oral tablet 150 mg 300 mg 600 mg

(Trileptal) 2

OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR 150 MG 300 MG 600 MG

4

PEGANONE ORAL TABLET 250 MG

4

phenobarbital oral elixir 20 mg5 ml (4 mgml)

2 PA NSO-HRM AGE (Max 64 Years)

phenobarbital oral tablet 100 mg 15 mg 162 mg 30 mg 324 mg 60 mg 648 mg 972 mg


phenytoin oral suspension 125 mg5 ml

(Dilantin-125) 2

phenytoin oral tabletchewable 50 mg

(Dilantin Infatabs) 2

phenytoin sodium extended oral capsule 100 mg

(Dilantin Extended) 2

phenytoin sodium extended oral capsule 200 mg 300 mg

(Phenytek) 2

phenytoin sodium intravenous solution 50 mgml

2

phenytoin sodium intravenous syringe 50 mgml

2

pregabalin oral capsule 100 mg 150 mg 200 mg 225 mg 25 mg 300 mg 50 mg 75 mg

(Lyrica) 2 QL (90 per 30 days)

pregabalin oral solution 20 mgml (Lyrica) 2 QL (900 per 30 days)

primidone oral tablet 250 mg 50 mg (Mysoline) 2

SABRIL ORAL TABLET 500 MG


SPRITAM ORAL TABLET FOR SUSPENSION 1000 MG


SPRITAM ORAL TABLET FOR SUSPENSION 250 MG 500 MG 750 MG


subvenite oral tablet 100 mg 150 mg 200 mg 25 mg

1 GC


40


SYMPAZAN ORAL FILM 10 MG 20 MG


SYMPAZAN ORAL FILM 5 MG 4 PA NSO QL (60 per 30 days)

tiagabine oral tablet 12 mg 16 mg 2 mg 4 mg

(Gabitril) 4

topiramate oral capsule sprinkle 15 mg 25 mg

(Topamax) 2

topiramate oral capsulesprinkleer 24hr 100 mg 150 mg 200 mg 25 mg 50 mg

(Qudexy XR) 4

topiramate oral tablet 100 mg 200 mg 25 mg 50 mg

(Topamax) 1 GC

valproate sodium intravenous solution 500 mg5 ml (100 mgml)

2

valproic acid (as sodium salt) oral solution 250 mg5 ml

2

valproic acid oral capsule 250 mg 2

VALTOCO NASAL SPRAYNON-AEROSOL 10 MGSPRAY (01 ML) 15 MG2 SPRAY (7501ML X 2) 20 MG2 SPRAY (10MG01ML X2) 5 MGSPRAY (01 ML)

4

vigabatrin oral powder in packet 500 mg

(Vigadrone) 5 PA NSO NEDS QL (180 per 30 days)

vigabatrin oral tablet 500 mg (Sabril) 5 PA NSO NEDS QL (180 per 30 days)

vigadrone oral powder in packet 500 mg


VIMPAT INTRAVENOUS SOLUTION 200 MG20 ML


VIMPAT ORAL SOLUTION 10 MGML

3 QL (1200 per 30 days)

VIMPAT ORAL TABLET 100 MG 150 MG 200 MG 50 MG


zonisamide oral capsule 100 mg 25 mg

(Zonegran) 2

zonisamide oral capsule 50 mg 2


41


Antidementia AgentsAntidementia Agentsdonepezil oral tablet 10 mg 5 mg (Aricept) 1 GC QL (30 per 30

days)

donepezil oral tablet 23 mg (Aricept) 4 QL (30 per 30 days)

donepezil oral tabletdisintegrating10 mg 5 mg


galantamine oral capsuleext rel pellets 24 hr 16 mg 24 mg 8 mg

(Razadyne ER) 2 QL (30 per 30 days)

galantamine oral solution 4 mgml 4 QL (200 per 30 days)

galantamine oral tablet 12 mg 4 mg 8 mg

(Razadyne) 2 QL (60 per 30 days)

memantine oral capsulesprinkleer 24hr 14 mg 21 mg 28 mg 7 mg

(Namenda XR) 4 QL (30 per 30 days)

memantine oral solution 2 mgml 4 QL (360 per 30 days)

memantine oral tablet 10 mg 5 mg (Namenda) 2 QL (60 per 30 days)

memantine oral tabletsdose pack 5-10 mg

(Namenda Titration Pak)

4

NAMZARIC ORAL CAPSPRINKLEER 24HR DOSE PACK 7142128 MG-10 MG

3

NAMZARIC ORAL CAPSULESPRINKLEER 24HR 14-10 MG 21-10 MG 28-10 MG 7-10 MG


rivastigmine tartrate oral capsule15 mg 3 mg 45 mg 6 mg


rivastigmine transdermal patch 24 hour 133 mg24 hour 46 mg24 hr 95 mg24 hr

(Exelon) 4 QL (30 per 30 days)

AntidepressantsAntidepressantsamitriptyline oral tablet 10 mg 100 mg 150 mg 25 mg 50 mg 75 mg

2

amitriptyline-chlordiazepoxide oral tablet 125-5 mg 25-10 mg

2

amoxapine oral tablet 100 mg 150 mg 25 mg 50 mg

2

bupropion hcl oral tablet 100 mg 75 mg

2


42


bupropion hcl oral tablet extended release 24 hr 150 mg 300 mg

(Wellbutrin XL) 2

bupropion hcl oral tablet sustained-release 12 hr 100 mg 150 mg 200 mg

(Wellbutrin SR) 2

citalopram oral solution 10 mg5 ml 2 QL (600 per 30 days)

citalopram oral tablet 10 mg 20 mg 40 mg

(Celexa) 1 GC QL (30 per 30 days)

clomipramine oral capsule 25 mg 50 mg 75 mg

(Anafranil) 4

desipramine oral tablet 10 mg 25 mg

(Norpramin) 4

desipramine oral tablet 100 mg 150 mg 50 mg 75 mg

4

desvenlafaxine succinate oral tablet extended release 24 hr 100 mg 25 mg 50 mg

(Pristiq) 2 QL (30 per 30 days)

doxepin oral capsule 10 mg 100 mg 150 mg 25 mg 50 mg 75 mg

2

doxepin oral concentrate 10 mgml 1 GC

DRIZALMA SPRINKLE ORAL CAPSULE DELAYED REL SPRINKLE 20 MG 30 MG 60 MG


DRIZALMA SPRINKLE ORAL CAPSULE DELAYED REL SPRINKLE 40 MG


duloxetine oral capsuledelayed release(drec) 20 mg 30 mg 60 mg

(Cymbalta) 2 QL (60 per 30 days)

duloxetine oral capsuledelayed release(drec) 40 mg


EMSAM TRANSDERMAL PATCH 24 HOUR 12 MG24 HR 6 MG24 HR 9 MG24 HR


escitalopram oxalate oral solution 5 mg5 ml

2

escitalopram oxalate oral tablet 10 mg 20 mg 5 mg

(Lexapro) 1 GC


43


FETZIMA ORAL CAPSULEEXT REL 24HR DOSE PACK 20 MG (2)- 40 MG (26)

4 ST

FETZIMA ORAL CAPSULEEXTENDED RELEASE 24 HR 120 MG 20 MG 40 MG 80 MG


fluoxetine oral capsule 10 mg 20 mg 40 mg

(Prozac) 1 GC

fluoxetine oral solution 20 mg5 ml (4 mgml)

4

fluvoxamine oral tablet 100 mg 25 mg 50 mg

2

imipramine hcl oral tablet 10 mg 25 mg 50 mg

2

imipramine pamoate oral capsule100 mg 125 mg 150 mg 75 mg

4

maprotiline oral tablet 25 mg 50 mg 75 mg

2

MARPLAN ORAL TABLET 10 MG

4

mirtazapine oral tablet 15 mg 30 mg

(Remeron) 2


2

mirtazapine oral tabletdisintegrating 15 mg 30 mg 45 mg

(Remeron SolTab) 2

nefazodone oral tablet 100 mg 150 mg 200 mg 250 mg 50 mg

4

nortriptyline oral capsule 10 mg 25 mg 50 mg 75 mg

(Pamelor) 1 GC

nortriptyline oral solution 10 mg5 ml

2

paroxetine hcl oral tablet 10 mg 20 mg 30 mg 40 mg

(Paxil) 1 PA NSO-HRM GC AGE (Max 64 Years)

paroxetine hcl oral tablet extended release 24 hr 125 mg 25 mg 375 mg

(Paxil CR) 4 PA NSO-HRM AGE (Max 64 Years)


44


PAXIL ORAL SUSPENSION 10 MG5 ML


perphenazine-amitriptyline oral tablet 2-10 mg 2-25 mg 4-10 mg 4-25 mg 4-50 mg

2

phenelzine oral tablet 15 mg (Nardil) 2

protriptyline oral tablet 10 mg 5 mg 4

sertraline oral concentrate 20 mgml (Zoloft) 2

sertraline oral tablet 100 mg 25 mg 50 mg

(Zoloft) 1 GC

SPRAVATO NASAL SPRAYNON-AEROSOL 56 MG (28 MG X 2) 84 MG (28 MG X 3)

5 PA NSO NEDS

tranylcypromine oral tablet 10 mg (Parnate) 4

trazodone oral tablet 100 mg 150 mg 50 mg

1 GC

trazodone oral tablet 300 mg 4

trimipramine oral capsule 100 mg 25 mg 50 mg

4

TRINTELLIX ORAL TABLET 10 MG 20 MG 5 MG


venlafaxine oral capsuleextended release 24hr 150 mg

(Effexor XR) 2 QL (30 per 30 days)

venlafaxine oral capsuleextended release 24hr 375 mg 75 mg


venlafaxine oral tablet 100 mg 25 mg 375 mg 50 mg 75 mg

2

venlafaxine oral tablet extended release 24hr 150 mg 375 mg


venlafaxine oral tablet extended release 24hr 75 mg


VIIBRYD ORAL TABLET 10 MG 20 MG 40 MG


VIIBRYD ORAL TABLETSDOSE PACK 10 MG (7)- 20 MG (23)

3

ZULRESSO INTRAVENOUS SOLUTION 5 MGML

5 NEDS


45


Antidiabetic AgentsAntidiabetic Agents Miscellaneousacarbose oral tablet 100 mg 25 mg 50 mg

(Precose) 2 QL (90 per 30 days)

GLYXAMBI ORAL TABLET 10-5 MG 25-5 MG


INVOKAMET ORAL TABLET 150-1000 MG 150-500 MG 50-1000 MG


INVOKAMET ORAL TABLET 50-500 MG


INVOKAMET XR ORAL TABLET IR - ER BIPHASIC 24HR 150-1000 MG 150-500 MG 50-1000 MG 50-500 MG


INVOKANA ORAL TABLET 100 MG




JANUMET ORAL TABLET 50-1000 MG 50-500 MG


JANUMET XR ORAL TABLET ER MULTIPHASE 24 HR 100-1000 MG


JANUMET XR ORAL TABLET ER MULTIPHASE 24 HR 50-1000 MG 50-500 MG


JANUVIA ORAL TABLET 100 MG 25 MG 50 MG


JARDIANCE ORAL TABLET 10 MG 25 MG


JENTADUETO ORAL TABLET 25-1000 MG 25-500 MG 25-850 MG


JENTADUETO XR ORAL TABLET IR - ER BIPHASIC 24HR 25-1000 MG





46


KORLYM ORAL TABLET 300 MG


metformin oral tablet 1000 mg (Glucophage) 1 GC QL (75 per 30 days)



metformin oral tablet extended release 24 hr 500 mg

(Glucophage XR) 1 GC QL (120 per 30 days)



miglitol oral tablet 100 mg 25 mg 50 mg

(Glyset) 4 QL (90 per 30 days)

nateglinide oral tablet 120 mg 60 mg

(Starlix) 2 QL (90 per 30 days)

OZEMPIC SUBCUTANEOUS PEN INJECTOR 025 MG OR 05 MG(2 MG15 ML) 1 MGDOSE (2 MG15 ML)


pioglitazone oral tablet 15 mg 30 mg 45 mg

(Actos) 1 GC QL (30 per 30 days)

repaglinide oral tablet 05 mg 1 GC QL (120 per 30 days)

repaglinide oral tablet 1 mg (Prandin) 1 GC QL (120 per 30 days)


repaglinide-metformin oral tablet 1-500 mg 2-500 mg


RYBELSUS ORAL TABLET 14 MG 3 MG 7 MG


SYMLINPEN 120 SUBCUTANEOUS PEN INJECTOR 2700 MCG27 ML




SYNJARDY ORAL TABLET 125-1000 MG 125-500 MG 5-1000 MG 5-500 MG



47


SYNJARDY XR ORAL TABLET IR - ER BIPHASIC 24HR 10-1000 MG 25-1000 MG




TRADJENTA ORAL TABLET 5 MG


TRULICITY SUBCUTANEOUS PEN INJECTOR 075 MG05 ML 15 MG05 ML


VICTOZA SUBCUTANEOUS PEN INJECTOR 06 MG01 ML (18 MG3 ML)


InsulinsFIASP FLEXTOUCH U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)


FIASP PENFILL U-100 INSULIN SUBCUTANEOUS CARTRIDGE 100 UNITML (3 ML)


FIASP U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNITML


HUMULIN R U-500 (CONC) INSULIN SUBCUTANEOUS SOLUTION 500 UNITML


HUMULIN R U-500 (CONC) KWIKPEN SUBCUTANEOUS INSULIN PEN 500 UNITML (3 ML)


LANTUS SOLOSTAR U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)


LANTUS U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNITML



48


NOVOLIN 7030 U-100 INSULIN SUBCUTANEOUS SUSPENSION 100 UNITML (70-30)


NOVOLIN 70-30 FLEXPEN U-100 SUBCUTANEOUS INSULIN PEN 100 UNITML (70-30)


NOVOLIN N FLEXPEN SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)


NOVOLIN N NPH U-100 INSULIN SUBCUTANEOUS SUSPENSION 100 UNITML


NOVOLIN R FLEXPEN SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)


NOVOLIN R REGULAR U-100 INSULN INJECTION SOLUTION 100 UNITML


NOVOLOG FLEXPEN U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)


NOVOLOG MIX 70-30 U-100 INSULN SUBCUTANEOUS SOLUTION 100 UNITML (70-30)


NOVOLOG MIX 70-30FLEXPEN U-100 SUBCUTANEOUS INSULIN PEN 100 UNITML (70-30)


NOVOLOG PENFILL U-100 INSULIN SUBCUTANEOUS CARTRIDGE 100 UNITML


NOVOLOG U-100 INSULIN ASPART SUBCUTANEOUS SOLUTION 100 UNITML


SOLIQUA 10033 SUBCUTANEOUS INSULIN PEN 100 UNIT-33 MCGML



49


TOUJEO MAX U-300 SOLOSTAR SUBCUTANEOUS INSULIN PEN 300 UNITML (3 ML)


TOUJEO SOLOSTAR U-300 INSULIN SUBCUTANEOUS INSULIN PEN 300 UNITML (15 ML)


TRESIBA FLEXTOUCH U-100 SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)




TRESIBA U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNITML


XULTOPHY 10036 SUBCUTANEOUS INSULIN PEN 100 UNIT-36 MG ML (3 ML)


Sulfonylureasglimepiride oral tablet 1 mg 2 mg (Amaryl) 1 GC QL (30 per 30

days)

glimepiride oral tablet 4 mg (Amaryl) 1 GC QL (60 per 30 days)

glipizide oral tablet 10 mg (Glucotrol) 1 GC QL (120 per 30 days)


glipizide oral tablet extended release 24hr 10 mg

(Glucotrol XL) 1 GC QL (60 per 30 days)

glipizide oral tablet extended release 24hr 25 mg 5 mg


glipizide-metformin oral tablet 25-250 mg

1 GC QL (240 per 30 days)

glipizide-metformin oral tablet 25-500 mg 5-500 mg


glyburide micronized oral tablet 15 mg 3 mg 6 mg

(Glynase) 1 PA-HRM GC AGE (Max 64 Years)


50


glyburide oral tablet 125 mg 25 mg 5 mg

1 PA-HRM GC AGE (Max 64 Years)

glyburide-metformin oral tablet125-250 mg 25-500 mg 5-500 mg


tolazamide oral tablet 250 mg 4 QL (120 per 30 days)


tolbutamide oral tablet 500 mg 4 QL (180 per 30 days)

AntifungalsAntifungalsABELCET INTRAVENOUS SUSPENSION 5 MGML

5 PA BvD NEDS

AMBISOME INTRAVENOUS SUSPENSION FOR RECONSTITUTION 50 MG

5 PA BvD NEDS

amphotericin b injection recon soln50 mg

2 PA BvD

caspofungin intravenous recon soln50 mg 70 mg

(Cancidas) 5 NEDS

ciclopirox topical cream 077 (Ciclodan) 2

ciclopirox topical gel 077 4

ciclopirox topical shampoo 1 (Loprox) 4

ciclopirox topical solution 8 (Ciclodan) 2

ciclopirox topical suspension 077 (Loprox (as olamine)) 4

clotrimazole mucous membrane troche 10 mg

2

clotrimazole topical cream 1 (Antifungal (clotrimazole))

1 GC

clotrimazole topical solution 1 2

clotrimazole-betamethasone topical cream 1-005

(Lotrisone) 2

clotrimazole-betamethasone topical lotion 1-005

4

econazole topical cream 1 4

fluconazole in nacl (iso-osm) intravenous piggyback 100 mg50 ml 200 mg100 ml 400 mg200 ml

2 PA BvD

fluconazole oral suspension for reconstitution 10 mgml 40 mgml

(Diflucan) 2

fluconazole oral tablet 100 mg 150 mg 200 mg 50 mg

(Diflucan) 2


51


flucytosine oral capsule 250 mg 500 mg

(Ancobon) 5 NEDS

griseofulvin microsize oral suspension 125 mg5 ml

4

griseofulvin microsize oral tablet500 mg

4

griseofulvin ultramicrosize oral tablet 125 mg 250 mg

4

itraconazole oral capsule 100 mg (Sporanox) 2

itraconazole oral solution 10 mgml (Sporanox) 3

ketoconazole oral tablet 200 mg 2

ketoconazole topical cream 2 2

ketoconazole topical shampoo 2 (Nizoral) 2

miconazole-3 vaginal suppository200 mg

2

NOXAFIL INTRAVENOUS SOLUTION 300 MG167 ML

5 NEDS

NOXAFIL ORAL SUSPENSION 200 MG5 ML (40 MGML)

5 NEDS

NOXAFIL ORAL TABLETDELAYED RELEASE (DREC) 100 MG

5 NEDS

nyamyc topical powder 100000 unitgram

2

nystatin oral suspension 100000 unitml

2

nystatin oral tablet 500000 unit 2

nystatin topical cream 100000 unitgram

2

nystatin topical ointment 100000 unitgram

2

nystatin topical powder 100000 unitgram

(Nyamyc) 2

nystatin-triamcinolone topical cream 100000-01 unitg-

4

nystatin-triamcinolone topical ointment 100000-01 unitgram-

4

nystop topical powder 100000 unitgram

2

posaconazole oral tabletdelayed release (drec) 100 mg

(Noxafil) 5 NEDS


52


terbinafine hcl oral tablet 250 mg 1 GC

voriconazole intravenous recon soln200 mg

(Vfend IV) 5 PA BvD NEDS

voriconazole oral suspension for reconstitution 200 mg5 ml (40 mgml)

(Vfend) 5 NEDS

voriconazole oral tablet 200 mg 50 mg

(Vfend) 5 NEDS

Antigout AgentsAntigout Agents Otherallopurinol oral tablet 100 mg 300 mg

(Zyloprim) 1 GC

colchicine oral tablet 06 mg (Colcrys) 4 PA QL (120 per 30 days)

febuxostat oral tablet 40 mg 80 mg (Uloric) 2 QL (30 per 30 days)

MITIGARE ORAL CAPSULE 06 MG


probenecid oral tablet 500 mg 2

probenecid-colchicine oral tablet500-05 mg

2

AntihistaminesAntihistaminescarbinoxamine maleate oral liquid 4 mg5 ml

2 PA-HRM AGE (Max 64 Years)

carbinoxamine maleate oral tablet 4 mg


clemastine oral tablet 268 mg 2 PA-HRM AGE (Max 64 Years)

cyproheptadine oral syrup 2 mg5 ml 2 PA-HRM AGE (Max 64 Years)

cyproheptadine oral tablet 4 mg 2 PA-HRM AGE (Max 64 Years)

diphenhydramine 50 mgml crpjt outerlfsuvpf 50 mgml

4

diphenhydramine hcl injection solution 50 mgml

2

diphenhydramine hcl injection syringe 50 mgml

2

diphenhydramine hcl oral elixir 125 mg5 ml

(Diphen) 1 PA-HRM GC AGE (Max 64 Years)


53


hydroxyzine hcl intramuscular solution 25 mgml 50 mgml

2

hydroxyzine hcl oral solution 10 mg5 ml

2

hydroxyzine hcl oral tablet 10 mg 25 mg 50 mg

1 GC

levocetirizine oral solution 25 mg5 ml

(Xyzal) 4

levocetirizine oral tablet 5 mg (24HR Allergy Relief) 1 GC

promethazine oral syrup 625 mg5 ml


Anti-Infectives (Skin And Mucous Membrane)Anti-Infectives (Skin And Mucous Membrane)clindamycin phosphate vaginal cream 2

(Cleocin) 2

metronidazole vaginal gel 075 (Metrogel Vaginal) 2

terconazole vaginal cream 04 08

2

terconazole vaginal suppository 80 mg

4

Antimigraine AgentsAntimigraine AgentsAIMOVIG AUTOINJECTOR (2 PACK) SUBCUTANEOUS AUTO-INJECTOR 70 MGML


AIMOVIG AUTOINJECTOR SUBCUTANEOUS AUTO-INJECTOR 140 MGML 70 MGML


AJOVY SUBCUTANEOUS SYRINGE 225 MG15 ML


dihydroergotamine injection solution1 mgml

(DHE45) 5 NEDS QL (24 per 28 days)

dihydroergotamine nasal spraynon-aerosol 05 mgpump act (4 mgml)

(Migranal) 5 NEDS QL (8 per 28 days)

EMGALITY PEN SUBCUTANEOUS PEN INJECTOR 120 MGML



54


EMGALITY SYRINGE SUBCUTANEOUS SYRINGE 120 MGML


EMGALITY SYRINGE SUBCUTANEOUS SYRINGE 300 MG3 ML (100 MGML X 3)


ERGOMAR SUBLINGUAL TABLET 2 MG


naratriptan oral tablet 1 mg 25 mg (Amerge) 4 QL (9 per 30 days)

rizatriptan oral tablet 10 mg (Maxalt) 2 QL (12 per 30 days)

rizatriptan oral tablet 5 mg 2 QL (12 per 30 days)

rizatriptan oral tabletdisintegrating10 mg

(Maxalt-MLT) 2 QL (12 per 30 days)



sumatriptan nasal spraynon-aerosol20 mgactuation

(Imitrex) 4 QL (12 per 30 days)



sumatriptan succinate oral tablet100 mg

(Imitrex) 1 GC QL (9 per 30 days)

sumatriptan succinate oral tablet 25 mg 50 mg


sumatriptan succinate subcutaneous cartridge 6 mg05 ml

(Imitrex STATdose Refill)


sumatriptan succinate subcutaneous pen injector 4 mg05 ml 6 mg05 ml

(Imitrex STATdose Pen)


sumatriptan succinate subcutaneous solution 6 mg05 ml


sumatriptan succinate subcutaneous syringe 6 mg05 ml


zolmitriptan oral tablet 25 mg 5 mg

(Zomig) 4 QL (6 per 30 days)

zolmitriptan oral tabletdisintegrating 25 mg 5 mg

(Zomig ZMT) 4 QL (6 per 30 days)

AntimycobacterialsAntimycobacterialsCAPASTAT INJECTION RECON SOLN 1 GRAM

4

dapsone oral tablet 100 mg 25 mg 2


55


ethambutol oral tablet 100 mg 2

ethambutol oral tablet 400 mg (Myambutol) 2

isoniazid oral solution 50 mg5 ml 2

isoniazid oral tablet 100 mg 300 mg 1 GC

PASER ORAL GRANULES DR FOR SUSP IN PACKET 4 GRAM

4

PRETOMANID ORAL TABLET 200 MG


PRIFTIN ORAL TABLET 150 MG

4

pyrazinamide oral tablet 500 mg 2

rifabutin oral capsule 150 mg (Mycobutin) 4

rifampin intravenous recon soln 600 mg

(Rifadin) 4

rifampin oral capsule 150 mg 300 mg

(Rifadin) 2

SIRTURO ORAL TABLET 100 MG

5 PA NEDS

TRECATOR ORAL TABLET 250 MG

4

Antinausea AgentsAntinausea AgentsAKYNZEO (FOSNETUPITANT) INTRAVENOUS RECON SOLN 235-025 MG

4

AKYNZEO (NETUPITANT) ORAL CAPSULE 300-05 MG

4 PA BvD

aprepitant oral capsule 125 mg 2 PA BvD QL (2 per 28 days)

aprepitant oral capsule 40 mg (Emend) 2 PA BvD QL (1 per 28 days)


aprepitant oral capsuledose pack125 mg (1)- 80 mg (2)

(Emend) 2 PA BvD QL (6 per 28 days)

CINVANTI INTRAVENOUS EMULSION 72 MGML


compro rectal suppository 25 mg 2

dimenhydrinate injection solution 50 mgml

2


56


dronabinol oral capsule 10 mg 25 mg 5 mg


EMEND (FOSAPREPITANT) INTRAVENOUS RECON SOLN 150 MG


EMEND ORAL SUSPENSION FOR RECONSTITUTION 125 MG (25 MG ML FINAL CONC)

4 PA BvD QL (6 per 28 days)

fosaprepitant intravenous recon soln150 mg

(Emend (fosaprepitant))


granisetron (pf) intravenous solution 100 mcgml

2

granisetron hcl intravenous solution1 mgml 1 mgml (1 ml)

2

granisetron hcl oral tablet 1 mg 4 PA BvD

meclizine oral tablet 125 mg 2

meclizine oral tablet 25 mg (Dramamine Less Drowsy)

2

ondansetron hcl (pf) injection solution 4 mg2 ml

1 GC

ondansetron hcl (pf) injection syringe 4 mg2 ml

1 GC

ondansetron hcl intravenous solution2 mgml

2

ondansetron hcl oral solution 4 mg5 ml

4 PA BvD

ondansetron hcl oral tablet 24 mg 4 PA BvD

ondansetron hcl oral tablet 4 mg 8 mg

(Zofran) 2 PA BvD

ondansetron oral tabletdisintegrating 4 mg 8 mg

2 PA BvD

phenadoz rectal suppository 125 mg 25 mg


prochlorperazine edisylate injection solution 10 mg2 ml (5 mgml) 5 mgml

2

prochlorperazine maleate oral tablet10 mg 5 mg

(Compazine) 1 GC

prochlorperazine rectal suppository25 mg

(Compro) 2


57


promethazine injection solution 25 mgml 50 mgml

(Phenergan) 4 PA-HRM AGE (Max 64 Years)

promethazine oral tablet 125 mg 25 mg 50 mg


promethazine rectal suppository125 mg 25 mg

(Phenadoz) 4 PA-HRM AGE (Max 64 Years)

promethazine rectal suppository 50 mg

(Promethegan) 4 PA-HRM AGE (Max 64 Years)

promethegan rectal suppository 125 mg 25 mg 50 mg


scopolamine base transdermal patch 3 day 1 mg over 3 days

(Transderm-Scop) 2 PA-HRM QL (10 per 30 days) AGE (Max 64 Years)

SYNDROS ORAL SOLUTION 5 MGML


TRANSDERM-SCOP TRANSDERMAL PATCH 3 DAY 1 MG OVER 3 DAYS


Antiparasite AgentsAntiparasite Agentsalbendazole oral tablet 200 mg (Albenza) 5 NEDS

ALINIA ORAL SUSPENSION FOR RECONSTITUTION 100 MG5 ML

5 NEDS

ALINIA ORAL TABLET 500 MG

5 NEDS

atovaquone oral suspension 750 mg5 ml

(Mepron) 5 NEDS

atovaquone-proguanil oral tablet250-100 mg

(Malarone) 2


(Malarone Pediatric) 2

chloroquine phosphate oral tablet250 mg 500 mg

2

COARTEM ORAL TABLET 20-120 MG

4

DARAPRIM ORAL TABLET 25 MG

5 PA NEDS

hydroxychloroquine oral tablet 200 mg

(Plaquenil) 2


58


IMPAVIDO ORAL CAPSULE 50 MG


ivermectin oral tablet 3 mg (Stromectol) 2

KRINTAFEL ORAL TABLET 150 MG

4

mefloquine oral tablet 250 mg 2

NEBUPENT INHALATION RECON SOLN 300 MG

4 PA BvD

paromomycin oral capsule 250 mg 4

PENTAM INJECTION RECON SOLN 300 MG

4

pentamidine inhalation recon soln300 mg

(Nebupent) 2 PA BvD

pentamidine injection recon soln 300 mg

(Pentam) 4

PRIMAQUINE ORAL TABLET 263 MG

4

quinine sulfate oral capsule 324 mg (Qualaquin) 4 PA QL (42 per 7 days)

tinidazole oral tablet 250 mg 500 mg

2

Antiparkinsonian AgentsAntiparkinsonian Agentsamantadine hcl oral capsule 100 mg 2

amantadine hcl oral solution 50 mg5 ml

2

amantadine hcl oral tablet 100 mg 2

APOKYN SUBCUTANEOUS CARTRIDGE 10 MGML


benztropine injection solution 2 mg2 ml

(Cogentin) 2

benztropine oral tablet 05 mg 1 mg 2 mg

2

bromocriptine oral capsule 5 mg (Parlodel) 2

bromocriptine oral tablet 25 mg (Parlodel) 2

cabergoline oral tablet 05 mg 2

carbidopa oral tablet 25 mg (Lodosyn) 2

carbidopa-levodopa oral tablet 10-100 mg 25-100 mg 25-250 mg

(Sinemet) 2


59


carbidopa-levodopa oral tablet extended release 25-100 mg 50-200 mg

(Sinemet CR) 2

carbidopa-levodopa oral tabletdisintegrating 10-100 mg 25-100 mg 25-250 mg

4

carbidopa-levodopa-entacapone oral tablet 125-50-200 mg

(Stalevo 50) 4


(Stalevo 75) 4


(Stalevo 100) 4


(Stalevo 125) 4


(Stalevo 150) 4


(Stalevo 200) 4

entacapone oral tablet 200 mg (Comtan) 2

GOCOVRI ORAL CAPSULEEXTENDED RELEASE 24HR 137 MG




INBRIJA 42 MG INHALATION CAP 42 MG


INBRIJA INHALATION CAPSULE WINHALATION DEVICE 42 MG


NEUPRO TRANSDERMAL PATCH 24 HOUR 1 MG24 HOUR 2 MG24 HOUR 3 MG24 HOUR 4 MG24 HOUR 6 MG24 HOUR 8 MG24 HOUR


OSMOLEX ER ORAL TABLET IR - ER BIPHASIC 24HR 129 MG 193 MG 258 MG


pramipexole oral tablet 0125 mg 025 mg 05 mg 075 mg 1 mg 15 mg

(Mirapex) 1 GC


60


rasagiline oral tablet 05 mg 1 mg (Azilect) 4

ropinirole oral tablet 025 mg 3 mg 5 mg

(Requip) 2

ropinirole oral tablet 05 mg 1 mg 2 mg 4 mg

2

ropinirole oral tablet extended release 24 hr 12 mg 2 mg 6 mg

(Requip XL) 4

ropinirole oral tablet extended release 24 hr 4 mg 8 mg

4

selegiline hcl oral capsule 5 mg 2

selegiline hcl oral tablet 5 mg 2

trihexyphenidyl oral elixir 04 mgml

2

trihexyphenidyl oral tablet 2 mg 5 mg

1 GC

XADAGO ORAL TABLET 100 MG 50 MG


Antipsychotic AgentsAntipsychotic AgentsABILIFY MAINTENA INTRAMUSCULAR SUSPENSIONEXTENDED REL RECON 300 MG 400 MG


ABILIFY MAINTENA INTRAMUSCULAR SUSPENSIONEXTENDED REL SYRING 300 MG 400 MG


aripiprazole oral solution 1 mgml 5 NEDS QL (900 per 30 days)

aripiprazole oral tablet 10 mg 15 mg 20 mg 30 mg 5 mg

(Abilify) 4 QL (30 per 30 days)

aripiprazole oral tablet 2 mg (Abilify) 4 QL (60 per 30 days)

aripiprazole oral tabletdisintegrating 10 mg




ARISTADA INITIO INTRAMUSCULAR SUSPENSIONEXTENDED REL SYRING 675 MG24 ML



61


ARISTADA INTRAMUSCULAR SUSPENSIONEXTENDED REL SYRING 1064 MG39 ML








CAPLYTA ORAL CAPSULE 42 MG


chlorpromazine injection solution 25 mgml

2

chlorpromazine oral tablet 10 mg 100 mg 200 mg 25 mg 50 mg

4

clozapine oral tablet 100 mg (Clozaril) 2 QL (270 per 30 days)


clozapine oral tablet 25 mg 50 mg (Clozaril) 2 QL (90 per 30 days)

clozapine oral tabletdisintegrating100 mg 125 mg 25 mg


clozapine oral tabletdisintegrating150 mg




FANAPT ORAL TABLET 1 MG 2 MG 4 MG


FANAPT ORAL TABLET 10 MG 12 MG 6 MG 8 MG


FANAPT ORAL TABLETSDOSE PACK 1MG(2)-2MG(2)- 4MG(2)-6MG(2)

4 ST

fluphenazine decanoate injection solution 25 mgml

2


62


fluphenazine hcl injection solution25 mgml

2

fluphenazine hcl oral concentrate 5 mgml

2

fluphenazine hcl oral elixir 25 mg5 ml

2

fluphenazine hcl oral tablet 1 mg 10 mg 25 mg 5 mg

4

GEODON INTRAMUSCULAR RECON SOLN 20 MGML (FINAL CONC)


haloperidol dec 50 mgml vial mdv50 mgml

(Haldol Decanoate) 2

haloperidol decanoate intramuscular solution 100 mgml


haloperidol decanoate intramuscular solution 100 mgml (1 ml)

2



haloperidol lactate injection solution5 mgml

(Haldol) 2

haloperidol lactate intramuscular syringe 5 mgml

2

haloperidol lactate oral concentrate2 mgml

2

haloperidol oral tablet 05 mg 1 mg 10 mg 2 mg 20 mg 5 mg

2

INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 117 MG075 ML


INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 156 MGML







63




INVEGA TRINZA INTRAMUSCULAR SYRINGE 273 MG0875 ML








LATUDA ORAL TABLET 120 MG 20 MG 40 MG 60 MG


LATUDA ORAL TABLET 80 MG


loxapine succinate oral capsule 10 mg 25 mg 5 mg 50 mg

2

molindone oral tablet 10 mg 2 QL (240 per 30 days)



NUPLAZID ORAL CAPSULE 34 MG


NUPLAZID ORAL TABLET 10 MG


olanzapine intramuscular recon soln10 mg

(Zyprexa) 2 QL (30 per 30 days)

olanzapine oral tablet 10 mg 15 mg 25 mg 20 mg 5 mg 75 mg


olanzapine oral tabletdisintegrating10 mg 15 mg 20 mg 5 mg

(Zyprexa Zydis) 4 QL (30 per 30 days)

paliperidone oral tablet extended release 24hr 15 mg 3 mg

(Invega) 4 QL (30 per 30 days)

paliperidone oral tablet extended release 24hr 6 mg



(Invega) 5 NEDS QL (30 per 30 days)


64


perphenazine oral tablet 16 mg 2 mg 4 mg 8 mg

4

PERSERIS ABDOMINAL SUBCUTANEOUS SUSPENSIONEXTEND REL SYR KIT 120 MG 90 MG


pimozide oral tablet 1 mg 2 mg 2

quetiapine oral tablet 100 mg 200 mg 25 mg 300 mg 400 mg 50 mg

(Seroquel) 2 QL (90 per 30 days)

quetiapine oral tablet extended release 24 hr 150 mg 200 mg 50 mg

(Seroquel XR) 4 QL (30 per 30 days)

quetiapine oral tablet extended release 24 hr 300 mg 400 mg


REXULTI ORAL TABLET 025 MG




REXULTI ORAL TABLET 1 MG 2 MG 3 MG 4 MG


RISPERDAL CONSTA INTRAMUSCULAR SUSPENSIONEXTENDED REL RECON 125 MG2 ML 25 MG2 ML




risperidone oral solution 1 mgml (Risperdal) 2 QL (480 per 30 days)

risperidone oral tablet 025 mg 1 GC QL (60 per 30 days)

risperidone oral tablet 05 mg 1 mg 2 mg 3 mg 4 mg

(Risperdal) 1 GC QL (60 per 30 days)

risperidone oral tabletdisintegrating025 mg 05 mg 1 mg 2 mg


risperidone oral tabletdisintegrating3 mg 4 mg


SAPHRIS SUBLINGUAL TABLET 10 MG 25 MG 5 MG



65


SECUADO TRANSDERMAL PATCH 24 HOUR 38 MG24 HOUR 57 MG24 HOUR 76 MG24 HOUR


thioridazine oral tablet 10 mg 100 mg 25 mg 50 mg

2

thiothixene oral capsule 1 mg 10 mg 2 mg 5 mg

4

trifluoperazine oral tablet 1 mg 10 mg 2 mg 5 mg

2

VERSACLOZ ORAL SUSPENSION 50 MGML


VRAYLAR ORAL CAPSULE 15 MG 3 MG 45 MG 6 MG


VRAYLAR ORAL CAPSULEDOSE PACK 15 MG (1)- 3 MG (6)

4 ST

ziprasidone hcl oral capsule 20 mg 40 mg 60 mg 80 mg

(Geodon) 2 QL (60 per 30 days)

ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 210 MG






Antivirals (Systemic)Antiretroviralsabacavir oral solution 20 mgml (Ziagen) 2

abacavir oral tablet 300 mg (Ziagen) 2

abacavir-lamivudine oral tablet 600-300 mg

(Epzicom) 2

abacavir-lamivudine-zidovudine oral tablet 300-150-300 mg

(Trizivir) 5 NEDS

APTIVUS (WITH VITAMIN E) ORAL SOLUTION 100 MGML

5 NEDS


66


APTIVUS ORAL CAPSULE 250 MG

5 NEDS

atazanavir oral capsule 150 mg 200 mg 300 mg

(Reyataz) 5 NEDS

ATRIPLA ORAL TABLET 600-200-300 MG

5 NEDS

BIKTARVY ORAL TABLET 50-200-25 MG

5 NEDS

CIMDUO ORAL TABLET 300-300 MG

5 NEDS

COMPLERA ORAL TABLET 200-25-300 MG

5 NEDS

CRIXIVAN ORAL CAPSULE 200 MG 400 MG

4

DELSTRIGO ORAL TABLET 100-300-300 MG

5 NEDS

DESCOVY ORAL TABLET 200-25 MG

5 NEDS

didanosine oral capsuledelayed release(drec) 125 mg 250 mg

(Videx EC) 2


2

DOVATO ORAL TABLET 50-300 MG

5 NEDS

EDURANT ORAL TABLET 25 MG

5 NEDS

efavirenz oral capsule 200 mg (Sustiva) 5 NEDS

efavirenz oral capsule 50 mg (Sustiva) 2

efavirenz oral tablet 600 mg (Sustiva) 5 NEDS

EMTRIVA ORAL CAPSULE 200 MG

4

EMTRIVA ORAL SOLUTION 10 MGML

4

EPIVIR HBV ORAL SOLUTION 25 MG5 ML (5 MGML)

4

EVOTAZ ORAL TABLET 300-150 MG

5 NEDS

fosamprenavir oral tablet 700 mg (Lexiva) 5 NEDS

FUZEON SUBCUTANEOUS RECON SOLN 90 MG

5 NEDS


67


GENVOYA ORAL TABLET 150-150-200-10 MG

5 NEDS

INTELENCE ORAL TABLET 100 MG 200 MG

5 NEDS

INTELENCE ORAL TABLET 25 MG

4

INVIRASE ORAL TABLET 500 MG

5 NEDS

ISENTRESS HD ORAL TABLET 600 MG

5 NEDS

ISENTRESS ORAL POWDER IN PACKET 100 MG

4

ISENTRESS ORAL TABLET 400 MG

5 NEDS

ISENTRESS ORAL TABLETCHEWABLE 100 MG 25 MG

4

JULUCA ORAL TABLET 50-25 MG

5 NEDS

KALETRA ORAL TABLET 100-25 MG

4


5 NEDS

lamivudine oral solution 10 mgml (Epivir) 2

lamivudine oral tablet 100 mg (Epivir HBV) 4

lamivudine oral tablet 150 mg 300 mg

(Epivir) 2

lamivudine-zidovudine oral tablet150-300 mg

(Combivir) 2

LEXIVA ORAL SUSPENSION 50 MGML

4

lopinavir-ritonavir oral solution 400-100 mg5 ml

(Kaletra) 2

nevirapine oral suspension 50 mg5 ml

(Viramune) 2

nevirapine oral tablet 200 mg (Viramune) 2

nevirapine oral tablet extended release 24 hr 100 mg

2


(Viramune XR) 2


68


NORVIR ORAL CAPSULE 100 MG

4

NORVIR ORAL POWDER IN PACKET 100 MG

4

NORVIR ORAL SOLUTION 80 MGML

4

ODEFSEY ORAL TABLET 200-25-25 MG

5 NEDS

PIFELTRO ORAL TABLET 100 MG

5 NEDS

PREZCOBIX ORAL TABLET 800-150 MG-MG

5 NEDS

PREZISTA ORAL SUSPENSION 100 MGML

5 NEDS

PREZISTA ORAL TABLET 150 MG 600 MG 800 MG

5 NEDS

PREZISTA ORAL TABLET 75 MG

4

RESCRIPTOR ORAL TABLET 200 MG

4

RESCRIPTOR ORAL TABLET DISPERSIBLE 100 MG

4

RETROVIR INTRAVENOUS SOLUTION 10 MGML

4

REYATAZ ORAL POWDER IN PACKET 50 MG

5 NEDS

ritonavir oral tablet 100 mg (Norvir) 2

SELZENTRY ORAL SOLUTION 20 MGML

4

SELZENTRY ORAL TABLET 150 MG 300 MG 75 MG

5 NEDS

SELZENTRY ORAL TABLET 25 MG

4

stavudine oral capsule 15 mg 20 mg 30 mg 40 mg

2

STRIBILD ORAL TABLET 150-150-200-300 MG

5 NEDS

SYMFI LO ORAL TABLET 400-300-300 MG

5 NEDS

SYMFI ORAL TABLET 600-300-300 MG

5 NEDS


69


SYMTUZA ORAL TABLET 800-150-200-10 MG

5 NEDS

TEMIXYS ORAL TABLET 300-300 MG

5 NEDS

tenofovir disoproxil fumarate oral tablet 300 mg

(Viread) 2

TIVICAY ORAL TABLET 10 MG

4

TIVICAY ORAL TABLET 25 MG 50 MG

5 NEDS

TRIUMEQ ORAL TABLET 600-50-300 MG

5 NEDS

TROGARZO INTRAVENOUS SOLUTION 200 MG133 ML (150 MGML)

5 NEDS

TRUVADA ORAL TABLET 100-150 MG 133-200 MG 167-250 MG 200-300 MG

5 NEDS

VEMLIDY ORAL TABLET 25 MG


VIDEX 2 GRAM PEDIATRIC ORAL RECON SOLN 10 MGML (FINAL)

4

VIDEX EC ORAL CAPSULEDELAYED RELEASE(DREC) 125 MG

4

VIRACEPT ORAL TABLET 250 MG 625 MG

5 NEDS

VIREAD ORAL POWDER 40 MGSCOOP (40 MGGRAM)

5 NEDS

VIREAD ORAL TABLET 150 MG 200 MG 250 MG

5 NEDS

zidovudine oral capsule 100 mg (Retrovir) 2

zidovudine oral syrup 10 mgml (Retrovir) 2

zidovudine oral tablet 300 mg 2Antivirals Miscellaneousfoscarnet intravenous solution 24 mgml

(Foscavir) 4 PA BvD

oseltamivir oral capsule 30 mg (Tamiflu) 2 QL (84 per 180 days)




70


oseltamivir oral suspension for reconstitution 6 mgml

(Tamiflu) 2 QL (540 per 180 days)

PREVYMIS INTRAVENOUS SOLUTION 240 MG12 ML




PREVYMIS ORAL TABLET 240 MG 480 MG


RELENZA DISKHALER INHALATION BLISTER WITH DEVICE 5 MGACTUATION


rimantadine oral tablet 100 mg (Flumadine) 2

SYNAGIS INTRAMUSCULAR SOLUTION 100 MGML 50 MG05 ML

5 PA NEDS

XOFLUZA ORAL TABLET 20 MG 40 MG


Hcv AntiviralsEPCLUSA ORAL TABLET 400-100 MG


HARVONI ORAL TABLET 45-200 MG 90-400 MG


ledipasvir-sofosbuvir oral tablet 90-400 mg

(Harvoni) 5 PA NEDS QL (28 per 28 days)

MAVYRET ORAL TABLET 100-40 MG


sofosbuvir-velpatasvir oral tablet400-100 mg

(Epclusa) 5 PA NEDS QL (28 per 28 days)

SOVALDI ORAL TABLET 200 MG 400 MG


TECHNIVIE ORAL TABLET 125-75-50 MG


VIEKIRA PAK ORAL TABLETSDOSE PACK 125 MG-75 MG -50 MG250 MG

5 PA NEDS

VOSEVI ORAL TABLET 400-100-100 MG


ZEPATIER ORAL TABLET 50-100 MG



71


InterferonsINTRON A INJECTION RECON SOLN 10 MILLION UNIT (1 ML) 18 MILLION UNIT (1 ML) 50 MILLION UNIT (1 ML)

5 PA NSO NEDS

INTRON A INJECTION SOLUTION 10 MILLION UNITML 6 MILLION UNITML

5 PA NSO NEDS

PEGASYS PROCLICK SUBCUTANEOUS PEN INJECTOR 180 MCG05 ML

5 NEDS

PEGASYS SUBCUTANEOUS SOLUTION 180 MCGML

5 NEDS

PEGASYS SUBCUTANEOUS SYRINGE 180 MCG05 ML

5 NEDS

PEGINTRON SUBCUTANEOUS KIT 50 MCG05 ML

5 NEDS

SYLATRON SUBCUTANEOUS KIT 200 MCG 300 MCG 600 MCG

5 PA NSO NEDS

Nucleosides And Nucleotidesacyclovir oral capsule 200 mg 2

acyclovir oral suspension 200 mg5 ml

(Zovirax) 2

acyclovir oral tablet 400 mg 800 mg 2

acyclovir sodium intravenous recon soln 1000 mg 500 mg

2 PA BvD

acyclovir sodium intravenous solution 50 mgml

2 PA BvD

adefovir oral tablet 10 mg (Hepsera) 5 NEDS

cidofovir intravenous solution 75 mgml

5 NEDS

entecavir oral tablet 05 mg 1 mg (Baraclude) 2

famciclovir oral tablet 125 mg 250 mg 500 mg

2

ganciclovir sodium intravenous recon soln 500 mg

(Cytovene) 2 PA BvD


72


ganciclovir sodium intravenous solution 50 mgml

2 PA BvD

ribasphere oral capsule 200 mg 2

ribasphere oral tablet 600 mg 5 NEDS

ribasphere ribapak oral tabletsdose pack 600 mg (7)- 400 mg (7) 600 mg (7)- 600 mg (7)

5 NEDS

ribavirin inhalation recon soln 6 gram

(Virazole) 5 PA BvD NEDS

ribavirin oral capsule 200 mg 2

ribavirin oral tablet 200 mg 2

valacyclovir oral tablet 1 gram 500 mg

(Valtrex) 2

valganciclovir oral recon soln 50 mgml

(Valcyte) 5 NEDS

valganciclovir oral tablet 450 mg (Valcyte) 5 NEDS

Blood ProductsModifiersVolume ExpandersAnticoagulantsBEVYXXA ORAL CAPSULE 40 MG 80 MG


ELIQUIS DVT-PE TREAT 30D START ORAL TABLETSDOSE PACK 5 MG (74 TABS)

3

ELIQUIS ORAL TABLET 25 MG 5 MG


enoxaparin subcutaneous solution300 mg3 ml

(Lovenox) 2

enoxaparin subcutaneous syringe100 mgml 120 mg08 ml 150 mgml 30 mg03 ml 40 mg04 ml 60 mg06 ml 80 mg08 ml

(Lovenox) 2

fondaparinux subcutaneous syringe10 mg08 ml 5 mg04 ml 75 mg06 ml

(Arixtra) 5 NEDS

fondaparinux subcutaneous syringe25 mg05 ml

(Arixtra) 2

heparin (porcine) injection cartridge5000 unitml (1 ml)

2


73


heparin (porcine) injection solution1000 unitml 10000 unitml 20000 unitml 5000 unitml

2

heparin (porcine) injection syringe5000 unitml

2

heparin porcine (pf) injection solution 1000 unitml

2

heparin porcine (pf) injection syringe 5000 unit05 ml

2

jantoven oral tablet 1 mg 10 mg 2 mg 25 mg 3 mg 4 mg 5 mg 6 mg 75 mg

1 GC

PRADAXA ORAL CAPSULE 110 MG 150 MG 75 MG


warfarin oral tablet 1 mg 10 mg 2 mg 25 mg 3 mg 4 mg 5 mg 6 mg 75 mg

(Jantoven) 1 GC

XARELTO ORAL TABLET 10 MG 20 MG




XARELTO ORAL TABLETSDOSE PACK 15 MG (42)- 20 MG (9)

3

Blood Formation ModifiersCINRYZE INTRAVENOUS RECON SOLN 500 UNIT (5 ML)


DOPTELET (10 TAB PACK) ORAL TABLET 20 MG






FULPHILA SUBCUTANEOUS SYRINGE 6 MG06 ML

5 PA NEDS

GRANIX SUBCUTANEOUS SOLUTION 300 MCGML 480 MCG16 ML

5 PA NEDS

GRANIX SUBCUTANEOUS SYRINGE 300 MCG05 ML 480 MCG08 ML

5 PA NEDS


74


HAEGARDA SUBCUTANEOUS RECON SOLN 2000 UNIT




LEUKINE INJECTION RECON SOLN 250 MCG

5 NEDS

MOZOBIL SUBCUTANEOUS SOLUTION 24 MG12 ML (20 MGML)

5 NEDS

MULPLETA ORAL TABLET 3 MG


NEULASTA SUBCUTANEOUS SYRINGE 6 MG06ML

5 PA NEDS

NEUPOGEN INJECTION SOLUTION 300 MCGML 480 MCG16 ML

5 PA NEDS

NEUPOGEN INJECTION SYRINGE 300 MCG05 ML 480 MCG08 ML

5 PA NEDS

NIVESTYM INJECTION SOLUTION 300 MCGML 480 MCG16 ML

5 NEDS

NIVESTYM SUBCUTANEOUS SYRINGE 300 MCG05 ML 480 MCG08 ML

5 PA NEDS

NPLATE SUBCUTANEOUS RECON SOLN 125 MCG 250 MCG 500 MCG

5 PA NEDS

PROCRIT INJECTION SOLUTION 10000 UNITML 2000 UNITML 20000 UNIT2 ML 3000 UNITML 4000 UNITML


PROCRIT INJECTION SOLUTION 20000 UNITML




PROMACTA ORAL POWDER IN PACKET 125 MG


PROMACTA ORAL TABLET 125 MG



75








RETACRIT INJECTION SOLUTION 10000 UNITML 2000 UNITML 3000 UNITML 4000 UNITML


RETACRIT INJECTION SOLUTION 40000 UNITML


UDENYCA SUBCUTANEOUS SYRINGE 6 MG06 ML

5 PA NEDS

ZARXIO INJECTION SYRINGE 300 MCG05 ML 480 MCG08 ML

5 NEDS

ZIEXTENZO SUBCUTANEOUS SYRINGE 6 MG06 ML

5 PA NEDS

Hematologic Agents MiscellaneousADAKVEO INTRAVENOUS SOLUTION 10 MGML

5 PA NEDS

anagrelide oral capsule 05 mg (Agrylin) 2

anagrelide oral capsule 1 mg 2

GIVLAARI SUBCUTANEOUS SOLUTION 189 MGML

5 PA NEDS

protamine intravenous solution 10 mgml

2

SIKLOS ORAL TABLET 1000 MG 100 MG

4 PA

TAVALISSE ORAL TABLET 100 MG 150 MG


tranexamic acid intravenous solution1000 mg10 ml (100 mgml)

(Cyklokapron) 2

tranexamic acid oral tablet 650 mg (Lysteda) 2 QL (30 per 30 days)Platelet-Aggregation Inhibitorsaspirin-dipyridamole oral capsule er multiphase 12 hr 25-200 mg

(Aggrenox) 2 QL (60 per 30 days)

BRILINTA ORAL TABLET 60 MG 90 MG

3

cilostazol oral tablet 100 mg 50 mg 2


76


clopidogrel oral tablet 75 mg (Plavix) 1 GC

dipyridamole oral tablet 25 mg 50 mg 75 mg


pentoxifylline oral tablet extended release 400 mg

2

prasugrel oral tablet 10 mg 5 mg (Effient) 4 QL (30 per 30 days)

Caloric AgentsCaloric AgentsAMINOSYN 10 INTRAVENOUS PARENTERAL SOLUTION 10

4 PA BvD

AMINOSYN 7 WITH ELECTROLYTES INTRAVENOUS PARENTERAL SOLUTION 7

4 PA BvD

AMINOSYN 85 INTRAVENOUS PARENTERAL SOLUTION 85

4 PA BvD

AMINOSYN 85 -ELECTROLYTES INTRAVENOUS PARENTERAL SOLUTION 85

4 PA BvD

AMINOSYN II 10 INTRAVENOUS PARENTERAL SOLUTION 10

4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


77


AMINOSYN II 85 -ELECTROLYTES INTRAVENOUS PARENTERAL SOLUTION 85

4 PA BvD

AMINOSYN M 35 INTRAVENOUS PARENTERAL SOLUTION 35

4 PA BvD

AMINOSYN-HBC 7 INTRAVENOUS PARENTERAL SOLUTION 7

4 PA BvD

AMINOSYN-PF 10 INTRAVENOUS PARENTERAL SOLUTION 10

4 PA BvD

AMINOSYN-PF 7 (SULFITE-FREE) INTRAVENOUS PARENTERAL SOLUTION 7

4 PA BvD

AMINOSYN-RF 52 INTRAVENOUS PARENTERAL SOLUTION 52

4 PA BvD

CLINIMIX 5D15W SULFITE FREE INTRAVENOUS PARENTERAL SOLUTION 5

4 PA BvD

CLINIMIX 5D25W SULFITE-FREE INTRAVENOUS PARENTERAL SOLUTION 5

4 PA BvD

CLINIMIX 425D10W SULF FREE INTRAVENOUS PARENTERAL SOLUTION 425

4 PA BvD

CLINIMIX 425D5W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 425

4 PA BvD

CLINIMIX 425-D25W SULF-FREE INTRAVENOUS PARENTERAL SOLUTION 425

4 PA BvD


78


CLINIMIX 5-D20W(SULFITE-FREE) INTRAVENOUS PARENTERAL SOLUTION 5

4 PA BvD

CLINIMIX E 275D10W SUL FREE INTRAVENOUS PARENTERAL SOLUTION 275

4 PA BvD

CLINIMIX E 275D5W SULF FREE INTRAVENOUS PARENTERAL SOLUTION 275

4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD

CLINIMIX E 5D15W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 5

4 PA BvD


4 PA BvD


4 PA BvD

CLINOLIPID INTRAVENOUS EMULSION 20

4 PA BvD

dextrose 10 in water (d10w) intravenous parenteral solution 10

4 PA BvD


4 PA BvD

dextrose 25 in water (d25w) intravenous syringe

4 PA BvD

dextrose 30 in water (d30w) intravenous parenteral solution

4 PA BvD


79



4 PA BvD


2


4 PA BvD


4 PA BvD


4 PA BvD

FREAMINE HBC 69 INTRAVENOUS PARENTERAL SOLUTION 69

4 PA BvD

FREAMINE III 10 INTRAVENOUS PARENTERAL SOLUTION 10

4 PA BvD

HEPATAMINE 8 INTRAVENOUS PARENTERAL SOLUTION 8

4 PA BvD

INTRALIPID INTRAVENOUS EMULSION 20 30

4 PA BvD

KABIVEN INTRAVENOUS EMULSION 331-98-39

4 PA BvD

NEPHRAMINE 54 INTRAVENOUS PARENTERAL SOLUTION 54

4 PA BvD

NUTRILIPID INTRAVENOUS EMULSION 20

4 PA BvD

PERIKABIVEN INTRAVENOUS EMULSION 236-68-35

4 PA BvD

PROCALAMINE 3 INTRAVENOUS PARENTERAL SOLUTION 3

4 PA BvD

PROSOL 20 INTRAVENOUS PARENTERAL SOLUTION

4 PA BvD

smoflipid intravenous emulsion 20 4 PA BvD


80


TRAVASOL 10 INTRAVENOUS PARENTERAL SOLUTION 10

4 PA BvD

TROPHAMINE 10 INTRAVENOUS PARENTERAL SOLUTION 10

4 PA BvD


4 PA BvD

Cardiovascular AgentsAlpha-Adrenergic Agentsclonidine hcl oral tablet 01 mg 02 mg 03 mg

(Catapres) 1 GC

clonidine transdermal patch weekly01 mg24 hr

(Catapres-TTS-1) 2 QL (4 per 28 days)





doxazosin oral tablet 1 mg 2 mg 4 mg 8 mg

(Cardura) 2

guanfacine oral tablet 1 mg 2 mg 1 GC

midodrine oral tablet 10 mg 25 mg 5 mg

2

NORTHERA ORAL CAPSULE 100 MG 200 MG 300 MG


phenylephrine hcl injection solution10 mgml

(Vazculep) 2

prazosin oral capsule 1 mg 2 mg 5 mg

(Minipress) 2

Angiotensin Ii Receptor Antagonistscandesartan oral tablet 16 mg 32 mg 4 mg 8 mg

(Atacand) 4

candesartan-hydrochlorothiazid oral tablet 16-125 mg 32-125 mg 32-25 mg

(Atacand HCT) 4

EDARBI ORAL TABLET 40 MG 80 MG

3


81


EDARBYCLOR ORAL TABLET 40-125 MG 40-25 MG

3

ENTRESTO ORAL TABLET 24-26 MG 49-51 MG 97-103 MG


eprosartan oral tablet 600 mg 4

irbesartan oral tablet 150 mg 300 mg 75 mg

(Avapro) 1 GC

irbesartan-hydrochlorothiazide oral tablet 150-125 mg 300-125 mg

(Avalide) 1 GC

losartan oral tablet 100 mg 25 mg 50 mg

(Cozaar) 1 GC

losartan-hydrochlorothiazide oral tablet 100-125 mg 100-25 mg 50-125 mg

(Hyzaar) 1 GC

olmesartan oral tablet 20 mg 40 mg 5 mg

(Benicar) 2

olmesartan-amlodipin-hcthiazid oral tablet 20-5-125 mg 40-10-125 mg 40-10-25 mg 40-5-125 mg 40-5-25 mg

(Tribenzor) 4

olmesartan-hydrochlorothiazide oral tablet 20-125 mg 40-125 mg 40-25 mg

(Benicar HCT) 2

telmisartan oral tablet 20 mg 40 mg 80 mg

(Micardis) 1 GC

telmisartan-amlodipine oral tablet40-10 mg 40-5 mg 80-10 mg 80-5 mg

(Twynsta) 4

telmisartan-hydrochlorothiazid oral tablet 40-125 mg 80-125 mg 80-25 mg

(Micardis HCT) 4

valsartan oral tablet 160 mg 320 mg 40 mg 80 mg

(Diovan) 1 GC

valsartan-hydrochlorothiazide oral tablet 160-125 mg 160-25 mg 320-125 mg 320-25 mg 80-125 mg

(Diovan HCT) 1 GC

Angiotensin-Converting Enzyme Inhibitorsbenazepril oral tablet 10 mg 20 mg 40 mg

(Lotensin) 1 GC

benazepril oral tablet 5 mg 1 GC


82


benazepril-hydrochlorothiazide oral tablet 10-125 mg 20-125 mg 20-25 mg

(Lotensin HCT) 2

benazepril-hydrochlorothiazide oral tablet 5-625 mg

2

captopril oral tablet 100 mg 125 mg 25 mg 50 mg

2

captopril-hydrochlorothiazide oral tablet 25-15 mg 25-25 mg 50-15 mg 50-25 mg

2

enalapril maleate oral tablet 10 mg 25 mg 20 mg 5 mg

(Vasotec) 1 GC

enalaprilat intravenous solution 125 mgml

2

enalapril-hydrochlorothiazide oral tablet 10-25 mg

(Vaseretic) 1 GC


1 GC

EPANED ORAL SOLUTION 1 MGML

4 ST

fosinopril oral tablet 10 mg 20 mg 40 mg

1 GC

fosinopril-hydrochlorothiazide oral tablet 10-125 mg 20-125 mg

2

lisinopril oral tablet 10 mg 20 mg 5 mg

(Prinivil) 1 GC


(Zestril) 1 GC

lisinopril-hydrochlorothiazide oral tablet 10-125 mg 20-125 mg 20-25 mg

(Zestoretic) 1 GC

moexipril oral tablet 15 mg 75 mg 2

perindopril erbumine oral tablet 2 mg 4 mg 8 mg

1 GC

QBRELIS ORAL SOLUTION 1 MGML

5 ST NEDS

quinapril oral tablet 10 mg 20 mg 40 mg 5 mg

(Accupril) 1 GC

quinapril-hydrochlorothiazide oral tablet 10-125 mg 20-125 mg 20-25 mg

(Accuretic) 2


83


ramipril oral capsule 125 mg 10 mg 25 mg 5 mg

(Altace) 1 GC

trandolapril oral tablet 1 mg 2 mg 4 mg

1 GC

Antiarrhythmic Agentsamiodarone oral tablet 100 mg 400 mg

(Pacerone) 4

amiodarone oral tablet 200 mg (Pacerone) 1 GC

disopyramide phosphate oral capsule100 mg 150 mg

(Norpace) 2 PA-HRM AGE (Max 64 Years)

dofetilide oral capsule 125 mcg 250 mcg 500 mcg

(Tikosyn) 4

flecainide oral tablet 100 mg 150 mg 50 mg

2

lidocaine (pf) intravenous syringe100 mg5 ml (2 ) 50 mg5 ml (1 )

1 GC

mexiletine oral capsule 150 mg 200 mg 250 mg

2

MULTAQ ORAL TABLET 400 MG

3

pacerone oral tablet 100 mg 400 mg 4

pacerone oral tablet 200 mg 1 GC

procainamide injection solution 100 mgml 500 mgml

2

procainamide intravenous syringe100 mgml

2

propafenone oral capsuleextended release 12 hr 225 mg 325 mg 425 mg

(Rythmol SR) 4

propafenone oral tablet 150 mg 225 mg 300 mg

2

quinidine gluconate oral tablet extended release 324 mg

4

quinidine sulfate oral tablet 200 mg 300 mg

2

Beta-Adrenergic Blocking Agentsacebutolol oral capsule 200 mg 400 mg

2

atenolol oral tablet 100 mg 25 mg 50 mg

(Tenormin) 1 GC


84


atenolol-chlorthalidone oral tablet100-25 mg

(Tenoretic 100) 2


(Tenoretic 50) 2

betaxolol oral tablet 10 mg 20 mg 2

bisoprolol fumarate oral tablet 10 mg 5 mg

2

bisoprolol-hydrochlorothiazide oral tablet 10-625 mg 25-625 mg 5-625 mg

(Ziac) 1 GC

BYSTOLIC ORAL TABLET 10 MG 25 MG 20 MG 5 MG

3

BYVALSON ORAL TABLET 5-80 MG

3

carvedilol oral tablet 125 mg 25 mg 3125 mg 625 mg

(Coreg) 1 GC

labetalol intravenous solution 5 mgml

2

labetalol intravenous syringe 20 mg4 ml (5 mgml)

2

labetalol oral tablet 100 mg 200 mg 300 mg

2

metoprolol succinate oral tablet extended release 24 hr 100 mg 200 mg 25 mg 50 mg

(Toprol XL) 2

metoprolol ta-hydrochlorothiaz oral tablet 100-25 mg 100-50 mg

2

metoprolol ta-hydrochlorothiaz oral tablet 50-25 mg

(Lopressor HCT) 2

metoprolol tartrate intravenous solution 5 mg5 ml

(Lopressor) 2

metoprolol tartrate intravenous syringe 5 mg5 ml

2

metoprolol tartrate oral tablet 100 mg 50 mg

(Lopressor) 1 GC

metoprolol tartrate oral tablet 25 mg

1 GC

nadolol oral tablet 20 mg 40 mg 80 mg

(Corgard) 2

pindolol oral tablet 10 mg 5 mg 4


85


propranolol intravenous solution 1 mgml

2

propranolol oral capsuleextended release 24 hr 120 mg 160 mg 60 mg 80 mg

(Inderal LA) 4

propranolol oral solution 20 mg5 ml (4 mgml) 40 mg5 ml (8 mgml)

2

propranolol oral tablet 10 mg 20 mg 40 mg 60 mg 80 mg

2

propranolol-hydrochlorothiazid oral tablet 40-25 mg 80-25 mg

2

sorine oral tablet 120 mg 160 mg 240 mg 80 mg

2

sotalol af oral tablet 120 mg 160 mg 80 mg

2

sotalol oral tablet 120 mg 160 mg 240 mg 80 mg

(Sorine) 2

timolol maleate oral tablet 10 mg 20 mg 5 mg

4

Calcium-Channel Blocking Agentscartia xt oral capsuleextended release 24hr 120 mg 180 mg 240 mg 300 mg

2

diltiazem hcl intravenous solution 5 mgml

2

diltiazem hcl oral capsuleextended release 12 hr 120 mg 60 mg 90 mg

2

diltiazem hcl oral capsuleextended release 24 hr 360 mg

(Taztia XT) 4


(Tiadylt ER) 2

diltiazem hcl oral capsuleextended release 24hr 120 mg 180 mg 240 mg 300 mg

(Cartia XT) 2

diltiazem hcl oral tablet 120 mg 30 mg 60 mg

(Cardizem) 2

diltiazem hcl oral tablet 90 mg 2

dilt-xr oral capsuleextrel 24h degradable 120 mg 180 mg 240 mg

2


86


matzim la oral tablet extended release 24 hr 180 mg 240 mg 300 mg 360 mg 420 mg

4

taztia xt oral capsuleextended release 24 hr 120 mg 180 mg 240 mg 300 mg 360 mg

2

tiadylt er oral capsuleextended release 24 hr 120 mg 180 mg 240 mg 300 mg 420 mg

2

tiadylt er oral capsuleextended release 24 hr 360 mg

2

verapamil intravenous syringe 25 mgml

2

verapamil oral capsule 24 hr er pellet ct 100 mg 200 mg 300 mg

(Verelan PM) 2

verapamil oral capsuleext rel pellets 24 hr 120 mg 180 mg 240 mg

(Verelan) 2

verapamil oral capsuleext rel pellets 24 hr 360 mg

(Verelan) 4

verapamil oral tablet 120 mg 40 mg 80 mg

1 GC

verapamil oral tablet extended release 120 mg 180 mg 240 mg

(Calan SR) 1 GC

Cardiovascular Agents MiscellaneousCORLANOR ORAL SOLUTION 5 MG5 ML


CORLANOR ORAL TABLET 5 MG 75 MG


DEMSER ORAL CAPSULE 250 MG

5 NEDS

digitek oral tablet 125 mcg (0125 mg) 250 mcg (025 mg)

2

digox oral tablet 125 mcg (0125 mg) 250 mcg (025 mg)

2

digoxin injection syringe 250 mcgml (025 mgml)

2

DIGOXIN ORAL SOLUTION 50 MCGML (005 MGML)

4


87


digoxin oral tablet 125 mcg (0125 mg)

(Digitek) 2


(Digitek) 2

epinephrine injection auto-injector015 mg03 ml

(EpiPen Jr) 2 QL (4 per 30 days)


(Auvi-Q) 2 QL (4 per 30 days)

hydralazine injection solution 20 mgml

2

hydralazine oral tablet 10 mg 100 mg 25 mg 50 mg

2

icatibant subcutaneous syringe 30 mg3 ml

(Firazyr) 5 PA NEDS QL (18 per 30 days)

ranolazine oral tablet extended release 12 hr 1000 mg 500 mg

(Ranexa) 4

SYMJEPI INJECTION SYRINGE 015 MG03 ML 03 MG03 ML


VYNDAMAX ORAL CAPSULE 61 MG


VYNDAQEL ORAL CAPSULE 20 MG


Dihydropyridinesafeditab cr oral tablet extended release 30 mg

2

amlodipine oral tablet 10 mg 25 mg 5 mg

(Norvasc) 1 GC

amlodipine-benazepril oral capsule10-20 mg 10-40 mg 5-10 mg 5-20 mg 5-40 mg

(Lotrel) 1 GC

amlodipine-benazepril oral capsule25-10 mg

1 GC

amlodipine-olmesartan oral tablet10-20 mg 10-40 mg 5-20 mg 5-40 mg

(Azor) 2

amlodipine-valsartan oral tablet 10-160 mg 10-320 mg 5-160 mg 5-320 mg

(Exforge) 1 GC


88


amlodipine-valsartan-hcthiazid oral tablet 10-160-125 mg 10-160-25 mg 10-320-25 mg 5-160-125 mg 5-160-25 mg

(Exforge HCT) 4

felodipine oral tablet extended release 24 hr 10 mg 25 mg 5 mg

2

isradipine oral capsule 25 mg 5 mg 4

KATERZIA ORAL SUSPENSION 1 MGML


nicardipine oral capsule 20 mg 30 mg

4

nifedipine oral capsule 10 mg (Procardia) 2

nifedipine oral capsule 20 mg 2

nifedipine oral tablet extended release 24hr 30 mg 60 mg 90 mg

(Procardia XL) 2

nifedipine oral tablet extended release 30 mg 90 mg

(Adalat CC) 2

nifedipine oral tablet extended release 60 mg

(Adalat CC) 2

Diureticsamiloride oral tablet 5 mg 2

amiloride-hydrochlorothiazide oral tablet 5-50 mg

2

bumetanide injection solution 025 mgml

4

bumetanide oral tablet 05 mg 1 mg 2 mg

2

chlorothiazide oral tablet 250 mg 500 mg

2

chlorothiazide sodium intravenous recon soln 500 mg

(Diuril IV) 2

chlorthalidone oral tablet 25 mg 50 mg

2

furosemide injection solution 10 mgml

2

furosemide injection syringe 10 mgml

2

furosemide oral solution 10 mgml 40 mg5 ml (8 mgml)

1 GC

furosemide oral tablet 20 mg 40 mg 80 mg

(Lasix) 1 GC


89


hydrochlorothiazide oral capsule125 mg

1 GC

hydrochlorothiazide oral tablet 125 mg 25 mg 50 mg

1 GC

indapamide oral tablet 125 mg 25 mg

1 GC

JYNARQUE ORAL TABLET 15 MG 30 MG


JYNARQUE ORAL TABLETS SEQUENTIAL 45 MG (AM) 15 MG (PM) 60 MG (AM) 30 MG (PM) 90 MG (AM) 30 MG (PM)


methyclothiazide oral tablet 5 mg 2

metolazone oral tablet 10 mg 25 mg 5 mg

2

spironolactone oral tablet 100 mg 25 mg 50 mg

(Aldactone) 1 GC

spironolacton-hydrochlorothiaz oral tablet 25-25 mg

(Aldactazide) 2

torsemide oral tablet 10 mg 100 mg 20 mg 5 mg

1 GC

triamterene-hydrochlorothiazid oral capsule 375-25 mg

(Dyazide) 1 GC


1 GC

triamterene-hydrochlorothiazid oral tablet 375-25 mg

(Maxzide-25mg) 1 GC


(Maxzide) 1 GC

Dyslipidemicsamlodipine-atorvastatin oral tablet10-10 mg 10-20 mg 10-40 mg 10-80 mg 5-10 mg 5-20 mg 5-40 mg 5-80 mg

(Caduet) 4

amlodipine-atorvastatin oral tablet25-10 mg 25-20 mg 25-40 mg

4

atorvastatin oral tablet 10 mg 20 mg 40 mg 80 mg

(Lipitor) 1 GC

cholestyramine (with sugar) oral powder in packet 4 gram

(Questran) 2


90


cholestyramine light oral powder 4 gram

2

cholestyramine light packet 4 gram 2

colesevelam oral tablet 625 mg (WelChol) 2

colestipol oral packet 5 gram (Colestid) 2

colestipol oral tablet 1 gram (Colestid) 2

EZALLOR SPRINKLE ORAL CAPSULE SPRINKLE 10 MG 20 MG 40 MG 5 MG


ezetimibe oral tablet 10 mg (Zetia) 2 QL (30 per 30 days)

ezetimibe-simvastatin oral tablet 10-10 mg

(Vytorin 10-10) 2 QL (30 per 30 days)







fenofibrate micronized oral capsule130 mg

4

fenofibrate micronized oral capsule134 mg 200 mg 43 mg 67 mg

2

fenofibrate nanocrystallized oral tablet 145 mg 48 mg

(Tricor) 2

fenofibrate oral tablet 160 mg 54 mg

2

fenofibric acid (choline) oral capsuledelayed release(drec) 135 mg 45 mg

(Trilipix) 4

fenofibric acid oral tablet 105 mg 35 mg

(Fibricor) 4

FLOLIPID ORAL SUSPENSION 20 MG5 ML (4 MGML) 40 MG5 ML (8 MGML)

4 ST

fluvastatin oral capsule 20 mg 40 mg

(Lescol) 4

gemfibrozil oral tablet 600 mg (Lopid) 1 GC

JUXTAPID ORAL CAPSULE 10 MG 30 MG 40 MG 60 MG


JUXTAPID ORAL CAPSULE 20 MG



91




LIVALO ORAL TABLET 1 MG 2 MG 4 MG


lovastatin oral tablet 10 mg 20 mg 40 mg

1 GC

niacin oral tablet 500 mg (Niacor) 4

niacin oral tablet extended release 24 hr 1000 mg 750 mg

(Niaspan Extended-Release)

4

niacin oral tablet extended release 24 hr 500 mg


2

niacor oral tablet 500 mg 2

omega-3 acid ethyl esters oral capsule 1 gram

(Lovaza) 2 QL (120 per 30 days)

PRALUENT PEN SUBCUTANEOUS PEN INJECTOR 150 MGML 75 MGML


pravastatin oral tablet 10 mg 80 mg 1 GC

pravastatin oral tablet 20 mg 40 mg (Pravachol) 1 GC

prevalite oral powder in packet 4 gram

2

REPATHA PUSHTRONEX SUBCUTANEOUS WEARABLE INJECTOR 420 MG35 ML


REPATHA SURECLICK SUBCUTANEOUS PEN INJECTOR 140 MGML


REPATHA SYRINGE SUBCUTANEOUS SYRINGE 140 MGML


rosuvastatin oral tablet 10 mg 20 mg 40 mg 5 mg

(Crestor) 1 GC QL (30 per 30 days)

simvastatin oral tablet 10 mg 20 mg 40 mg 80 mg

(Zocor) 1 GC QL (30 per 30 days)

simvastatin oral tablet 5 mg 1 GC QL (30 per 30 days)

VASCEPA ORAL CAPSULE 05 GRAM





92


WELCHOL ORAL POWDER IN PACKET 375 GRAM

2

WELCHOL ORAL TABLET 625 MG

2

Renin-Angiotensin-Aldosterone System Inhibitorsaliskiren oral tablet 150 mg 300 mg (Tekturna) 4

CAROSPIR ORAL SUSPENSION 25 MG5 ML

4 ST

eplerenone oral tablet 25 mg 50 mg (Inspra) 4

TEKTURNA HCT ORAL TABLET 150-125 MG 150-25 MG 300-125 MG 300-25 MG

3 ST

VasodilatorsBIDIL ORAL TABLET 20-375 MG

3

isosorbide dinitrate oral tablet 10 mg 20 mg 30 mg

2

isosorbide dinitrate oral tablet 5 mg (Isordil Titradose) 2

isosorbide dinitrate oral tablet extended release 40 mg

(ISOCHRON) 2

isosorbide mononitrate oral tablet10 mg 20 mg

2

isosorbide mononitrate oral tablet extended release 24 hr 120 mg 30 mg 60 mg

1 GC

minitran transdermal patch 24 hour01 mghr 02 mghr 04 mghr 06 mghr

2

minoxidil oral tablet 10 mg 25 mg 2

nitroglycerin intravenous solution 50 mg10 ml (5 mgml)

2

nitroglycerin sublingual tablet 03 mg 04 mg 06 mg

(Nitrostat) 2

nitroglycerin transdermal patch 24 hour 01 mghr 02 mghr 04 mghr 06 mghr

(Minitran) 2

Central Nervous System AgentsCentral Nervous System Agentsatomoxetine oral capsule 10 mg 18 mg 25 mg 40 mg

(Strattera) 2 QL (60 per 30 days)


93


atomoxetine oral capsule 100 mg 60 mg 80 mg


AUBAGIO ORAL TABLET 14 MG 7 MG


AUSTEDO ORAL TABLET 12 MG 9 MG


AUSTEDO ORAL TABLET 6 MG


AVONEX (WITH ALBUMIN) INTRAMUSCULAR KIT 30 MCG


AVONEX INTRAMUSCULAR PEN INJECTOR 30 MCG05 ML


AVONEX INTRAMUSCULAR PEN INJECTOR KIT 30 MCG05 ML


AVONEX INTRAMUSCULAR SYRINGE KIT 30 MCG05 ML


BETASERON SUBCUTANEOUS KIT 03 MG


caffeine citrate intravenous solution60 mg3 ml (20 mgml)

(Cafcit) 2 PA BvD

caffeine citrate oral solution 60 mg3 ml (20 mgml)

2

clonidine hcl oral tablet extended release 12 hr 01 mg

(Kapvay) 4

dalfampridine oral tablet extended release 12 hr 10 mg

(Ampyra) 5 PA NEDS QL (60 per 30 days)

dexmethylphenidate oral tablet 10 mg 25 mg 5 mg

(Focalin) 2 QL (60 per 30 days)

dextroamphetamine oral capsule extended release 10 mg 15 mg 5 mg

(Dexedrine Spansule) 4 QL (120 per 30 days)

dextroamphetamine oral tablet 10 mg 5 mg

(Zenzedi) 4 QL (180 per 30 days)

dextroamphetamine-amphetamine oral capsuleextended release 24hr10 mg 15 mg 5 mg

(Adderall XR) 4 QL (30 per 30 days)




94


dextroamphetamine-amphetamine oral tablet 10 mg 125 mg 15 mg 20 mg 30 mg 5 mg 75 mg

(Adderall) 2 QL (60 per 30 days)

EXTAVIA SUBCUTANEOUS KIT 03 MG


flumazenil intravenous solution 01 mgml

2

GILENYA ORAL CAPSULE 025 MG 05 MG


glatiramer subcutaneous syringe 20 mgml

(Glatopa) 5 PA NEDS QL (30 per 30 days)



glatopa subcutaneous syringe 20 mgml




guanfacine oral tablet extended release 24 hr 1 mg 2 mg 3 mg 4 mg

(Intuniv ER) 2

INGREZZA INITIATION PACK ORAL CAPSULEDOSE PACK 40 MG (7)- 80 MG (21)

5 PA NEDS

INGREZZA ORAL CAPSULE 40 MG 80 MG


LEMTRADA INTRAVENOUS SOLUTION 12 MG12 ML


lithium carbonate oral capsule 150 mg 300 mg 600 mg

1 GC

lithium carbonate oral tablet 300 mg 1 GC

lithium carbonate oral tablet extended release 300 mg

(Lithobid) 2


2

lithium citrate oral solution 8 meq5 ml

4

MAVENCLAD (10 TABLET PACK) ORAL TABLET 10 MG

5 PA NEDS


5 PA NEDS


5 PA NEDS


95



5 PA NEDS


5 PA NEDS


5 PA NEDS


5 PA NEDS

MAYZENT ORAL TABLET 025 MG




metadate er oral tablet extended release 20 mg


methylphenidate hcl oral capsule er biphasic 30-70 10 mg 20 mg 40 mg 50 mg 60 mg


methylphenidate hcl oral capsule er biphasic 30-70 30 mg


methylphenidate hcl oral capsuleer biphasic 50-50 10 mg 20 mg 40 mg

(Ritalin LA) 4 QL (30 per 30 days)

methylphenidate hcl oral capsuleer biphasic 50-50 30 mg




methylphenidate hcl oral solution 10 mg5 ml 5 mg5 ml

(Methylin) 2 QL (900 per 30 days)

methylphenidate hcl oral tablet 10 mg 20 mg 5 mg

(Ritalin) 2 QL (90 per 30 days)

methylphenidate hcl oral tablet extended release 10 mg



(Metadate ER) 4 QL (90 per 30 days)

methylphenidate hcl oral tablet extended release 24hr 18 mg (bx rating) 27 mg (bx rating) 54 mg (bx rating)


methylphenidate hcl oral tablet extended release 24hr 18 mg 27 mg 54 mg

(Concerta) 4 QL (30 per 30 days)


96


methylphenidate hcl oral tablet extended release 24hr 36 mg


methylphenidate hcl oral tablet extended release 24hr 36 mg (bx rating)


methylphenidate la 30 mg cap 30 mg (Ritalin LA) 4 QL (60 per 30 days)

NUEDEXTA ORAL CAPSULE 20-10 MG


OCREVUS INTRAVENOUS SOLUTION 30 MGML


PLEGRIDY SUBCUTANEOUS PEN INJECTOR 125 MCG05 ML


PLEGRIDY SUBCUTANEOUS PEN INJECTOR 63 MCG05 ML- 94 MCG05 ML

5 PA NEDS

PLEGRIDY SUBCUTANEOUS SYRINGE 125 MCG05 ML


PLEGRIDY SUBCUTANEOUS SYRINGE 63 MCG05 ML- 94 MCG05 ML

5 PA NEDS

RADICAVA INTRAVENOUS PIGGYBACK 30 MG100 ML


REBIF (WITH ALBUMIN) SUBCUTANEOUS SYRINGE 22 MCG05 ML 44 MCG05 ML


REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 22 MCG05 ML 44 MCG05 ML


REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 88MCG02ML-22 MCG05ML (6)

5 PA NEDS

REBIF TITRATION PACK SUBCUTANEOUS SYRINGE 88MCG02ML-22 MCG05ML (6)

5 PA NEDS

riluzole oral tablet 50 mg (Rilutek) 2

SAVELLA ORAL TABLET 100 MG 125 MG 25 MG 50 MG



97


SAVELLA ORAL TABLETSDOSE PACK 125 MG (5)-25 MG(8)-50 MG(42)

3

TECFIDERA ORAL CAPSULEDELAYED RELEASE(DREC) 120 MG


TECFIDERA ORAL CAPSULEDELAYED RELEASE(DREC) 120 MG (14)- 240 MG (46)

5 PA NEDS



tetrabenazine oral tablet 125 mg 25 mg

(Xenazine) 5 PA NEDS QL (112 per 28 days)

VUMERITY ORAL CAPSULEDELAYED RELEASE(DREC) 231 MG


ContraceptivesContraceptivesafirmelle oral tablet 01-20 mg-mcg 2

altavera (28) oral tablet 015-003 mg

2

alyacen 135 (28) oral tablet 1-35 mg-mcg

2

alyacen 777 (28) oral tablet050751 mg- 35 mcg

2

amethia lo oral tabletsdose pack3 month 010 mg-20 mcg (84)10 mcg (7)


amethia oral tabletsdose pack3 month 015 mg-30 mcg (84)10 mcg (7)


apri oral tablet 015-003 mg 2

aranelle (28) oral tablet 05105-35 mg-mcg

2

ashlyna oral tabletsdose pack3 month 015 mg-30 mcg (84)10 mcg (7)


aubra oral tablet 01-20 mg-mcg 2


98


aurovela 1530 (21) oral tablet 15-30 mg-mcg

2


2

aurovela 24 fe oral tablet 1 mg-20 mcg (24)75 mg (4)

2

aurovela fe 1530 (28) oral tablet15 mg-30 mcg (21)75 mg (7)

2

aurovela fe 1-20 (28) oral tablet 1 mg-20 mcg (21)75 mg (7)

2

aviane oral tablet 01-20 mg-mcg 2

ayuna oral tablet 015-003 mg 2

azurette (28) oral tablet 015-002 mgx21 001 mg x 5

2

balziva (28) oral tablet 04-35 mg-mcg

2

bekyree (28) oral tablet 015-002 mgx21 001 mg x 5

2

blisovi 24 fe oral tablet 1 mg-20 mcg (24)75 mg (4)

2

blisovi fe 1530 (28) oral tablet 15 mg-30 mcg (21)75 mg (7)

2


2

briellyn oral tablet 04-35 mg-mcg 2

camila oral tablet 035 mg 2

caziant (28) oral tablet0112515-25 mg-mcg

2

cryselle (28) oral tablet 03-30 mg-mcg

2

cyclafem 135 (28) oral tablet 1-35 mg-mcg

2

cyclafem 777 (28) oral tablet050751 mg- 35 mcg

2

cyred oral tablet 015-003 mg 2

dasetta 135 (28) oral tablet 1-35 mg-mcg

2

dasetta 777 (28) oral tablet050751 mg- 35 mcg

2


99


daysee oral tabletsdose pack3 month 015 mg-30 mcg (84)10 mcg (7)


deblitane oral tablet 035 mg 2

delyla (28) oral tablet 01-20 mg-mcg

2

desog-eestradioleestradiol oral tablet 015-002 mgx21 001 mg x 5

(Azurette (28)) 2

desogestrel-ethinyl estradiol oral tablet 015-003 mg

(Apri) 2

drospirenone-ethinyl estradiol oral tablet 3-002 mg

(Jasmiel (28)) 2


(Syeda) 2

elinest oral tablet 03-30 mg-mcg 2

ELLA ORAL TABLET 30 MG 4 QL (6 per 365 days)

eluryng vaginal ring 012-0015 mg24 hr


emoquette oral tablet 015-003 mg 2

enpresse oral tablet 50-30 (6)75-40 (5)125-30(10)

2

enskyce oral tablet 015-003 mg 2

errin oral tablet 035 mg 2

estarylla oral tablet 025-35 mg-mcg 2

ethynodiol diac-eth estradiol oral tablet 1-35 mg-mcg

(Kelnor 135 (28)) 2


(Kelnor 1-50) 2

etonogestrel-ethinyl estradiol vaginal ring 012-0015 mg24 hr

(EluRyng) 4 QL (1 per 28 days)

falmina (28) oral tablet 01-20 mg-mcg

2

femynor oral tablet 025-35 mg-mcg 2

hailey 24 fe oral tablet 1 mg-20 mcg (24)75 mg (4)

2

hailey oral tablet 15-30 mg-mcg 2

heather oral tablet 035 mg 2

incassia oral tablet 035 mg 2

introvale oral tabletsdose pack3 month 015 mg-30 mcg (91)



100


isibloom oral tablet 015-003 mg 2

jasmiel (28) oral tablet 3-002 mg 2

jencycla oral tablet 035 mg 1 GC

jolivette oral tablet 035 mg 4

juleber oral tablet 015-003 mg 2

junel 1530 (21) oral tablet 15-30 mg-mcg

2


2

junel fe 1530 (28) oral tablet 15 mg-30 mcg (21)75 mg (7)

2


2

junel fe 24 oral tablet 1 mg-20 mcg (24)75 mg (4)

2

kalliga oral tablet 015-003 mg 2

kariva (28) oral tablet 015-002 mgx21 001 mg x 5

2

kelnor 135 (28) oral tablet 1-35 mg-mcg

2

kelnor 1-50 oral tablet 1-50 mg-mcg 2

kurvelo (28) oral tablet 015-003 mg

2

l norgesteestradiol-eestrad oral tabletsdose pack3 month 010 mg-20 mcg (84)10 mcg (7)

(Amethia Lo) 2 QL (91 per 84 days)

l norgesteestradiol-eestrad oral tabletsdose pack3 month 015 mg-20 mcg 015 mg-25 mcg

(Fayosim) 2 QL (91 per 84 days)


(Amethia) 2 QL (91 per 84 days)

larin 1530 (21) oral tablet 15-30 mg-mcg

2


2

larin 24 fe oral tablet 1 mg-20 mcg (24)75 mg (4)

2

larin fe 1530 (28) oral tablet 15 mg-30 mcg (21)75 mg (7)

2


101



2

larissia oral tablet 01-20 mg-mcg 2

leena 28 oral tablet 05105-35 mg-mcg

4

lessina oral tablet 01-20 mg-mcg 2

levonest (28) oral tablet 50-30 (6)75-40 (5)125-30(10)

2

levonorgestrel-ethinyl estrad oral tablet 01-20 mg-mcg

(Afirmelle) 2

levonorgestrel-ethinyl estrad oral tablet 015-003 mg

(Altavera (28)) 2

levonorgestrel-ethinyl estrad oral tabletsdose pack3 month 015 mg-30 mcg (91)

(Introvale) 2 QL (91 per 84 days)

levonorg-eth estrad triphasic oral tablet 50-30 (6)75-40 (5)125-30(10)

(Enpresse) 2

levora-28 oral tablet 015-003 mg 2

lillow (28) oral tablet 015-003 mg 2

loryna (28) oral tablet 3-002 mg 2

low-ogestrel (28) oral tablet 03-30 mg-mcg

2

lo-zumandimine (28) oral tablet 3-002 mg

2

lutera (28) oral tablet 01-20 mg-mcg

2

lyza oral tablet 035 mg 2

marlissa (28) oral tablet 015-003 mg

2

microgestin fe 120 (28) oral tablet1 mg-20 mcg (21)75 mg (7)

2

mili oral tablet 025-35 mg-mcg 2

mono-linyah oral tablet 025-35 mg-mcg

2

mononessa (28) oral tablet 025-35 mg-mcg

4

myzilra oral tablet 50-30 (6)75-40 (5)125-30(10)

2

necon 0535 (28) oral tablet 05-35 mg-mcg

2


102


nikki (28) oral tablet 3-002 mg 2

nora-be oral tablet 035 mg 4

norethindrone (contraceptive) oral tablet 035 mg

(Jencycla) 2

norethindrone ac-eth estradiol oral tablet 15-30 mg-mcg

(Aurovela 1530 (21)) 2


(Aurovela 120 (21)) 2

norethindrone-eestradiol-iron oral tablet 1 mg-20 mcg (21)75 mg (7)

(Aurovela Fe 1-20 (28)) 2


(Aurovela 24 Fe) 2


(Aurovela Fe 1530 (28))

2

norgestimate-ethinyl estradiol oral tablet 0180215025 mg-25 mcg

(Tri-Lo-Estarylla) 2

norgestimate-ethinyl estradiol oral tablet 0180215025 mg-35 mcg (28)

(Tri Femynor) 2

norgestimate-ethinyl estradiol oral tablet 025-35 mg-mcg

(Estarylla) 2

norlyda oral tablet 035 mg 2

norlyroc oral tablet 035 mg 2

nortrel 0535 (28) oral tablet 05-35 mg-mcg

2

nortrel 135 (21) oral tablet 1-35 mg-mcg (21)

2


2

nortrel 777 (28) oral tablet050751 mg- 35 mcg

2

ogestrel (28) oral tablet 05-50 mg-mcg

2

orsythia oral tablet 01-20 mg-mcg 2

philith oral tablet 04-35 mg-mcg 2

pimtrea (28) oral tablet 015-002 mgx21 001 mg x 5

2

pirmella oral tablet 050751 mg- 35 mcg 1-35 mg-mcg

2

portia 28 oral tablet 015-003 mg 2


103


previfem oral tablet 025-35 mg-mcg 2

reclipsen (28) oral tablet 015-003 mg

2

setlakin oral tabletsdose pack3 month 015 mg-30 mcg (91)


sharobel oral tablet 035 mg 2

simliya (28) oral tablet 015-002 mgx21 001 mg x 5

2

simpesse oral tabletsdose pack3 month 015 mg-30 mcg (84)10 mcg (7)


SLYND ORAL TABLET 4 MG (28)

4

sprintec (28) oral tablet 025-35 mg-mcg

2

sronyx oral tablet 01-20 mg-mcg 2

syeda oral tablet 3-003 mg 2

tarina 24 fe oral tablet 1 mg-20 mcg (24)75 mg (4)

2

tarina fe 120 (28) oral tablet 1 mg-20 mcg (21)75 mg (7)

2

tilia fe oral tablet 1-20(5)1-30(7) 1mg-35mcg (9)

2

tri femynor oral tablet0180215025 mg-35 mcg (28)

2

tri-estarylla oral tablet0180215025 mg-35 mcg (28)

2

tri-legest fe oral tablet 1-20(5)1-30(7) 1mg-35mcg (9)

2

tri-linyah oral tablet 0180215025 mg-35 mcg (28)

2

tri-lo-estarylla oral tablet0180215025 mg-25 mcg

2

tri-lo-marzia oral tablet0180215025 mg-25 mcg

2

tri-lo-mili oral tablet 0180215025 mg-25 mcg

2

tri-lo-sprintec oral tablet0180215025 mg-25 mcg

2

tri-mili oral tablet 0180215025 mg-35 mcg (28)

2


104


tri-previfem (28) oral tablet0180215025 mg-35 mcg (28)

2

tri-sprintec (28) oral tablet0180215025 mg-35 mcg (28)

2

trivora (28) oral tablet 50-30 (6)75-40 (5)125-30(10)

2

tri-vylibra lo oral tablet0180215025 mg-25 mcg

2

tri-vylibra oral tablet0180215025 mg-35 mcg (28)

2

tulana oral tablet 035 mg 2

velivet triphasic regimen (28) oral tablet 0112515-25 mg-mcg

2

vienva oral tablet 01-20 mg-mcg 2

viorele (28) oral tablet 015-002 mgx21 001 mg x 5

2

vyfemla (28) oral tablet 04-35 mg-mcg

2

vylibra oral tablet 025-35 mg-mcg 2

wera (28) oral tablet 05-35 mg-mcg

2

xulane transdermal patch weekly150-35 mcg24 hr


zarah oral tablet 3-003 mg 2

zenchent (28) oral tablet 04-35 mg-mcg

2

zovia 135e (28) oral tablet 1-35 mg-mcg

2

zumandimine (28) oral tablet 3-003 mg

2

Dental And Oral AgentsDental And Oral Agentscevimeline oral capsule 30 mg (Evoxac) 4

chlorhexidine gluconate mucous membrane mouthwash 012

(Paroex Oral Rinse) 1 GC

oralone dental paste 01 2

paroex oral rinse mucous membrane mouthwash 012

1 GC

periogard mucous membrane mouthwash 012

1 GC


105


pilocarpine hcl oral tablet 5 mg 75 mg

(Salagen (pilocarpine)) 2

triamcinolone acetonide dental paste01

(Oralone) 2

Dermatological AgentsDermatological Agents Otheracitretin oral capsule 10 mg 25 mg (Soriatane) 2

acitretin oral capsule 175 mg 2

acyclovir topical cream 5 (Zovirax) 4 QL (5 per 4 days)

acyclovir topical ointment 5 (Zovirax) 4 QL (30 per 30 days)

ALCOHOL PADS TOPICAL PADS MEDICATED

1 GC

ammonium lactate topical cream 12

(Geri-Hydrolac) 2

ammonium lactate topical lotion 12

(Geri-Hydrolac) 2

calcipotriene scalp solution 0005 4

calcipotriene topical cream 0005 (Dovonex) 4

calcipotriene topical ointment 0005

4

calcitrene topical ointment 0005 4

calcitriol topical ointment 3 mcggram

(Vectical) 4

DENAVIR TOPICAL CREAM 1

5 NEDS

fluorouracil topical cream 05 (Carac) 5 NEDS

fluorouracil topical cream 5 (Efudex) 2

fluorouracil topical solution 2 5

2

imiquimod topical cream in packet 5

(Aldara) 2 QL (24 per 30 days)

methoxsalen oral capsuleliqd-filledrapid rel 10 mg

(Oxsoralen Ultra) 5 NEDS

PANRETIN TOPICAL GEL 01

5 NEDS

PICATO TOPICAL GEL 0015 3 QL (3 per 56 days)


podofilox topical solution 05 2

REGRANEX TOPICAL GEL 001



106


SANTYL TOPICAL OINTMENT 250 UNITGRAM

4

TOLAK TOPICAL CREAM 4 4

VALCHLOR TOPICAL GEL 0016

5 NEDS

VEREGEN TOPICAL OINTMENT 15

5 NEDS

zenatane oral capsule 10 mg 20 mg 30 mg 40 mg

2

Dermatological Antibacterialsclindamycin phosphate topical foam1

(Evoclin) 4

clindamycin phosphate topical solution 1

(Cleocin T) 2

clindamycin phosphate topical swab1

(Clindacin ETZ) 2

clindamycin-benzoyl peroxide topical gel 12 (1 base) -5

(Neuac) 4

clindamycin-benzoyl peroxide topical gel 1-5

(Benzaclin) 4

ery pads topical swab 2 2

erythromycin with ethanol topical gel 2

(Erygel) 4

erythromycin with ethanol topical solution 2

2

erythromycin with ethanol topical swab 2

(Ery Pads) 2

erythromycin-benzoyl peroxide topical gel 3-5

(Benzamycin) 4

gentamicin topical cream 01 2

gentamicin topical ointment 01 2

metronidazole topical cream 075 (Rosadan) 2

metronidazole topical gel 075 (Rosadan) 2

metronidazole topical gel 1 (Metrogel) 4

metronidazole topical lotion 075 (MetroLotion) 2

mupirocin topical ointment 2 (Centany) 1 GC

neomycin-polymyxin b gu irrigation solution 40 mg-200000 unitml

2

rosadan topical cream 075 2

selenium sulfide topical lotion 25 2


107


silver sulfadiazine topical cream 1 (SSD) 2

ssd topical cream 1 4

sulfacetamide sodium (acne) topical suspension 10

(Klaron) 2

Dermatological Anti-Inflammatory Agentsala-cort topical cream 1 1 GC

ala-scalp topical lotion 2 4

alclometasone topical cream 005 2

alclometasone topical ointment 005

2

betamethasone dipropionate topical cream 005

2

betamethasone dipropionate topical lotion 005

2

betamethasone dipropionate topical ointment 005

2

betamethasone valerate topical cream 01

2

betamethasone valerate topical foam012

(Luxiq) 4

betamethasone valerate topical lotion 01

2

betamethasone valerate topical ointment 01

2

betamethasone augmented topical cream 005

2

betamethasone augmented topical gel 005

2

betamethasone augmented topical lotion 005

2

betamethasone augmented topical ointment 005

(Diprolene) 2

clobetasol scalp solution 005 2

clobetasol topical cream 005 (Temovate) 2

clobetasol topical foam 005 (Olux) 4

clobetasol topical gel 005 4

clobetasol topical lotion 005 (Clobex) 4

clobetasol topical ointment 005 (Temovate) 4

clobetasol topical shampoo 005 (Clobex) 4


108


clobetasol-emollient topical cream005

2

clobetasol-emollient topical foam005

(Olux-E) 4

clocortolone pivalate topical cream01

(Cloderm) 4

cormax scalp solution 005 2

desonide topical cream 005 (DesOwen) 4

desonide topical lotion 005 (DesOwen) 4

desonide topical ointment 005 4

desoximetasone topical cream 005

(Topicort) 4


(Topicort) 2

desoximetasone topical gel 005 (Topicort) 4

desoximetasone topical ointment005 025

(Topicort) 4

diflorasone topical ointment 005 4

EUCRISA TOPICAL OINTMENT 2

3

fluocinolone topical cream 001 2

fluocinolone topical cream 0025 (Synalar) 2

fluocinolone topical ointment 0025

(Synalar) 2

fluocinonide topical cream 005 2

fluocinonide topical gel 005 2

fluocinonide topical ointment 005 2

fluocinonide topical solution 005 2

fluocinonide-e topical cream 005 4

fluticasone propionate topical cream005

(Cutivate) 2

fluticasone propionate topical ointment 0005

2

halobetasol propionate topical cream 005

2

halobetasol propionate topical ointment 005

2

hydrocort buty 01 lipo cream 01

(Locoid Lipocream) 4


109


hydrocortisone butyrate topical cream 01

(Locoid) 4

hydrocortisone butyrate topical lotion 01

(Locoid) 4

hydrocortisone butyrate topical ointment 01

4

hydrocortisone butyrate topical solution 01

(Locoid) 4

hydrocortisone topical cream 1 (Ala-Cort) 1 GC

hydrocortisone topical cream 25 1 GC

hydrocortisone topical lotion 25 2

hydrocortisone topical ointment 1 (Anti-Itch (HC)) 1 GC

hydrocortisone topical ointment 25

1 GC

hydrocortisone valerate topical cream 02

4

hydrocortisone valerate topical ointment 02

4

mometasone topical cream 01 (Elocon) 2

mometasone topical ointment 01 2

mometasone topical solution 01 2

pimecrolimus topical cream 1 (Elidel) 4

prednicarbate topical cream 01 4

prednicarbate topical ointment 01

2

procto-med hc topical cream with perineal applicator 25

2

procto-pak topical cream with perineal applicator 1

2

proctosol hc topical cream with perineal applicator 25

2

proctozone-hc topical cream with perineal applicator 25

2

tacrolimus topical ointment 003 01

(Protopic) 4 QL (100 per 30 days)

triamcinolone acetonide topical cream 0025

1 GC

triamcinolone acetonide topical cream 01 05

(Triderm) 1 GC

triamcinolone acetonide topical lotion 0025 01

2


110


triamcinolone acetonide topical ointment 0025 01 05

2

triamcinolone acetonide topical ointment 005

(Trianex) 2

Dermatological Retinoidsadapalene topical cream 01 (Differin) 2

adapalene topical gel 01 (Differin) 2

ALTRENO TOPICAL LOTION 005

4 PA

tazarotene topical cream 01 (Tazorac) 4

TAZORAC TOPICAL CREAM 005

4

tretinoin topical cream 0025 (Avita) 2 PA

tretinoin topical cream 005 01

(Retin-A) 2 PA

tretinoin topical gel 001 (Retin-A) 2 PA

tretinoin topical gel 0025 (Avita) 2 PA

tretinoin topical gel 005 (Atralin) 2 PAScabicides And Pediculicidesmalathion topical lotion 05 (Ovide) 4

permethrin topical cream 5 (Elimite) 2

DevicesDevicesASSURE ID INSULIN SAFETY SYRINGE 1 ML 29 GAUGE X 12

2

BD UF NANO PEN NEEDLE 4MMX32G 32 GAUGE X 532

2

BD VEO INS 03 ML 6MMX31G (12) 03 ML 31 GAUGE X 1564

2

BD VEO INS SYRING 1 ML 6MMX31G 1 ML 31 GAUGE X 1564

2

BD VEO INS SYRN 05 ML 6MMX31G 12 ML 31 GAUGE X 1564

2

GAUZE PAD TOPICAL BANDAGE 2 X 2

1 GC

INSULIN SYRINGE-NEEDLE U-100 SYRINGE 03 ML 29 GAUGE

(Ultilet Insulin Syringe) 2


111


INSULIN SYRINGE-NEEDLE U-100 SYRINGE 1 ML 29 GAUGE X 12

(Advocate Syringes) 2


(Lite Touch Insulin Syringe)

2

PEN NEEDLE DIABETIC NEEDLE 29 GAUGE X 12

(1st Tier Unifine Pentips)

2

V-GO 40 DISPOSABLE DEVICE 2

Enzyme ReplacementModifiersEnzyme ReplacementModifiersADAGEN INTRAMUSCULAR SOLUTION 250 UNITML

5 NEDS

ALDURAZYME INTRAVENOUS SOLUTION 29 MG5 ML

5 NEDS

CERDELGA ORAL CAPSULE 84 MG

5 PA NEDS

CEREZYME INTRAVENOUS RECON SOLN 400 UNIT

5 NEDS

CREON ORAL CAPSULEDELAYED RELEASE(DREC) 12000-38000 -60000 UNIT 24000-76000 -120000 UNIT 3000-9500- 15000 UNIT 36000-114000- 180000 UNIT 6000-19000 -30000 UNIT

3

ELAPRASE INTRAVENOUS SOLUTION 6 MG3 ML

5 NEDS

ELITEK INTRAVENOUS RECON SOLN 15 MG 75 MG

5 NEDS

FABRAZYME INTRAVENOUS RECON SOLN 35 MG 5 MG

5 PA NEDS

GALAFOLD ORAL CAPSULE 123 MG


KANUMA INTRAVENOUS SOLUTION 2 MGML

5 PA NEDS

KRYSTEXXA INTRAVENOUS SOLUTION 8 MGML

5 PA BvD NEDS

KUVAN ORAL TABLETSOLUBLE 100 MG

5 NEDS


112


MEPSEVII INTRAVENOUS SOLUTION 2 MGML

5 PA NEDS

miglustat oral capsule 100 mg (Zavesca) 5 PA NEDS QL (90 per 30 days)

NAGLAZYME INTRAVENOUS SOLUTION 5 MG5 ML

5 NEDS

nitisinone oral capsule 10 mg 2 mg 5 mg

(Orfadin) 5 PA NEDS

NITYR ORAL TABLET 10 MG 2 MG 5 MG

5 PA NEDS

ORFADIN ORAL CAPSULE 10 MG 2 MG 20 MG 5 MG

5 PA NEDS

ORFADIN ORAL SUSPENSION 4 MGML

5 PA NEDS

PALYNZIQ SUBCUTANEOUS SYRINGE 10 MG05 ML 25 MG05 ML 20 MGML

5 PA NEDS

PULMOZYME INHALATION SOLUTION 1 MGML

5 PA BvD NEDS

REVCOVI INTRAMUSCULAR SOLUTION 24 MG15 ML (16 MGML)

5 PA NEDS

STRENSIQ SUBCUTANEOUS SOLUTION 18 MG045 ML 28 MG07 ML 40 MGML 80 MG08 ML

5 PA LA NEDS

VIMIZIM INTRAVENOUS SOLUTION 5 MG5 ML (1 MGML)

5 PA NEDS

VPRIV INTRAVENOUS RECON SOLN 400 UNIT

5 NEDS

ZENPEP ORAL CAPSULEDELAYED RELEASE(DREC) 10000-32000 -42000 UNIT 15000-47000 -63000 UNIT 20000-63000- 84000 UNIT 25000-79000- 105000 UNIT 3000-10000 -14000-UNIT 40000-126000- 168000 UNIT 5000-17000- 24000 UNIT

3


113


Eye Ear Nose Throat AgentsEye Ear Nose Throat Agents Miscellaneousalcaine ophthalmic (eye) drops 05

2

apraclonidine ophthalmic (eye) drops 05

2

atropine ophthalmic (eye) drops 1

(Isopto Atropine) 4

azelastine nasal aerosolspray 137 mcg (01 )


azelastine nasal spraynon-aerosol015 (2055 mcg)


azelastine ophthalmic (eye) drops005

2

BEPREVE OPHTHALMIC (EYE) DROPS 15

4 ST

cromolyn ophthalmic (eye) drops 4

2

cyclopentolate ophthalmic (eye) drops 05 1 2

(Cyclogyl) 2

CYSTARAN OPHTHALMIC (EYE) DROPS 044

5 NEDS

epinastine ophthalmic (eye) drops005

2

ipratropium bromide nasal spraynon-aerosol 003


ipratropium bromide nasal spraynon-aerosol 42 mcg (006 )


olopatadine nasal spraynon-aerosol06

(Patanase) 4 QL (305 per 30 days)

olopatadine ophthalmic (eye) drops01

(Pataday) 2


(Pataday) 4

phenylephrine hcl ophthalmic (eye) drops 10 25

4

proparacaine ophthalmic (eye) drops 05

(Alcaine) 2

TEPEZZA INTRAVENOUS RECON SOLN 500 MG

5 PA NEDS


114


Eye Ear Nose Throat Anti-Infectives Agentsacetic acid otic (ear) solution 2 2

bacitracin ophthalmic (eye) ointment 500 unitgram

4

bacitracin-polymyxin b ophthalmic (eye) ointment 500-10000 unitgram

(Polycin) 2

bleph-10 ophthalmic (eye) drops 10

2

CIPRODEX OTIC (EAR) DROPSSUSPENSION 03-01

3

ciprofloxacin hcl ophthalmic (eye) drops 03

(Ciloxan) 1 GC

ciprofloxacin hcl otic (ear) dropperette 02

(Cetraxal) 4

erythromycin ophthalmic (eye) ointment 5 mggram (05 )

2

gatifloxacin ophthalmic (eye) drops05

(Zymaxid) 4

gentak ophthalmic (eye) ointment03 (3 mggram)

2

gentamicin ophthalmic (eye) drops03

1 GC

hydrocortisone-acetic acid otic (ear) drops 1-2

4

levofloxacin ophthalmic (eye) drops05

2

MOXEZA OPHTHALMIC (EYE) DROPS VISCOUS 05

3

moxifloxacin ophthalmic (eye) drops 05

(Vigamox) 2

moxifloxacin ophthalmic (eye) drops viscous 05

(Moxeza) 2

NATACYN OPHTHALMIC (EYE) DROPSSUSPENSION 5

4

neomycin-bacitracin-poly-hc ophthalmic (eye) ointment 35-400-10000 mg-unitg-1

(Neo-Polycin HC) 2


115


neomycin-bacitracin-polymyxin ophthalmic (eye) ointment 35-400-10000 mg-unit-unitg

(Neo-Polycin) 2

neomycin-polymyxin b-dexameth ophthalmic (eye) dropssuspension35mgml-10000 unitml-01

(Maxitrol) 2

neomycin-polymyxin b-dexameth ophthalmic (eye) ointment 35 mgg-10000 unitg-01

(Maxitrol) 2

neomycin-polymyxin-gramicidin ophthalmic (eye) drops 175 mg-10000 unit-0025mgml

2

neomycin-polymyxin-hc ophthalmic (eye) dropssuspension 35-10000-10 mg-unit-mgml

2

neomycin-polymyxin-hc otic (ear) dropssuspension 35-10000-1 mgml-unitml-

2

neomycin-polymyxin-hc otic (ear) solution 35-10000-1 mgml-unitml-

2

neo-polycin hc ophthalmic (eye) ointment 35-400-10000 mg-unitg-1

2

neo-polycin ophthalmic (eye) ointment 35-400-10000 mg-unit-unitg

2

ofloxacin ophthalmic (eye) drops03

(Ocuflox) 2

ofloxacin otic (ear) drops 03 2

polycin ophthalmic (eye) ointment500-10000 unitgram

2

polymyxin b sulf-trimethoprim ophthalmic (eye) drops 10000 unit- 1 mgml

(Polytrim) 1 GC

sulfacetamide sodium ophthalmic (eye) drops 10

(Bleph-10) 2

sulfacetamide sodium ophthalmic (eye) ointment 10

2


116


sulfacetamide-prednisolone ophthalmic (eye) drops 10 -023 (025 )

2

tobramycin ophthalmic (eye) drops03

(Tobrex) 1 GC

tobramycin-dexamethasone ophthalmic (eye) dropssuspension03-01

(TobraDex) 2

trifluridine ophthalmic (eye) drops1

2

ZIRGAN OPHTHALMIC (EYE) GEL 015

4

ZYLET OPHTHALMIC (EYE) DROPSSUSPENSION 03-05

3

Eye Ear Nose Throat Anti-Inflammatory AgentsALREX OPHTHALMIC (EYE) DROPSSUSPENSION 02

3 ST

bromfenac ophthalmic (eye) drops009

4

BROMSITE OPHTHALMIC (EYE) DROPS 0075

3

dexamethasone sodium phosphate ophthalmic (eye) drops 01

2

diclofenac sodium ophthalmic (eye) drops 01

2

DUREZOL OPHTHALMIC (EYE) DROPS 005

3

flunisolide nasal spraynon-aerosol25 mcg (0025 )


fluocinolone acetonide oil otic (ear) drops 001

(DermOtic Oil) 4

fluorometholone ophthalmic (eye) dropssuspension 01

(FML Liquifilm) 4

flurbiprofen sodium ophthalmic (eye) drops 003

1 GC

fluticasone propionate nasal spraysuspension 50 mcgactuation

(24 Hour Allergy Relief)


ILEVRO OPHTHALMIC (EYE) DROPSSUSPENSION 03

3


117


INVELTYS OPHTHALMIC (EYE) DROPSSUSPENSION 1

3

ketorolac ophthalmic (eye) drops05

(Acular) 2

LOTEMAX OPHTHALMIC (EYE) DROPSGEL 05

3

LOTEMAX OPHTHALMIC (EYE) OINTMENT 05

3

LOTEMAX SM OPHTHALMIC (EYE) DROPSGEL 038

3

loteprednol etabonate ophthalmic (eye) dropssuspension 05

(Lotemax) 2

mometasone nasal spraynon-aerosol50 mcgactuation

(Nasonex) 2 QL (34 per 28 days)

prednisolone acetate ophthalmic (eye) dropssuspension 1

(Pred Forte) 4

prednisolone sodium phosphate ophthalmic (eye) drops 1

2

PROLENSA OPHTHALMIC (EYE) DROPS 007

3

RESTASIS OPHTHALMIC (EYE) DROPPERETTE 005


XHANCE NASAL AEROSOL BREATH ACTIVATED 93 MCGACTUATION


XIIDRA OPHTHALMIC (EYE) DROPPERETTE 5


Gastrointestinal AgentsAntiulcer Agents And Acid Suppressantsamoxicil-clarithromy-lansopraz oral combo pack 500-500-30 mg

4

cimetidine hcl oral solution 300 mg5 ml

2

cimetidine oral tablet 200 mg (Acid Reducer (cimetidine))

2

cimetidine oral tablet 300 mg 400 mg 800 mg

2


118


DEXILANT ORAL CAPSULEBIPHASE DELAYED RELEAS 30 MG 60 MG


esomeprazole sodium intravenous recon soln 20 mg

2


(Nexium IV) 2

famotidine (pf) intravenous solution20 mg2 ml

1 GC

famotidine (pf)-nacl (iso-os) intravenous piggyback 20 mg50 ml

2

famotidine intravenous solution 10 mgml

2

famotidine oral suspension 40 mg5 ml (8 mgml)

4

famotidine oral tablet 20 mg (Acid Controller) 1 GC

famotidine oral tablet 40 mg (Pepcid) 1 GC

lansoprazole oral capsuledelayed release(drec) 15 mg

(Heartburn Treatment 24 Hour)



(Prevacid) 2 QL (60 per 30 days)

misoprostol oral tablet 100 mcg 200 mcg

(Cytotec) 2

nizatidine oral capsule 150 mg 300 mg

2

nizatidine oral solution 150 mg10 ml

2

omeprazole oral capsuledelayed release(drec) 10 mg 20 mg 40 mg

1 GC

omeprazole-sodium bicarbonate oral capsule 20-11 mg-gram 40-11 mg-gram

(Zegerid) 4 ST QL (30 per 30 days)

pantoprazole intravenous recon soln40 mg

(Protonix) 2

pantoprazole oral tabletdelayed release (drec) 20 mg

(Protonix) 1 GC QL (30 per 30 days)



rabeprazole oral tabletdelayed release (drec) 20 mg

(AcipHex) 2 ST QL (30 per 30 days)


119


ranitidine hcl injection solution 25 mgml 50 mg2 ml (25 mgml)

(Zantac) 2

ranitidine hcl oral syrup 15 mgml 2

ranitidine hcl oral tablet 150 mg (Acid Control (ranitidine))

1 GC

ranitidine hcl oral tablet 300 mg 1 GC

sucralfate oral tablet 1 gram (Carafate) 2Gastrointestinal Agents OtherAMITIZA ORAL CAPSULE 24 MCG 8 MCG


CARBAGLU ORAL TABLET DISPERSIBLE 200 MG

5 NEDS

constulose oral solution 10 gram15 ml

2

cromolyn oral concentrate 100 mg5 ml

(Gastrocrom) 2

dicyclomine oral capsule 10 mg 2

dicyclomine oral solution 10 mg5 ml 2

dicyclomine oral tablet 20 mg 2

diphenoxylate-atropine oral liquid25-0025 mg5 ml


diphenoxylate-atropine oral tablet25-0025 mg

(Lomotil) 2 PA-HRM AGE (Max 64 Years)

enulose oral solution 10 gram15 ml 2

GATTEX 30-VIAL SUBCUTANEOUS KIT 5 MG

5 PA NEDS

generlac oral solution 10 gram15 ml 2

glycopyrrolate injection solution 02 mgml

2

glycopyrrolate oral tablet 1 mg 2 mg

2

kionex (with sorbitol) oral suspension 15-193 gram60 ml

2

lactulose oral solution 10 gram15 ml

(Constulose) 2

LINZESS ORAL CAPSULE 145 MCG 290 MCG 72 MCG


LOKELMA ORAL POWDER IN PACKET 10 GRAM 5 GRAM


loperamide oral capsule 2 mg (Anti-Diarrheal (loperamide))

2


120


methscopolamine oral tablet 25 mg 5 mg

4

metoclopramide hcl injection solution 5 mgml

2

metoclopramide hcl injection syringe5 mgml

2

metoclopramide hcl oral solution 5 mg5 ml

2

metoclopramide hcl oral tablet 10 mg 5 mg

(Reglan) 1 GC

MOVANTIK ORAL TABLET 125 MG 25 MG


OCALIVA ORAL TABLET 10 MG 5 MG


propantheline oral tablet 15 mg 4

RAVICTI ORAL LIQUID 11 GRAMML

5 PA NEDS

RELISTOR ORAL TABLET 150 MG


RELISTOR SUBCUTANEOUS SOLUTION 12 MG06 ML


RELISTOR SUBCUTANEOUS SYRINGE 12 MG06 ML




sod polystyren sulf 15 g60 ml 15 gram60 ml

2

sodium phenylbutyrate oral tablet500 mg

(Buphenyl) 5 NEDS

sodium polystyrene sulfonate oral powder

2

sodium polystyrene sulfonate oral suspension 15 gram60 ml

(sodium polystyrene (sorb free))

2

sps (with sorbitol) oral suspension15-20 gram60 ml

2

TRULANCE ORAL TABLET 3 MG


ursodiol oral capsule 300 mg (Actigall) 2

ursodiol oral tablet 250 mg (URSO 250) 2

ursodiol oral tablet 500 mg (URSO Forte) 2


121


VELTASSA ORAL POWDER IN PACKET 168 GRAM 252 GRAM 84 GRAM


VIBERZI ORAL TABLET 100 MG 75 MG


XERMELO ORAL TABLET 250 MG


LaxativesCLENPIQ ORAL SOLUTION 10 MG-35 GRAM -12 GRAM160 ML

3

gavilyte-c oral recon soln 240-2272-672 -584 gram

2

gavilyte-g oral recon soln 236-2274-674 -586 gram

2

gavilyte-n oral recon soln 420 gram 2

peg 3350-electrolytes oral recon soln240-2272-672 -584 gram

(Gavilyte-C) 4

SUPREP BOWEL PREP KIT ORAL RECON SOLN 175-313-16 GRAM

3

trilyte with flavor packets oral recon soln 420 gram

2

Phosphate Binderscalcium acetate(phosphat bind) oral capsule 667 mg

2

calcium acetate(phosphat bind) oral tablet 667 mg

2

lanthanum oral tabletchewable1000 mg 500 mg 750 mg

(Fosrenol) 5 NEDS

PHOSLYRA ORAL SOLUTION 667 MG (169 MG CALCIUM)5 ML

4

sevelamer carbonate oral powder in packet 08 gram 24 gram

(Renvela) 5 NEDS

sevelamer carbonate oral tablet 800 mg

(Renvela) 4

sevelamer hcl oral tablet 400 mg 2

sevelamer hcl oral tablet 800 mg (Renagel) 2

VELPHORO ORAL TABLETCHEWABLE 500 MG

3


122


Genitourinary AgentsAntispasmodics Urinarybethanechol chloride oral tablet 10 mg 5 mg

2

bethanechol chloride oral tablet 25 mg 50 mg

(Urecholine) 2

flavoxate oral tablet 100 mg 2

MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR 25 MG 50 MG

3

oxybutynin chloride oral syrup 5 mg5 ml

2

oxybutynin chloride oral tablet 5 mg 2

oxybutynin chloride oral tablet extended release 24hr 10 mg 5 mg

(Ditropan XL) 2

oxybutynin chloride oral tablet extended release 24hr 15 mg

2

tolterodine oral capsuleextended release 24hr 2 mg 4 mg

(Detrol LA) 2

tolterodine oral tablet 1 mg 2 mg (Detrol) 2

TOVIAZ ORAL TABLET EXTENDED RELEASE 24 HR 4 MG 8 MG

3

trospium oral capsuleextended release 24hr 60 mg

4

trospium oral tablet 20 mg 4Genitourinary Agents Miscellaneousalfuzosin oral tablet extended release 24 hr 10 mg

(Uroxatral) 1 GC

dutasteride oral capsule 05 mg (Avodart) 2

dutasteride-tamsulosin oral capsule er multiphase 24 hr 05-04 mg

(Jalyn) 4

finasteride oral tablet 5 mg (Proscar) 1 GC

PROCYSBI ORAL CAPSULE DELAYED REL SPRINKLE 25 MG 75 MG

5 NEDS

tamsulosin oral capsule 04 mg (Flomax) 1 GC

terazosin oral capsule 1 mg 10 mg 2 mg 5 mg

1 GC


123


THIOLA EC ORAL TABLETDELAYED RELEASE (DREC) 100 MG 300 MG

5 PA NEDS

THIOLA ORAL TABLET 100 MG

5 NEDS

Heavy Metal AntagonistsHeavy Metal Antagonistsclovique oral capsule 250 mg 5 PA NEDS QL (240

per 30 days)

deferasirox oral tablet 180 mg 360 mg 90 mg

(Jadenu) 5 PA NEDS

deferasirox oral tablet dispersible125 mg 250 mg 500 mg

(Exjade) 5 PA NEDS

deferoxamine injection recon soln 2 gram 500 mg

(Desferal) 2 PA

DEPEN TITRATABS ORAL TABLET 250 MG

5 PA NEDS

FERRIPROX ORAL SOLUTION 100 MGML

5 PA NEDS

FERRIPROX ORAL TABLET 1000 MG 500 MG

5 PA NEDS

JADENU ORAL TABLET 180 MG 360 MG 90 MG

5 PA NEDS

JADENU SPRINKLE ORAL GRANULES IN PACKET 180 MG 360 MG 90 MG

5 PA NEDS

penicillamine oral capsule 250 mg (Cuprimine) 5 PA NEDS

penicillamine oral tablet 250 mg (Depen Titratabs) 5 PA NEDS

trientine oral capsule 250 mg (Clovique) 5 PA NEDS QL (240 per 30 days)

Hormonal Agents StimulantReplacementModifyingAndrogensANADROL-50 ORAL TABLET 50 MG

5 PA NEDS

danazol oral capsule 100 mg 200 mg 50 mg

2

oxandrolone oral tablet 10 mg (Oxandrin) 5 NEDS

oxandrolone oral tablet 25 mg (Oxandrin) 4


124


testosterone cypionate intramuscular oil 100 mgml 200 mgml

(Depo-Testosterone) 2 PA

testosterone cypionate intramuscular oil 200 mgml (1 ml)

2 PA

testosterone enanthate intramuscular oil 200 mgml


testosterone transdermal gel in packet 1 (25 mg25gram) 1 (50 mg5 gram)

(AndroGel) 2 PA QL (300 per 30 days)

XYOSTED SUBCUTANEOUS AUTO-INJECTOR 100 MG05 ML 50 MG05 ML 75 MG05 ML


Estrogens And Antiestrogensamabelz oral tablet 05-01 mg 1-05 mg


dotti transdermal patch semiweekly0025 mg24 hr 00375 mg24 hr 005 mg24 hr 0075 mg24 hr 01 mg24 hr


DUAVEE ORAL TABLET 045-20 MG


estradiol oral tablet 05 mg 1 mg 2 mg

(Estrace) 1 PA-HRM GC AGE (Max 64 Years)

estradiol transdermal patch semiweekly 0025 mg24 hr 00375 mg24 hr 005 mg24 hr 0075 mg24 hr 01 mg24 hr

(Dotti) 2 PA-HRM QL (8 per 28 days) AGE (Max 64 Years)

estradiol transdermal patch weekly0025 mg24 hr 00375 mg24 hr 005 mg24 hr 006 mg24 hr 0075 mg24 hr 01 mg24 hr

(Climara) 2 PA-HRM QL (4 per 28 days) AGE (Max 64 Years)

estradiol vaginal cream 001 (01 mggram)

(Estrace) 2

estradiol vaginal tablet 10 mcg (Yuvafem) 2 QL (18 per 28 days)

estradiol valerate intramuscular oil20 mgml 40 mgml

(Delestrogen) 2

estradiol-norethindrone acet oral tablet 05-01 mg

(Amabelz) 2 PA-HRM AGE (Max 64 Years)


125


FEMRING VAGINAL RING 005 MG24 HR 01 MG24 HR


fyavolv oral tablet 05-25 mg-mcg 1-5 mg-mcg


jinteli oral tablet 1-5 mg-mcg 2 PA-HRM AGE (Max 64 Years)

mimvey lo oral tablet 05-01 mg 2 PA-HRM AGE (Max 64 Years)

mimvey oral tablet 1-05 mg 2 PA-HRM AGE (Max 64 Years)

norethindrone ac-eth estradiol oral tablet 05-25 mg-mcg 1-5 mg-mcg

(Fyavolv) 2 PA-HRM AGE (Max 64 Years)

PREMARIN INJECTION RECON SOLN 25 MG

3

PREMARIN ORAL TABLET 03 MG 045 MG 0625 MG 09 MG 125 MG


PREMARIN VAGINAL CREAM 0625 MGGRAM

3

PREMPHASE ORAL TABLET 0625 MG (14) 0625MG-5MG(14)


PREMPRO ORAL TABLET 03-15 MG 045-15 MG 0625-25 MG 0625-5 MG


raloxifene oral tablet 60 mg (Evista) 2

yuvafem vaginal tablet 10 mcg 2 QL (18 per 28 days)GlucocorticoidsMineralocorticoidsa-hydrocort injection recon soln 100 mg

2

betamethasone acetsod phos injection suspension 6 mgml

(Celestone Soluspan) 2

cortisone oral tablet 25 mg 2

decadron oral elixir 05 mg5 ml 2 PA BvD

dexamethasone oral elixir 05 mg5 ml

2 PA BvD

dexamethasone oral tablet 05 mg 075 mg 4 mg 6 mg

(Decadron) 1 PA BvD GC

dexamethasone oral tablet 1 mg 15 mg 2 mg

1 PA BvD GC


126


dexamethasone sodium phos (pf) injection solution 10 mgml

1 GC

dexamethasone sodium phos (pf) injection syringe 10 mgml

1 GC

dexamethasone sodium phosphate injection solution 10 mgml 4 mgml

1 GC

dexamethasone sodium phosphate injection syringe 4 mgml

1 GC

EMFLAZA ORAL SUSPENSION 2275 MGML


EMFLAZA ORAL TABLET 18 MG


EMFLAZA ORAL TABLET 30 MG 36 MG 6 MG


fludrocortisone oral tablet 01 mg 2

hydrocortisone oral tablet 10 mg 20 mg 5 mg

(Cortef) 2

methylprednisolone acetate injection suspension 40 mgml 80 mgml

(Depo-Medrol) 2

methylprednisolone oral tablet 16 mg 32 mg 4 mg 8 mg

(Medrol) 2

methylprednisolone oral tabletsdose pack 4 mg

(Medrol (Pak)) 2

methylprednisolone sodium succ injection recon soln 125 mg 40 mg

2

methylprednisolone sodium succ intravenous recon soln 1000 mg 500 mg

(Solu-Medrol) 2

prednisolone 15 mg5 ml soln af df15 mg5 ml (3 mgml)

2 PA BvD

prednisolone oral solution 15 mg5 ml

2 PA BvD

prednisolone sodium phosphate oral solution 25 mg5 ml (5 mgml)

2 PA BvD

prednisolone sodium phosphate oral solution 5 mg base5 ml (67 mg5 ml)

(Pediapred) 2 PA BvD

prednisone oral solution 5 mg5 ml 2 PA BvD

prednisone oral tablet 1 mg 10 mg 25 mg 20 mg 5 mg 50 mg

1 PA BvD GC


127


prednisone oral tabletsdose pack 10 mg 10 mg (48 pack) 5 mg 5 mg (48 pack)

2

SOLU-CORTEF ACT-O-VIAL (PF) INJECTION RECON SOLN 1000 MG8 ML 100 MG2 ML 250 MG2 ML 500 MG4 ML

4

triamcinolone acetonide injection suspension 40 mgml

(Kenalog) 2

Pituitarydesmopressin 10 mcg01 ml spr 10 mcgspray (01 ml)

(DDAVP) 2

desmopressin injection solution 4 mcgml

(DDAVP) 2

desmopressin nasal spraynon-aerosol 10 mcgspray (01 ml)

2

desmopressin oral tablet 01 mg 02 mg

(DDAVP) 2

EGRIFTA SUBCUTANEOUS RECON SOLN 1 MG


GENOTROPIN MINIQUICK SUBCUTANEOUS SYRINGE 02 MG025 ML

4 PA

GENOTROPIN MINIQUICK SUBCUTANEOUS SYRINGE 04 MG025 ML 06 MG025 ML 08 MG025 ML 1 MG025 ML 12 MG025 ML 14 MG025 ML 16 MG025 ML 18 MG025 ML 2 MG025 ML

5 PA NEDS

GENOTROPIN SUBCUTANEOUS CARTRIDGE 12 MGML (36 UNITML) 5 MGML (15 UNITML)

5 PA NEDS

HUMATROPE INJECTION CARTRIDGE 12 MG (36 UNIT) 24 MG (72 UNIT) 6 MG (18 UNIT)

5 PA NEDS

HUMATROPE INJECTION RECON SOLN 5 (15 UNIT) MG

5 PA NEDS


128


INCRELEX SUBCUTANEOUS SOLUTION 10 MGML

5 NEDS


5 NEDS


5 NEDS

LUPRON DEPOT-PED (3 MONTH) INTRAMUSCULAR SYRINGE KIT 30 MG

5 NEDS

LUPRON DEPOT-PED INTRAMUSCULAR KIT 1125 MG 15 MG

5 NEDS

NOCDURNA (MEN) SUBLINGUAL TABLETDISINTEGRATING 553 MCG


NOCDURNA (WOMEN) SUBLINGUAL TABLETDISINTEGRATING 277 MCG


NORDITROPIN FLEXPRO SUBCUTANEOUS PEN INJECTOR 10 MG15 ML (67 MGML) 15 MG15 ML (10 MGML) 30 MG3 ML (10 MGML)

5 PA NEDS

NORDITROPIN FLEXPRO SUBCUTANEOUS PEN INJECTOR 5 MG15 ML (33 MGML)

4 PA

NUTROPIN AQ NUSPIN SUBCUTANEOUS PEN INJECTOR 10 MG2 ML (5 MGML) 20 MG2 ML (10 MGML) 5 MG2 ML (25 MGML)

5 PA NEDS

octreotide acetate injection solution1000 mcgml 200 mcgml

2

octreotide acetate injection solution100 mcgml 50 mcgml 500 mcgml

(Sandostatin) 2


129


octreotide acetate injection syringe100 mcgml (1 ml) 50 mcgml (1 ml) 500 mcgml (1 ml)

2

OMNITROPE SUBCUTANEOUS CARTRIDGE 10 MG15 ML (67 MGML) 5 MG15 ML (33 MGML)

5 PA NEDS

OMNITROPE SUBCUTANEOUS RECON SOLN 58 MG

5 PA NEDS

ORILISSA ORAL TABLET 150 MG




SAIZEN SAIZENPREP SUBCUTANEOUS CARTRIDGE 88 MG151 ML (FINAL CONC)

5 PA NEDS

SAIZEN SUBCUTANEOUS RECON SOLN 5 MG 88 MG

5 PA NEDS

SANDOSTATIN LAR DEPOT INTRAMUSCULAR SUSPENSIONEXTENDED REL RECON 10 MG 20 MG 30 MG

5 NEDS

SEROSTIM SUBCUTANEOUS RECON SOLN 4 MG 5 MG 6 MG

5 PA NEDS

SIGNIFOR SUBCUTANEOUS SOLUTION 03 MGML (1 ML) 06 MGML (1 ML) 09 MGML (1 ML)


SOMATULINE DEPOT SUBCUTANEOUS SYRINGE 120 MG05 ML


SOMATULINE DEPOT SUBCUTANEOUS SYRINGE 60 MG02 ML 90 MG03 ML


SOMAVERT SUBCUTANEOUS RECON SOLN 10 MG 15 MG 20 MG 25 MG 30 MG

5 PA NEDS


130


STIMATE NASAL SPRAYNON-AEROSOL 150 MCGSPRAY (01 ML)

3

SUPPRELIN LA IMPLANT KIT 50 MG (65 MCGDAY)


SYNAREL NASAL SPRAYNON-AEROSOL 2 MGML

5 NEDS

TRIPTODUR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 225 MG


ZOMACTON SUBCUTANEOUS RECON SOLN 10 MG

5 PA NEDS


4 PA

ZORBTIVE SUBCUTANEOUS RECON SOLN 88 MG

5 PA NEDS

ProgestinsDEPO-PROVERA INTRAMUSCULAR SUSPENSION 400 MGML


hydroxyprogesterone cap(ppres) intramuscular oil 250 mgml

(Makena) 5 PA NSO NEDS

medroxyprogesterone intramuscular suspension 150 mgml

(Depo-Provera) 2 QL (1 per 84 days)

medroxyprogesterone intramuscular syringe 150 mgml


medroxyprogesterone oral tablet 10 mg 25 mg 5 mg

(Provera) 1 GC

megestrol oral suspension 400 mg10 ml (40 mgml)


norethindrone acetate oral tablet 5 mg

(Aygestin) 2

progesterone intramuscular oil 50 mgml

2

progesterone micronized oral capsule 100 mg 200 mg

(Prometrium) 2


131


Thyroid And Antithyroid Agentslevothyroxine oral tablet 100 mcg 112 mcg 125 mcg 137 mcg 150 mcg 175 mcg 200 mcg 25 mcg 50 mcg 75 mcg 88 mcg

(Euthyrox) 1 GC

levothyroxine oral tablet 300 mcg (Levo-T) 1 GC

liothyronine oral tablet 25 mcg 5 mcg 50 mcg

(Cytomel) 2

methimazole oral tablet 10 mg 5 mg (Tapazole) 1 GC

propylthiouracil oral tablet 50 mg 2

Immunological AgentsImmunological AgentsACTEMRA ACTPEN SUBCUTANEOUS PEN INJECTOR 162 MG09 ML

5 PA NEDS

ACTEMRA INTRAVENOUS SOLUTION 200 MG10 ML (20 MGML) 400 MG20 ML (20 MGML) 80 MG4 ML (20 MGML)

5 PA NEDS

ACTEMRA SUBCUTANEOUS SYRINGE 162 MG09 ML

5 PA NEDS

ARCALYST SUBCUTANEOUS RECON SOLN 220 MG

5 NEDS

azathioprine oral tablet 50 mg (Imuran) 2 PA BvD

azathioprine sodium injection recon soln 100 mg

2 PA BvD

CIMZIA POWDER FOR RECONST SUBCUTANEOUS KIT 400 MG (200 MG X 2 VIALS)

5 PA NEDS

CIMZIA SUBCUTANEOUS SYRINGE KIT 400 MG2 ML (200 MGML X 2)

5 PA NEDS

COSENTYX (2 SYRINGES) SUBCUTANEOUS SYRINGE 150 MGML

5 PA NEDS

COSENTYX PEN (2 PENS) SUBCUTANEOUS PEN INJECTOR 150 MGML

5 PA NEDS


132


cyclosporine intravenous solution250 mg5 ml

(Sandimmune) 2 PA BvD

cyclosporine modified oral capsule100 mg 25 mg

(Gengraf) 2 PA BvD

cyclosporine modified oral capsule50 mg

2 PA BvD

cyclosporine modified oral solution100 mgml

(Gengraf) 2 PA BvD

cyclosporine oral capsule 100 mg 25 mg


DUPIXENT SUBCUTANEOUS SYRINGE 200 MG114 ML 300 MG2 ML

5 PA NEDS

ENBREL MINI SUBCUTANEOUS CARTRIDGE 50 MGML (1 ML)

5 PA NEDS

ENBREL SUBCUTANEOUS RECON SOLN 25 MG (1 ML)

5 PA NEDS

ENBREL SUBCUTANEOUS SYRINGE 25 MG05 ML (05) 50 MGML (1 ML)

5 PA NEDS

ENBREL SURECLICK SUBCUTANEOUS PEN INJECTOR 50 MGML (1 ML)

5 PA NEDS

FLEBOGAMMA DIF INTRAVENOUS SOLUTION 10 5

5 PA BvD NEDS

GAMASTAN INTRAMUSCULAR SOLUTION 15-18 RANGE

4 PA BvD

GAMMAGARD LIQUID INJECTION SOLUTION 10

5 PA BvD NEDS

GAMMAGARD S-D (IGA lt 1 MCGML) INTRAVENOUS RECON SOLN 10 GRAM 5 GRAM

5 PA BvD NEDS

GAMMAPLEX (WITH SORBITOL) INTRAVENOUS SOLUTION 5

5 PA BvD NEDS


133


GAMMAPLEX INTRAVENOUS SOLUTION 10 10 (100 ML) 10 (200 ML)

5 PA BvD NEDS

GAMUNEX-C INJECTION SOLUTION 1 GRAM10 ML (10 ) 10 GRAM100 ML (10 ) 25 GRAM25 ML (10 ) 20 GRAM200 ML (10 ) 40 GRAM400 ML (10 ) 5 GRAM50 ML (10 )

5 PA BvD NEDS

gengraf oral capsule 100 mg 25 mg 2 PA BvD

gengraf oral solution 100 mgml 2 PA BvD

HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS SYRINGE KIT 40 MG08 ML

5 PA NEDS

HUMIRA PEN CROHNS-UC-HS START SUBCUTANEOUS PEN INJECTOR KIT 40 MG08 ML

5 PA NEDS

HUMIRA PEN PSOR-UVEITS-ADOL HS SUBCUTANEOUS PEN INJECTOR KIT 40 MG08 ML

5 PA NEDS

HUMIRA PEN SUBCUTANEOUS PEN INJECTOR KIT 40 MG08 ML

5 PA NEDS

HUMIRA SUBCUTANEOUS SYRINGE KIT 10 MG02 ML 20 MG04 ML 40 MG08 ML

5 PA NEDS

HUMIRA(CF) PEDI CROHNS STARTER SUBCUTANEOUS SYRINGE KIT 80 MG08 ML 80 MG08 ML-40 MG04 ML

5 PA NEDS

HUMIRA(CF) PEN CROHNS-UC-HS SUBCUTANEOUS PEN INJECTOR KIT 80 MG08 ML

5 PA NEDS

HUMIRA(CF) PEN PSOR-UV-ADOL HS SUBCUTANEOUS PEN INJECTOR KIT 80 MG08 ML-40 MG04 ML

5 PA NEDS


134


HUMIRA(CF) PEN SUBCUTANEOUS PEN INJECTOR KIT 40 MG04 ML

5 PA NEDS

HUMIRA(CF) SUBCUTANEOUS SYRINGE KIT 10 MG01 ML 20 MG02 ML 40 MG04 ML

5 PA NEDS

HYPERRAB (PF) INTRAMUSCULAR SOLUTION 300 UNITML

4

HYPERRAB SD (PF) INTRAMUSCULAR SOLUTION 150 UNITML

4

HYQVIA SUBCUTANEOUS SOLUTION 10 GRAM 100 ML (10 ) 25 GRAM 25 ML (10 ) 20 GRAM 200 ML (10 ) 30 GRAM 300 ML (10 ) 5 GRAM 50 ML (10 )

5 PA BvD NEDS

ILARIS (PF) SUBCUTANEOUS RECON SOLN 150 MGML

5 PA NEDS

ILARIS (PF) SUBCUTANEOUS SOLUTION 150 MGML

5 PA NEDS

ILUMYA SUBCUTANEOUS SYRINGE 100 MGML

5 PA NEDS

IMOGAM RABIES-HT (PF) INTRAMUSCULAR SOLUTION 150 UNITML

4

INFLECTRA INTRAVENOUS RECON SOLN 100 MG

5 PA NEDS

KEDRAB (PF) INTRAMUSCULAR SOLUTION 150 UNITML

4

KEVZARA SUBCUTANEOUS PEN INJECTOR 150 MG114 ML 200 MG114 ML

5 PA NEDS

KEVZARA SUBCUTANEOUS SYRINGE 150 MG114 ML 200 MG114 ML

5 PA NEDS

KINERET SUBCUTANEOUS SYRINGE 100 MG067 ML

5 PA NEDS

leflunomide oral tablet 10 mg 20 mg (Arava) 2


135


mycophenolate mofetil (hcl) intravenous recon soln 500 mg

(CellCept Intravenous) 2 PA BvD

mycophenolate mofetil oral capsule250 mg

(CellCept) 2 PA BvD

mycophenolate mofetil oral suspension for reconstitution 200 mgml

(CellCept) 5 PA BvD NEDS

mycophenolate mofetil oral tablet500 mg

(CellCept) 2 PA BvD

NULOJIX INTRAVENOUS RECON SOLN 250 MG

5 PA BvD NEDS

OCTAGAM INTRAVENOUS SOLUTION 10 5

5 PA BvD NEDS

OLUMIANT ORAL TABLET 1 MG 2 MG

5 PA NEDS

ORENCIA (WITH MALTOSE) INTRAVENOUS RECON SOLN 250 MG

5 PA NEDS

ORENCIA CLICKJECT SUBCUTANEOUS AUTO-INJECTOR 125 MGML

5 PA NEDS

ORENCIA SUBCUTANEOUS SYRINGE 125 MGML 50 MG04 ML 875 MG07 ML

5 PA NEDS

OTEZLA ORAL TABLET 30 MG 5 PA NEDS

OTEZLA STARTER ORAL TABLETSDOSE PACK 10 MG (4)-20 MG (4)-30 MG (47) 10 MG (4)-20 MG (4)-30 MG(19)

5 PA NEDS

PRIVIGEN INTRAVENOUS SOLUTION 10

5 PA BvD NEDS

PROGRAF INTRAVENOUS SOLUTION 5 MGML

4 PA BvD

PROGRAF ORAL GRANULES IN PACKET 02 MG 1 MG

4 PA BvD ST


136


RASUVO (PF) SUBCUTANEOUS AUTO-INJECTOR 10 MG02 ML 125 MG025 ML 15 MG03 ML 175 MG035 ML 20 MG04 ML 225 MG045 ML 25 MG05 ML 30 MG06 ML 75 MG015 ML

3

REMICADE INTRAVENOUS RECON SOLN 100 MG

5 PA NEDS

RENFLEXIS INTRAVENOUS RECON SOLN 100 MG

5 PA NEDS

RIDAURA ORAL CAPSULE 3 MG

5 NEDS

RINVOQ ORAL TABLET EXTENDED RELEASE 24 HR 15 MG

5 PA NEDS

SILIQ SUBCUTANEOUS SYRINGE 210 MG15 ML

5 PA NEDS

SIMPONI ARIA INTRAVENOUS SOLUTION 125 MGML

5 PA NEDS

SIMPONI SUBCUTANEOUS PEN INJECTOR 100 MGML 50 MG05 ML

5 PA NEDS

SIMPONI SUBCUTANEOUS SYRINGE 100 MGML 50 MG05 ML

5 PA NEDS

sirolimus oral solution 1 mgml (Rapamune) 5 PA BvD NEDS

sirolimus oral tablet 05 mg 1 mg (Rapamune) 4 PA BvD

sirolimus oral tablet 2 mg (Rapamune) 5 PA BvD NEDS

SKYRIZI SUBCUTANEOUS SYRINGE KIT 150MG166ML(75 MG083 ML X2)

5 PA NEDS

STELARA INTRAVENOUS SOLUTION 130 MG26 ML

5 PA NEDS

STELARA SUBCUTANEOUS SOLUTION 45 MG05 ML

5 PA NEDS

STELARA SUBCUTANEOUS SYRINGE 45 MG05 ML 90 MGML

5 PA NEDS


137


tacrolimus oral capsule 05 mg 1 mg 5 mg

(Prograf) 2 PA BvD

TALTZ AUTOINJECTOR SUBCUTANEOUS AUTO-INJECTOR 80 MGML

5 PA NEDS

TALTZ SYRINGE SUBCUTANEOUS SYRINGE 80 MGML

5 PA NEDS

TICE BCG INTRAVESICAL SUSPENSION FOR RECONSTITUTION 50 MG

4

TREMFYA SUBCUTANEOUS AUTO-INJECTOR 100 MGML

5 PA NEDS

TREMFYA SUBCUTANEOUS SYRINGE 100 MGML

5 PA NEDS

TYSABRI INTRAVENOUS SOLUTION 300 MG15 ML

5 PA LA NEDS

XELJANZ ORAL TABLET 10 MG 5 MG

5 PA NEDS

XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HR 11 MG 22 MG

5 PA NEDS

ZORTRESS ORAL TABLET 025 MG 05 MG 075 MG 1 MG

5 PA BvD NEDS

VaccinesACTHIB (PF) INTRAMUSCULAR RECON SOLN 10 MCG05 ML

6 NEDS

ADACEL(TDAP ADOLESNADULT)(PF) INTRAMUSCULAR SUSPENSION 2 LF-(25-5-3-5 MCG)-5LF05 ML

6 NEDS

ADACEL(TDAP ADOLESNADULT)(PF) INTRAMUSCULAR SYRINGE 2 LF-(25-5-3-5 MCG)-5LF05 ML

6 NEDS

BCG VACCINE LIVE (PF) PERCUTANEOUS SUSPENSION FOR RECONSTITUTION 50 MG

6 PA BvD NEDS


138


BEXSERO INTRAMUSCULAR SYRINGE 50-50-50-25 MCG05 ML

6 NEDS

BOOSTRIX TDAP INTRAMUSCULAR SUSPENSION 25-8-5 LF-MCG-LF05ML

6 NEDS

BOOSTRIX TDAP INTRAMUSCULAR SYRINGE 25-8-5 LF-MCG-LF05ML

6 NEDS

DAPTACEL (DTAP PEDIATRIC) (PF) INTRAMUSCULAR SUSPENSION 15-10-5 LF-MCG-LF05ML

6 NEDS

ENGERIX-B (PF) INTRAMUSCULAR SUSPENSION 20 MCGML

6 PA BvD NEDS

ENGERIX-B (PF) INTRAMUSCULAR SYRINGE 20 MCGML

6 PA BvD NEDS

ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SYRINGE 10 MCG05 ML

6 PA BvD NEDS

GARDASIL 9 (PF) INTRAMUSCULAR SUSPENSION 05 ML


GARDASIL 9 (PF) INTRAMUSCULAR SYRINGE 05 ML


HAVRIX (PF) INTRAMUSCULAR SUSPENSION 1440 ELISA UNITML 720 ELISA UNIT05 ML

6 NEDS

HAVRIX (PF) INTRAMUSCULAR SYRINGE 1440 ELISA UNITML 720 ELISA UNIT05 ML

6 NEDS

HIBERIX (PF) INTRAMUSCULAR RECON SOLN 10 MCG05 ML

6 NEDS


139


IMOVAX RABIES VACCINE (PF) INTRAMUSCULAR RECON SOLN 25 UNIT

6 PA BvD NEDS

INFANRIX (DTAP) (PF) INTRAMUSCULAR SUSPENSION 25-58-10 LF-MCG-LF05ML

6 NEDS

INFANRIX (DTAP) (PF) INTRAMUSCULAR SYRINGE 25-58-10 LF-MCG-LF05ML

6 NEDS

IPOL INJECTION SUSPENSION 40-8-32 UNIT05 ML

6 NEDS

IXIARO (PF) INTRAMUSCULAR SYRINGE 6 MCG05 ML

6 NEDS

KINRIX (PF) INTRAMUSCULAR SUSPENSION 25 LF-58 MCG-10 LF05 ML

6 NEDS

KINRIX (PF) INTRAMUSCULAR SYRINGE 25 LF-58 MCG-10 LF05 ML

6 NEDS

MENACTRA (PF) INTRAMUSCULAR SOLUTION 4 MCG05 ML

6 NEDS

MENVEO A-C-Y-W-135-DIP (PF) INTRAMUSCULAR KIT 10-5 MCG05 ML

6 NEDS

M-M-R II (PF) SUBCUTANEOUS RECON SOLN 1000-12500 TCID5005 ML

6 NEDS

PEDIARIX (PF) INTRAMUSCULAR SYRINGE 10 MCG-25LF-25 MCG-10LF05 ML

6 NEDS

PEDVAX HIB (PF) INTRAMUSCULAR SOLUTION 75 MCG05 ML

6 NEDS

PENTACEL (PF) INTRAMUSCULAR KIT 15 LF UNIT-20 MCG-5 LF05 ML

6 NEDS


140


PROQUAD (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 10EXP3-43-3- 399 TCID5005

6 NEDS

QUADRACEL (PF) INTRAMUSCULAR SUSPENSION 15 LF-48 MCG- 5 LF UNIT05ML

6 NEDS

RABAVERT (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 25 UNIT

6 PA BvD NEDS

RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION 10 MCGML 40 MCGML 5 MCG05 ML

6 PA BvD NEDS

RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 10 MCGML 5 MCG05 ML

6 PA BvD NEDS

ROTARIX ORAL SUSPENSION FOR RECONSTITUTION 10EXP6 CCID50ML

6 NEDS

ROTATEQ VACCINE ORAL SOLUTION 2 ML

6 NEDS

SHINGRIX (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 50 MCG05 ML


TDVAX INTRAMUSCULAR SUSPENSION 2-2 LF UNIT05 ML

6 NEDS

TENIVAC (PF) INTRAMUSCULAR SUSPENSION 5 LF UNIT- 2 LF UNIT05ML

6 NEDS

TENIVAC (PF) INTRAMUSCULAR SYRINGE 5-2 LF UNIT05 ML

6 NEDS


141


TETANUSDIPHTHERIA TOX PED(PF) INTRAMUSCULAR SUSPENSION 5-25 LF UNIT05 ML

6 NEDS

TRUMENBA INTRAMUSCULAR SYRINGE 120 MCG05 ML

6 NEDS

TWINRIX (PF) INTRAMUSCULAR SYRINGE 720 ELISA UNIT- 20 MCGML

6 NEDS

TYPHIM VI INTRAMUSCULAR SOLUTION 25 MCG05 ML

6 NEDS

TYPHIM VI INTRAMUSCULAR SYRINGE 25 MCG05 ML

6 NEDS

VAQTA (PF) INTRAMUSCULAR SUSPENSION 25 UNIT05 ML 50 UNITML

6 NEDS

VAQTA (PF) INTRAMUSCULAR SYRINGE 25 UNIT05 ML 50 UNITML

6 NEDS

VARIVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 1350 UNIT05 ML


YF-VAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 10 EXP474 UNIT05 ML

6 NEDS

ZOSTAVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 19400 UNIT065 ML


Inflammatory Bowel Disease AgentsInflammatory Bowel Disease Agentsalosetron oral tablet 05 mg 1 mg (Lotronex) 5 NEDS


142


APRISO ORAL CAPSULEEXTENDED RELEASE 24HR 0375 GRAM

3

balsalazide oral capsule 750 mg (Colazal) 2

budesonide oral capsuledelayedextendrelease 3 mg

(Entocort EC) 4

colocort rectal enema 100 mg60 ml 2

DIPENTUM ORAL CAPSULE 250 MG

5 ST NEDS

hydrocortisone rectal enema 100 mg60 ml

(Colocort) 4

LIALDA ORAL TABLETDELAYED RELEASE (DREC) 12 GRAM

2

mesalamine oral capsule (with del rel tablets) 400 mg

(Delzicol) 4

mesalamine oral capsuleextended release 24hr 0375 gram

(Apriso) 2

mesalamine oral tabletdelayed release (drec) 12 gram

(Lialda) 2

mesalamine oral tabletdelayed release (drec) 800 mg

(Asacol HD) 4

mesalamine rectal suppository 1000 mg

(Canasa) 5 NEDS

sulfasalazine oral tablet 500 mg (Azulfidine) 2

sulfasalazine oral tabletdelayed release (drec) 500 mg

(Azulfidine EN-tabs) 2

UCERIS RECTAL FOAM 2 MGACTUATION

3

Irrigating SolutionsIrrigating Solutionsacetic acid irrigation solution 025 4

LACTATED RINGERS IRRIGATION SOLUTION

4

sodium chloride irrigation solution09

(Aqua Care Sodium Chloride)

4

water for irrigation sterile irrigation solution

(Aqua Care Sterile Water)

4


143


Metabolic Bone Disease AgentsMetabolic Bone Disease Agentsalendronate oral solution 70 mg75 ml


alendronate oral tablet 10 mg 5 mg 1 GC

alendronate oral tablet 35 mg 1 GC QL (4 per 28 days)

alendronate oral tablet 40 mg 2

alendronate oral tablet 70 mg (Fosamax) 1 GC QL (4 per 28 days)

calcitonin (salmon) nasal spraynon-aerosol 200 unitactuation


calcitriol intravenous solution 1 mcgml

2

calcitriol oral capsule 025 mcg 05 mcg

(Rocaltrol) 2

calcitriol oral solution 1 mcgml (Rocaltrol) 2

cinacalcet oral tablet 30 mg 60 mg (Sensipar) 5 NEDS QL (60 per 30 days)

cinacalcet oral tablet 90 mg (Sensipar) 5 NEDS QL (120 per 30 days)

doxercalciferol intravenous solution4 mcg2 ml

(Hectorol) 2

doxercalciferol oral capsule 05 mcg 1 mcg 25 mcg

4

etidronate disodium oral tablet 200 mg 400 mg

4

EVENITY 105 MG117 ML SYRINGE 105 MG117 ML


EVENITY SUBCUTANEOUS SYRINGE 210MG234ML ( 105MG117MLX2)


FORTEO SUBCUTANEOUS PEN INJECTOR 20 MCGDOSE - 600 MCG24 ML


ibandronate intravenous solution 3 mg3 ml


ibandronate intravenous syringe 3 mg3 ml

(Boniva) 4 QL (3 per 84 days)

ibandronate oral tablet 150 mg (Boniva) 2 QL (1 per 28 days)

MIACALCIN INJECTION SOLUTION 200 UNITML

5 NEDS


144


NATPARA SUBCUTANEOUS CARTRIDGE 100 MCGDOSE 25 MCGDOSE 50 MCGDOSE 75 MCGDOSE


pamidronate intravenous recon soln30 mg 90 mg

2

pamidronate intravenous solution 30 mg10 ml (3 mgml) 60 mg10 ml (6 mgml) 90 mg10 ml (9 mgml)

2

paricalcitol hemodialysis port injection solution 2 mcgml

4

PARICALCITOL HEMODIALYSIS PORT INJECTION SOLUTION 5 MCGML

4

paricalcitol oral capsule 1 mcg 2 mcg

(Zemplar) 4

paricalcitol oral capsule 4 mcg 4

PROLIA SUBCUTANEOUS SYRINGE 60 MGML


RAYALDEE ORAL CAPSULEEXTENDED RELEASE 24 HR 30 MCG


risedronate oral tablet 150 mg (Actonel) 4 QL (1 per 28 days)

risedronate oral tablet 30 mg 4 QL (30 per 30 days)


risedronate oral tablet 35 mg (12 pack) 35 mg (4 pack)



risedronate oral tabletdelayed release (drec) 35 mg

(Atelvia) 4 QL (4 per 28 days)

TYMLOS SUBCUTANEOUS PEN INJECTOR 80 MCG (3120 MCG156 ML)


XGEVA SUBCUTANEOUS SOLUTION 120 MG17 ML (70 MGML)

5 PA NEDS

zoledronic acid intravenous recon soln 4 mg

4

zoledronic acid intravenous solution4 mg5 ml

4


145


zoledronic acid-mannitol-water intravenous piggyback 5 mg100 ml

(Reclast) 4 QL (100 per 300 days)

Miscellaneous Therapeutic AgentsMiscellaneous Therapeutic AgentsACTHAR INJECTION GEL 80 UNITML


ACTIMMUNE SUBCUTANEOUS SOLUTION 100 MCG05 ML

5 NEDS

amifostine crystalline intravenous recon soln 500 mg

(Ethyol) 2

BENLYSTA INTRAVENOUS RECON SOLN 120 MG 400 MG

5 PA NEDS

BENLYSTA SUBCUTANEOUS AUTO-INJECTOR 200 MGML


BENLYSTA SUBCUTANEOUS SYRINGE 200 MGML


CABLIVI INJECTION KIT 11 MG


CETYLEV ORAL TABLET EFFERVESCENT 25 GRAM 500 MG

4

CYSTADANE ORAL POWDER 1 GRAM17 ML

5 NEDS

dexrazoxane hcl intravenous recon soln 250 mg 500 mg

(Zinecard (as HCl)) 5 NEDS

droperidol injection solution 25 mgml

2

ELMIRON ORAL CAPSULE 100 MG


ENDARI ORAL POWDER IN PACKET 5 GRAM


ergoloid oral tablet 1 mg 4

EXONDYS-51 INTRAVENOUS SOLUTION 50 MGML

5 PA LA NEDS

fomepizole intravenous solution 1 gramml

5 NEDS

GLUCAGEN HYPOKIT INJECTION RECON SOLN 1 MG

3


146


guanidine oral tablet 125 mg 4

GVOKE HYPOPEN SUBCUTANEOUS AUTO-INJECTOR 05 MG01 ML 1 MG02 ML

3

GVOKE SYRINGE SUBCUTANEOUS SYRINGE 05 MG01 ML 1 MG02 ML

3

hydroxyzine pamoate oral capsule100 mg

1 GC

hydroxyzine pamoate oral capsule25 mg 50 mg

(Vistaril) 1 GC

KEVEYIS ORAL TABLET 50 MG


leucovorin calcium injection recon soln 100 mg 200 mg 350 mg 50 mg 500 mg

2

leucovorin calcium injection solution10 mgml

2

leucovorin calcium oral tablet 10 mg 15 mg 25 mg 5 mg

2

levocarnitine (with sugar) oral solution 100 mgml

(Carnitor) 2

levocarnitine oral tablet 330 mg (Carnitor) 2

LEVOLEUCOVORIN CALCIUM INTRAVENOUS RECON SOLN 175 MG

4

levoleucovorin calcium intravenous recon soln 50 mg

(Fusilev) 5 NEDS

mesna intravenous solution 100 mgml

(Mesnex) 2

MESNEX ORAL TABLET 400 MG

5 NEDS

MESTINON ORAL SYRUP 60 MG5 ML

5 NEDS

PROCYSBI ORAL GRANULES DEL RELEASE IN PACKET 300 MG 75 MG

5 NEDS

PROGLYCEM ORAL SUSPENSION 50 MGML

4


147


pyridostigmine bromide oral syrup60 mg5 ml

(Mestinon) 4

pyridostigmine bromide oral tablet30 mg

4


(Mestinon) 2

pyridostigmine bromide oral tablet extended release 180 mg

(Mestinon Timespan) 4

RECTIV RECTAL OINTMENT 04 (WW)


TAKHZYRO SUBCUTANEOUS SOLUTION 300 MG2 ML (150 MGML)


THALOMID ORAL CAPSULE 100 MG 150 MG 200 MG 50 MG


TOTECT INTRAVENOUS RECON SOLN 500 MG

5 NEDS

TYBOST ORAL TABLET 150 MG


VISTOGARD ORAL GRANULES IN PACKET 10 GRAM


XURIDEN ORAL GRANULES IN PACKET 2 GRAM


Ophthalmic AgentsAntiglaucoma Agentsacetazolamide oral capsule extended release 500 mg

2

acetazolamide oral tablet 125 mg 250 mg

2

acetazolamide sodium injection recon soln 500 mg

2

ALPHAGAN P OPHTHALMIC (EYE) DROPS 01

3

AZOPT OPHTHALMIC (EYE) DROPSSUSPENSION 1

3

betaxolol ophthalmic (eye) drops05

2

bimatoprost ophthalmic (eye) drops003

4


148


brimonidine ophthalmic (eye) drops015

(Alphagan P) 4


1 GC

carteolol ophthalmic (eye) drops 1

1 GC

COMBIGAN OPHTHALMIC (EYE) DROPS 02-05

3

dorzolamide ophthalmic (eye) drops2

(Trusopt) 2

dorzolamide-timolol ophthalmic (eye) drops 223-68 mgml

(Cosopt) 2

latanoprost ophthalmic (eye) drops0005

(Xalatan) 1 GC QL (25 per 25 days)

levobunolol ophthalmic (eye) drops05

1 GC

LUMIGAN OPHTHALMIC (EYE) DROPS 001


methazolamide oral tablet 25 mg 50 mg

4

metipranolol ophthalmic (eye) drops 03

2

pilocarpine hcl ophthalmic (eye) drops 1 2 4

(Isopto Carpine) 2

RHOPRESSA OPHTHALMIC (EYE) DROPS 002


ROCKLATAN OPHTHALMIC (EYE) DROPS 002-0005


SIMBRINZA OPHTHALMIC (EYE) DROPSSUSPENSION 1-02

3

timolol maleate ophthalmic (eye) drops 025 05

(Timoptic) 1 GC

timolol maleate ophthalmic (eye) gel forming solution 025 05

(Timoptic-XE) 4

TRAVATAN Z OPHTHALMIC (EYE) DROPS 0004


travoprost ophthalmic (eye) drops0004

(Travatan Z) 2 QL (25 per 25 days)

VYZULTA OPHTHALMIC (EYE) DROPS 0024



149


XELPROS OPHTHALMIC (EYE) DROPS EMULSION 0005


ZIOPTAN (PF) OPHTHALMIC (EYE) DROPPERETTE 00015


Replacement PreparationsReplacement Preparationscalcium chloride intravenous syringe100 mgml (10 )

2

IONOSOL-B IN D5W INTRAVENOUS PARENTERAL SOLUTION 5

4

IONOSOL-MB IN D5W INTRAVENOUS PARENTERAL SOLUTION 5

4

ISOLYTE-P IN 5 DEXTROSE INTRAVENOUS PARENTERAL SOLUTION 5

4

ISOLYTE-S INTRAVENOUS PARENTERAL SOLUTION

4

klor-con m10 oral tableter particlescrystals 10 meq

2


2


2

klor-con sprinkle oral capsule extended release 8 meq

2

magnesium sulfate in d5w intravenous piggyback 1 gram100 ml

2

magnesium sulfate in water intravenous parenteral solution 20 gram500 ml (4 ) 40 gram1000 ml (4 )

2 PA BvD

magnesium sulfate in water intravenous piggyback 2 gram50 ml (4 ) 4 gram100 ml (4 ) 4 gram50 ml (8 )

2 PA BvD

magnesium sulfate injection solution4 meqml (50 )

2 PA BvD


150


magnesium sulfate injection syringe4 meqml

2 PA BvD

NORMOSOL-M IN 5 DEXTROSE INTRAVENOUS PARENTERAL SOLUTION

4

NORMOSOL-R IV SOLUTION LF SINGLE-USE

4

NORMOSOL-R PH 74 INTRAVENOUS PARENTERAL SOLUTION

4

PLASMA-LYTE 148 INTRAVENOUS PARENTERAL SOLUTION

4

PLASMA-LYTE A INTRAVENOUS PARENTERAL SOLUTION

4

potassium chloride intravenous solution 2 meqml

2 PA BvD

potassium chloride intravenous solution 2 meqml (20 ml)

2 PA BvD

potassium chloride oral capsule extended release 10 meq 8 meq

2

potassium chloride oral liquid 20 meq15 ml 40 meq15 ml

4

potassium chloride oral tablet extended release 10 meq 8 meq

(K-Tab) 2

potassium chloride oral tablet extended release 20 meq

(K-Tab) 4

potassium chloride oral tableter particlescrystals 10 meq

(Klor-Con M10) 2


(Klor-Con M20) 2

potassium chloride-045 nacl intravenous parenteral solution 20 meql

2

potassium citrate oral tablet extended release 10 meq (1080 mg)

(Urocit-K 10) 2

potassium citrate oral tablet extended release 15 meq

(Urocit-K 15) 2


(Urocit-K 5) 2


151


sodium chloride 09 intravenous parenteral solution

2

Respiratory Tract AgentsAnti-Inflammatories Inhaled CorticosteroidsADVAIR DISKUS INHALATION BLISTER WITH DEVICE 100-50 MCGDOSE 250-50 MCGDOSE 500-50 MCGDOSE


ADVAIR HFA INHALATION HFA AEROSOL INHALER 115-21 MCGACTUATION 230-21 MCGACTUATION 45-21 MCGACTUATION


ARNUITY ELLIPTA INHALATION BLISTER WITH DEVICE 100 MCGACTUATION 200 MCGACTUATION 50 MCGACTUATION


BREO ELLIPTA INHALATION BLISTER WITH DEVICE 100-25 MCGDOSE 200-25 MCGDOSE


budesonide inhalation suspension for nebulization 025 mg2 ml 05 mg2 ml 1 mg2 ml

(Pulmicort) 2 PA BvD

FLOVENT 100 MCG DISKUS 100 MCGACTUATION




FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCGACTUATION 50 MCGACTUATION


FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 250 MCGACTUATION



152


FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCGACTUATION






SYMBICORT 160-45 MCG INHALER 60 INHALATIONS 160-45 MCGACTUATION




SYMBICORT INHALATION HFA AEROSOL INHALER 160-45 MCGACTUATION 80-45 MCGACTUATION


Antileukotrienesmontelukast oral tablet 10 mg (Singulair) 1 GC

montelukast oral tabletchewable 4 mg 5 mg

(Singulair) 1 GC

zafirlukast oral tablet 10 mg 20 mg (Accolate) 4Bronchodilatorsalbuterol 5 mgml solution 5 mgml 2 PA BvD

albuterol sulfate inhalation hfa aerosol inhaler 90 mcgactuation

(ProAir HFA) 2 QL (17 per 30 days)

albuterol sulfate inhalation hfa aerosol inhaler 90 mcgactuation (nda020503)




albuterol sulfate inhalation solution for nebulization 063 mg3 ml 125 mg3 ml 25 mg 3 ml (0083 ) 25 mg05 ml

2 PA BvD

albuterol sulfate oral syrup 2 mg5 ml

2


153


albuterol sulfate oral tablet 2 mg 4 mg

2

albuterol sulfate oral tablet extended release 12 hr 4 mg 8 mg

2

ANORO ELLIPTA INHALATION BLISTER WITH DEVICE 625-25 MCGACTUATION

3

ATROVENT HFA INHALATION HFA AEROSOL INHALER 17 MCGACTUATION


COMBIVENT RESPIMAT INHALATION MIST 20-100 MCGACTUATION


elixophyllin oral elixir 80 mg15 ml 4

INCRUSE ELLIPTA INHALATION BLISTER WITH DEVICE 625 MCGACTUATION

3

ipratropium bromide inhalation solution 002

2 PA BvD

LONHALA MAGNAIR 25 MCG STARTER 25 MCGML


LONHALA MAGNAIR REFILL INHALATION SOLUTION FOR NEBULIZATION 25 MCGML


metaproterenol oral syrup 10 mg5 ml

1 GC

metaproterenol oral tablet 10 mg 20 mg

2

PROAIR RESPICLICK INHALATION AEROSOL POWDR BREATH ACTIVATED 90 MCGACTUATION


SEREVENT DISKUS INHALATION BLISTER WITH DEVICE 50 MCGDOSE


SPIRIVA RESPIMAT INHALATION MIST 125 MCGACTUATION



154




SPIRIVA WITH HANDIHALER INHALATION CAPSULE WINHALATION DEVICE 18 MCG


STIOLTO RESPIMAT INHALATION MIST 25-25 MCGACTUATION

3

STRIVERDI RESPIMAT INHALATION MIST 25 MCGACTUATION


terbutaline oral tablet 25 mg 5 mg 2

terbutaline subcutaneous solution 1 mgml

5 NEDS

theophylline oral solution 80 mg15 ml

4

theophylline oral tablet extended release 12 hr 100 mg 200 mg

2


4


2

TRELEGY ELLIPTA INHALATION BLISTER WITH DEVICE 100-625-25 MCG

3

TUDORZA PRESSAIR INHALATION AEROSOL POWDR BREATH ACTIVATED 400 MCGACTUATION


TUDORZA PRESSAIR INHALATION AEROSOL POWDR BREATH ACTIVATED 400 MCGACTUATION (30 ACTUAT)


Respiratory Tract Agents Otheracetylcysteine intravenous solution200 mgml (20 )

(Acetadote) 2 PA

acetylcysteine solution 100 mgml (10 ) 200 mgml (20 )

2 PA BvD


155


CINQAIR INTRAVENOUS SOLUTION 10 MGML

5 PA NEDS

cromolyn inhalation solution for nebulization 20 mg2 ml

2 PA BvD

DALIRESP ORAL TABLET 250 MCG




ESBRIET ORAL CAPSULE 267 MG


ESBRIET ORAL TABLET 267 MG




FASENRA PEN SUBCUTANEOUS AUTO-INJECTOR 30 MGML


FASENRA SUBCUTANEOUS SYRINGE 30 MGML


KALYDECO ORAL GRANULES IN PACKET 25 MG 50 MG 75 MG


KALYDECO ORAL TABLET 150 MG


NUCALA SUBCUTANEOUS AUTO-INJECTOR 100 MGML

5 PA LA NEDS QL (3 per 28 days)

NUCALA SUBCUTANEOUS RECON SOLN 100 MG


NUCALA SUBCUTANEOUS SYRINGE 100 MGML


OFEV ORAL CAPSULE 100 MG 150 MG


ORKAMBI ORAL GRANULES IN PACKET 100-125 MG 150-188 MG


ORKAMBI ORAL TABLET 100-125 MG 200-125 MG


PROLASTIN-C INTRAVENOUS RECON SOLN 1000 MG

5 PA BvD NEDS


156


SYMDEKO ORAL TABLETS SEQUENTIAL 100-150 MG (D) 150 MG (N) 50-75 MG (D) 75 MG (N)


TRIKAFTA ORAL TABLETS SEQUENTIAL 100-50-75 MG(D) 150 MG (N)


XOLAIR SUBCUTANEOUS RECON SOLN 150 MG

5 PA NEDS

XOLAIR SUBCUTANEOUS SYRINGE 150 MGML 75 MG05 ML

5 PA NEDS

Skeletal Muscle RelaxantsSkeletal Muscle Relaxantsbaclofen oral tablet 10 mg 20 mg 2

chlorzoxazone oral tablet 500 mg 2 PA-HRM AGE (Max 64 Years)

cyclobenzaprine oral tablet 10 mg 5 mg


dantrolene oral capsule 100 mg 2

dantrolene oral capsule 25 mg 50 mg

(Dantrium) 2

methocarbamol oral tablet 500 mg 2 PA-HRM AGE (Max 64 Years)

methocarbamol oral tablet 750 mg (Robaxin-750) 2 PA-HRM AGE (Max 64 Years)

revonto intravenous recon soln 20 mg

2

tizanidine oral tablet 2 mg 2

tizanidine oral tablet 4 mg (Zanaflex) 2

Sleep Disorder AgentsSleep Disorder Agentsarmodafinil oral tablet 150 mg 200 mg 250 mg 50 mg

(Nuvigil) 2 PA QL (30 per 30 days)

BELSOMRA ORAL TABLET 10 MG 15 MG 20 MG 5 MG


eszopiclone oral tablet 1 mg 2 mg 3 mg

(Lunesta) 2 QL (30 per 30 days)

HETLIOZ ORAL CAPSULE 20 MG



157


SILENOR ORAL TABLET 3 MG 6 MG


SUNOSI ORAL TABLET 150 MG 75 MG


XYREM ORAL SOLUTION 500 MGML


zaleplon oral capsule 10 mg 5 mg 2 QL (30 per 30 days)

zolpidem oral tablet 10 mg 5 mg (Ambien) 1 GC QL (30 per 30 days)

zolpidem oral tabletext release multiphase 125 mg 625 mg

(Ambien CR) 2 QL (30 per 30 days)

Vasodilating AgentsVasodilating AgentsADEMPAS ORAL TABLET 05 MG 1 MG 15 MG 2 MG 25 MG


alyq oral tablet 20 mg 5 PA NEDS QL (60 per 30 days)

ambrisentan oral tablet 10 mg 5 mg (Letairis) 5 PA NEDS QL (30 per 30 days)

epoprostenol (glycine) intravenous recon soln 05 mg

(Flolan) 2 PA


(Flolan) 5 PA NEDS

OPSUMIT ORAL TABLET 10 MG


ORENITRAM ORAL TABLET EXTENDED RELEASE 0125 MG

3 PA

ORENITRAM ORAL TABLET EXTENDED RELEASE 025 MG 1 MG 25 MG 5 MG

5 PA NEDS

sildenafil (pulmhypertension) intravenous solution 10 mg125 ml

(Revatio) 5 PA NEDS QL (375 per 1 day)

sildenafil (pulmhypertension) oral tablet 20 mg

(Revatio) 2 PA QL (90 per 30 days)

sildenafil oral tablet 100 mg 25 mg 50 mg

(Viagra) 2 EX CB (6 EA per 30 days)

tadalafil (pulm hypertension) oral tablet 20 mg

(Alyq) 5 PA NEDS QL (60 per 30 days)


158


tadalafil oral tablet 25 mg 5 mg (Cialis) 2 PA QL (30 per 30 days)

TRACLEER ORAL TABLET 125 MG 625 MG


TRACLEER ORAL TABLET FOR SUSPENSION 32 MG


treprostinil sodium injection solution1 mgml 10 mgml 25 mgml 5 mgml

(Remodulin) 5 PA NEDS

TYVASO INHALATION SOLUTION FOR NEBULIZATION 174 MG29 ML (06 MGML)

5 PA NEDS

UPTRAVI ORAL TABLET 1000 MCG 1200 MCG 1400 MCG 1600 MCG 400 MCG 600 MCG 800 MCG


UPTRAVI ORAL TABLET 200 MCG


UPTRAVI ORAL TABLETSDOSE PACK 200 MCG (140)- 800 MCG (60)

5 PA NEDS

Vitamins And MineralsVitamins And Mineralspnv prenatal plus multivit tab sf gluten-free (rx) 27 mg iron- 1 mg

3

prenatal vitamin plus low iron oral tablet 27 mg iron- 1 mg

3


159


160

INDEX

Index

abacavir 66abacavir-lamivudine 66abacavir-lamivudine-zidovudine 66ABELCET 51ABILIFY MAINTENA 61ABRAXANE22acamprosate 11acarbose 46acebutolol 84acetaminophen-codeine 3acetazolamide 148acetazolamide sodium 148acetic acid 115 143acetylcysteine 155acitretin 106ACTEMRA 132ACTEMRA ACTPEN132ACTHAR 146ACTHIB (PF) 138ACTIMMUNE146acyclovir 72 106acyclovir sodium 72ADACEL(TDAP ADOLESNADULT)(PF) 138ADAGEN112ADAKVEO 76adapalene 111ADCETRIS 22adefovir 72ADEMPAS158adriamycin 23adrucil 23ADVAIR DISKUS152ADVAIR HFA 152afeditab cr 88AFINITOR 23AFINITOR DISPERZ 23afirmelle 98

Index

a-hydrocort 126AIMOVIG AUTOINJECTOR 54AIMOVIG AUTOINJECTOR (2 PACK) 54AJOVY 54AKYNZEO (FOSNETUPITANT)56AKYNZEO (NETUPITANT)56ala-cort 108ala-scalp 108albendazole 58albuterol sulfate 153 154alcaine 114alclometasone 108ALCOHOL PADS106ALDURAZYME 112ALECENSA 23alendronate 144alfuzosin 123ALIMTA 23ALINIA58ALIQOPA 23aliskiren 93allopurinol 53alosetron 142ALPHAGAN P 148alprazolam 12ALREX 117altavera (28) 98ALTRENO 111ALUNBRIG23alyacen 135 (28) 98alyacen 777 (28) 98alyq 158amabelz 125amantadine hcl 59AMBISOME 51

Index

ambrisentan 158amethia 98amethia lo 98amifostine crystalline 146amiloride 89amiloride-hydrochlorothiazide 89AMINOSYN 10 77AMINOSYN 7 WITH ELECTROLYTES 77AMINOSYN 85 77AMINOSYN 85 -ELECTROLYTES 77AMINOSYN II 10 77AMINOSYN II 15 77AMINOSYN II 7 77AMINOSYN II 85 77AMINOSYN II 85 -ELECTROLYTES 78AMINOSYN M 35 78AMINOSYN-HBC 778AMINOSYN-PF 10 78AMINOSYN-PF 7 (SULFITE-FREE)78AMINOSYN-RF 52 78amiodarone 84AMITIZA120amitriptyline 42amitriptyline-chlordiazepoxide 42amlodipine 88amlodipine-atorvastatin 90amlodipine-benazepril 88amlodipine-olmesartan 88amlodipine-valsartan 88amlodipine-valsartan-hcthiazid 89ammonium lactate 106amoxapine 42amoxicil-clarithromy-lansopraz 118

I-1

Index

amoxicillin 19amoxicillin-pot clavulanate 19amphotericin b 51ampicillin 19ampicillin sodium 19ampicillin-sulbactam 19ANADROL-50 124anagrelide 76anastrozole 23ANORO ELLIPTA 154APOKYN 59apraclonidine 114aprepitant 56apri 98APRISO143APTIOM 37APTIVUS 67APTIVUS (WITH VITAMIN E) 66aranelle (28) 98ARCALYST 132aripiprazole 61ARISTADA 62ARISTADA INITIO61armodafinil 157ARNUITY ELLIPTA 152arsenic trioxide 23ascomp with codeine 3ashlyna 98aspirin-dipyridamole 76ASSURE ID INSULIN SAFETY111atazanavir 67atenolol 84atenolol-chlorthalidone 85atomoxetine 93 94atorvastatin 90atovaquone 58atovaquone-proguanil 58ATRIPLA67

Index

atropine 37 114ATROVENT HFA 154AUBAGIO 94aubra 98aurovela 1530 (21) 99aurovela 120 (21) 99aurovela 24 fe 99aurovela fe 1530 (28) 99aurovela fe 1-20 (28) 99AUSTEDO 94AVASTIN 23aviane 99AVONEX 94AVONEX (WITH ALBUMIN)94ayuna 99AYVAKIT23azacitidine 23azathioprine 132azathioprine sodium 132azelastine 114azithromycin 17 18AZOPT 148aztreonam 18azurette (28) 99baciim 14bacitracin 14 115bacitracin-polymyxin b 115baclofen 157balsalazide 143BALVERSA23 24balziva (28) 99BANZEL 37BAVENCIO 24BAXDELA20BCG VACCINE LIVE (PF) 138BD ULTRA-FINE NANO PEN NEEDLE 111BD VEO INSULIN SYR HALF UNIT 111

Index

BD VEO INSULIN SYRINGE UF111bekyree (28) 99BELEODAQ 24BELSOMRA 157benazepril 82benazepril-hydrochlorothiazide 83BENDEKA 24BENLYSTA 146benztropine 59BEPREVE 114BESPONSA24betamethasone acetsod phos 126betamethasone dipropionate 108betamethasone valerate 108betamethasone augmented 108BETASERON 94betaxolol 85 148bethanechol chloride 123BETHKIS14BEVYXXA73bexarotene 24BEXSERO 139bicalutamide 24BICILLIN L-A 19BIDIL 93BIKTARVY 67bimatoprost 148bisoprolol fumarate 85bisoprolol-hydrochlorothiazide 85bleomycin 24bleph-10 115BLINCYTO24blisovi 24 fe 99blisovi fe 1530 (28) 99blisovi fe 120 (28) 99BOOSTRIX TDAP139BORTEZOMIB24BOSULIF 24BRAFTOVI24

I-2

Index

BREO ELLIPTA 152briellyn 99BRILINTA76brimonidine 149BRIVIACT 37bromfenac 117bromocriptine 59BROMSITE117BRUKINSA 24budesonide 143 152bumetanide 89buprenorphine 3buprenorphine hcl 3 11buprenorphine-naloxone 11bupropion hcl 42 43bupropion hcl (smoking deter) 11buspirone 12butalbital compound wcodeine 3butalbital-acetaminop-caf-cod 3butalbital-acetaminophen 3butalbital-acetaminophen-caff 3butalbital-aspirin-caffeine 4butorphanol tartrate 4BYSTOLIC85BYVALSON85cabergoline 59CABLIVI 146CABOMETYX24caffeine citrate 94calcipotriene 106calcitonin (salmon) 144calcitrene 106calcitriol 106 144calcium acetate(phosphat bind) 122calcium chloride 150CALDOLOR8CALQUENCE 24camila 99candesartan 81

Index

candesartan-hydrochlorothiazid81capacet 4CAPASTAT 55CAPLYTA 62CAPRELSA 24captopril 83captopril-hydrochlorothiazide 83CARBAGLU120carbamazepine 37carbidopa 59carbidopa-levodopa 59 60carbidopa-levodopa-entacapone60carbinoxamine maleate 53carboplatin 25CAROSPIR 93carteolol 149cartia xt 86carvedilol 85caspofungin 51CAYSTON 18caziant (28) 99cefaclor 16cefadroxil 16cefazolin 16cefdinir 16cefditoren pivoxil 16cefepime 16cefixime 16cefotaxime 16cefoxitin 17cefpodoxime 17cefprozil 17ceftazidime 17ceftriaxone 17cefuroxime axetil 17cefuroxime sodium 17celecoxib 8CELONTIN 37cephalexin 17CERDELGA 112

Index

CEREZYME 112CETYLEV 146cevimeline 105CHANTIX 11CHANTIX CONTINUING MONTH BOX11CHANTIX STARTING MONTH BOX11chloramphenicol sod succinate 14chlordiazepoxide hcl 12chlorhexidine gluconate 105chloroquine phosphate 58chlorothiazide 89chlorothiazide sodium 89chlorpromazine 62chlorthalidone 89chlorzoxazone 157cholestyramine (with sugar) 90cholestyramine light 91ciclopirox 51cidofovir 72cilostazol 76CIMDUO 67cimetidine 118cimetidine hcl 118CIMZIA 132CIMZIA POWDER FOR RECONST132cinacalcet 144CINQAIR156CINRYZE 74CINVANTI 56CIPRODEX115ciprofloxacin 20ciprofloxacin (mixture) 20ciprofloxacin hcl 20 115ciprofloxacin in 5 dextrose 20citalopram 43cladribine 25clarithromycin 18

I-3

Index

clemastine 53CLENPIQ122clindamycin hcl 15clindamycin in 5 dextrose 15clindamycin palmitate hcl 14clindamycin pediatric 15clindamycin phosphate 15 54 107clindamycin-benzoyl peroxide 107CLINIMIX 5D15W SULFITE FREE 78CLINIMIX 5D25W SULFITE-FREE 78CLINIMIX 425D10W SULF FREE78CLINIMIX 425D5W SULFIT FREE78CLINIMIX 425-D25W SULF-FREE 78CLINIMIX 5-D20W(SULFITE-FREE) 79CLINIMIX E 275D10W SUL FREE 79CLINIMIX E 275D5W SULF FREE79CLINIMIX E 425D10W SUL FREE 79CLINIMIX E 425D25W SUL FREE 79CLINIMIX E 425D5W SULF FREE79CLINIMIX E 5D15W SULFIT FREE79CLINIMIX E 5D20W SULFIT FREE79CLINIMIX E 5D25W SULFIT FREE79CLINOLIPID79clobazam 37 38clobetasol 108clobetasol-emollient 109

Index

clocortolone pivalate 109clofarabine 25clomipramine 43clonazepam 12 13clonidine 81clonidine hcl 81 94clopidogrel 77clorazepate dipotassium 13clotrimazole 51clotrimazole-betamethasone 51clovique 124clozapine 62COARTEM 58codeine sulfate 4colchicine 53colesevelam 91colestipol 91colistin (colistimethate na) 15colocort 143COMBIGAN 149COMBIVENT RESPIMAT 154COMETRIQ25COMPLERA67compro 56constulose 120COPIKTRA 25CORLANOR 87cormax 109cortisone 126COSENTYX (2 SYRINGES) 132COSENTYX PEN (2 PENS) 132COTELLIC 25CREON 112CRIXIVAN 67cromolyn 114 120 156cryselle (28) 99cyclafem 135 (28) 99cyclafem 777 (28) 99cyclobenzaprine 157

Index

cyclopentolate 114cyclophosphamide 25CYCLOPHOSPHAMIDE 25cyclosporine 133cyclosporine modified 133cyproheptadine 53CYRAMZA25cyred 99CYSTADANE146CYSTARAN 114dalfampridine 94DALIRESP156danazol 124dantrolene 157dapsone 55DAPTACEL (DTAP PEDIATRIC) (PF) 139daptomycin 15DARAPRIM 58DARZALEX 25dasetta 135 (28) 99dasetta 777 (28) 99DAURISMO 25daysee 100deblitane 100decadron 126decitabine 25deferasirox 124deferoxamine 124DELSTRIGO 67delyla (28) 100demeclocycline 21DEMSER 87DENAVIR106DEPEN TITRATABS 124DEPO-PROVERA 131DESCOVY 67desipramine 43desmopressin 128desog-eestradioleestradiol 100

I-4

Index

desogestrel-ethinyl estradiol 100desonide 109desoximetasone 109desvenlafaxine succinate 43dexamethasone 126dexamethasone sodium phos (pf) 127dexamethasone sodium phosphate 117 127DEXILANT 119dexmethylphenidate 94dexrazoxane hcl 146dextroamphetamine 94dextroamphetamine-amphetamine 94 95dextrose 10 in water (d10w) 79dextrose 20 in water (d20w) 79dextrose 25 in water (d25w) 79dextrose 30 in water (d30w) 79dextrose 40 in water (d40w) 80dextrose 5 in water (d5w) 80dextrose 50 in water (d50w) 80dextrose 70 in water (d70w) 80DIASTAT38DIASTAT ACUDIAL 38diazepam 13 38diazepam intensol 13diclofenac epolamine 8diclofenac potassium 8diclofenac sodium 8 117diclofenac-misoprostol 8dicloxacillin 20dicyclomine 120didanosine 67DIFICID 18diflorasone 109diflunisal 8digitek 87digox 87digoxin 87 88

Index

DIGOXIN 87dihydroergotamine 54diltiazem hcl 86dilt-xr 86dimenhydrinate 56DIPENTUM143diphenhydramine hcl 53diphenoxylate-atropine 120dipyridamole 77disopyramide phosphate 84disulfiram 12divalproex 38docetaxel 25dofetilide 84donepezil 42DOPTELET (10 TAB PACK) 74DOPTELET (15 TAB PACK) 74DOPTELET (30 TAB PACK) 74dorzolamide 149dorzolamide-timolol 149dotti 125DOVATO 67doxazosin 81doxepin 43doxercalciferol 144doxorubicin 25doxorubicin peg-liposomal 25doxy-100 21doxycycline hyclate 21doxycycline monohydrate 22DRIZALMA SPRINKLE43dronabinol 57droperidol 146drospirenone-ethinyl estradiol 100DROXIA 26DUAVEE 125DUEXIS8duloxetine 43DUPIXENT 133DUREZOL117

Index

dutasteride 123dutasteride-tamsulosin 123econazole 51EDARBI81EDARBYCLOR 82EDURANT 67efavirenz 67EGRIFTA 128ELAPRASE112ELIGARD26ELIGARD (3 MONTH) 26ELIGARD (4 MONTH) 26ELIGARD (6 MONTH) 26elinest 100ELIQUIS 73ELIQUIS DVT-PE TREAT 30D START 73ELITEK112elixophyllin 154ELLA100ELMIRON 146eluryng 100EMCYT26EMEND 57EMEND (FOSAPREPITANT) 57EMFLAZA127EMGALITY PEN 54EMGALITY SYRINGE 55emoquette 100EMPLICITI26EMSAM 43EMTRIVA 67enalapril maleate 83enalaprilat 83enalapril-hydrochlorothiazide 83ENBREL 133ENBREL MINI133ENBREL SURECLICK133ENDARI 146

I-5

Index

endocet 4ENGERIX-B (PF) 139ENGERIX-B PEDIATRIC (PF)139ENHERTU 26enoxaparin 73enpresse 100enskyce 100entacapone 60entecavir 72ENTRESTO 82enulose 120EPANED83EPCLUSA 71EPIDIOLEX38epinastine 114epinephrine 88epitol 38EPIVIR HBV67eplerenone 93epoprostenol (glycine) 158eprosartan 82ergoloid 146ERGOMAR 55ERIVEDGE 26ERLEADA26erlotinib 26errin 100ertapenem 18ery pads 107erythromycin 18 115erythromycin ethylsuccinate 18erythromycin with ethanol 107erythromycin-benzoyl peroxide 107ESBRIET156escitalopram oxalate 43esomeprazole sodium 119estarylla 100estazolam 13

Index

estradiol 125estradiol valerate 125estradiol-norethindrone acet 125eszopiclone 157ethambutol 56ethosuximide 38ethynodiol diac-eth estradiol 100etidronate disodium 144etodolac 8etonogestrel-ethinyl estradiol 100ETOPOPHOS26etoposide 26EUCRISA109EVENITY144EVOTAZ 67exemestane 26EXONDYS-51146EXTAVIA 95EZALLOR SPRINKLE 91ezetimibe 91ezetimibe-simvastatin 91FABRAZYME 112falmina (28) 100famciclovir 72famotidine 119famotidine (pf) 119famotidine (pf)-nacl (iso-os) 119FANAPT62FARYDAK26FASENRA 156FASENRA PEN156febuxostat 53felbamate 38felodipine 89FEMRING 126femynor 100fenofibrate 91fenofibrate micronized 91fenofibrate nanocrystallized 91fenofibric acid 91

Index

fenofibric acid (choline) 91fenoprofen 8fentanyl 4fentanyl citrate 4FERRIPROX 124FETZIMA 44FIASP FLEXTOUCH U-100 INSULIN 48FIASP PENFILL U-100 INSULIN 48FIASP U-100 INSULIN48finasteride 123FIRVANQ15flavoxate 123FLEBOGAMMA DIF 133flecainide 84FLOLIPID 91FLOVENT DISKUS 152FLOVENT HFA 153floxuridine 26fluconazole 51fluconazole in nacl (iso-osm) 51flucytosine 52fludrocortisone 127flumazenil 95flunisolide 117fluocinolone 109fluocinolone acetonide oil 117fluocinonide 109fluocinonide-e 109fluorometholone 117fluorouracil 26 106fluoxetine 44fluphenazine decanoate 62fluphenazine hcl 63flurazepam 13flurbiprofen 8flurbiprofen sodium 117flutamide 26fluticasone propionate 109 117

I-6

Index

fluvastatin 91fluvoxamine 44fomepizole 146fondaparinux 73FORTEO 144fosamprenavir 67fosaprepitant 57foscarnet 70fosinopril 83fosinopril-hydrochlorothiazide 83fosphenytoin 38FREAMINE HBC 69 80FREAMINE III 10 80FULPHILA74fulvestrant 27furosemide 89FUZEON 67fyavolv 126FYCOMPA 38gabapentin 38 39GALAFOLD 112galantamine 42GAMASTAN 133GAMMAGARD LIQUID 133GAMMAGARD S-D (IGA lt 1 MCGML) 133GAMMAPLEX134GAMMAPLEX (WITH SORBITOL) 133GAMUNEX-C 134ganciclovir sodium 72 73GARDASIL 9 (PF)139gatifloxacin 115GATTEX 30-VIAL120GAUZE PAD 111gavilyte-c 122gavilyte-g 122gavilyte-n 122GAZYVA 27gemcitabine 27

Index

gemfibrozil 91generlac 120gengraf 134GENOTROPIN128GENOTROPIN MINIQUICK 128gentak 115gentamicin 14 107 115gentamicin sulfate (ped) (pf) 14gentamicin sulfate (pf) 14GENVOYA 68GEODON63GILENYA95GILOTRIF27GIVLAARI 76glatiramer 95glatopa 95GLEOSTINE27glimepiride 50glipizide 50glipizide-metformin 50GLUCAGEN HYPOKIT146glyburide 51glyburide micronized 50glyburide-metformin 51glycopyrrolate 120glydo 10GLYXAMBI 46GOCOVRI 60GRALISE39GRALISE 30-DAY STARTER PACK 39granisetron (pf) 57granisetron hcl 57GRANIX74griseofulvin microsize 52griseofulvin ultramicrosize 52guanfacine 81 95guanidine 147GVOKE HYPOPEN 147

Index

GVOKE SYRINGE 147HAEGARDA75hailey 100hailey 24 fe 100halobetasol propionate 109haloperidol 63haloperidol decanoate 63haloperidol lactate 63HARVONI 71HAVRIX (PF) 139heather 100heparin (porcine) 73 74heparin porcine (pf) 74HEPATAMINE 880HERCEPTIN 27HERCEPTIN HYLECTA 27HETLIOZ157HIBERIX (PF) 139HUMATROPE128HUMIRA 134HUMIRA PEDIATRIC CROHNS START134HUMIRA PEN 134HUMIRA PEN CROHNS-UC-HS START 134HUMIRA PEN PSOR-UVEITS-ADOL HS 134HUMIRA(CF)135HUMIRA(CF) PEDI CROHNS STARTER134HUMIRA(CF) PEN135HUMIRA(CF) PEN CROHNS-UC-HS 134HUMIRA(CF) PEN PSOR-UV-ADOL HS134HUMULIN R U-500 (CONC) INSULIN48HUMULIN R U-500 (CONC) KWIKPEN 48hydralazine 88

I-7

Index

hydrochlorothiazide 90hydrocodone-acetaminophen 4hydrocodone-ibuprofen 5hydrocortisone 110 127 143hydrocortisone butyrate 110hydrocortisone butyr-emollient 109hydrocortisone valerate 110hydrocortisone-acetic acid 115hydromorphone 5hydromorphone (pf) 5hydroxychloroquine 58hydroxyprogesterone cap(ppres) 131hydroxyurea 27hydroxyzine hcl 54hydroxyzine pamoate 147HYPERRAB (PF) 135HYPERRAB SD (PF) 135HYQVIA 135ibandronate 144IBRANCE 27ibu 8ibuprofen 9icatibant 88ICLUSIG27IDHIFA27ifosfamide 27ifosfamide-mesna 27ILARIS (PF)135ILEVRO 117ILUMYA135imatinib 27 28IMBRUVICA28IMFINZI28imipenem-cilastatin 18imipramine hcl 44imipramine pamoate 44imiquimod 106IMLYGIC 28

Index

IMOGAM RABIES-HT (PF) 135IMOVAX RABIES VACCINE (PF) 140IMPAVIDO59INBRIJA 60incassia 100INCRELEX129INCRUSE ELLIPTA 154indapamide 90indomethacin 9INFANRIX (DTAP) (PF) 140INFLECTRA 135INFUGEM28INGREZZA 95INGREZZA INITIATION PACK 95INLYTA28INREBIC 28INSULIN SYRINGE-NEEDLE U-100111 112INTELENCE 68INTRALIPID80INTRON A 72introvale 100INVEGA SUSTENNA63 64INVEGA TRINZA 64INVELTYS118INVIRASE 68INVOKAMET 46INVOKAMET XR46INVOKANA 46IONOSOL-B IN D5W150IONOSOL-MB IN D5W 150IPOL 140ipratropium bromide 114 154irbesartan 82irbesartan-hydrochlorothiazide 82IRESSA 28irinotecan 28

Index

ISENTRESS 68ISENTRESS HD 68isibloom 101ISOLYTE-P IN 5 DEXTROSE 150ISOLYTE-S 150isoniazid 56isosorbide dinitrate 93isosorbide mononitrate 93isradipine 89itraconazole 52ivermectin 59IXEMPRA 29IXIARO (PF)140JADENU124JADENU SPRINKLE 124JAKAFI29jantoven 74JANUMET46JANUMET XR 46JANUVIA 46JARDIANCE 46jasmiel (28) 101jencycla 101JENTADUETO46JENTADUETO XR46jinteli 126jolivette 101juleber 101JULUCA 68junel 1530 (21) 101junel 120 (21) 101junel fe 1530 (28) 101junel fe 120 (28) 101junel fe 24 101JUXTAPID91 92JYNARQUE 90KABIVEN80KALETRA68kalliga 101

I-8

Index

KALYDECO156KANJINTI29KANUMA 112kariva (28) 101KATERZIA 89KEDRAB (PF) 135kelnor 135 (28) 101kelnor 1-50 101ketoconazole 52ketoprofen 9ketorolac 9 10 118KEVEYIS 147KEVZARA135KEYTRUDA 29KINERET 135KINRIX (PF) 140kionex (with sorbitol) 120KISQALI29KISQALI FEMARA CO-PACK 29klor-con m10 150klor-con m15 150klor-con m20 150klor-con sprinkle 150KORLYM 47KRINTAFEL59KRYSTEXXA112kurvelo (28) 101KUVAN 112KYPROLIS 29l norgesteestradiol-eestrad 101labetalol 85LACTATED RINGERS 143lactulose 120lamivudine 68lamivudine-zidovudine 68lamotrigine 39lansoprazole 119lanthanum 122

Index

LANTUS SOLOSTAR U-100 INSULIN 48LANTUS U-100 INSULIN48larin 1530 (21) 101larin 120 (21) 101larin 24 fe 101larin fe 1530 (28) 101larin fe 120 (28) 102larissia 102latanoprost 149LATUDA 64LAZANDA 5ledipasvir-sofosbuvir 71leena 28 102leflunomide 135LEMTRADA 95LENVIMA 29lessina 102letrozole 29leucovorin calcium 147LEUKERAN29LEUKINE75leuprolide 29levetiracetam 39levobunolol 149levocarnitine 147levocarnitine (with sugar) 147levocetirizine 54levofloxacin 21 115levofloxacin in d5w 21LEVOLEUCOVORIN CALCIUM 147levoleucovorin calcium 147levonest (28) 102levonorgestrel-ethinyl estrad 102levonorg-eth estrad triphasic 102levora-28 102levothyroxine 132LEXIVA 68LIALDA143

Index

LIBTAYO 29lidocaine 11lidocaine (pf) 10 84lidocaine hcl 11lidocaine viscous 11lidocaine-prilocaine 11lillow (28) 102linezolid 15linezolid in dextrose 5 15linezolid-09 sodium chloride 15LINZESS 120liothyronine 132lisinopril 83lisinopril-hydrochlorothiazide 83lithium carbonate 95lithium citrate 95LIVALO 92LOKELMA 120LONHALA MAGNAIR REFILL154LONHALA MAGNAIR STARTER 154LONSURF 30loperamide 120lopinavir-ritonavir 68lorazepam 13LORBRENA 30lorcet (hydrocodone) 5lorcet hd 5lorcet plus 5loryna (28) 102losartan 82losartan-hydrochlorothiazide 82LOTEMAX 118LOTEMAX SM118loteprednol etabonate 118lovastatin 92low-ogestrel (28) 102loxapine succinate 64lo-zumandimine (28) 102

I-9

Index

LUCEMYRA 12LUMIGAN 149LUMOXITI30LUPRON DEPOT30 129LUPRON DEPOT (3 MONTH) 30 129LUPRON DEPOT (4 MONTH)30LUPRON DEPOT (6 MONTH)30LUPRON DEPOT-PED129LUPRON DEPOT-PED (3 MONTH)129lutera (28) 102LYNPARZA 30LYSODREN 30lyza 102magnesium sulfate 150 151magnesium sulfate in d5w 150magnesium sulfate in water 150malathion 111maprotiline 44marlissa (28) 102MARPLAN44MARQIBO30MATULANE 30matzim la 87MAVENCLAD (10 TABLET PACK)95MAVENCLAD (4 TABLET PACK)95MAVENCLAD (5 TABLET PACK)95MAVENCLAD (6 TABLET PACK)96MAVENCLAD (7 TABLET PACK)96MAVENCLAD (8 TABLET PACK)96

Index

MAVENCLAD (9 TABLET PACK)96MAVYRET 71MAYZENT 96meclizine 57medroxyprogesterone 131mefenamic acid 10mefloquine 59megestrol 30 131MEKINIST 30MEKTOVI 30meloxicam 10melphalan hcl 30memantine 42MENACTRA (PF) 140MENVEO A-C-Y-W-135-DIP (PF)140MEPSEVII113mercaptopurine 31meropenem 18meropenem-09 sodium chloride 18mesalamine 143mesna 147MESNEX 147MESTINON 147metadate er 96metaproterenol 154metformin 47methadone 5methadose 5methazolamide 149methenamine hippurate 15methimazole 132methocarbamol 157methotrexate sodium 31methotrexate sodium (pf) 31methoxsalen 106methscopolamine 121methyclothiazide 90

Index

methylphenidate hcl 96 97methylprednisolone 127methylprednisolone acetate 127methylprednisolone sodium succ 127metipranolol 149metoclopramide hcl 121metolazone 90metoprolol succinate 85metoprolol ta-hydrochlorothiaz 85metoprolol tartrate 85metronidazole 15 54 107metronidazole in nacl (iso-os) 15mexiletine 84MIACALCIN 144miconazole-3 52microgestin fe 120 (28) 102midazolam 13midodrine 81miglitol 47miglustat 113mili 102mimvey 126mimvey lo 126minitran 93minocycline 22minoxidil 93mirtazapine 44misoprostol 119MITIGARE53mitoxantrone 31M-M-R II (PF) 140moexipril 83molindone 64mometasone 110 118mondoxyne nl 22mono-linyah 102mononessa (28) 102montelukast 153MORPHINE 5 6

I-10

Index

morphine 5 6morphine concentrate 5MOVANTIK 121MOXEZA115moxifloxacin 21 115MOZOBIL75MULPLETA 75MULTAQ 84mupirocin 107mycophenolate mofetil 136mycophenolate mofetil (hcl) 136MYLOTARG31MYRBETRIQ 123myzilra 102nabumetone 10nadolol 85nafcillin 20nafcillin in dextrose iso-osm 20NAGLAZYME 113naloxone 12naltrexone 12NAMZARIC 42naproxen 10naratriptan 55NARCAN12NATACYN 115nateglinide 47NATPARA145NAYZILAM 39NEBUPENT59necon 0535 (28) 102nefazodone 44neomycin 14neomycin-bacitracin-poly-hc 115neomycin-bacitracin-polymyxin 116neomycin-polymyxin b gu 107neomycin-polymyxin b-dexameth 116

Index

neomycin-polymyxin-gramicidin 116neomycin-polymyxin-hc 116neo-polycin 116neo-polycin hc 116NEPHRAMINE 54 80NERLYNX 31NEULASTA75NEUPOGEN75NEUPRO 60nevirapine 68NEXAVAR 31niacin 92niacor 92nicardipine 89NICOTROL 12nifedipine 89nikki (28) 103nilutamide 31NINLARO 31nitisinone 113nitrofurantoin macrocrystal 15nitrofurantoin monohydm-cryst 15nitroglycerin 93NITYR 113NIVESTYM 75nizatidine 119NOCDURNA (MEN) 129NOCDURNA (WOMEN)129nora-be 103NORDITROPIN FLEXPRO 129norethindrone (contraceptive) 103norethindrone acetate 131norethindrone ac-eth estradiol103 126norethindrone-eestradiol-iron 103norgestimate-ethinyl estradiol 103norlyda 103

Index

norlyroc 103NORMOSOL-M IN 5 DEXTROSE 151NORMOSOL-R 151NORMOSOL-R PH 74 151NORTHERA 81nortrel 0535 (28) 103nortrel 135 (21) 103nortrel 135 (28) 103nortrel 777 (28) 103nortriptyline 44NORVIR 69NOVOLIN 7030 U-100 INSULIN 49NOVOLIN 70-30 FLEXPEN U-100 49NOVOLIN N FLEXPEN49NOVOLIN N NPH U-100 INSULIN 49NOVOLIN R FLEXPEN49NOVOLIN R REGULAR U-100 INSULN 49NOVOLOG FLEXPEN U-100 INSULIN49NOVOLOG MIX 70-30 U-100 INSULN 49NOVOLOG MIX 70-30FLEXPEN U-100 49NOVOLOG PENFILL U-100 INSULIN 49NOVOLOG U-100 INSULIN ASPART49NOXAFIL52NPLATE 75NUBEQA 31NUCALA 156NUCYNTA6NUCYNTA ER 6NUEDEXTA97NULOJIX136

I-11

Index

NUPLAZID 64NUTRILIPID 80NUTROPIN AQ NUSPIN129nyamyc 52nystatin 52nystatin-triamcinolone 52nystop 52OCALIVA 121OCREVUS 97OCTAGAM136octreotide acetate 129 130ODEFSEY69ODOMZO 31OFEV156ofloxacin 116ogestrel (28) 103OGIVRI31okebo 22olanzapine 64olmesartan 82olmesartan-amlodipin-hcthiazid82olmesartan-hydrochlorothiazide82olopatadine 114OLUMIANT 136omega-3 acid ethyl esters 92omeprazole 119omeprazole-sodium bicarbonate 119OMNITROPE 130ONCASPAR 31ondansetron 57ondansetron hcl 57ondansetron hcl (pf) 57ONIVYDE 31OPDIVO31OPSUMIT 158oralone 105ORENCIA136ORENCIA (WITH MALTOSE) 136

Index

ORENCIA CLICKJECT 136ORENITRAM158ORFADIN 113ORILISSA 130ORKAMBI156orsythia 103oseltamivir 70 71OSMOLEX ER 60OTEZLA 136OTEZLA STARTER136oxaliplatin 31oxandrolone 124oxazepam 14oxcarbazepine 40OXTELLAR XR 40oxybutynin chloride 123oxycodone 6oxycodone-acetaminophen 6oxycodone-aspirin 7OXYCONTIN7oxymorphone 7OZEMPIC 47pacerone 84paclitaxel 31PADCEV32paliperidone 64PALYNZIQ113pamidronate 145PANRETIN106pantoprazole 119paricalcitol 145PARICALCITOL145paroex oral rinse 105paromomycin 59paroxetine hcl 44PASER 56PAXIL 45PEDIARIX (PF)140PEDVAX HIB (PF) 140peg 3350-electrolytes 122

Index

PEGANONE40PEGASYS 72PEGASYS PROCLICK 72PEGINTRON 72PEN NEEDLE DIABETIC112penicillamine 124penicillin g potassium 20penicillin g procaine 20penicillin v potassium 20PENNSAID10PENTACEL (PF) 140PENTAM 59pentamidine 59pentoxifylline 77PERIKABIVEN80perindopril erbumine 83periogard 105PERJETA32permethrin 111perphenazine 65perphenazine-amitriptyline 45PERSERIS 65pfizerpen-g 20phenadoz 57phenelzine 45phenobarbital 40phenylephrine hcl 81 114phenytoin 40phenytoin sodium 40phenytoin sodium extended 40philith 103PHOSLYRA122PICATO 106PIFELTRO69pilocarpine hcl 106 149pimecrolimus 110pimozide 65pimtrea (28) 103pindolol 85pioglitazone 47

I-12

Index

piperacillin-tazobactam 20PIQRAY32pirmella 103piroxicam 10PLASMA-LYTE 148 151PLASMA-LYTE A151PLEGRIDY 97podofilox 106POLIVY 32polycin 116polymyxin b sulfate 15polymyxin b sulf-trimethoprim116POMALYST 32portia 28 103PORTRAZZA 32posaconazole 52potassium chloride 151potassium chloride-045 nacl 151potassium citrate 151PRADAXA 74PRALUENT PEN92pramipexole 60prasugrel 77pravastatin 92prazosin 81prednicarbate 110prednisolone 127prednisolone acetate 118prednisolone sodium phosphate118 127prednisone 127 128pregabalin 40PREMARIN126PREMPHASE 126PREMPRO126prenatal plus (calcium carb) 159prenatal vitamin plus low iron 159PRETOMANID 56prevalite 92

Index

previfem 104PREVYMIS71PREZCOBIX69PREZISTA 69PRIFTIN56PRIMAQUINE 59primidone 40PRIVIGEN136PROAIR RESPICLICK154probenecid 53probenecid-colchicine 53procainamide 84PROCALAMINE 380prochlorperazine 57prochlorperazine edisylate 57prochlorperazine maleate 57PROCRIT 75procto-med hc 110procto-pak 110proctosol hc 110proctozone-hc 110PROCYSBI 123 147progesterone 131progesterone micronized 131PROGLYCEM147PROGRAF136PROLASTIN-C156PROLENSA 118PROLEUKIN 32PROLIA 145PROMACTA75 76promethazine 54 58promethegan 58propafenone 84propantheline 121proparacaine 114propranolol 86propranolol-hydrochlorothiazid 86propylthiouracil 132PROQUAD (PF) 141

Index

PROSOL 20 80protamine 76protriptyline 45PULMOZYME 113PURIXAN32pyrazinamide 56pyridostigmine bromide 148QBRELIS 83QUADRACEL (PF)141quetiapine 65quinapril 83quinapril-hydrochlorothiazide 83quinidine gluconate 84quinidine sulfate 84quinine sulfate 59RABAVERT (PF) 141rabeprazole 119RADICAVA97raloxifene 126ramipril 84ranitidine hcl 120ranolazine 88rasagiline 61RASUVO (PF)137RAVICTI121RAYALDEE 145REBIF (WITH ALBUMIN) 97REBIF REBIDOSE97REBIF TITRATION PACK97reclipsen (28) 104RECOMBIVAX HB (PF)141RECTIV 148REGRANEX106RELENZA DISKHALER 71RELISTOR121REMICADE137RENFLEXIS137repaglinide 47repaglinide-metformin 47REPATHA PUSHTRONEX 92

I-13

Index

REPATHA SURECLICK92REPATHA SYRINGE 92RESCRIPTOR 69RESTASIS118RETACRIT76RETROVIR 69REVCOVI 113REVLIMID32revonto 157REXULTI 65REYATAZ 69RHOPRESSA149ribasphere 73ribasphere ribapak 73ribavirin 73RIDAURA 137rifabutin 56rifampin 56riluzole 97rimantadine 71RINVOQ 137risedronate 145RISPERDAL CONSTA65risperidone 65ritonavir 69RITUXAN 32RITUXAN HYCELA 32rivastigmine 42rivastigmine tartrate 42rizatriptan 55ROCKLATAN149ropinirole 61rosadan 107rosuvastatin 92ROTARIX141ROTATEQ VACCINE141ROZLYTREK32RUBRACA 32RUXIENCE 32RYBELSUS47

Index

RYDAPT32SABRIL40SAIZEN130SAIZEN SAIZENPREP130SANDOSTATIN LAR DEPOT130SANTYL 107SAPHRIS 65SAVELLA 97 98scopolamine base 58SECUADO66selegiline hcl 61selenium sulfide 107SELZENTRY69SEREVENT DISKUS 154SEROSTIM 130sertraline 45setlakin 104sevelamer carbonate 122sevelamer hcl 122sharobel 104SHINGRIX (PF) 141SIGNIFOR130SIKLOS 76sildenafil 158sildenafil (pulmhypertension)158SILENOR158SILIQ137silver sulfadiazine 108SIMBRINZA149simliya (28) 104simpesse 104SIMPONI 137SIMPONI ARIA 137simvastatin 92sirolimus 137SIRTURO 56SKYRIZI137SLYND104smoflipid 80

Index

sodium chloride 143sodium chloride 09 152sodium phenylbutyrate 121sodium polystyrene (sorb free) 121sodium polystyrene sulfonate 121sofosbuvir-velpatasvir 71SOLIQUA 10033 49soloxide 22SOLTAMOX33SOLU-CORTEF ACT-O-VIAL (PF) 128SOMATULINE DEPOT130SOMAVERT 130sorine 86sotalol 86sotalol af 86SOVALDI 71SPIRIVA RESPIMAT 154 155SPIRIVA WITH HANDIHALER155spironolactone 90spironolacton-hydrochlorothiaz 90SPRAVATO 45sprintec (28) 104SPRITAM 40SPRYCEL 33sps (with sorbitol) 121sronyx 104ssd 108stavudine 69STELARA 137STIMATE131STIOLTO RESPIMAT155STIVARGA33STRENSIQ113streptomycin 14STRIBILD69STRIVERDI RESPIMAT155SUBLOCADE 12

I-14

Index

subvenite 40sucralfate 120sulfacetamide sodium 116sulfacetamide sodium (acne) 108sulfacetamide-prednisolone 117sulfadiazine 21sulfamethoxazole-trimethoprim 21sulfasalazine 143sulfatrim 21sulindac 10sumatriptan 55sumatriptan succinate 55SUNOSI158SUPPRELIN LA 131SUPREP BOWEL PREP KIT 122SUTENT 33syeda 104SYLATRON 72SYLVANT 33SYMBICORT153SYMDEKO 157SYMFI 69SYMFI LO 69SYMJEPI88SYMLINPEN 120 47SYMLINPEN 60 47SYMPAZAN41SYMTUZA 70SYNAGIS71SYNAREL 131SYNDROS 58SYNERCID 16SYNJARDY47SYNJARDY XR 48SYNRIBO 33TABLOID 33tacrolimus 110 138tadalafil 159tadalafil (pulm hypertension)158

Index

TAFINLAR 33TAGRISSO 33TAKHZYRO148TALTZ AUTOINJECTOR138TALTZ SYRINGE138TALZENNA 33tamoxifen 33tamsulosin 123TARGRETIN 33tarina 24 fe 104tarina fe 120 (28) 104TASIGNA 33TAVALISSE76tazarotene 111TAZORAC 111taztia xt 87TAZVERIK33TDVAX 141TECENTRIQ 33TECFIDERA 98TECHNIVIE 71TEFLARO 17TEKTURNA HCT93telmisartan 82telmisartan-amlodipine 82telmisartan-hydrochlorothiazid 82temazepam 14TEMIXYS 70TEMODAR33temsirolimus 34tencon 7TENIVAC (PF) 141tenofovir disoproxil fumarate 70TEPEZZA114terazosin 123terbinafine hcl 53terbutaline 155terconazole 54testosterone 125testosterone cypionate 125

Index

testosterone enanthate 125TETANUSDIPHTHERIA TOX PED(PF) 142tetrabenazine 98tetracycline 22THALOMID 148theophylline 155THIOLA124THIOLA EC124thioridazine 66thiotepa 34thiothixene 66tiadylt er 87tiagabine 41TIBSOVO 34TICE BCG138tigecycline 22tilia fe 104timolol maleate 86 149tinidazole 59TIVICAY 70tizanidine 157TOBI PODHALER14tobramycin 117tobramycin in 0225 nacl 14tobramycin sulfate 14tobramycin-dexamethasone 117TOLAK 107tolazamide 51tolbutamide 51tolmetin 10tolterodine 123topiramate 41toposar 34topotecan 34toremifene 34torsemide 90TOTECT148TOUJEO MAX U-300 SOLOSTAR 50

I-15

Index

TOUJEO SOLOSTAR U-300 INSULIN 50TOVIAZ 123TRACLEER159TRADJENTA 48tramadol 7tramadol-acetaminophen 7trandolapril 84tranexamic acid 76TRANSDERM-SCOP58tranylcypromine 45TRAVASOL 10 81TRAVATAN Z149travoprost 149TRAZIMERA 34trazodone 45TREANDA 34TRECATOR 56TRELEGY ELLIPTA 155TRELSTAR 34TREMFYA 138treprostinil sodium 159TRESIBA FLEXTOUCH U-100 50TRESIBA FLEXTOUCH U-200 50TRESIBA U-100 INSULIN 50tretinoin 111tretinoin (chemotherapy) 34tri femynor 104triamcinolone acetonide106 110 111 128triamterene-hydrochlorothiazid 90triazolam 14trientine 124tri-estarylla 104trifluoperazine 66trifluridine 117trihexyphenidyl 61TRIKAFTA157

Index

tri-legest fe 104tri-linyah 104tri-lo-estarylla 104tri-lo-marzia 104tri-lo-mili 104tri-lo-sprintec 104trilyte with flavor packets 122trimethoprim 16tri-mili 104trimipramine 45TRINTELLIX45tri-previfem (28) 105TRIPTODUR131tri-sprintec (28) 105TRIUMEQ 70trivora (28) 105tri-vylibra 105tri-vylibra lo 105TROGARZO70TROPHAMINE 10 81TROPHAMINE 6 81trospium 123TRULANCE 121TRULICITY 48TRUMENBA 142TRUVADA 70TRUXIMA34TUDORZA PRESSAIR155tulana 105TURALIO34TWINRIX (PF) 142TYBOST148TYKERB34TYMLOS145TYPHIM VI 142TYSABRI 138TYVASO 159UCERIS 143UDENYCA76UNITUXIN 34

Index

UPTRAVI 159ursodiol 121valacyclovir 73VALCHLOR 107valganciclovir 73valproate sodium 41valproic acid 41valproic acid (as sodium salt) 41valrubicin 34valsartan 82valsartan-hydrochlorothiazide 82VALTOCO 41vancomycin 16VAQTA (PF) 142VARIVAX (PF)142VASCEPA 92VECTIBIX 35VELCADE 35velivet triphasic regimen (28) 105VELPHORO122VELTASSA 122VEMLIDY 70VENCLEXTA35VENCLEXTA STARTING PACK 35venlafaxine 45verapamil 87VEREGEN 107VERSACLOZ66VERZENIO35V-GO 40112VIBERZI 122vicodin 7vicodin es 7vicodin hp 7VICTOZA 48VIDEX 2 GRAM PEDIATRIC 70VIDEX EC 70VIEKIRA PAK 71

I-16

Index

vienva 105vigabatrin 41vigadrone 41VIIBRYD 45VIMIZIM 113VIMOVO10VIMPAT41vinblastine 35vincasar pfs 35vincristine 35vinorelbine 35viorele (28) 105VIRACEPT 70VIREAD70VISTOGARD148VITRAKVI 35VIZIMPRO 35VOLTAREN 10voriconazole 53VOSEVI71VOTRIENT35VPRIV 113VRAYLAR 66VUMERITY 98vyfemla (28) 105vylibra 105VYNDAMAX 88VYNDAQEL88VYXEOS 35VYZULTA 149warfarin 74water for irrigation sterile 143WELCHOL 93wera (28) 105XADAGO 61XALKORI 35XARELTO 74XATMEP 35XELJANZ 138XELJANZ XR138

Index

XELPROS 150XERMELO 122XGEVA 145XHANCE 118XIFAXAN 16XIIDRA118XOFLUZA71XOLAIR157XOSPATA36XPOVIO 36XTAMPZA ER 7XTANDI 36xulane 105XULTOPHY 1003650XURIDEN 148XYOSTED 125XYREM 158YERVOY 36YF-VAX (PF) 142YONDELIS36YONSA 36yuvafem 126zafirlukast 153zaleplon 158ZALTRAP36zarah 105ZARXIO76zebutal 7ZEJULA36ZELBORAF 36zenatane 107zenchent (28) 105ZENPEP 113ZEPATIER71zidovudine 70ZIEXTENZO 76ZIOPTAN (PF)150ziprasidone hcl 66ZIRABEV36ZIRGAN 117

Index

ZOLADEX36zoledronic acid 145zoledronic acid-mannitol-water 146ZOLINZA 36zolmitriptan 55zolpidem 158ZOMACTON 131zonisamide 41ZORBTIVE 131ZORTRESS 138ZOSTAVAX (PF)142zovia 135e (28) 105ZTLIDO 11ZUBSOLV12ZULRESSO45zumandimine (28) 105ZYDELIG 36ZYKADIA36 37ZYLET 117ZYPREXA RELPREVV66ZYTIGA37

I-17



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Para obtener maacutes informacioacuten

Formulario de Vitality Health Plan of California

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病症

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瞭解更多資訊

Vitality Health Plan of California 處方藥一覽表

Vitality Health Plan of California 처방집이란 무엇입니까

처방집(의약품 목록)은 변경될 수 있습니까

처방집은 어떻게 사용합니까

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복제약이란 무엇인가요

제 보장에 어떤 제약이 있습니까

비처방(OTC) 의약품이란 무엇인가요

제 약이 처방집에 없으면 어떻게 하나요

Vitality Health Plan of California의 처방집에 대한 예외는 어떻게 요청하나요

저의 약을 변경하거나 예외를 요청하는 문제에 대해 의사와 상의하기 전 저는 어떻게 대처하나요

자세한 정보

Vitality Health Plan of California 처방집

Danh mục thuốc của Vitality Health Plan of California lagrave gigrave

Danh mục Thuốc (danh saacutech thuốc) coacute thể thay đổi khocircng

Tocirci sử dụng Danh mục Thuốc như thế nagraveo

Theo Bệnh

Theo vần abc

Thuốc gốc lagrave gigrave

Coacute hạn chế nagraveo về việc bảo hiểm cho tocirci khocircng

Thuốc khocircng cần toa (OTC) lagrave gigrave

Điều gigrave xảy ra nếu thuốc của tocirci khocircng coacute trong Danh saacutech Thuốc

Tocirci xin hưởng ngoại lệ đối với danh mục thuốc của Vitality Health Plan of California bằng caacutech nagraveo

Tocirci sẽ được đối xử ra sao khi chưa bagraven được với baacutec sĩ để đổi thuốc hay xin hưởng ngoại lệ

Để tigravem hiểu thecircm

Danh mục Thuốc của Vitality Health Plan of California

VHP_20576_000_15778_04012020_v13 (002)pdf

Analgesics

Anesthetics

Anti-AddictionSubstance Abuse Treatment Agents

Antianxiety Agents

Antibacterials

Anticancer Agents

Anticholinergic Agents

Anticonvulsants

Antidementia Agents

Antidepressants

Antidiabetic Agents

Antifungals

Antigout Agents

Antihistamines

Anti-Infectives (Skin And Mucous Membrane)

Antimigraine Agents

Antimycobacterials

Antinausea Agents

Antiparasite Agents

Antiparkinsonian Agents

Antipsychotic Agents

Antivirals (Systemic)

Blood ProductsModifiersVolume Expanders

Caloric Agents

Cardiovascular Agents

Central Nervous System Agents

Contraceptives

Dental And Oral Agents

Dermatological Agents

Devices

Enzyme ReplacementModifiers

Eye Ear Nose Throat Agents

Gastrointestinal Agents

Genitourinary Agents

Heavy Metal Antagonists

Hormonal Agents StimulantReplacementModifying

Immunological Agents

Inflammatory Bowel Disease Agents

Irrigating Solutions

Metabolic Bone Disease Agents

Miscellaneous Therapeutic Agents

Ophthalmic Agents

Replacement Preparations

Respiratory Tract Agents

Skeletal Muscle Relaxants

Sleep Disorder Agents

Vasodilating Agents

Vitamins And Minerals

Blank Page

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2020 Vitality Plus Drug Cover 032420_Xerox back

HistoryItem_V1 TrimAndShift Range all pages Trim fix size 8375 x 10875 inches 2127 x 2762 mm Shift none Normalise (advanced option) original Keep bleed margin no D20200330161235 96 D20120322075346 7830000 8375x10875 Blank 6030000 Tall 1 0 No 1165 1144 None Right 135000 00000 Both 11 AllDoc 81 CurrentAVDoc Uniform 00000 Top QITE_QuiteImposingPlus5 Quite Imposing Plus 50 Quite Imposing Plus 5 1 0 234 233 234 1 HistoryList_V1 qi2base

II-1

Table of Contents Proficiency of Language Assistance Services are Availablehelliphelliphelliphelliphelliphelliphelliphellip Page II-3 Discrimination is Against the Lawhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip Page II-5 Introduction in Englishhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip Page II-10 Introduction in Spanishhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip Page II-19 Introduction in Chinesehelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip Page II-28 Introduction in Koreanhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip Page II-36 Introduction in Vietnamesehelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip Page II-45 List of Covered Drugshelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip Page 1 Indexhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip Page I-1 Iacutendice Tiene a su disposicioacuten servicios profesionales de asistencia linguumliacutesticahelliphelliphellip Paacutegina II-3 La discriminacioacuten es ilegalhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip Paacutegina II-6 Introduccioacuten en ingleacuteshelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip Paacutegina II-10 Introduccioacuten en espantildeolhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip Paacutegina II-19 Introduccioacuten en chinohelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip Paacutegina II-28 Introduccioacuten en coreanohelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip Paacutegina II-36 Introduccioacuten en vietnamitahelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip Paacutegina II-45 Lista de medicamentos cubiertoshelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip Paacutegina 1 Iacutendicehelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip Paacutegina I-1

II-2

目錄


II-3














II-4








II-5





II-6






II-7













II-8





II-9






II-10





II-11





II-12






II-13




II-14







II-15


II-16




PA BvD



PA-HRM





PA NSO-HRM











II-17












II-18




II-19




II-20







II-21






II-22



II-23









II-24


II-25




PA BvD



PA-HRM



II-26


PA NSO



PA NSO-HRM




















II-27












II-28








II-29







II-30






II-31





II-32






II-33









II-34

縮寫描述說明

PA NSO-HRM



















II-35




II-36



II-37






II-38





II-39



II-40








II-41


II-42




PA BvD







PA NSO-HRM








II-43














II-44




II-45




II-46







II-47






II-48



II-49









II-50


II-51




PA BvD



PA-HRM



PA NSO



PA NSO-HRM





II-52
















II-53








Table of Contents


1


2













(Buprenex) 2


2
















3




































4









2











2









4


2


5


































6

























7



4





(Flector) 4 PA


2


(Voltaren-XR) 2


2






(Arthrotec 50) 4


(Arthrotec 75) 4





4





2


1 GC


8



(Childrens Advil) 2


(IBU) 1 GC






4


4
















9








2


1 GC



(EC-Naprosyn) 2




(Feldene) 4












1 GC



1 GC


10



(Xylocaine) 1 GC




2





2






2










2


3 QL (336 per 365 days)


3 QL (336 per 365 days)


3


11



(Antabuse) 2




2


2





4 QL (1008 per 90 days)


5 NEDS













2





12
































13









5 PA BvD NEDS


2


2


2



4






4


2


4


2



4


14



(Cleocin HCl) 1 GC


2


4


2


(Cleocin) 2


(Cleocin) 2



5 PA BvD NEDS


(Cubicin) 5 NEDS


4


5 NEDS


(Zyvox) 5 NEDS


(Zyvox) 5 NEDS



(Hiprex) 2


(Metro IV) 2


(Flagyl) 1 GC








2


15



5 NEDS



2


(Vancocin) 4




5 PA NEDS


2


4


4



2



2



2




(Maxipime) 2



(Suprax) 4


2


16



4


2


2


2



(Tazicef) 2


2


2


2


2


(Keflex) 1 GC



2


2


5 NEDS


(Zithromax) 2



(Zithromax) 4


(Zithromax) 2


17



1 GC


(Zithromax) 1 GC


2


2


4




(EES Granules) 4


(EryPed 400) 4


2


(Azactam) 2


5 PA LA NEDS


(Invanz) 4


2


(Primaxin IV) 2


(Merrem) 4


(Merrem) 4


4


18



1 GC


1 GC


1 GC


1 GC


2


(Augmentin) 4




4


(Augmentin) 1 GC


(Augmentin XR) 4


2


2


2


(Unasyn) 2


4


19



2


2



5 NEDS



(Pfizerpen-G) 4


2


2


1 GC


4


(Zosyn) 2 PA BvD


(Zosyn) 4 PA BvD




2



(Cipro) 1 GC



2


(Cipro) 2


20



2


4


4



(Levaquin) 1 GC



2


(Sulfatrim) 2


(Bactrim) 1 GC


(Bactrim DS) 1 GC


4


4


2


(Doxy-100) 2


(Morgidox) 2


2


4


(Doryx) 4


21



(Mondoxyne NL) 2


4


(Monodox) 2


(Mondoxyne NL) 4


(Vibramycin) 2


(Avidoxy) 2


4


2


2



4


2




4


2


(Tygacil) 5 NEDS


5 NEDS


5 PA NSO NEDS


22



2 PA BvD


2 PA BvD










5 NEDS








5 PA NSO NEDS



5 NEDS


(Trisenox) 5 NEDS


5 PA NSO NEDS




(Vidaza) 5 NEDS






23





5 PA NSO NEDS


5 PA NSO NEDS


5 PA NSO NEDS


5 PA NSO NEDS




2


5 PA NSO NEDS


5 PA NSO NEDS










5 PA NSO NEDS












24



(Paraplatin) 2


2 PA BvD


(Clolar) 5 NEDS








5 PA BvD NEDS


2 PA BvD ST


5 PA NSO NEDS


5 PA NSO LA NEDS






(Dacogen) 5 NEDS


5 NEDS


(Taxotere) 5 NEDS






25



4


4


4


4


4


5 NEDS


5 PA NSO NEDS


5 PA NSO NEDS








4


(Toposar) 2



5 PA NSO NEDS


2 PA BvD


2 PA BvD


(Adrucil) 2 PA BvD



26



(Faslodex) 5 NEDS


5 PA NSO NEDS


2


5 NEDS


5 NEDS




4


5 NEDS




5 PA NSO NEDS











(Ifex) 2


2


4



27










5 PA NSO NEDS






5 NEDS







(Camptosar) 2


2


28



5 NEDS




5 PA NSO NEDS
















5 PA NSO NEDS


5 PA NSO NEDS



4


2




29











5 PA NSO NEDS


5 NEDS


5 NEDS


5 NEDS


5 NEDS




5 NEDS


5 PA NSO NEDS


5 NEDS











30




2 PA BvD


2 PA BvD


2 PA BvD


2 PA BvD ST


2


5 PA NSO NEDS











5 PA NSO LA NEDS


5 PA NSO NEDS


5 PA NSO NEDS


5 NEDS


5 PA NSO NEDS


2


2


2 PA BvD


31



5 PA NSO NEDS


5 PA NSO NEDS






5 PA NSO NEDS






5 NEDS


5 NEDS




5 PA NSO NEDS


5 PA NSO NEDS








5 PA NSO NEDS




32



5 NEDS










5 PA NSO NEDS


5 PA NSO NEDS


4



















5 PA NSO NEDS


5 PA NSO NEDS


33








2


(Hycamtin) 5 NEDS


5 NEDS



5 PA NSO NEDS


5 PA NSO NEDS








5 NEDS


5 PA NSO NEDS




5 PA NSO NEDS


5 PA NSO NEDS


(Valstar) 5 NEDS


34



5 PA NSO NEDS


5 PA NSO NEDS








5 PA NSO LA NEDS




2 PA BvD


2 PA BvD




(Navelbine) 2












5 PA BvD NEDS




4 PA BvD ST


35















5 PA NSO NEDS


5 PA NSO NEDS



5 PA NSO NEDS






5 PA NSO NEDS






5 NEDS






36







4






5 NEDS


5 NEDS








(Carbatrol) 2


(Tegretol) 2



(Tegretol XR) 2


2


4



37




4



(Diastat AcuDial) 4





(Depakote ER) 2


(Depakote) 2


5 PA NSO NEDS




(Zarontin) 2


(Felbatol) 4


(Felbatol) 4


(Cerebyx) 2













38







4 ST




(Subvenite) 1 GC



4



4



4


(Lamictal XR) 4


(Lamictal) 2


(Lamictal ODT) 4


(Keppra) 2


(Keppra) 2


(Keppra) 2


(Keppra XR) 2




39



(Trileptal) 2


(Trileptal) 2


4


4






(Dilantin-125) 2






(Phenytek) 2


2


2












1 GC


40






(Gabitril) 4


(Topamax) 2


(Qudexy XR) 4


(Topamax) 1 GC


2


2



4









3 QL (1200 per 30 days)




(Zonegran) 2



41



days)















4


3








2


2


2


2


42



(Wellbutrin XL) 2


(Wellbutrin SR) 2





(Anafranil) 4


(Norpramin) 4


4




2













2


(Lexapro) 1 GC


43



4 ST




(Prozac) 1 GC


4


2


2


4


2


4


(Remeron) 2


2


(Remeron SolTab) 2


4


(Pamelor) 1 GC


2






44





2





(Zoloft) 1 GC


5 PA NSO NEDS



1 GC



4








2








3


5 NEDS


45

































46

































47



























48



























49















days)















50










5 PA BvD NEDS


5 PA BvD NEDS


2 PA BvD


(Cancidas) 5 NEDS







2


1 GC



(Lotrisone) 2


4



2 PA BvD


(Diflucan) 2


(Diflucan) 2


51



(Ancobon) 5 NEDS


4


4


4







2


5 NEDS


5 NEDS


5 NEDS


2


2



2


2


(Nyamyc) 2


4


4


2


(Noxafil) 5 NEDS


52






(Vfend) 5 NEDS


(Vfend) 5 NEDS


(Zyloprim) 1 GC







2









4


2


2




53



2


2


1 GC


(Xyzal) 4





(Cleocin) 2



2


4














54






































4



55







4




4




(Rifadin) 4


(Rifadin) 2


5 PA NEDS


4


4


4 PA BvD










2


56












2


2




2


1 GC


1 GC


2


4 PA BvD



(Zofran) 2 PA BvD


2 PA BvD




2


(Compazine) 1 GC


(Compro) 2


57




















5 NEDS


5 NEDS


(Mepron) 5 NEDS


(Malarone) 2




2


4


5 PA NEDS


(Plaquenil) 2


58






4



4 PA BvD



4


(Nebupent) 2 PA BvD


(Pentam) 4


4



2



2





(Cogentin) 2


2






(Sinemet) 2


59



(Sinemet CR) 2


4


(Stalevo 50) 4


(Stalevo 75) 4


(Stalevo 100) 4


(Stalevo 125) 4


(Stalevo 150) 4


(Stalevo 200) 4















(Mirapex) 1 GC


60




(Requip) 2


2


(Requip XL) 4


4




2


1 GC


















61













2


4















4 ST


2


62



2


2


2


4








2




(Haldol) 2


2


2


2










63

















2





















64



4































65





2


4


2






4 ST












(Epzicom) 2


(Trizivir) 5 NEDS


5 NEDS


66



5 NEDS


(Reyataz) 5 NEDS


5 NEDS


5 NEDS


5 NEDS


5 NEDS


4


5 NEDS


5 NEDS


(Videx EC) 2


2


5 NEDS


5 NEDS





4


4


4


5 NEDS



5 NEDS


67



5 NEDS


5 NEDS


4


5 NEDS


5 NEDS


4


5 NEDS


4


5 NEDS


4


5 NEDS




(Epivir) 2


(Combivir) 2


4


(Kaletra) 2


(Viramune) 2



2


(Viramune XR) 2


68



4


4


4


5 NEDS


5 NEDS


5 NEDS


5 NEDS


5 NEDS


4


4


4


4


5 NEDS



4


5 NEDS


4


2


5 NEDS


5 NEDS


5 NEDS


69



5 NEDS


5 NEDS


(Viread) 2


4


5 NEDS


5 NEDS


5 NEDS


5 NEDS




4


4


5 NEDS


5 NEDS


5 NEDS




(Foscavir) 4 PA BvD





70














5 PA NEDS


















5 PA NEDS






71



5 PA NSO NEDS


5 PA NSO NEDS


5 NEDS


5 NEDS


5 NEDS


5 NEDS


5 PA NSO NEDS



(Zovirax) 2



2 PA BvD


2 PA BvD



5 NEDS



2


(Cytovene) 2 PA BvD


72



2 PA BvD




5 NEDS






(Valtrex) 2


(Valcyte) 5 NEDS





3




(Lovenox) 2


(Lovenox) 2


(Arixtra) 5 NEDS


(Arixtra) 2


2


73



2


2


2


2


1 GC




(Jantoven) 1 GC






3










5 PA NEDS


5 PA NEDS


5 PA NEDS


74







5 NEDS


5 NEDS




5 PA NEDS


5 PA NEDS


5 PA NEDS


5 NEDS


5 PA NEDS


5 PA NEDS












75













5 PA NEDS


5 NEDS


5 PA NEDS


5 PA NEDS




5 PA NEDS


2


4 PA




(Cyklokapron) 2




3



76






2



4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


77



4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


78



4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


79



4 PA BvD


2


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD



80



4 PA BvD


4 PA BvD


4 PA BvD


(Catapres) 1 GC








(Cardura) 2



2




(Vazculep) 2


(Minipress) 2


(Atacand) 4


(Atacand HCT) 4


3


81



3





(Avapro) 1 GC


(Avalide) 1 GC


(Cozaar) 1 GC


(Hyzaar) 1 GC


(Benicar) 2


(Tribenzor) 4


(Benicar HCT) 2


(Micardis) 1 GC


(Twynsta) 4


(Micardis HCT) 4


(Diovan) 1 GC


(Diovan HCT) 1 GC


(Lotensin) 1 GC



82



(Lotensin HCT) 2


2


2


2


(Vasotec) 1 GC


2


(Vaseretic) 1 GC


1 GC


4 ST


1 GC


2


(Prinivil) 1 GC


(Zestril) 1 GC


(Zestoretic) 1 GC



1 GC


5 ST NEDS


(Accupril) 1 GC


(Accuretic) 2


83



(Altace) 1 GC


1 GC


(Pacerone) 4





(Tikosyn) 4


2


1 GC


2


3




2


2


(Rythmol SR) 4


2


4


2


2


(Tenormin) 1 GC


84



(Tenoretic 100) 2


(Tenoretic 50) 2



2


(Ziac) 1 GC


3


3


(Coreg) 1 GC


2


2


2


(Toprol XL) 2


2


(Lopressor HCT) 2


(Lopressor) 2


2


(Lopressor) 1 GC


1 GC


(Corgard) 2



85



2


(Inderal LA) 4


2


2


2


2


2


(Sorine) 2


4


2


2


2


(Taztia XT) 4


(Tiadylt ER) 2


(Cartia XT) 2


(Cardizem) 2



2


86



4


2


2


2


2


(Verelan PM) 2


(Verelan) 2


(Verelan) 4


1 GC


(Calan SR) 1 GC






5 NEDS


2


2


2


4


87



(Digitek) 2


(Digitek) 2






2


2




(Ranexa) 4








2


(Norvasc) 1 GC


(Lotrel) 1 GC


1 GC


(Azor) 2


(Exforge) 1 GC


88



(Exforge HCT) 4


2





4




(Procardia XL) 2


(Adalat CC) 2


(Adalat CC) 2



2


4


2


2


(Diuril IV) 2


2


2


2


1 GC


(Lasix) 1 GC


89



1 GC


1 GC


1 GC







2


(Aldactone) 1 GC


(Aldactazide) 2


1 GC


(Dyazide) 1 GC


1 GC


(Maxzide-25mg) 1 GC


(Maxzide) 1 GC


(Caduet) 4


4


(Lipitor) 1 GC


(Questran) 2


90



2

















4


2


(Tricor) 2


2


(Trilipix) 4


(Fibricor) 4


4 ST


(Lescol) 4







91







1 GC




4



2









2

















92



2


2



4 ST



3 ST


3


2



(ISOCHRON) 2


2


1 GC


2



2


(Nitrostat) 2


(Minitran) 2




93





















(Cafcit) 2 PA BvD


2


(Kapvay) 4














94







2












(Intuniv ER) 2


5 PA NEDS






1 GC



(Lithobid) 2


2


4


5 PA NEDS


5 PA NEDS


5 PA NEDS


95



5 PA NEDS


5 PA NEDS


5 PA NEDS


5 PA NEDS






























96














5 PA NEDS




5 PA NEDS








5 PA NEDS


5 PA NEDS





97



3




5 PA NEDS









2


2


2







2





98



2


2


2


2


2




2


2


2


2


2


2




2


2


2


2



2


2


99






2


(Azurette (28)) 2


(Apri) 2


(Jasmiel (28)) 2


(Syeda) 2







2





(Kelnor 135 (28)) 2


(Kelnor 1-50) 2




2



2







100








2


2


2


2


2



2


2



2








2


2


2


2


101



2



4



2


(Afirmelle) 2


(Altavera (28)) 2




(Enpresse) 2





2


2


2



2


2



2


4


2


2


102





(Jencycla) 2


(Aurovela 1530 (21)) 2


(Aurovela 120 (21)) 2




(Aurovela 24 Fe) 2



2




(Tri Femynor) 2


(Estarylla) 2




2


2


2


2


2




2


2



103




2





2




4


2




2


2


2


2


2


2


2


2


2


2


2


2


104



2


2


2


2


2



2



2


2



2





2


2


2






1 GC


1 GC


105





(Oralone) 2






1 GC


(Geri-Hydrolac) 2


(Geri-Hydrolac) 2




4



(Vectical) 4


5 NEDS




2






5 NEDS







106



4



5 NEDS


5 NEDS


2


(Evoclin) 4


(Cleocin T) 2


(Clindacin ETZ) 2


(Neuac) 4


(Benzaclin) 4



(Erygel) 4


2


(Ery Pads) 2


(Benzamycin) 4









2




107





(Klaron) 2





2


2


2


2


2


(Luxiq) 4


2


2


2


2


2


(Diprolene) 2









108



2


(Olux-E) 4


(Cloderm) 4






(Topicort) 4


(Topicort) 2



(Topicort) 4



3




(Synalar) 2







(Cutivate) 2


2


2


2




109



(Locoid) 4


(Locoid) 4


4


(Locoid) 4






1 GC


4


4







2


2


2


2


2




1 GC


(Triderm) 1 GC


2


110



2


(Trianex) 2




4 PA



4



(Retin-A) 2 PA






2


2


2


2


2


1 GC




111






2



2



5 NEDS


5 NEDS


5 PA NEDS


5 NEDS


3


5 NEDS


5 NEDS


5 PA NEDS




5 PA NEDS


5 PA BvD NEDS


5 NEDS


112



5 PA NEDS



5 NEDS


(Orfadin) 5 PA NEDS


5 PA NEDS


5 PA NEDS


5 PA NEDS


5 PA NEDS


5 PA BvD NEDS


5 PA NEDS


5 PA LA NEDS


5 PA NEDS


5 NEDS


3


113



2


2


(Isopto Atropine) 4






2


4 ST


2


(Cyclogyl) 2


5 NEDS


2








(Pataday) 2


(Pataday) 4


4


(Alcaine) 2


5 PA NEDS


114




4


(Polycin) 2


2


3


(Ciloxan) 1 GC


(Cetraxal) 4


2


(Zymaxid) 4


2


1 GC


4


2


3


(Vigamox) 2


(Moxeza) 2


4


(Neo-Polycin HC) 2


115



(Neo-Polycin) 2


(Maxitrol) 2


(Maxitrol) 2


2


2


2


2


2


2


(Ocuflox) 2



2


(Polytrim) 1 GC


(Bleph-10) 2


2


116



2


(Tobrex) 1 GC


(TobraDex) 2


2


4


3


3 ST


4


3


2


2


3




(DermOtic Oil) 4


(FML Liquifilm) 4


1 GC





3


117



3


(Acular) 2


3


3


3


(Lotemax) 2




(Pred Forte) 4


2


3








4


2


2


2


118





2


(Nexium IV) 2


1 GC


2


2


4









(Cytotec) 2


2


2


1 GC




(Protonix) 2








119



(Zantac) 2



1 GC





5 NEDS


2


(Gastrocrom) 2










5 PA NEDS



2


2


2


(Constulose) 2






2


120



4


2


2


2


(Reglan) 1 GC







5 PA NEDS










2


(Buphenyl) 5 NEDS


2



2


2







121









3


2


2



(Gavilyte-C) 4


3


2


2


2


(Fosrenol) 5 NEDS


4


(Renvela) 5 NEDS


(Renvela) 4




3


122



2


(Urecholine) 2



3


2



(Ditropan XL) 2


2


(Detrol LA) 2



3


4


(Uroxatral) 1 GC



(Jalyn) 4



5 NEDS



1 GC


123



5 PA NEDS


5 NEDS


per 30 days)


(Jadenu) 5 PA NEDS


(Exjade) 5 PA NEDS


(Desferal) 2 PA


5 PA NEDS


5 PA NEDS


5 PA NEDS


5 PA NEDS


5 PA NEDS





5 PA NEDS


2




124





2 PA




















(Estrace) 2



(Delestrogen) 2




125












3




3







2






2 PA BvD




1 PA BvD GC


126



1 GC


1 GC


1 GC


1 GC









(Cortef) 2


(Depo-Medrol) 2


(Medrol) 2


(Medrol (Pak)) 2


2


(Solu-Medrol) 2


2 PA BvD


2 PA BvD


2 PA BvD





1 PA BvD GC


127



2


4


(Kenalog) 2


(DDAVP) 2


(DDAVP) 2


2


(DDAVP) 2




4 PA


5 PA NEDS


5 PA NEDS


5 PA NEDS


5 PA NEDS


128



5 NEDS


5 NEDS


5 NEDS


5 NEDS


5 NEDS






5 PA NEDS


4 PA


5 PA NEDS


2


(Sandostatin) 2


129



2


5 PA NEDS


5 PA NEDS






5 PA NEDS


5 PA NEDS


5 NEDS


5 PA NEDS








5 PA NEDS


130



3




5 NEDS




5 PA NEDS


4 PA


5 PA NEDS










(Provera) 1 GC




(Aygestin) 2


2


(Prometrium) 2


131



(Euthyrox) 1 GC



(Cytomel) 2




5 PA NEDS


5 PA NEDS


5 PA NEDS


5 NEDS



2 PA BvD


5 PA NEDS


5 PA NEDS


5 PA NEDS


5 PA NEDS


132





(Gengraf) 2 PA BvD


2 PA BvD


(Gengraf) 2 PA BvD




5 PA NEDS


5 PA NEDS


5 PA NEDS


5 PA NEDS


5 PA NEDS


5 PA BvD NEDS


4 PA BvD


5 PA BvD NEDS


5 PA BvD NEDS


5 PA BvD NEDS


133



5 PA BvD NEDS


5 PA BvD NEDS




5 PA NEDS


5 PA NEDS


5 PA NEDS


5 PA NEDS


5 PA NEDS


5 PA NEDS


5 PA NEDS


5 PA NEDS


134



5 PA NEDS


5 PA NEDS


4


4


5 PA BvD NEDS


5 PA NEDS


5 PA NEDS


5 PA NEDS


4


5 PA NEDS


4


5 PA NEDS


5 PA NEDS


5 PA NEDS



135





(CellCept) 2 PA BvD




(CellCept) 2 PA BvD


5 PA BvD NEDS


5 PA BvD NEDS


5 PA NEDS


5 PA NEDS


5 PA NEDS


5 PA NEDS



5 PA NEDS


5 PA BvD NEDS


4 PA BvD


4 PA BvD ST


136



3


5 PA NEDS


5 PA NEDS


5 NEDS


5 PA NEDS


5 PA NEDS


5 PA NEDS


5 PA NEDS


5 PA NEDS





5 PA NEDS


5 PA NEDS


5 PA NEDS


5 PA NEDS


137



(Prograf) 2 PA BvD


5 PA NEDS


5 PA NEDS


4


5 PA NEDS


5 PA NEDS


5 PA LA NEDS


5 PA NEDS


5 PA NEDS


5 PA BvD NEDS


6 NEDS


6 NEDS


6 NEDS


6 PA BvD NEDS


138



6 NEDS


6 NEDS


6 NEDS


6 NEDS


6 PA BvD NEDS


6 PA BvD NEDS


6 PA BvD NEDS






6 NEDS


6 NEDS


6 NEDS


139



6 PA BvD NEDS


6 NEDS


6 NEDS


6 NEDS


6 NEDS


6 NEDS


6 NEDS


6 NEDS


6 NEDS


6 NEDS


6 NEDS


6 NEDS


6 NEDS


140



6 NEDS


6 NEDS


6 PA BvD NEDS


6 PA BvD NEDS


6 PA BvD NEDS


6 NEDS


6 NEDS




6 NEDS


6 NEDS


6 NEDS


141



6 NEDS


6 NEDS


6 NEDS


6 NEDS


6 NEDS


6 NEDS


6 NEDS




6 NEDS





142



3



(Entocort EC) 4



5 ST NEDS


(Colocort) 4


2


(Delzicol) 4


(Apriso) 2


(Lialda) 2


(Asacol HD) 4


(Canasa) 5 NEDS





3



4



4



4


143











2


(Rocaltrol) 2





(Hectorol) 2


4


4













5 NEDS


144





2


2


4


4


(Zemplar) 4

















5 PA NEDS


4


4


145







5 NEDS


(Ethyol) 2


5 PA NEDS








4


5 NEDS




2







5 PA LA NEDS


5 NEDS


3


146




3


3


1 GC


(Vistaril) 1 GC




2


2


2


(Carnitor) 2



4


(Fusilev) 5 NEDS


(Mesnex) 2


5 NEDS


5 NEDS


5 NEDS


4


147



(Mestinon) 4


4


(Mestinon) 2










5 NEDS








2


2


2


3


3


2


4


148



(Alphagan P) 4


1 GC


1 GC


3


(Trusopt) 2


(Cosopt) 2




1 GC




4


2


(Isopto Carpine) 2






3


(Timoptic) 1 GC


(Timoptic-XE) 4








149







2


4


4


4


4


2


2


2


2


2


2 PA BvD


2 PA BvD


2 PA BvD


150



2 PA BvD


4


4


4


4


4


2 PA BvD


2 PA BvD


2


4


(K-Tab) 2


(K-Tab) 4


(Klor-Con M10) 2


(Klor-Con M20) 2


2


(Urocit-K 10) 2


(Urocit-K 15) 2


(Urocit-K 5) 2


151



2




















152
















(Singulair) 1 GC









2 PA BvD


2


153



2


2


3







3


2 PA BvD






1 GC


2








154







3





5 NEDS


4


2


4


2


3






(Acetadote) 2 PA


2 PA BvD


155



5 PA NEDS


2 PA BvD
































5 PA BvD NEDS


156







5 PA NEDS


5 PA NEDS







(Dantrium) 2




2












157

















(Flolan) 2 PA


(Flolan) 5 PA NEDS




3 PA


5 PA NEDS










158










5 PA NEDS






5 PA NEDS


3


3


159


160

INDEX

Index


Index


Index


I-1

Index


Index


Index


I-2

Index


Index


Index


I-3

Index


Index


Index


I-4

Index


Index


Index


I-5

Index


Index


Index


I-6

Index


Index


Index


I-7

Index


Index


Index


I-8

Index


Index


Index


I-9

Index


Index


Index


I-10

Index


Index


Index


I-11

Index


Index


Index


I-12

Index


Index


Index


I-13

Index


Index


Index


I-14

Index


Index


Index


I-15

Index


Index


Index


I-16

Index


Index


Index


I-17



Plus (HMO) 2020















Medical Condition













Afeccioacuten













病症


什麼是普通藥






瞭解更多資訊





의학적 증상








자세한 정보





Theo Bệnh

Theo vần abc









VHP_20576_000_15778_04012020_v13 (002)pdf

Analgesics

Anesthetics


Antianxiety Agents

Antibacterials

Anticancer Agents


Anticonvulsants

Antidementia Agents

Antidepressants

Antidiabetic Agents

Antifungals

Antigout Agents

Antihistamines


Antimigraine Agents

Antimycobacterials

Antinausea Agents

Antiparasite Agents





Caloric Agents



Contraceptives



Devices












Ophthalmic Agents





Vasodilating Agents


Blank Page

Blank Page



II-2

目錄


II-3














II-4








II-5





II-6






II-7













II-8





II-9






II-10





II-11





II-12






II-13




II-14







II-15


II-16




PA BvD



PA-HRM





PA NSO-HRM











II-17












II-18




II-19




II-20







II-21






II-22



II-23









II-24


II-25




PA BvD



PA-HRM



II-26


PA NSO



PA NSO-HRM




















II-27












II-28








II-29







II-30






II-31





II-32






II-33









II-34

縮寫描述說明

PA NSO-HRM



















II-35




II-36



II-37






II-38





II-39



II-40








II-41


II-42




PA BvD







PA NSO-HRM








II-43














II-44




II-45




II-46







II-47






II-48



II-49









II-50


II-51




PA BvD



PA-HRM



PA NSO



PA NSO-HRM





II-52
















II-53








Table of Contents


1


2













(Buprenex) 2


2
















3




































4









2











2









4


2


5


































6

























7



4





(Flector) 4 PA


2


(Voltaren-XR) 2


2






(Arthrotec 50) 4


(Arthrotec 75) 4





4





2


1 GC


8



(Childrens Advil) 2


(IBU) 1 GC






4


4
















9








2


1 GC



(EC-Naprosyn) 2




(Feldene) 4












1 GC



1 GC


10



(Xylocaine) 1 GC




2





2






2










2


3 QL (336 per 365 days)


3 QL (336 per 365 days)


3


11



(Antabuse) 2




2


2





4 QL (1008 per 90 days)


5 NEDS













2





12
































13









5 PA BvD NEDS


2


2


2



4






4


2


4


2



4


14



(Cleocin HCl) 1 GC


2


4


2


(Cleocin) 2


(Cleocin) 2



5 PA BvD NEDS


(Cubicin) 5 NEDS


4


5 NEDS


(Zyvox) 5 NEDS


(Zyvox) 5 NEDS



(Hiprex) 2


(Metro IV) 2


(Flagyl) 1 GC








2


15



5 NEDS



2


(Vancocin) 4




5 PA NEDS


2


4


4



2



2



2




(Maxipime) 2



(Suprax) 4


2


16



4


2


2


2



(Tazicef) 2


2


2


2


2


(Keflex) 1 GC



2


2


5 NEDS


(Zithromax) 2



(Zithromax) 4


(Zithromax) 2


17



1 GC


(Zithromax) 1 GC


2


2


4




(EES Granules) 4


(EryPed 400) 4


2


(Azactam) 2


5 PA LA NEDS


(Invanz) 4


2


(Primaxin IV) 2


(Merrem) 4


(Merrem) 4


4


18



1 GC


1 GC


1 GC


1 GC


2


(Augmentin) 4




4


(Augmentin) 1 GC


(Augmentin XR) 4


2


2


2


(Unasyn) 2


4


19



2


2



5 NEDS



(Pfizerpen-G) 4


2


2


1 GC


4


(Zosyn) 2 PA BvD


(Zosyn) 4 PA BvD




2



(Cipro) 1 GC



2


(Cipro) 2


20



2


4


4



(Levaquin) 1 GC



2


(Sulfatrim) 2


(Bactrim) 1 GC


(Bactrim DS) 1 GC


4


4


2


(Doxy-100) 2


(Morgidox) 2


2


4


(Doryx) 4


21



(Mondoxyne NL) 2


4


(Monodox) 2


(Mondoxyne NL) 4


(Vibramycin) 2


(Avidoxy) 2


4


2


2



4


2




4


2


(Tygacil) 5 NEDS


5 NEDS


5 PA NSO NEDS


22



2 PA BvD


2 PA BvD










5 NEDS








5 PA NSO NEDS



5 NEDS


(Trisenox) 5 NEDS


5 PA NSO NEDS




(Vidaza) 5 NEDS






23





5 PA NSO NEDS


5 PA NSO NEDS


5 PA NSO NEDS


5 PA NSO NEDS




2


5 PA NSO NEDS


5 PA NSO NEDS










5 PA NSO NEDS












24



(Paraplatin) 2


2 PA BvD


(Clolar) 5 NEDS








5 PA BvD NEDS


2 PA BvD ST


5 PA NSO NEDS


5 PA NSO LA NEDS






(Dacogen) 5 NEDS


5 NEDS


(Taxotere) 5 NEDS






25



4


4


4


4


4


5 NEDS


5 PA NSO NEDS


5 PA NSO NEDS








4


(Toposar) 2



5 PA NSO NEDS


2 PA BvD


2 PA BvD


(Adrucil) 2 PA BvD



26



(Faslodex) 5 NEDS


5 PA NSO NEDS


2


5 NEDS


5 NEDS




4


5 NEDS




5 PA NSO NEDS











(Ifex) 2


2


4



27










5 PA NSO NEDS






5 NEDS







(Camptosar) 2


2


28



5 NEDS




5 PA NSO NEDS
















5 PA NSO NEDS


5 PA NSO NEDS



4


2




29











5 PA NSO NEDS


5 NEDS


5 NEDS


5 NEDS


5 NEDS




5 NEDS


5 PA NSO NEDS


5 NEDS











30




2 PA BvD


2 PA BvD


2 PA BvD


2 PA BvD ST


2


5 PA NSO NEDS











5 PA NSO LA NEDS


5 PA NSO NEDS


5 PA NSO NEDS


5 NEDS


5 PA NSO NEDS


2


2


2 PA BvD


31



5 PA NSO NEDS


5 PA NSO NEDS






5 PA NSO NEDS






5 NEDS


5 NEDS




5 PA NSO NEDS


5 PA NSO NEDS








5 PA NSO NEDS




32



5 NEDS










5 PA NSO NEDS


5 PA NSO NEDS


4



















5 PA NSO NEDS


5 PA NSO NEDS


33








2


(Hycamtin) 5 NEDS


5 NEDS



5 PA NSO NEDS


5 PA NSO NEDS








5 NEDS


5 PA NSO NEDS




5 PA NSO NEDS


5 PA NSO NEDS


(Valstar) 5 NEDS


34



5 PA NSO NEDS


5 PA NSO NEDS








5 PA NSO LA NEDS




2 PA BvD


2 PA BvD




(Navelbine) 2












5 PA BvD NEDS




4 PA BvD ST


35















5 PA NSO NEDS


5 PA NSO NEDS



5 PA NSO NEDS






5 PA NSO NEDS






5 NEDS






36







4






5 NEDS


5 NEDS








(Carbatrol) 2


(Tegretol) 2



(Tegretol XR) 2


2


4



37




4



(Diastat AcuDial) 4





(Depakote ER) 2


(Depakote) 2


5 PA NSO NEDS




(Zarontin) 2


(Felbatol) 4


(Felbatol) 4


(Cerebyx) 2













38







4 ST




(Subvenite) 1 GC



4



4



4


(Lamictal XR) 4


(Lamictal) 2


(Lamictal ODT) 4


(Keppra) 2


(Keppra) 2


(Keppra) 2


(Keppra XR) 2




39



(Trileptal) 2


(Trileptal) 2


4


4






(Dilantin-125) 2






(Phenytek) 2


2


2












1 GC


40






(Gabitril) 4


(Topamax) 2


(Qudexy XR) 4


(Topamax) 1 GC


2


2



4









3 QL (1200 per 30 days)




(Zonegran) 2



41



days)















4


3








2


2


2


2


42



(Wellbutrin XL) 2


(Wellbutrin SR) 2





(Anafranil) 4


(Norpramin) 4


4




2













2


(Lexapro) 1 GC


43



4 ST




(Prozac) 1 GC


4


2


2


4


2


4


(Remeron) 2


2


(Remeron SolTab) 2


4


(Pamelor) 1 GC


2






44





2





(Zoloft) 1 GC


5 PA NSO NEDS



1 GC



4








2








3


5 NEDS


45

































46

































47



























48



























49















days)















50










5 PA BvD NEDS


5 PA BvD NEDS


2 PA BvD


(Cancidas) 5 NEDS







2


1 GC



(Lotrisone) 2


4



2 PA BvD


(Diflucan) 2


(Diflucan) 2


51



(Ancobon) 5 NEDS


4


4


4







2


5 NEDS


5 NEDS


5 NEDS


2


2



2


2


(Nyamyc) 2


4


4


2


(Noxafil) 5 NEDS


52






(Vfend) 5 NEDS


(Vfend) 5 NEDS


(Zyloprim) 1 GC







2









4


2


2




53



2


2


1 GC


(Xyzal) 4





(Cleocin) 2



2


4














54






































4



55







4




4




(Rifadin) 4


(Rifadin) 2


5 PA NEDS


4


4


4 PA BvD










2


56












2


2




2


1 GC


1 GC


2


4 PA BvD



(Zofran) 2 PA BvD


2 PA BvD




2


(Compazine) 1 GC


(Compro) 2


57




















5 NEDS


5 NEDS


(Mepron) 5 NEDS


(Malarone) 2




2


4


5 PA NEDS


(Plaquenil) 2


58






4



4 PA BvD



4


(Nebupent) 2 PA BvD


(Pentam) 4


4



2



2





(Cogentin) 2


2






(Sinemet) 2


59



(Sinemet CR) 2


4


(Stalevo 50) 4


(Stalevo 75) 4


(Stalevo 100) 4


(Stalevo 125) 4


(Stalevo 150) 4


(Stalevo 200) 4















(Mirapex) 1 GC


60




(Requip) 2


2


(Requip XL) 4


4




2


1 GC


















61













2


4















4 ST


2


62



2


2


2


4








2




(Haldol) 2


2


2


2










63

















2





















64



4































65





2


4


2






4 ST












(Epzicom) 2


(Trizivir) 5 NEDS


5 NEDS


66



5 NEDS


(Reyataz) 5 NEDS


5 NEDS


5 NEDS


5 NEDS


5 NEDS


4


5 NEDS


5 NEDS


(Videx EC) 2


2


5 NEDS


5 NEDS





4


4


4


5 NEDS



5 NEDS


67



5 NEDS


5 NEDS


4


5 NEDS


5 NEDS


4


5 NEDS


4


5 NEDS


4


5 NEDS




(Epivir) 2


(Combivir) 2


4


(Kaletra) 2


(Viramune) 2



2


(Viramune XR) 2


68



4


4


4


5 NEDS


5 NEDS


5 NEDS


5 NEDS


5 NEDS


4


4


4


4


5 NEDS



4


5 NEDS


4


2


5 NEDS


5 NEDS


5 NEDS


69



5 NEDS


5 NEDS


(Viread) 2


4


5 NEDS


5 NEDS


5 NEDS


5 NEDS




4


4


5 NEDS


5 NEDS


5 NEDS




(Foscavir) 4 PA BvD





70














5 PA NEDS


















5 PA NEDS






71



5 PA NSO NEDS


5 PA NSO NEDS


5 NEDS


5 NEDS


5 NEDS


5 NEDS


5 PA NSO NEDS



(Zovirax) 2



2 PA BvD


2 PA BvD



5 NEDS



2


(Cytovene) 2 PA BvD


72



2 PA BvD




5 NEDS






(Valtrex) 2


(Valcyte) 5 NEDS





3




(Lovenox) 2


(Lovenox) 2


(Arixtra) 5 NEDS


(Arixtra) 2


2


73



2


2


2


2


1 GC




(Jantoven) 1 GC






3










5 PA NEDS


5 PA NEDS


5 PA NEDS


74







5 NEDS


5 NEDS




5 PA NEDS


5 PA NEDS


5 PA NEDS


5 NEDS


5 PA NEDS


5 PA NEDS












75













5 PA NEDS


5 NEDS


5 PA NEDS


5 PA NEDS




5 PA NEDS


2


4 PA




(Cyklokapron) 2




3



76






2



4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


77



4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


78



4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


79



4 PA BvD


2


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD



80



4 PA BvD


4 PA BvD


4 PA BvD


(Catapres) 1 GC








(Cardura) 2



2




(Vazculep) 2


(Minipress) 2


(Atacand) 4


(Atacand HCT) 4


3


81



3





(Avapro) 1 GC


(Avalide) 1 GC


(Cozaar) 1 GC


(Hyzaar) 1 GC


(Benicar) 2


(Tribenzor) 4


(Benicar HCT) 2


(Micardis) 1 GC


(Twynsta) 4


(Micardis HCT) 4


(Diovan) 1 GC


(Diovan HCT) 1 GC


(Lotensin) 1 GC



82



(Lotensin HCT) 2


2


2


2


(Vasotec) 1 GC


2


(Vaseretic) 1 GC


1 GC


4 ST


1 GC


2


(Prinivil) 1 GC


(Zestril) 1 GC


(Zestoretic) 1 GC



1 GC


5 ST NEDS


(Accupril) 1 GC


(Accuretic) 2


83



(Altace) 1 GC


1 GC


(Pacerone) 4





(Tikosyn) 4


2


1 GC


2


3




2


2


(Rythmol SR) 4


2


4


2


2


(Tenormin) 1 GC


84



(Tenoretic 100) 2


(Tenoretic 50) 2



2


(Ziac) 1 GC


3


3


(Coreg) 1 GC


2


2


2


(Toprol XL) 2


2


(Lopressor HCT) 2


(Lopressor) 2


2


(Lopressor) 1 GC


1 GC


(Corgard) 2



85



2


(Inderal LA) 4


2


2


2


2


2


(Sorine) 2


4


2


2


2


(Taztia XT) 4


(Tiadylt ER) 2


(Cartia XT) 2


(Cardizem) 2



2


86



4


2


2


2


2


(Verelan PM) 2


(Verelan) 2


(Verelan) 4


1 GC


(Calan SR) 1 GC






5 NEDS


2


2


2


4


87



(Digitek) 2


(Digitek) 2






2


2




(Ranexa) 4








2


(Norvasc) 1 GC


(Lotrel) 1 GC


1 GC


(Azor) 2


(Exforge) 1 GC


88



(Exforge HCT) 4


2





4




(Procardia XL) 2


(Adalat CC) 2


(Adalat CC) 2



2


4


2


2


(Diuril IV) 2


2


2


2


1 GC


(Lasix) 1 GC


89



1 GC


1 GC


1 GC







2


(Aldactone) 1 GC


(Aldactazide) 2


1 GC


(Dyazide) 1 GC


1 GC


(Maxzide-25mg) 1 GC


(Maxzide) 1 GC


(Caduet) 4


4


(Lipitor) 1 GC


(Questran) 2


90



2

















4


2


(Tricor) 2


2


(Trilipix) 4


(Fibricor) 4


4 ST


(Lescol) 4







91







1 GC




4



2









2

















92



2


2



4 ST



3 ST


3


2



(ISOCHRON) 2


2


1 GC


2



2


(Nitrostat) 2


(Minitran) 2




93





















(Cafcit) 2 PA BvD


2


(Kapvay) 4














94







2












(Intuniv ER) 2


5 PA NEDS






1 GC



(Lithobid) 2


2


4


5 PA NEDS


5 PA NEDS


5 PA NEDS


95



5 PA NEDS


5 PA NEDS


5 PA NEDS


5 PA NEDS






























96














5 PA NEDS




5 PA NEDS








5 PA NEDS


5 PA NEDS





97



3




5 PA NEDS









2


2


2







2





98



2


2


2


2


2




2


2


2


2


2


2




2


2


2


2



2


2


99






2


(Azurette (28)) 2


(Apri) 2


(Jasmiel (28)) 2


(Syeda) 2







2





(Kelnor 135 (28)) 2


(Kelnor 1-50) 2




2



2







100








2


2


2


2


2



2


2



2








2


2


2


2


101



2



4



2


(Afirmelle) 2


(Altavera (28)) 2




(Enpresse) 2





2


2


2



2


2



2


4


2


2


102





(Jencycla) 2


(Aurovela 1530 (21)) 2


(Aurovela 120 (21)) 2




(Aurovela 24 Fe) 2



2




(Tri Femynor) 2


(Estarylla) 2




2


2


2


2


2




2


2



103




2





2




4


2




2


2


2


2


2


2


2


2


2


2


2


2


104



2


2


2


2


2



2



2


2



2





2


2


2






1 GC


1 GC


105





(Oralone) 2






1 GC


(Geri-Hydrolac) 2


(Geri-Hydrolac) 2




4



(Vectical) 4


5 NEDS




2






5 NEDS







106



4



5 NEDS


5 NEDS


2


(Evoclin) 4


(Cleocin T) 2


(Clindacin ETZ) 2


(Neuac) 4


(Benzaclin) 4



(Erygel) 4


2


(Ery Pads) 2


(Benzamycin) 4









2




107





(Klaron) 2





2


2


2


2


2


(Luxiq) 4


2


2


2


2


2


(Diprolene) 2









108



2


(Olux-E) 4


(Cloderm) 4






(Topicort) 4


(Topicort) 2



(Topicort) 4



3




(Synalar) 2







(Cutivate) 2


2


2


2




109



(Locoid) 4


(Locoid) 4


4


(Locoid) 4






1 GC


4


4







2


2


2


2


2




1 GC


(Triderm) 1 GC


2


110



2


(Trianex) 2




4 PA



4



(Retin-A) 2 PA






2


2


2


2


2


1 GC




111






2



2



5 NEDS


5 NEDS


5 PA NEDS


5 NEDS


3


5 NEDS


5 NEDS


5 PA NEDS




5 PA NEDS


5 PA BvD NEDS


5 NEDS


112



5 PA NEDS



5 NEDS


(Orfadin) 5 PA NEDS


5 PA NEDS


5 PA NEDS


5 PA NEDS


5 PA NEDS


5 PA BvD NEDS


5 PA NEDS


5 PA LA NEDS


5 PA NEDS


5 NEDS


3


113



2


2


(Isopto Atropine) 4






2


4 ST


2


(Cyclogyl) 2


5 NEDS


2








(Pataday) 2


(Pataday) 4


4


(Alcaine) 2


5 PA NEDS


114




4


(Polycin) 2


2


3


(Ciloxan) 1 GC


(Cetraxal) 4


2


(Zymaxid) 4


2


1 GC


4


2


3


(Vigamox) 2


(Moxeza) 2


4


(Neo-Polycin HC) 2


115



(Neo-Polycin) 2


(Maxitrol) 2


(Maxitrol) 2


2


2


2


2


2


2


(Ocuflox) 2



2


(Polytrim) 1 GC


(Bleph-10) 2


2


116



2


(Tobrex) 1 GC


(TobraDex) 2


2


4


3


3 ST


4


3


2


2


3




(DermOtic Oil) 4


(FML Liquifilm) 4


1 GC





3


117



3


(Acular) 2


3


3


3


(Lotemax) 2




(Pred Forte) 4


2


3








4


2


2


2


118





2


(Nexium IV) 2


1 GC


2


2


4









(Cytotec) 2


2


2


1 GC




(Protonix) 2








119



(Zantac) 2



1 GC





5 NEDS


2


(Gastrocrom) 2










5 PA NEDS



2


2


2


(Constulose) 2






2


120



4


2


2


2


(Reglan) 1 GC







5 PA NEDS










2


(Buphenyl) 5 NEDS


2



2


2







121









3


2


2



(Gavilyte-C) 4


3


2


2


2


(Fosrenol) 5 NEDS


4


(Renvela) 5 NEDS


(Renvela) 4




3


122



2


(Urecholine) 2



3


2



(Ditropan XL) 2


2


(Detrol LA) 2



3


4


(Uroxatral) 1 GC



(Jalyn) 4



5 NEDS



1 GC


123



5 PA NEDS


5 NEDS


per 30 days)


(Jadenu) 5 PA NEDS


(Exjade) 5 PA NEDS


(Desferal) 2 PA


5 PA NEDS


5 PA NEDS


5 PA NEDS


5 PA NEDS


5 PA NEDS





5 PA NEDS


2




124





2 PA




















(Estrace) 2



(Delestrogen) 2




125












3




3







2






2 PA BvD




1 PA BvD GC


126



1 GC


1 GC


1 GC


1 GC









(Cortef) 2


(Depo-Medrol) 2


(Medrol) 2


(Medrol (Pak)) 2


2


(Solu-Medrol) 2


2 PA BvD


2 PA BvD


2 PA BvD





1 PA BvD GC


127



2


4


(Kenalog) 2


(DDAVP) 2


(DDAVP) 2


2


(DDAVP) 2




4 PA


5 PA NEDS


5 PA NEDS


5 PA NEDS


5 PA NEDS


128



5 NEDS


5 NEDS


5 NEDS


5 NEDS


5 NEDS






5 PA NEDS


4 PA


5 PA NEDS


2


(Sandostatin) 2


129



2


5 PA NEDS


5 PA NEDS






5 PA NEDS


5 PA NEDS


5 NEDS


5 PA NEDS








5 PA NEDS


130



3




5 NEDS




5 PA NEDS


4 PA


5 PA NEDS










(Provera) 1 GC




(Aygestin) 2


2


(Prometrium) 2


131



(Euthyrox) 1 GC



(Cytomel) 2




5 PA NEDS


5 PA NEDS


5 PA NEDS


5 NEDS



2 PA BvD


5 PA NEDS


5 PA NEDS


5 PA NEDS


5 PA NEDS


132





(Gengraf) 2 PA BvD


2 PA BvD


(Gengraf) 2 PA BvD




5 PA NEDS


5 PA NEDS


5 PA NEDS


5 PA NEDS


5 PA NEDS


5 PA BvD NEDS


4 PA BvD


5 PA BvD NEDS


5 PA BvD NEDS


5 PA BvD NEDS


133



5 PA BvD NEDS


5 PA BvD NEDS




5 PA NEDS


5 PA NEDS


5 PA NEDS


5 PA NEDS


5 PA NEDS


5 PA NEDS


5 PA NEDS


5 PA NEDS


134



5 PA NEDS


5 PA NEDS


4


4


5 PA BvD NEDS


5 PA NEDS


5 PA NEDS


5 PA NEDS


4


5 PA NEDS


4


5 PA NEDS


5 PA NEDS


5 PA NEDS



135





(CellCept) 2 PA BvD




(CellCept) 2 PA BvD


5 PA BvD NEDS


5 PA BvD NEDS


5 PA NEDS


5 PA NEDS


5 PA NEDS


5 PA NEDS



5 PA NEDS


5 PA BvD NEDS


4 PA BvD


4 PA BvD ST


136



3


5 PA NEDS


5 PA NEDS


5 NEDS


5 PA NEDS


5 PA NEDS


5 PA NEDS


5 PA NEDS


5 PA NEDS





5 PA NEDS


5 PA NEDS


5 PA NEDS


5 PA NEDS


137



(Prograf) 2 PA BvD


5 PA NEDS


5 PA NEDS


4


5 PA NEDS


5 PA NEDS


5 PA LA NEDS


5 PA NEDS


5 PA NEDS


5 PA BvD NEDS


6 NEDS


6 NEDS


6 NEDS


6 PA BvD NEDS


138



6 NEDS


6 NEDS


6 NEDS


6 NEDS


6 PA BvD NEDS


6 PA BvD NEDS


6 PA BvD NEDS






6 NEDS


6 NEDS


6 NEDS


139



6 PA BvD NEDS


6 NEDS


6 NEDS


6 NEDS


6 NEDS


6 NEDS


6 NEDS


6 NEDS


6 NEDS


6 NEDS


6 NEDS


6 NEDS


6 NEDS


140



6 NEDS


6 NEDS


6 PA BvD NEDS


6 PA BvD NEDS


6 PA BvD NEDS


6 NEDS


6 NEDS




6 NEDS


6 NEDS


6 NEDS


141



6 NEDS


6 NEDS


6 NEDS


6 NEDS


6 NEDS


6 NEDS


6 NEDS




6 NEDS





142



3



(Entocort EC) 4



5 ST NEDS


(Colocort) 4


2


(Delzicol) 4


(Apriso) 2


(Lialda) 2


(Asacol HD) 4


(Canasa) 5 NEDS





3



4



4



4


143











2


(Rocaltrol) 2





(Hectorol) 2


4


4













5 NEDS


144





2


2


4


4


(Zemplar) 4

















5 PA NEDS


4


4


145







5 NEDS


(Ethyol) 2


5 PA NEDS








4


5 NEDS




2







5 PA LA NEDS


5 NEDS


3


146




3


3


1 GC


(Vistaril) 1 GC




2


2


2


(Carnitor) 2



4


(Fusilev) 5 NEDS


(Mesnex) 2


5 NEDS


5 NEDS


5 NEDS


4


147



(Mestinon) 4


4


(Mestinon) 2










5 NEDS








2


2


2


3


3


2


4


148



(Alphagan P) 4


1 GC


1 GC


3


(Trusopt) 2


(Cosopt) 2




1 GC




4


2


(Isopto Carpine) 2






3


(Timoptic) 1 GC


(Timoptic-XE) 4








149







2


4


4


4


4


2


2


2


2


2


2 PA BvD


2 PA BvD


2 PA BvD


150



2 PA BvD


4


4


4


4


4


2 PA BvD


2 PA BvD


2


4


(K-Tab) 2


(K-Tab) 4


(Klor-Con M10) 2


(Klor-Con M20) 2


2


(Urocit-K 10) 2


(Urocit-K 15) 2


(Urocit-K 5) 2


151



2




















152
















(Singulair) 1 GC









2 PA BvD


2


153



2


2


3







3


2 PA BvD






1 GC


2








154







3





5 NEDS


4


2


4


2


3






(Acetadote) 2 PA


2 PA BvD


155



5 PA NEDS


2 PA BvD
































5 PA BvD NEDS


156







5 PA NEDS


5 PA NEDS







(Dantrium) 2




2












157

















(Flolan) 2 PA


(Flolan) 5 PA NEDS




3 PA


5 PA NEDS










158










5 PA NEDS






5 PA NEDS


3


3


159


160

INDEX

Index


Index


Index


I-1

Index


Index


Index


I-2

Index


Index


Index


I-3

Index


Index


Index


I-4

Index


Index


Index


I-5

Index


Index


Index


I-6

Index


Index


Index


I-7

Index


Index


Index


I-8

Index


Index


Index


I-9

Index


Index


Index


I-10

Index


Index


Index


I-11

Index


Index


Index


I-12

Index


Index


Index


I-13

Index


Index


Index


I-14

Index


Index


Index


I-15

Index


Index


Index


I-16

Index


Index


Index


I-17



Plus (HMO) 2020















Medical Condition













Afeccioacuten













病症


什麼是普通藥






瞭解更多資訊





의학적 증상








자세한 정보





Theo Bệnh

Theo vần abc









VHP_20576_000_15778_04012020_v13 (002)pdf

Analgesics

Anesthetics


Antianxiety Agents

Antibacterials

Anticancer Agents


Anticonvulsants

Antidementia Agents

Antidepressants

Antidiabetic Agents

Antifungals

Antigout Agents

Antihistamines


Antimigraine Agents

Antimycobacterials

Antinausea Agents

Antiparasite Agents





Caloric Agents



Contraceptives



Devices












Ophthalmic Agents





Vasodilating Agents


Blank Page

Blank Page



II-3














II-4








II-5





II-6






II-7













II-8





II-9






II-10





II-11





II-12






II-13




II-14







II-15


II-16




PA BvD



PA-HRM





PA NSO-HRM











II-17












II-18




II-19




II-20







II-21






II-22



II-23









II-24


II-25




PA BvD



PA-HRM



II-26


PA NSO



PA NSO-HRM




















II-27












II-28








II-29







II-30






II-31





II-32






II-33









II-34

縮寫描述說明

PA NSO-HRM



















II-35




II-36



II-37






II-38





II-39



II-40








II-41


II-42




PA BvD







PA NSO-HRM








II-43














II-44




II-45




II-46







II-47






II-48



II-49









II-50


II-51




PA BvD



PA-HRM



PA NSO



PA NSO-HRM





II-52
















II-53








Table of Contents


1


2













(Buprenex) 2


2
















3




































4









2











2









4


2


5


































6

























7



4





(Flector) 4 PA


2


(Voltaren-XR) 2


2






(Arthrotec 50) 4


(Arthrotec 75) 4





4





2


1 GC


8



(Childrens Advil) 2


(IBU) 1 GC






4


4
















9








2


1 GC



(EC-Naprosyn) 2




(Feldene) 4












1 GC



1 GC


10



(Xylocaine) 1 GC




2





2






2










2


3 QL (336 per 365 days)


3 QL (336 per 365 days)


3


11



(Antabuse) 2




2


2





4 QL (1008 per 90 days)


5 NEDS













2





12
































13









5 PA BvD NEDS


2


2


2



4






4


2


4


2



4


14



(Cleocin HCl) 1 GC


2


4


2


(Cleocin) 2


(Cleocin) 2



5 PA BvD NEDS


(Cubicin) 5 NEDS


4


5 NEDS


(Zyvox) 5 NEDS


(Zyvox) 5 NEDS



(Hiprex) 2


(Metro IV) 2


(Flagyl) 1 GC








2


15



5 NEDS



2


(Vancocin) 4




5 PA NEDS


2


4


4



2



2



2




(Maxipime) 2



(Suprax) 4


2


16



4


2


2


2



(Tazicef) 2


2


2


2


2


(Keflex) 1 GC



2


2


5 NEDS


(Zithromax) 2



(Zithromax) 4


(Zithromax) 2


17



1 GC


(Zithromax) 1 GC


2


2


4




(EES Granules) 4


(EryPed 400) 4


2


(Azactam) 2


5 PA LA NEDS


(Invanz) 4


2


(Primaxin IV) 2


(Merrem) 4


(Merrem) 4


4


18



1 GC


1 GC


1 GC


1 GC


2


(Augmentin) 4




4


(Augmentin) 1 GC


(Augmentin XR) 4


2


2


2


(Unasyn) 2


4


19



2


2



5 NEDS



(Pfizerpen-G) 4


2


2


1 GC


4


(Zosyn) 2 PA BvD


(Zosyn) 4 PA BvD




2



(Cipro) 1 GC



2


(Cipro) 2


20



2


4


4



(Levaquin) 1 GC



2


(Sulfatrim) 2


(Bactrim) 1 GC


(Bactrim DS) 1 GC


4


4


2


(Doxy-100) 2


(Morgidox) 2


2


4


(Doryx) 4


21



(Mondoxyne NL) 2


4


(Monodox) 2


(Mondoxyne NL) 4


(Vibramycin) 2


(Avidoxy) 2


4


2


2



4


2




4


2


(Tygacil) 5 NEDS


5 NEDS


5 PA NSO NEDS


22



2 PA BvD


2 PA BvD










5 NEDS








5 PA NSO NEDS



5 NEDS


(Trisenox) 5 NEDS


5 PA NSO NEDS




(Vidaza) 5 NEDS






23





5 PA NSO NEDS


5 PA NSO NEDS


5 PA NSO NEDS


5 PA NSO NEDS




2


5 PA NSO NEDS


5 PA NSO NEDS










5 PA NSO NEDS












24



(Paraplatin) 2


2 PA BvD


(Clolar) 5 NEDS








5 PA BvD NEDS


2 PA BvD ST


5 PA NSO NEDS


5 PA NSO LA NEDS






(Dacogen) 5 NEDS


5 NEDS


(Taxotere) 5 NEDS






25



4


4


4


4


4


5 NEDS


5 PA NSO NEDS


5 PA NSO NEDS








4


(Toposar) 2



5 PA NSO NEDS


2 PA BvD


2 PA BvD


(Adrucil) 2 PA BvD



26



(Faslodex) 5 NEDS


5 PA NSO NEDS


2


5 NEDS


5 NEDS




4


5 NEDS




5 PA NSO NEDS











(Ifex) 2


2


4



27










5 PA NSO NEDS






5 NEDS







(Camptosar) 2


2


28



5 NEDS




5 PA NSO NEDS
















5 PA NSO NEDS


5 PA NSO NEDS



4


2




29











5 PA NSO NEDS


5 NEDS


5 NEDS


5 NEDS


5 NEDS




5 NEDS


5 PA NSO NEDS


5 NEDS











30




2 PA BvD


2 PA BvD


2 PA BvD


2 PA BvD ST


2


5 PA NSO NEDS











5 PA NSO LA NEDS


5 PA NSO NEDS


5 PA NSO NEDS


5 NEDS


5 PA NSO NEDS


2


2


2 PA BvD


31



5 PA NSO NEDS


5 PA NSO NEDS






5 PA NSO NEDS






5 NEDS


5 NEDS




5 PA NSO NEDS


5 PA NSO NEDS








5 PA NSO NEDS




32



5 NEDS










5 PA NSO NEDS


5 PA NSO NEDS


4



















5 PA NSO NEDS


5 PA NSO NEDS


33








2


(Hycamtin) 5 NEDS


5 NEDS



5 PA NSO NEDS


5 PA NSO NEDS








5 NEDS


5 PA NSO NEDS




5 PA NSO NEDS


5 PA NSO NEDS


(Valstar) 5 NEDS


34



5 PA NSO NEDS


5 PA NSO NEDS








5 PA NSO LA NEDS




2 PA BvD


2 PA BvD




(Navelbine) 2












5 PA BvD NEDS




4 PA BvD ST


35















5 PA NSO NEDS


5 PA NSO NEDS



5 PA NSO NEDS






5 PA NSO NEDS






5 NEDS






36







4






5 NEDS


5 NEDS








(Carbatrol) 2


(Tegretol) 2



(Tegretol XR) 2


2


4



37




4



(Diastat AcuDial) 4





(Depakote ER) 2


(Depakote) 2


5 PA NSO NEDS




(Zarontin) 2


(Felbatol) 4


(Felbatol) 4


(Cerebyx) 2













38







4 ST




(Subvenite) 1 GC



4



4



4


(Lamictal XR) 4


(Lamictal) 2


(Lamictal ODT) 4


(Keppra) 2


(Keppra) 2


(Keppra) 2


(Keppra XR) 2




39



(Trileptal) 2


(Trileptal) 2


4


4






(Dilantin-125) 2






(Phenytek) 2


2


2












1 GC


40






(Gabitril) 4


(Topamax) 2


(Qudexy XR) 4


(Topamax) 1 GC


2


2



4









3 QL (1200 per 30 days)




(Zonegran) 2



41



days)















4


3








2


2


2


2


42



(Wellbutrin XL) 2


(Wellbutrin SR) 2





(Anafranil) 4


(Norpramin) 4


4




2













2


(Lexapro) 1 GC


43



4 ST




(Prozac) 1 GC


4


2


2


4


2


4


(Remeron) 2


2


(Remeron SolTab) 2


4


(Pamelor) 1 GC


2






44





2





(Zoloft) 1 GC


5 PA NSO NEDS



1 GC



4








2








3


5 NEDS


45

































46

































47



























48



























49















days)















50










5 PA BvD NEDS


5 PA BvD NEDS


2 PA BvD


(Cancidas) 5 NEDS







2


1 GC



(Lotrisone) 2


4



2 PA BvD


(Diflucan) 2


(Diflucan) 2


51



(Ancobon) 5 NEDS


4


4


4







2


5 NEDS


5 NEDS


5 NEDS


2


2



2


2


(Nyamyc) 2


4


4


2


(Noxafil) 5 NEDS


52






(Vfend) 5 NEDS


(Vfend) 5 NEDS


(Zyloprim) 1 GC







2









4


2


2




53



2


2


1 GC


(Xyzal) 4





(Cleocin) 2



2


4














54






































4



55







4




4




(Rifadin) 4


(Rifadin) 2


5 PA NEDS


4


4


4 PA BvD










2


56












2


2




2


1 GC


1 GC


2


4 PA BvD



(Zofran) 2 PA BvD


2 PA BvD




2


(Compazine) 1 GC


(Compro) 2


57




















5 NEDS


5 NEDS


(Mepron) 5 NEDS


(Malarone) 2




2


4


5 PA NEDS


(Plaquenil) 2


58






4



4 PA BvD



4


(Nebupent) 2 PA BvD


(Pentam) 4


4



2



2





(Cogentin) 2


2






(Sinemet) 2


59



(Sinemet CR) 2


4


(Stalevo 50) 4


(Stalevo 75) 4


(Stalevo 100) 4


(Stalevo 125) 4


(Stalevo 150) 4


(Stalevo 200) 4















(Mirapex) 1 GC


60




(Requip) 2


2


(Requip XL) 4


4




2


1 GC


















61













2


4















4 ST


2


62



2


2


2


4








2




(Haldol) 2


2


2


2










63

















2





















64



4































65





2


4


2






4 ST












(Epzicom) 2


(Trizivir) 5 NEDS


5 NEDS


66



5 NEDS


(Reyataz) 5 NEDS


5 NEDS


5 NEDS


5 NEDS


5 NEDS


4


5 NEDS


5 NEDS


(Videx EC) 2


2


5 NEDS


5 NEDS





4


4


4


5 NEDS



5 NEDS


67



5 NEDS


5 NEDS


4


5 NEDS


5 NEDS


4


5 NEDS


4


5 NEDS


4


5 NEDS




(Epivir) 2


(Combivir) 2


4


(Kaletra) 2


(Viramune) 2



2


(Viramune XR) 2


68



4


4


4


5 NEDS


5 NEDS


5 NEDS


5 NEDS


5 NEDS


4


4


4


4


5 NEDS



4


5 NEDS


4


2


5 NEDS


5 NEDS


5 NEDS


69



5 NEDS


5 NEDS


(Viread) 2


4


5 NEDS


5 NEDS


5 NEDS


5 NEDS




4


4


5 NEDS


5 NEDS


5 NEDS




(Foscavir) 4 PA BvD





70














5 PA NEDS


















5 PA NEDS






71



5 PA NSO NEDS


5 PA NSO NEDS


5 NEDS


5 NEDS


5 NEDS


5 NEDS


5 PA NSO NEDS



(Zovirax) 2



2 PA BvD


2 PA BvD



5 NEDS



2


(Cytovene) 2 PA BvD


72



2 PA BvD




5 NEDS






(Valtrex) 2


(Valcyte) 5 NEDS





3




(Lovenox) 2


(Lovenox) 2


(Arixtra) 5 NEDS


(Arixtra) 2


2


73



2


2


2


2


1 GC




(Jantoven) 1 GC






3










5 PA NEDS


5 PA NEDS


5 PA NEDS


74







5 NEDS


5 NEDS




5 PA NEDS


5 PA NEDS


5 PA NEDS


5 NEDS


5 PA NEDS


5 PA NEDS












75













5 PA NEDS


5 NEDS


5 PA NEDS


5 PA NEDS




5 PA NEDS


2


4 PA




(Cyklokapron) 2




3



76






2



4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


77



4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


78



4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


79



4 PA BvD


2


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD



80



4 PA BvD


4 PA BvD


4 PA BvD


(Catapres) 1 GC








(Cardura) 2



2




(Vazculep) 2


(Minipress) 2


(Atacand) 4


(Atacand HCT) 4


3


81



3





(Avapro) 1 GC


(Avalide) 1 GC


(Cozaar) 1 GC


(Hyzaar) 1 GC


(Benicar) 2


(Tribenzor) 4


(Benicar HCT) 2


(Micardis) 1 GC


(Twynsta) 4


(Micardis HCT) 4


(Diovan) 1 GC


(Diovan HCT) 1 GC


(Lotensin) 1 GC



82



(Lotensin HCT) 2


2


2


2


(Vasotec) 1 GC


2


(Vaseretic) 1 GC


1 GC


4 ST


1 GC


2


(Prinivil) 1 GC


(Zestril) 1 GC


(Zestoretic) 1 GC



1 GC


5 ST NEDS


(Accupril) 1 GC


(Accuretic) 2


83



(Altace) 1 GC


1 GC


(Pacerone) 4





(Tikosyn) 4


2


1 GC


2


3




2


2


(Rythmol SR) 4


2


4


2


2


(Tenormin) 1 GC


84



(Tenoretic 100) 2


(Tenoretic 50) 2



2


(Ziac) 1 GC


3


3


(Coreg) 1 GC


2


2


2


(Toprol XL) 2


2


(Lopressor HCT) 2


(Lopressor) 2


2


(Lopressor) 1 GC


1 GC


(Corgard) 2



85



2


(Inderal LA) 4


2


2


2


2


2


(Sorine) 2


4


2


2


2


(Taztia XT) 4


(Tiadylt ER) 2


(Cartia XT) 2


(Cardizem) 2



2


86



4


2


2


2


2


(Verelan PM) 2


(Verelan) 2


(Verelan) 4


1 GC


(Calan SR) 1 GC






5 NEDS


2


2


2


4


87



(Digitek) 2


(Digitek) 2






2


2




(Ranexa) 4








2


(Norvasc) 1 GC


(Lotrel) 1 GC


1 GC


(Azor) 2


(Exforge) 1 GC


88



(Exforge HCT) 4


2





4




(Procardia XL) 2


(Adalat CC) 2


(Adalat CC) 2



2


4


2


2


(Diuril IV) 2


2


2


2


1 GC


(Lasix) 1 GC


89



1 GC


1 GC


1 GC







2


(Aldactone) 1 GC


(Aldactazide) 2


1 GC


(Dyazide) 1 GC


1 GC


(Maxzide-25mg) 1 GC


(Maxzide) 1 GC


(Caduet) 4


4


(Lipitor) 1 GC


(Questran) 2


90



2

















4


2


(Tricor) 2


2


(Trilipix) 4


(Fibricor) 4


4 ST


(Lescol) 4







91







1 GC




4



2









2

















92



2


2



4 ST



3 ST


3


2



(ISOCHRON) 2


2


1 GC


2



2


(Nitrostat) 2


(Minitran) 2




93





















(Cafcit) 2 PA BvD


2


(Kapvay) 4














94







2












(Intuniv ER) 2


5 PA NEDS






1 GC



(Lithobid) 2


2


4


5 PA NEDS


5 PA NEDS


5 PA NEDS


95



5 PA NEDS


5 PA NEDS


5 PA NEDS


5 PA NEDS






























96














5 PA NEDS




5 PA NEDS








5 PA NEDS


5 PA NEDS





97



3




5 PA NEDS









2


2


2







2





98



2


2


2


2


2




2


2


2


2


2


2




2


2


2


2



2


2


99






2


(Azurette (28)) 2


(Apri) 2


(Jasmiel (28)) 2


(Syeda) 2







2





(Kelnor 135 (28)) 2


(Kelnor 1-50) 2




2



2







100








2


2


2


2


2



2


2



2








2


2


2


2


101



2



4



2


(Afirmelle) 2


(Altavera (28)) 2




(Enpresse) 2





2


2


2



2


2



2


4


2


2


102





(Jencycla) 2


(Aurovela 1530 (21)) 2


(Aurovela 120 (21)) 2




(Aurovela 24 Fe) 2



2




(Tri Femynor) 2


(Estarylla) 2




2


2


2


2


2




2


2



103




2





2




4


2




2


2


2


2


2


2


2


2


2


2


2


2


104



2


2


2


2


2



2



2


2



2





2


2


2






1 GC


1 GC


105





(Oralone) 2






1 GC


(Geri-Hydrolac) 2


(Geri-Hydrolac) 2




4



(Vectical) 4


5 NEDS




2






5 NEDS







106



4



5 NEDS


5 NEDS


2


(Evoclin) 4


(Cleocin T) 2


(Clindacin ETZ) 2


(Neuac) 4


(Benzaclin) 4



(Erygel) 4


2


(Ery Pads) 2


(Benzamycin) 4









2




107





(Klaron) 2





2


2


2


2


2


(Luxiq) 4


2


2


2


2


2


(Diprolene) 2









108



2


(Olux-E) 4


(Cloderm) 4






(Topicort) 4


(Topicort) 2



(Topicort) 4



3




(Synalar) 2







(Cutivate) 2


2


2


2




109



(Locoid) 4


(Locoid) 4


4


(Locoid) 4






1 GC


4


4







2


2


2


2


2




1 GC


(Triderm) 1 GC


2


110



2


(Trianex) 2




4 PA



4



(Retin-A) 2 PA






2


2


2


2


2


1 GC




111






2



2



5 NEDS


5 NEDS


5 PA NEDS


5 NEDS


3


5 NEDS


5 NEDS


5 PA NEDS




5 PA NEDS


5 PA BvD NEDS


5 NEDS


112



5 PA NEDS



5 NEDS


(Orfadin) 5 PA NEDS


5 PA NEDS


5 PA NEDS


5 PA NEDS


5 PA NEDS


5 PA BvD NEDS


5 PA NEDS


5 PA LA NEDS


5 PA NEDS


5 NEDS


3


113



2


2


(Isopto Atropine) 4






2


4 ST


2


(Cyclogyl) 2


5 NEDS


2








(Pataday) 2


(Pataday) 4


4


(Alcaine) 2


5 PA NEDS


114




4


(Polycin) 2


2


3


(Ciloxan) 1 GC


(Cetraxal) 4


2


(Zymaxid) 4


2


1 GC


4


2


3


(Vigamox) 2


(Moxeza) 2


4


(Neo-Polycin HC) 2


115



(Neo-Polycin) 2


(Maxitrol) 2


(Maxitrol) 2


2


2


2


2


2


2


(Ocuflox) 2



2


(Polytrim) 1 GC


(Bleph-10) 2


2


116



2


(Tobrex) 1 GC


(TobraDex) 2


2


4


3


3 ST


4


3


2


2


3




(DermOtic Oil) 4


(FML Liquifilm) 4


1 GC





3


117



3


(Acular) 2


3


3


3


(Lotemax) 2




(Pred Forte) 4


2


3








4


2


2


2


118





2


(Nexium IV) 2


1 GC


2


2


4









(Cytotec) 2


2


2


1 GC




(Protonix) 2








119



(Zantac) 2



1 GC





5 NEDS


2


(Gastrocrom) 2










5 PA NEDS



2


2


2


(Constulose) 2






2


120



4


2


2


2


(Reglan) 1 GC







5 PA NEDS










2


(Buphenyl) 5 NEDS


2



2


2







121









3


2


2



(Gavilyte-C) 4


3


2


2


2


(Fosrenol) 5 NEDS


4


(Renvela) 5 NEDS


(Renvela) 4




3


122



2


(Urecholine) 2



3


2



(Ditropan XL) 2


2


(Detrol LA) 2



3


4


(Uroxatral) 1 GC



(Jalyn) 4



5 NEDS



1 GC


123



5 PA NEDS


5 NEDS


per 30 days)


(Jadenu) 5 PA NEDS


(Exjade) 5 PA NEDS


(Desferal) 2 PA


5 PA NEDS


5 PA NEDS


5 PA NEDS


5 PA NEDS


5 PA NEDS





5 PA NEDS


2




124





2 PA




















(Estrace) 2



(Delestrogen) 2




125












3




3







2






2 PA BvD




1 PA BvD GC


126



1 GC


1 GC


1 GC


1 GC









(Cortef) 2


(Depo-Medrol) 2


(Medrol) 2


(Medrol (Pak)) 2


2


(Solu-Medrol) 2


2 PA BvD


2 PA BvD


2 PA BvD





1 PA BvD GC


127



2


4


(Kenalog) 2


(DDAVP) 2


(DDAVP) 2


2


(DDAVP) 2




4 PA


5 PA NEDS


5 PA NEDS


5 PA NEDS


5 PA NEDS


128



5 NEDS


5 NEDS


5 NEDS


5 NEDS


5 NEDS






5 PA NEDS


4 PA


5 PA NEDS


2


(Sandostatin) 2


129



2


5 PA NEDS


5 PA NEDS






5 PA NEDS


5 PA NEDS


5 NEDS


5 PA NEDS








5 PA NEDS


130



3




5 NEDS




5 PA NEDS


4 PA


5 PA NEDS










(Provera) 1 GC




(Aygestin) 2


2


(Prometrium) 2


131



(Euthyrox) 1 GC



(Cytomel) 2




5 PA NEDS


5 PA NEDS


5 PA NEDS


5 NEDS



2 PA BvD


5 PA NEDS


5 PA NEDS


5 PA NEDS


5 PA NEDS


132





(Gengraf) 2 PA BvD


2 PA BvD


(Gengraf) 2 PA BvD




5 PA NEDS


5 PA NEDS


5 PA NEDS


5 PA NEDS


5 PA NEDS


5 PA BvD NEDS


4 PA BvD


5 PA BvD NEDS


5 PA BvD NEDS


5 PA BvD NEDS


133



5 PA BvD NEDS


5 PA BvD NEDS




5 PA NEDS


5 PA NEDS


5 PA NEDS


5 PA NEDS


5 PA NEDS


5 PA NEDS


5 PA NEDS


5 PA NEDS


134



5 PA NEDS


5 PA NEDS


4


4


5 PA BvD NEDS


5 PA NEDS


5 PA NEDS


5 PA NEDS


4


5 PA NEDS


4


5 PA NEDS


5 PA NEDS


5 PA NEDS



135





(CellCept) 2 PA BvD




(CellCept) 2 PA BvD


5 PA BvD NEDS


5 PA BvD NEDS


5 PA NEDS


5 PA NEDS


5 PA NEDS


5 PA NEDS



5 PA NEDS


5 PA BvD NEDS


4 PA BvD


4 PA BvD ST


136



3


5 PA NEDS


5 PA NEDS


5 NEDS


5 PA NEDS


5 PA NEDS


5 PA NEDS


5 PA NEDS


5 PA NEDS





5 PA NEDS


5 PA NEDS


5 PA NEDS


5 PA NEDS


137



(Prograf) 2 PA BvD


5 PA NEDS


5 PA NEDS


4


5 PA NEDS


5 PA NEDS


5 PA LA NEDS


5 PA NEDS


5 PA NEDS


5 PA BvD NEDS


6 NEDS


6 NEDS


6 NEDS


6 PA BvD NEDS


138



6 NEDS


6 NEDS


6 NEDS


6 NEDS


6 PA BvD NEDS


6 PA BvD NEDS


6 PA BvD NEDS






6 NEDS


6 NEDS


6 NEDS


139



6 PA BvD NEDS


6 NEDS


6 NEDS


6 NEDS


6 NEDS


6 NEDS


6 NEDS


6 NEDS


6 NEDS


6 NEDS


6 NEDS


6 NEDS


6 NEDS


140



6 NEDS


6 NEDS


6 PA BvD NEDS


6 PA BvD NEDS


6 PA BvD NEDS


6 NEDS


6 NEDS




6 NEDS


6 NEDS


6 NEDS


141



6 NEDS


6 NEDS


6 NEDS


6 NEDS


6 NEDS


6 NEDS


6 NEDS




6 NEDS





142



3



(Entocort EC) 4



5 ST NEDS


(Colocort) 4


2


(Delzicol) 4


(Apriso) 2


(Lialda) 2


(Asacol HD) 4


(Canasa) 5 NEDS





3



4



4



4


143











2


(Rocaltrol) 2





(Hectorol) 2


4


4













5 NEDS


144





2


2


4


4


(Zemplar) 4

















5 PA NEDS


4


4


145







5 NEDS


(Ethyol) 2


5 PA NEDS








4


5 NEDS




2







5 PA LA NEDS


5 NEDS


3


146




3


3


1 GC


(Vistaril) 1 GC




2


2


2


(Carnitor) 2



4


(Fusilev) 5 NEDS


(Mesnex) 2


5 NEDS


5 NEDS


5 NEDS


4


147



(Mestinon) 4


4


(Mestinon) 2










5 NEDS








2


2


2


3


3


2


4


148



(Alphagan P) 4


1 GC


1 GC


3


(Trusopt) 2


(Cosopt) 2




1 GC




4


2


(Isopto Carpine) 2






3


(Timoptic) 1 GC


(Timoptic-XE) 4








149







2


4


4


4


4


2


2


2


2


2


2 PA BvD


2 PA BvD


2 PA BvD


150



2 PA BvD


4


4


4


4


4


2 PA BvD


2 PA BvD


2


4


(K-Tab) 2


(K-Tab) 4


(Klor-Con M10) 2


(Klor-Con M20) 2


2


(Urocit-K 10) 2


(Urocit-K 15) 2


(Urocit-K 5) 2


151



2




















152
















(Singulair) 1 GC









2 PA BvD


2


153



2


2


3







3


2 PA BvD






1 GC


2








154







3





5 NEDS


4


2


4


2


3






(Acetadote) 2 PA


2 PA BvD


155



5 PA NEDS


2 PA BvD
































5 PA BvD NEDS


156







5 PA NEDS


5 PA NEDS







(Dantrium) 2




2












157

















(Flolan) 2 PA


(Flolan) 5 PA NEDS




3 PA


5 PA NEDS










158










5 PA NEDS






5 PA NEDS


3


3


159


160

INDEX

Index


Index


Index


I-1

Index


Index


Index


I-2

Index


Index


Index


I-3

Index


Index


Index


I-4

Index


Index


Index


I-5

Index


Index


Index


I-6

Index


Index


Index


I-7

Index


Index


Index


I-8

Index


Index


Index


I-9

Index


Index


Index


I-10

Index


Index


Index


I-11

Index


Index


Index


I-12

Index


Index


Index


I-13

Index


Index


Index


I-14

Index


Index


Index


I-15

Index


Index


Index


I-16

Index


Index


Index


I-17



Plus (HMO) 2020















Medical Condition













Afeccioacuten













病症


什麼是普通藥






瞭解更多資訊





의학적 증상








자세한 정보





Theo Bệnh

Theo vần abc









VHP_20576_000_15778_04012020_v13 (002)pdf

Analgesics

Anesthetics


Antianxiety Agents

Antibacterials

Anticancer Agents


Anticonvulsants

Antidementia Agents

Antidepressants

Antidiabetic Agents

Antifungals

Antigout Agents

Antihistamines


Antimigraine Agents

Antimycobacterials

Antinausea Agents

Antiparasite Agents





Caloric Agents



Contraceptives



Devices












Ophthalmic Agents





Vasodilating Agents


Blank Page

Blank Page



II-4








II-5





II-6






II-7













II-8





II-9






II-10





II-11





II-12






II-13




II-14







II-15


II-16




PA BvD



PA-HRM





PA NSO-HRM











II-17












II-18




II-19




II-20







II-21






II-22



II-23









II-24


II-25




PA BvD



PA-HRM



II-26


PA NSO



PA NSO-HRM




















II-27












II-28








II-29







II-30






II-31





II-32






II-33









II-34

縮寫描述說明

PA NSO-HRM



















II-35




II-36



II-37






II-38





II-39



II-40








II-41


II-42




PA BvD







PA NSO-HRM








II-43














II-44




II-45




II-46







II-47






II-48



II-49









II-50


II-51




PA BvD



PA-HRM



PA NSO



PA NSO-HRM





II-52
















II-53








Table of Contents


1


2













(Buprenex) 2


2
















3




































4









2











2









4


2


5


































6

























7



4





(Flector) 4 PA


2


(Voltaren-XR) 2


2






(Arthrotec 50) 4


(Arthrotec 75) 4





4





2


1 GC


8



(Childrens Advil) 2


(IBU) 1 GC






4


4
















9








2


1 GC



(EC-Naprosyn) 2




(Feldene) 4












1 GC



1 GC


10



(Xylocaine) 1 GC




2





2






2










2


3 QL (336 per 365 days)


3 QL (336 per 365 days)


3


11



(Antabuse) 2




2


2





4 QL (1008 per 90 days)


5 NEDS













2





12
































13









5 PA BvD NEDS


2


2


2



4






4


2


4


2



4


14



(Cleocin HCl) 1 GC


2


4


2


(Cleocin) 2


(Cleocin) 2



5 PA BvD NEDS


(Cubicin) 5 NEDS


4


5 NEDS


(Zyvox) 5 NEDS


(Zyvox) 5 NEDS



(Hiprex) 2


(Metro IV) 2


(Flagyl) 1 GC








2


15



5 NEDS



2


(Vancocin) 4




5 PA NEDS


2


4


4



2



2



2




(Maxipime) 2



(Suprax) 4


2


16



4


2


2


2



(Tazicef) 2


2


2


2


2


(Keflex) 1 GC



2


2


5 NEDS


(Zithromax) 2



(Zithromax) 4


(Zithromax) 2


17



1 GC


(Zithromax) 1 GC


2


2


4




(EES Granules) 4


(EryPed 400) 4


2


(Azactam) 2


5 PA LA NEDS


(Invanz) 4


2


(Primaxin IV) 2


(Merrem) 4


(Merrem) 4


4


18



1 GC


1 GC


1 GC


1 GC


2


(Augmentin) 4




4


(Augmentin) 1 GC


(Augmentin XR) 4


2


2


2


(Unasyn) 2


4


19



2


2



5 NEDS



(Pfizerpen-G) 4


2


2


1 GC


4


(Zosyn) 2 PA BvD


(Zosyn) 4 PA BvD




2



(Cipro) 1 GC



2


(Cipro) 2


20



2


4


4



(Levaquin) 1 GC



2


(Sulfatrim) 2


(Bactrim) 1 GC


(Bactrim DS) 1 GC


4


4


2


(Doxy-100) 2


(Morgidox) 2


2


4


(Doryx) 4


21



(Mondoxyne NL) 2


4


(Monodox) 2


(Mondoxyne NL) 4


(Vibramycin) 2


(Avidoxy) 2


4


2


2



4


2




4


2


(Tygacil) 5 NEDS


5 NEDS


5 PA NSO NEDS


22



2 PA BvD


2 PA BvD










5 NEDS








5 PA NSO NEDS



5 NEDS


(Trisenox) 5 NEDS


5 PA NSO NEDS




(Vidaza) 5 NEDS






23





5 PA NSO NEDS


5 PA NSO NEDS


5 PA NSO NEDS


5 PA NSO NEDS




2


5 PA NSO NEDS


5 PA NSO NEDS










5 PA NSO NEDS












24



(Paraplatin) 2


2 PA BvD


(Clolar) 5 NEDS








5 PA BvD NEDS


2 PA BvD ST


5 PA NSO NEDS


5 PA NSO LA NEDS






(Dacogen) 5 NEDS


5 NEDS


(Taxotere) 5 NEDS






25



4


4


4


4


4


5 NEDS


5 PA NSO NEDS


5 PA NSO NEDS








4


(Toposar) 2



5 PA NSO NEDS


2 PA BvD


2 PA BvD


(Adrucil) 2 PA BvD



26



(Faslodex) 5 NEDS


5 PA NSO NEDS


2


5 NEDS


5 NEDS




4


5 NEDS




5 PA NSO NEDS











(Ifex) 2


2


4



27










5 PA NSO NEDS






5 NEDS







(Camptosar) 2


2


28



5 NEDS




5 PA NSO NEDS
















5 PA NSO NEDS


5 PA NSO NEDS



4


2




29











5 PA NSO NEDS


5 NEDS


5 NEDS


5 NEDS


5 NEDS




5 NEDS


5 PA NSO NEDS


5 NEDS











30




2 PA BvD


2 PA BvD


2 PA BvD


2 PA BvD ST


2


5 PA NSO NEDS











5 PA NSO LA NEDS


5 PA NSO NEDS


5 PA NSO NEDS


5 NEDS


5 PA NSO NEDS


2


2


2 PA BvD


31



5 PA NSO NEDS


5 PA NSO NEDS






5 PA NSO NEDS






5 NEDS


5 NEDS




5 PA NSO NEDS


5 PA NSO NEDS








5 PA NSO NEDS




32



5 NEDS










5 PA NSO NEDS


5 PA NSO NEDS


4



















5 PA NSO NEDS


5 PA NSO NEDS


33








2


(Hycamtin) 5 NEDS


5 NEDS



5 PA NSO NEDS


5 PA NSO NEDS








5 NEDS


5 PA NSO NEDS




5 PA NSO NEDS


5 PA NSO NEDS


(Valstar) 5 NEDS


34



5 PA NSO NEDS


5 PA NSO NEDS








5 PA NSO LA NEDS




2 PA BvD


2 PA BvD




(Navelbine) 2












5 PA BvD NEDS




4 PA BvD ST


35















5 PA NSO NEDS


5 PA NSO NEDS



5 PA NSO NEDS






5 PA NSO NEDS






5 NEDS






36







4






5 NEDS


5 NEDS








(Carbatrol) 2


(Tegretol) 2



(Tegretol XR) 2


2


4



37




4



(Diastat AcuDial) 4





(Depakote ER) 2


(Depakote) 2


5 PA NSO NEDS




(Zarontin) 2


(Felbatol) 4


(Felbatol) 4


(Cerebyx) 2













38







4 ST




(Subvenite) 1 GC



4



4



4


(Lamictal XR) 4


(Lamictal) 2


(Lamictal ODT) 4


(Keppra) 2


(Keppra) 2


(Keppra) 2


(Keppra XR) 2




39



(Trileptal) 2


(Trileptal) 2


4


4






(Dilantin-125) 2






(Phenytek) 2


2


2












1 GC


40






(Gabitril) 4


(Topamax) 2


(Qudexy XR) 4


(Topamax) 1 GC


2


2



4









3 QL (1200 per 30 days)




(Zonegran) 2



41



days)















4


3








2


2


2


2


42



(Wellbutrin XL) 2


(Wellbutrin SR) 2





(Anafranil) 4


(Norpramin) 4


4




2













2


(Lexapro) 1 GC


43



4 ST




(Prozac) 1 GC


4


2


2


4


2


4


(Remeron) 2


2


(Remeron SolTab) 2


4


(Pamelor) 1 GC


2






44





2





(Zoloft) 1 GC


5 PA NSO NEDS



1 GC



4








2








3


5 NEDS


45

































46

































47



























48



























49















days)















50










5 PA BvD NEDS


5 PA BvD NEDS


2 PA BvD


(Cancidas) 5 NEDS







2


1 GC



(Lotrisone) 2


4



2 PA BvD


(Diflucan) 2


(Diflucan) 2


51



(Ancobon) 5 NEDS


4


4


4







2


5 NEDS


5 NEDS


5 NEDS


2


2



2


2


(Nyamyc) 2


4


4


2


(Noxafil) 5 NEDS


52






(Vfend) 5 NEDS


(Vfend) 5 NEDS


(Zyloprim) 1 GC







2









4


2


2




53



2


2


1 GC


(Xyzal) 4





(Cleocin) 2



2


4














54






































4



55







4




4




(Rifadin) 4


(Rifadin) 2


5 PA NEDS


4


4


4 PA BvD










2


56












2


2




2


1 GC


1 GC


2


4 PA BvD



(Zofran) 2 PA BvD


2 PA BvD




2


(Compazine) 1 GC


(Compro) 2


57




















5 NEDS


5 NEDS


(Mepron) 5 NEDS


(Malarone) 2




2


4


5 PA NEDS


(Plaquenil) 2


58






4



4 PA BvD



4


(Nebupent) 2 PA BvD


(Pentam) 4


4



2



2





(Cogentin) 2


2






(Sinemet) 2


59



(Sinemet CR) 2


4


(Stalevo 50) 4


(Stalevo 75) 4


(Stalevo 100) 4


(Stalevo 125) 4


(Stalevo 150) 4


(Stalevo 200) 4















(Mirapex) 1 GC


60




(Requip) 2


2


(Requip XL) 4


4




2


1 GC


















61













2


4















4 ST


2


62



2


2


2


4








2




(Haldol) 2


2


2


2










63

















2





















64



4































65





2


4


2






4 ST












(Epzicom) 2


(Trizivir) 5 NEDS


5 NEDS


66



5 NEDS


(Reyataz) 5 NEDS


5 NEDS


5 NEDS


5 NEDS


5 NEDS


4


5 NEDS


5 NEDS


(Videx EC) 2


2


5 NEDS


5 NEDS





4


4


4


5 NEDS



5 NEDS


67



5 NEDS


5 NEDS


4


5 NEDS


5 NEDS


4


5 NEDS


4


5 NEDS


4


5 NEDS




(Epivir) 2


(Combivir) 2


4


(Kaletra) 2


(Viramune) 2



2


(Viramune XR) 2


68



4


4


4


5 NEDS


5 NEDS


5 NEDS


5 NEDS


5 NEDS


4


4


4


4


5 NEDS



4


5 NEDS


4


2


5 NEDS


5 NEDS


5 NEDS


69



5 NEDS


5 NEDS


(Viread) 2


4


5 NEDS


5 NEDS


5 NEDS


5 NEDS




4


4


5 NEDS


5 NEDS


5 NEDS




(Foscavir) 4 PA BvD





70














5 PA NEDS


















5 PA NEDS






71



5 PA NSO NEDS


5 PA NSO NEDS


5 NEDS


5 NEDS


5 NEDS


5 NEDS


5 PA NSO NEDS



(Zovirax) 2



2 PA BvD


2 PA BvD



5 NEDS



2


(Cytovene) 2 PA BvD


72



2 PA BvD




5 NEDS






(Valtrex) 2


(Valcyte) 5 NEDS





3




(Lovenox) 2


(Lovenox) 2


(Arixtra) 5 NEDS


(Arixtra) 2


2


73



2


2


2


2


1 GC




(Jantoven) 1 GC






3










5 PA NEDS


5 PA NEDS


5 PA NEDS


74







5 NEDS


5 NEDS




5 PA NEDS


5 PA NEDS


5 PA NEDS


5 NEDS


5 PA NEDS


5 PA NEDS












75













5 PA NEDS


5 NEDS


5 PA NEDS


5 PA NEDS




5 PA NEDS


2


4 PA




(Cyklokapron) 2




3



76






2



4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


77



4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


78



4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


79



4 PA BvD


2


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD



80



4 PA BvD


4 PA BvD


4 PA BvD


(Catapres) 1 GC








(Cardura) 2



2




(Vazculep) 2


(Minipress) 2


(Atacand) 4


(Atacand HCT) 4


3


81



3





(Avapro) 1 GC


(Avalide) 1 GC


(Cozaar) 1 GC


(Hyzaar) 1 GC


(Benicar) 2


(Tribenzor) 4


(Benicar HCT) 2


(Micardis) 1 GC


(Twynsta) 4


(Micardis HCT) 4


(Diovan) 1 GC


(Diovan HCT) 1 GC


(Lotensin) 1 GC



82



(Lotensin HCT) 2


2


2


2


(Vasotec) 1 GC


2


(Vaseretic) 1 GC


1 GC


4 ST


1 GC


2


(Prinivil) 1 GC


(Zestril) 1 GC


(Zestoretic) 1 GC



1 GC


5 ST NEDS


(Accupril) 1 GC


(Accuretic) 2


83



(Altace) 1 GC


1 GC


(Pacerone) 4





(Tikosyn) 4


2


1 GC


2


3




2


2


(Rythmol SR) 4


2


4


2


2


(Tenormin) 1 GC


84



(Tenoretic 100) 2


(Tenoretic 50) 2



2


(Ziac) 1 GC


3


3


(Coreg) 1 GC


2


2


2


(Toprol XL) 2


2


(Lopressor HCT) 2


(Lopressor) 2


2


(Lopressor) 1 GC


1 GC


(Corgard) 2



85



2


(Inderal LA) 4


2


2


2


2


2


(Sorine) 2


4


2


2


2


(Taztia XT) 4


(Tiadylt ER) 2


(Cartia XT) 2


(Cardizem) 2



2


86



4


2


2


2


2


(Verelan PM) 2


(Verelan) 2


(Verelan) 4


1 GC


(Calan SR) 1 GC






5 NEDS


2


2


2


4


87



(Digitek) 2


(Digitek) 2






2


2




(Ranexa) 4








2


(Norvasc) 1 GC


(Lotrel) 1 GC


1 GC


(Azor) 2


(Exforge) 1 GC


88



(Exforge HCT) 4


2





4




(Procardia XL) 2


(Adalat CC) 2


(Adalat CC) 2



2


4


2


2


(Diuril IV) 2


2


2


2


1 GC


(Lasix) 1 GC


89



1 GC


1 GC


1 GC







2


(Aldactone) 1 GC


(Aldactazide) 2


1 GC


(Dyazide) 1 GC


1 GC


(Maxzide-25mg) 1 GC


(Maxzide) 1 GC


(Caduet) 4


4


(Lipitor) 1 GC


(Questran) 2


90



2

















4


2


(Tricor) 2


2


(Trilipix) 4


(Fibricor) 4


4 ST


(Lescol) 4







91







1 GC




4



2









2

















92



2


2



4 ST



3 ST


3


2



(ISOCHRON) 2


2


1 GC


2



2


(Nitrostat) 2


(Minitran) 2




93





















(Cafcit) 2 PA BvD


2


(Kapvay) 4














94







2












(Intuniv ER) 2


5 PA NEDS






1 GC



(Lithobid) 2


2


4


5 PA NEDS


5 PA NEDS


5 PA NEDS


95



5 PA NEDS


5 PA NEDS


5 PA NEDS


5 PA NEDS






























96














5 PA NEDS




5 PA NEDS








5 PA NEDS


5 PA NEDS





97



3




5 PA NEDS









2


2


2







2





98



2


2


2


2


2




2


2


2


2


2


2




2


2


2


2



2


2


99






2


(Azurette (28)) 2


(Apri) 2


(Jasmiel (28)) 2


(Syeda) 2







2





(Kelnor 135 (28)) 2


(Kelnor 1-50) 2




2



2







100








2


2


2


2


2



2


2



2








2


2


2


2


101



2



4



2


(Afirmelle) 2


(Altavera (28)) 2




(Enpresse) 2





2


2


2



2


2



2


4


2


2


102





(Jencycla) 2


(Aurovela 1530 (21)) 2


(Aurovela 120 (21)) 2




(Aurovela 24 Fe) 2



2




(Tri Femynor) 2


(Estarylla) 2




2


2


2


2


2




2


2



103




2





2




4


2




2


2


2


2


2


2


2


2


2


2


2


2


104



2


2


2


2


2



2



2


2



2





2


2


2






1 GC


1 GC


105





(Oralone) 2






1 GC


(Geri-Hydrolac) 2


(Geri-Hydrolac) 2




4



(Vectical) 4


5 NEDS




2






5 NEDS







106



4



5 NEDS


5 NEDS


2


(Evoclin) 4


(Cleocin T) 2


(Clindacin ETZ) 2


(Neuac) 4


(Benzaclin) 4



(Erygel) 4


2


(Ery Pads) 2


(Benzamycin) 4









2




107





(Klaron) 2





2


2


2


2


2


(Luxiq) 4


2


2


2


2


2


(Diprolene) 2









108



2


(Olux-E) 4


(Cloderm) 4






(Topicort) 4


(Topicort) 2



(Topicort) 4



3




(Synalar) 2







(Cutivate) 2


2


2


2




109



(Locoid) 4


(Locoid) 4


4


(Locoid) 4






1 GC


4


4







2


2


2


2


2




1 GC


(Triderm) 1 GC


2


110



2


(Trianex) 2




4 PA



4



(Retin-A) 2 PA






2


2


2


2


2


1 GC




111






2



2



5 NEDS


5 NEDS


5 PA NEDS


5 NEDS


3


5 NEDS


5 NEDS


5 PA NEDS




5 PA NEDS


5 PA BvD NEDS


5 NEDS


112



5 PA NEDS



5 NEDS


(Orfadin) 5 PA NEDS


5 PA NEDS


5 PA NEDS


5 PA NEDS


5 PA NEDS


5 PA BvD NEDS


5 PA NEDS


5 PA LA NEDS


5 PA NEDS


5 NEDS


3


113



2


2


(Isopto Atropine) 4






2


4 ST


2


(Cyclogyl) 2


5 NEDS


2








(Pataday) 2


(Pataday) 4


4


(Alcaine) 2


5 PA NEDS


114




4


(Polycin) 2


2


3


(Ciloxan) 1 GC


(Cetraxal) 4


2


(Zymaxid) 4


2


1 GC


4


2


3


(Vigamox) 2


(Moxeza) 2


4


(Neo-Polycin HC) 2


115



(Neo-Polycin) 2


(Maxitrol) 2


(Maxitrol) 2


2


2


2


2


2


2


(Ocuflox) 2



2


(Polytrim) 1 GC


(Bleph-10) 2


2


116



2


(Tobrex) 1 GC


(TobraDex) 2


2


4


3


3 ST


4


3


2


2


3




(DermOtic Oil) 4


(FML Liquifilm) 4


1 GC





3


117



3


(Acular) 2


3


3


3


(Lotemax) 2




(Pred Forte) 4


2


3








4


2


2


2


118





2


(Nexium IV) 2


1 GC


2


2


4









(Cytotec) 2


2


2


1 GC




(Protonix) 2








119



(Zantac) 2



1 GC





5 NEDS


2


(Gastrocrom) 2










5 PA NEDS



2


2


2


(Constulose) 2






2


120



4


2


2


2


(Reglan) 1 GC







5 PA NEDS










2


(Buphenyl) 5 NEDS


2



2


2







121









3


2


2



(Gavilyte-C) 4


3


2


2


2


(Fosrenol) 5 NEDS


4


(Renvela) 5 NEDS


(Renvela) 4




3


122



2


(Urecholine) 2



3


2



(Ditropan XL) 2


2


(Detrol LA) 2



3


4


(Uroxatral) 1 GC



(Jalyn) 4



5 NEDS



1 GC


123



5 PA NEDS


5 NEDS


per 30 days)


(Jadenu) 5 PA NEDS


(Exjade) 5 PA NEDS


(Desferal) 2 PA


5 PA NEDS


5 PA NEDS


5 PA NEDS


5 PA NEDS


5 PA NEDS





5 PA NEDS


2




124





2 PA




















(Estrace) 2



(Delestrogen) 2




125












3




3







2






2 PA BvD




1 PA BvD GC


126



1 GC


1 GC


1 GC


1 GC









(Cortef) 2


(Depo-Medrol) 2


(Medrol) 2


(Medrol (Pak)) 2


2


(Solu-Medrol) 2


2 PA BvD


2 PA BvD


2 PA BvD





1 PA BvD GC


127



2


4


(Kenalog) 2


(DDAVP) 2


(DDAVP) 2


2


(DDAVP) 2




4 PA


5 PA NEDS


5 PA NEDS


5 PA NEDS


5 PA NEDS


128



5 NEDS


5 NEDS


5 NEDS


5 NEDS


5 NEDS






5 PA NEDS


4 PA


5 PA NEDS


2


(Sandostatin) 2


129



2


5 PA NEDS


5 PA NEDS






5 PA NEDS


5 PA NEDS


5 NEDS


5 PA NEDS








5 PA NEDS


130



3




5 NEDS




5 PA NEDS


4 PA


5 PA NEDS










(Provera) 1 GC




(Aygestin) 2


2


(Prometrium) 2


131



(Euthyrox) 1 GC



(Cytomel) 2




5 PA NEDS


5 PA NEDS


5 PA NEDS


5 NEDS



2 PA BvD


5 PA NEDS


5 PA NEDS


5 PA NEDS


5 PA NEDS


132





(Gengraf) 2 PA BvD


2 PA BvD


(Gengraf) 2 PA BvD




5 PA NEDS


5 PA NEDS


5 PA NEDS


5 PA NEDS


5 PA NEDS


5 PA BvD NEDS


4 PA BvD


5 PA BvD NEDS


5 PA BvD NEDS


5 PA BvD NEDS


133



5 PA BvD NEDS


5 PA BvD NEDS




5 PA NEDS


5 PA NEDS


5 PA NEDS


5 PA NEDS


5 PA NEDS


5 PA NEDS


5 PA NEDS


5 PA NEDS


134



5 PA NEDS


5 PA NEDS


4


4


5 PA BvD NEDS


5 PA NEDS


5 PA NEDS


5 PA NEDS


4


5 PA NEDS


4


5 PA NEDS


5 PA NEDS


5 PA NEDS



135





(CellCept) 2 PA BvD




(CellCept) 2 PA BvD


5 PA BvD NEDS


5 PA BvD NEDS


5 PA NEDS


5 PA NEDS


5 PA NEDS


5 PA NEDS



5 PA NEDS


5 PA BvD NEDS


4 PA BvD


4 PA BvD ST


136



3


5 PA NEDS


5 PA NEDS


5 NEDS


5 PA NEDS


5 PA NEDS


5 PA NEDS


5 PA NEDS


5 PA NEDS





5 PA NEDS


5 PA NEDS


5 PA NEDS


5 PA NEDS


137



(Prograf) 2 PA BvD


5 PA NEDS


5 PA NEDS


4


5 PA NEDS


5 PA NEDS


5 PA LA NEDS


5 PA NEDS


5 PA NEDS


5 PA BvD NEDS


6 NEDS


6 NEDS


6 NEDS


6 PA BvD NEDS


138



6 NEDS


6 NEDS


6 NEDS


6 NEDS


6 PA BvD NEDS


6 PA BvD NEDS


6 PA BvD NEDS






6 NEDS


6 NEDS


6 NEDS


139



6 PA BvD NEDS


6 NEDS


6 NEDS


6 NEDS


6 NEDS


6 NEDS


6 NEDS


6 NEDS


6 NEDS


6 NEDS


6 NEDS


6 NEDS


6 NEDS


140



6 NEDS


6 NEDS


6 PA BvD NEDS


6 PA BvD NEDS


6 PA BvD NEDS


6 NEDS


6 NEDS




6 NEDS


6 NEDS


6 NEDS


141



6 NEDS


6 NEDS


6 NEDS


6 NEDS


6 NEDS


6 NEDS


6 NEDS




6 NEDS





142



3



(Entocort EC) 4



5 ST NEDS


(Colocort) 4


2


(Delzicol) 4


(Apriso) 2


(Lialda) 2


(Asacol HD) 4


(Canasa) 5 NEDS





3



4



4



4


143











2


(Rocaltrol) 2





(Hectorol) 2


4


4













5 NEDS


144





2


2


4


4


(Zemplar) 4

















5 PA NEDS


4


4


145







5 NEDS


(Ethyol) 2


5 PA NEDS








4


5 NEDS




2







5 PA LA NEDS


5 NEDS


3


146




3


3


1 GC


(Vistaril) 1 GC




2


2


2


(Carnitor) 2



4


(Fusilev) 5 NEDS


(Mesnex) 2


5 NEDS


5 NEDS


5 NEDS


4


147



(Mestinon) 4


4


(Mestinon) 2










5 NEDS








2


2


2


3


3


2


4


148



(Alphagan P) 4


1 GC


1 GC


3


(Trusopt) 2


(Cosopt) 2




1 GC




4


2


(Isopto Carpine) 2






3


(Timoptic) 1 GC


(Timoptic-XE) 4








149







2


4


4


4


4


2


2


2


2


2


2 PA BvD


2 PA BvD


2 PA BvD


150



2 PA BvD


4


4


4


4


4


2 PA BvD


2 PA BvD


2


4


(K-Tab) 2


(K-Tab) 4


(Klor-Con M10) 2


(Klor-Con M20) 2


2


(Urocit-K 10) 2


(Urocit-K 15) 2


(Urocit-K 5) 2


151



2




















152
















(Singulair) 1 GC









2 PA BvD


2


153



2


2


3







3


2 PA BvD






1 GC


2








154







3





5 NEDS


4


2


4


2


3






(Acetadote) 2 PA


2 PA BvD


155



5 PA NEDS


2 PA BvD
































5 PA BvD NEDS


156







5 PA NEDS


5 PA NEDS







(Dantrium) 2




2












157

















(Flolan) 2 PA


(Flolan) 5 PA NEDS




3 PA


5 PA NEDS










158










5 PA NEDS






5 PA NEDS


3


3


159


160

INDEX

Index


Index


Index


I-1

Index


Index


Index


I-2

Index


Index


Index


I-3

Index


Index


Index


I-4

Index


Index


Index


I-5

Index


Index


Index


I-6

Index


Index


Index


I-7

Index


Index


Index


I-8

Index


Index


Index


I-9

Index


Index


Index


I-10

Index


Index


Index


I-11

Index


Index


Index


I-12

Index


Index


Index


I-13

Index


Index


Index


I-14

Index


Index


Index


I-15

Index


Index


Index


I-16

Index


Index


Index


I-17



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Medical Condition













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