HF NY_CY17_2T_MMP_NOV_17_2_Comprehensive_Formulary-v1

전체의약품 처방집 2017 AbsoluteCare FIDA Plan ( 메디케어 - 메디케이드플랜 ) 뉴욕시, 낫소카운티, 웨체스터카운티 반드시읽어주세요 : 이문서에는이플랜에서저희가커버해드리는약종류에대한정보가들어있습니다. 본처방집은 2017-10-24 에갱신되었습니다. 다른최신정보가필요하시거나궁금하신사항은 Healthfirst FIDA 가입자서비스부에 1.855.675.7630 번으로, TTY 사용자는 711 번으로주 7 일, 오전 8 시 - 오후 8 시중에연락하여문의해주십시오. 온라인으로 healthfirst.org/mmp 를방문하실수도있습니다. H5441_QIP17_01k Approved 08112016 HPMS Approved Formulary File Submission ID 00017242, Version 16, as of 10/24/2017

Healthfirst AbsoluteCare FIDA Plan(Medicare-Medicaid Plan) 2017 년보장약목록 ( 처방집 ) 이목록은가입자가 Healthfirst AbsoluteCare FIDA Plan 으로구입할수있는의약품목록입니다. Healthfirst AbsoluteCare FIDA Plan(Medicare-Medicaid 플랜 ) 은관리형케어플랜으로서 Medicare 와뉴욕주보건부 (New York State Department of Health, Medicaid) 모두와계약을맺고두프로그램의혜택을완전히통합된이중이점 (Fully Integrated Duals Advantage, FIDA) 프로젝트이행을통해가입자에게제공하고있습니다. 보장약목록및 / 또는약국및서비스제공자네트워크는연중언제든변경될수있습니다. 귀하께영향을주는변경을가하기전에통지를드리겠습니다. 혜택은매년 1 월 1 일에변경될수있습니다. 귀하는 HealthfirstAbsoluteCare FIDA 플랜의최신보험커버리지약리스트를저희웹사이트 www.healthfirst.org/mmp 를방문하시거나가입자서비스에전화를해서확인하실수있습니다. 전화번호는 1-855-675-7630(TTY/TDD: 711) 이고연중무휴오전 8 시에서오후 8 시까지통화가능합니다. 제한및제약사항이적용될수있습니다. 자세한정보는 Healthfirst AbsoluteCare FIDA Plan 가입자서비스부로전화하시거나 Healthfirst AbsoluteCare FIDA Plan 가입자핸드북을참조해주십시오. 그렇다는것은 HealthfirstAbsoluteCare FIDA 플랜이귀하가받는서비스에대해비용을지불하길원하신다면일정한규칙을따라야함을의미합니다. 보장약에대한자기부담금은없습니다. 이와동일한정보를무상으로다른언어버전으로도얻으실수있습니다. 문의는 1-855-675-7630(TTY/TDD 711) 으로연중무휴오전 8 시에서오후 8 시사이에연락주십시오. 통화는무료입니다. You can get this information for free in other languages. Call 1-855-675-7630 or TTY/TDD: 711, 7 days a week from 8 am to 8 pm. The call is free. Usted puede obtener esta información de forma gratuita en otros idiomas. Llame al 1-855-675-7630 y al TTY/TDD 711, los 7 días de la semana de 8:00 a.m. a 8:00 p.m. La llamada es gratuita. H5441_QIP17_01k Approved 08112016 질문이있으시면저희 HealthfirstAbsoluteCare FIDA 플랜으로전화주시기바랍니다. 전화번호는 1-855-675-7630(TTY/TDD: 711) 이고연중무휴오전 8 시에서오후 8 시까지통화가능합니다. 통화는언제나무료이고좀더자세한정보를원하시면저희웹사이트 www.healthfirst.org/mmp 를방문해주세요. i

Вы можете получить эту информацию бесплатно на других языках. Звоните по телефону 1-855-675-7630 или 711 (для пользующихся TTY/TDD) 7 дней в неделю с 8 утра до 8 вечера. Звонок бесплатный. 1-855-675-7630 TTY/TDD 711 8 8 Ou kapab jwenn enfòmasyon sa yo gratis nan lòt lang yo. Rele nimewo 1-855-675-7630 ak TTY/TDD 711 pandan 7 jou pa semèn depi 8 am jiska to 8 pm. Koutfil la gratis. È possibile ottenere queste informazioni gratuitamente in altre lingue chiamando il numero 1-855-675-7630 (utenti TTY/TDD: 711), 7 giorni alla settimana dalle 8 alle 20. La telefonata è gratuita. 본정보는대형인쇄물, 점자또는오디오등의기타형식으로무료로받아보실수있습니다. 1-855-675-7630 번또는 TTY/TDD: 711 로주 7 일, 오전 8 시 - 오후 8 시중에연락해주십시오. 지금당장또는장래에귀하는플랜관련책자 ( 처방서도포함 ) 를무료로배송받으실수있는 요청을언제든지하실수있습니다. 영어로된책자를요청하실수있지만다른언어버전이나 다른포맷 ( 큰글자, 점자, 오디오버전등 ) 으로도입수하실수있습니다. 저희에게 1-855-675-7630(TTY/TDD: 711) 으로전화주시고연중무휴오전 8 시에서오후 8 시까지통화 가능합니다. 뉴욕주정부는 Healthfirst AbsoluteCare FIDA Plan(Medicare-Medicaid 플랜 ) 이제공하는모든서비스에대해가입자들의프라이버시를무료로보장하는독립소비자옹호네트워크 (ICAN) 라는이름의가입자옴부즈맨프로그램을마련했습니다. 가입자옴부즈만은수신자부담전화 1-844-614-8800(TTY 711) 으로통화를하시거나온라인 icannys.org 를통해연락하실수있습니다. 헬스퍼스트메디케어플랜은관련연방공민권법을준수하며인종, 피부색, 출신국가, 연령, 장애또는 ðñ을이ò로 óñ하지 ô습니다. 질문이있으시면저희 HealthfirstAbsoluteCare FIDA 플랜으로전화주시기바랍니다. 전화번호는 1-855-675-7630(TTY/TDD: 711) 이고연중무휴오전 8 시에서오후 8 시까지통화가능합니다. 통화는언제나무료이고좀더자세한정보를원하시면저희웹사이트 www.healthfirst.org/mmp 를방문해주세요. ii

Multi-Language Interpreter Services Español (Spanish) ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-855-675-7630 (TTY 711). 繁體中文 (Chinese Mandarin) 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 1-855-675-7630 (TTY 711) 繁體中文 (Chinese Cantonese) 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 1-855-675-7630 (TTY 711) Tagalog (Filipino) PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-855-675-7630 (TTY 711). Français (French) ATTENTION: Si vous parlez français, des services d aide linguistique vous sont proposés gratuitement. Appelez le 1-855-675-7630 (ATS 711). Tiếng Việt (Vietnamese) CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-855-675-7630 (TTY 711). Deutsch (German) ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-855-675-7630 (TTY 711). 한국어 (Korean) 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다. 1-855-675-7630 (TTY 711) 번으로전화해주십시오. Русский (Russian) ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-855-675-7630 (телетайп: 711). H5441_LGL17_03k Accepted 09042016? 질문이있으시면저희 HealthfirstAbsoluteCare FIDA 플랜으로전화주시기바랍니다. 전화번호는 1-855-675-7630(TTY/TDD: 711) 이고연중무휴오전 8 시에서오후 8 시까지통화가능합니다. 통화는언제나무료이고좀더자세한정보를원하시면저희웹사이트 www.healthfirst.org/mmp 를방문해주세요. iii

1-855 -675-7630 Italiano (Italian) ATTENZIONE: In caso la lingua parlata sia l italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-855-675-7630 (TTY 711). Português (Portuguese) ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 1-855-675-763 (TTY 711). Kreyòl Ayisyen (French Creole) ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd po lang ki disponib gratis pou ou. Rele 1-855- 675-7630 (TTY 711). Polski (Polish) UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 1-855-675-7630 (TTY 711). ह द (Hindi) ध न द : य द आप ह द ब लत ह त आपक लए म फ म भ ष सह यत स व ए उपलब ह 1-855-675-7630 (TTY 711) पर क ल कर 日本語 (Japanese) مل حوظة: إذا كن ت تتحدث اللغة العرب ي ة ف إن خدمات المساعدة ال ل غوي ة ت ت واف ر ل ك ب المجان. اتصل ب رق م والبكم ( 711 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 1-855-675-7630 (TTY 711) までお電話にてご連絡ください رق م( هات ف ال صم? 질문이있으시면저희 HealthfirstAbsoluteCare FIDA 플랜으로전화주시기바랍니다. 전화번호는 1-855-675-7630(TTY/TDD: 711) 이고연중무휴오전 8 시에서오후 8 시까지통화가능합니다. 통화는언제나무료이고좀더자세한정보를원하시면저희웹사이트 www.healthfirst.org/mmp 를방문해주세요. iv

자주 õ 는질문 (FAQ) 보장약목록 ö 관련된질문의 변은 ø 기에서확인해보십시오. 전 ù FAQ 를 ú 어보면자세한 정보를얻거나질문및 변을 û 을수있습니다. 1. 보장약목록에는어 ü 처방약이있나요? ( 보장약목록을 ý 의약품목록 þ 이라고도합니다.) 1 ÿ 이지부터시작되는보장약목록의의약품은 Healthfirst AbsoluteCare FIDA Plan 이보장하 는의약품입니다. 이의약품은네트워크소속약국에서구입할수있습니다. 약국이플랜 ö 제휴 하 ø 가입자에게서비스를제공한다는계약을맺은경우네트워크소속약국입니다. 이러한약국 을 " 네트워크약국 " 이라고합니다. Healthfirst AbsoluteCare FIDA Plan 은다음에해당할경우의약품목록의모든약을 보장합니다. 귀하의의사또는처방약사가귀하의치료나건강 ò 지목적으로해당약품이필요하다는 의견을내놓는경우, 귀하의증상에해당의약품이의학적으로필요함, 그리고 귀하가 Healthfirst AbsoluteCare FIDA Plan 네트워크약국에서처방약을구입함. Healthfirst AbsoluteCare FIDA Plan 에는특정의약품이용에대한추가적절 ó 가있을수 있습니다 ( 아래의질문 #5 참조 ). 경우에따라다른의약품을먼저시도하는등특정의약품을 이용하기전에해야할일이있을수있습니다. 귀하는저희가보험커버리지를제공하는최신처방약리스트를 www.healthfirst.org/mmp 에서확인하실수있고가입자서비스에전화를해도알아보실수 있습니다. 전화번호는 1-855-675-7630(TTY/TDD: 711) 이고연중무휴오전 8 시에서오후 8 시까지통화가능합니다. 2. 의약품목록이바뀌기도하나요? 예. Healthfirst AbsoluteCare FIDA Plan 은의약품목록에서의약품을추가하거나삭제할수 있습니다. 일반적으로의약품목록은다음의경우에만변경됩니다. 질문이있으시면저희 HealthfirstAbsoluteCare FIDA 플랜으로전화주시기바랍니다. 전화번호는 1-855-675-7630(TTY/TDD: 711) 이고연중무휴오전 8 시에서오후 8 시까지통화가능합니다. 통화는언제나무료이고좀더자세한정보를원하시면저희웹사이트 www.healthfirst.org/mmp 를방문해주세요. v

의약품목록에있는약ö 동일한효능을가진새로운의약품이출시또는 특정의약품이안전하지 ô다는사실을확인함. 또한의약품에대한규칙을변경할수도있습니다. 예 : 특정의약품에대한사전허가를요구하거나요구하지 ô기로결정. ( 사전허가란가입자가특정의약품을구입하기전에 Healthfirst AbsoluteCare FIDA Plan 또는통합팀 (IDT) 에서얻는허가를말함.) 수령할수있는의약품의양을추가또는변경 (ý수량한도 " 라함þ). 특정의약품에대한단계적치료법의제한을추가또는변경. ( 단계적치료법이란특정약을보장하기전에다른약을먼저시도해야하는것을의미.) ( 의약품규칙에대한자세한정보는 73 ÿ 이지를참조하십시오.) 귀하가복용하고있는약이의약품목록에서삭제되면귀하에게알려드릴것입니다. 의약품보장에대한저희규칙이변경되어도알려드릴것입니다. 아래의질문 3, 4 및 7 에는의약품목록이변경될경우에대한자세한내용이포함되어있습니다. Healthfirst AbsoluteCare FIDA Plan 의최신의약품목록은 www.healthfirst.org/mmp 에서온라인으로확인할수있습니다. 귀하는또저희가입자서비스에전화를해서최신처방약리스트에대해문의하실수있습니다. 전화번호는 1-855-675-7630(TTY/TDD: 711) 이고연중무휴오전 8 시에서오후 8 시까지통화가능합니다. 3. 가격이더저렴한약이출시되어의약품목록에포함되어있다면어떻게되나요? 저렴한약이출시되었으며의약품목록에있는약 ö 효능이 ò 사한경우 : 귀하가다음에처방약을구입할때담당약사가저렴한약을줄수있습니다. 귀하와담당 서비스제공자가귀하에게저렴한약이맞지 ô 는다고결정할경우, 서비스제공자는 현재복용중인약을계속제공하도록약사에게말할수있습니다. 질문이있으시면저희 HealthfirstAbsoluteCare FIDA 플랜으로전화주시기바랍니다. 전화번호는 1-855-675-7630(TTY/TDD: 711) 이고연중무휴오전 8 시에서오후 8 시까지통화가능합니다. 통화는언제나무료이고좀더자세한정보를원하시면저희웹사이트 www.healthfirst.org/mmp 를방문해주세요. vi

Healthfirst AbsoluteCare FIDA Plan 은의약품목록에서비싼의약품을삭제하기로결정할수있습니다. 효능이 ò사한의약품이출시되어의약품목록에서특정약을제외하려는경우, 의약품목록에서약을제외하기 60 일이상전또는귀하가리필을요청할때귀하에게알릴것입니다. 의약품목록이변경되기전에귀하는해당약의 60 일치를수령할수있습니다. 최근에특정약을조제한경우, 혜택설명을통해통지를받을것입니다. 새로운조제를하지 ô고지난 180 일동안그약을사용하신경우, 귀하에게변경사항을알리는서신을보내드릴것입니다. 어느경우에도변경을하기 60 일이상전에귀하에게알릴것입니다. 4. 특정의약품이안전하지 ô 다는것이확인되면어떻게되나요? 식품의약국 (FDA) 이귀하가현재쓰고있는약이안전하지 ô다고할경우, 그약을의약품목록에서즉시제외시킬것입니다. 또한안전하지 ô은의약품이의약품목록에서제외되었음을알리기위해서신을보내고전화를드릴수있습니다. 귀하에게연락하는것이외에도저희는귀하담당의사와접촉하ø 귀하의질환에적합한다른약을 û는데적극협력할것입니다. 귀하가질문이있으시면담당의사와직접상의하시든지아니면저희 Healthfirst 에전화로문의해주시기바랍니다. 전화번호는 1-855-675-7630(TTY/TDD: 711) 이고연중무휴오전 8 시에서오후 8 시까지통화가능합니다. 5. 약보장에대한제한이나한도가있습니까? 또는특정의약품을수령하기위해취해야하는조치가있습니까? 예, 일부의약품에는보장규칙이있거나수령할수있는양에제한이있습니다. 경우에따라해당 약을수령하기전에귀하, 귀하의담당의사또는다른처방자는해야할일이있습니다. ø 기에는 다음의예가포함됩니다. 사전승인 ( 또는사전허가 ): 일부의약품의경우처방약을수령하기전에귀하나담당의사 또는기타처방자는 Healthfirst AbsoluteCare FIDA Plan 이나담당통합팀 (IDT) 의승인을 받아야합니다. 승인을받지 ô 을경우, Healthfirst AbsoluteCare FIDA Plan 은해당 의약품을보장하지 ô 을수있습니다. 질문이있으시면저희 HealthfirstAbsoluteCare FIDA 플랜으로전화주시기바랍니다. 전화번호는 1-855-675-7630(TTY/TDD: 711) 이고연중무휴오전 8 시에서오후 8 시까지통화가능합니다. 통화는언제나무료이고좀더자세한정보를원하시면저희 vii 웹사이트 www.healthfirst.org/mmp 를방문해주세요.

용량한도 : Healthfirst AbsoluteCare FIDA Plan 은귀하가수령할수있는약의수량을제한하는경우가있습니다. 단계적치료법 : 또한 Healthfirst AbsoluteCare FIDA Plan 은단계적치료법을실시하도록요구하기도합니다. 즉, 귀하의의학적상태에대해특정순서로의약품을시도해야하는것입니다. 귀하는특정약을보장받기전에다른약을시도해보아야할수있습니다. 담당의사가첫번째약이귀하에게효ö가없다고판단하면저희는두번째약을보장합니다. 귀하의약에추가적인요건이나한도가있는지의 ø부는 1 ÿ 이지첫부분의표를확인하ø 알수있습니다. 저희웹사이트 www.healthfirst.org/mmp 를방문하ø 더자세한정보를확인할수있습니다. 사전허가와단계적치료법제한에대해설명한온라인문서가게시되어있습니다. 저희에게연락하ø 사본을요청하실수도있습니다. 귀하는이러한한도의 ý예외þ를요청할수있습니다. 예외에대한자세한정보는질문 11 을참조해주십시오. 가입자가간호시설이나기타장기요양원에있으며의약품목록에없는약이필요한경우, 또는필요한의약품을구하기어려운경우, 저희가도와드릴수있습니다. 가입자가 Healthfirst AbsoluteCare FIDA Plan 의신규가입자인지의 ø부에관계없이, 필요한응급의약품의 31 일치 ( 기간이더적은처방전을가진경우는제외 ) 를보장합니다. 이는그기간에담당의사나기타처방자와상담할수있도록하기위한것입니다. 귀하의담당의사또는처방약사는처방약리스트상에서다른 ò사약품을 û아줄수있습니다. 또는저희에게예외결정을요청할수도있습니다. 예외에대한자세한정보는질문 11 을참조해주십시오. 6. 원하는의약품에제한이있거나약을사용하기위해취해야할조치가있는지어떻게아나요? 보장약목록의 1 ÿ 이지에는 " 사용 ö 관련된필요조치, 제한및한도 þ 라는열이있습니다. 7. 일부약의보장방법에대한규칙이변경되면어떻게되나요? 예를들어, 특정약에대한사전허가 ( 승인 ), 수량한도및 / 또는단계적치료법제한을추가할경우 : 질문이있으시면저희 HealthfirstAbsoluteCare FIDA 플랜으로전화주시기바랍니다. 전화번호는 1-855-675-7630(TTY/TDD: 711) 이고연중무휴오전 8 시에서오후 8 시까지통화가능합니다. 통화는언제나무료이고좀더자세한정보를원하시면저희웹사이트 www.healthfirst.org/mmp 를방문해주세요. viii

특정약에대한사전승인 ) 수량한도및 / 또는단계적치료법제한을추가할경우가입자에게알려드립니다. 제한이추가되기 60 일이상전이나가입자가다음에리필을요청할때알려드릴것입니다. 의약품목록을변경하기전에가입자는해당약의 60 일치를수령할수있습니다. 이는다음절ó에대해담당의사나기타처방자와상담할시간을주기위한것입니다. 8. 특정약이의약품목록에있는지어떻게확인하나요? 의약품을 û는방법은다음의 2 가지입니다. 알파벳순서로검색 ( 의약품의스펠링을아는경우 ), 또는 의학적증상으로검색. 알파벳순서로찾으려면, 73 페이지의알파벳순서목록섹션으로가십시오. 그다음목록에서원하는약의이름을찾으십시오. 의학적증상으로 û 으려면 1 ÿ 이지의 ý 의학적증상 ñ 의약품목록 þ 이라는절을 û 으십시오. 이절의약들은치료를하는의학적증상종류에따라범주 ñ 로묶 ø 있습니다. 예를들어, 심장 증상이있을경우, 해당카테고리에서 Beta-Blockers 를 û 아보아야합니다. ø 기에서심장 증상을치료할의약품을 û 을수있습니다. 9. 사용하려는약이의약품목록에없을경우어떻게하나요? 귀하가 û는약이저희처방약리스트에없을경우저희가입자서비스에 1-855-675-7630(TTY/TDD: 711) 로전화주십시오. 연중무휴오전 8 시에서오후 8 시까지통화가가능합니다. HealthfirstAbsoluteCare FIDA 플랜에서귀하가 û는약품에대한보험커버리지를제공하지 ô을경우다음중한가지를시도해보실수있습니다. 가입자서비스부에연락하ø 원하는의약품ö ò사한약의목록을요청하십시오. 이목록을담당의사나기타처방자에게보ø주시면, 의약품목록에서원하시는약ö ò사한약을처방해줄수있을것입니다. 또는 플랜이나통합팀 (IDT) 에게이약의보장에대해예외를인정하도록요청할수있습니다. 예외에대한자세한정보는질문 11 을참조해주십시오. 질문이있으시면저희 HealthfirstAbsoluteCare FIDA 플랜으로전화주시기바랍니다. 전화번호는 1-855-675-7630(TTY/TDD: 711) 이고연중무휴오전 8 시에서오후 8 시까지통화가능합니다. 통화는언제나무료이고좀더자세한정보를원하시면저희웹사이트 www.healthfirst.org/mmp 를방문해주세요. ix

10. Healthfirst AbsoluteCare FIDA Plan 의신규가입자인데의약품목록에서원하는약을 û 지못했거나약을구하는데문제가있을경우어떻게하나요? 저희가도와드릴수있습니다. 귀하가 Healthfirst AbsoluteCare FIDA Plan 에가입한처음 90 일 동안은플랜이최고 90 일치의임시분을보장해야합니다. 이는그기간에담당의사나기타 처방자와상담할수있도록하기위한것입니다. 귀하의담당의사또는처방약사는처방약 리스트상에서다른 ò 사약품을 û 아줄수있습니다. 또는저희에게예외결정을요청할수도 있습니다. 다음에해당하는경우 90 일치의임시분을보장합니다. 의약품목록에없는약을복용하고있음, 또는 건강보험규칙에따라처방자가지시한양을수령할수없음, 또는 해당의약품은 Healthfirst AbsoluteCare FIDA Plan 또는담당통합팀 (IDT) 의사전승인을 받아야함, 또는 단계적치료법제한이적용되는약을복용하고있음. 간호시설이나기타장기요양원에거주하고있는경우, 처방약을최대 93 일치까지리필할수 있습니다. 플랜에서귀하의첫 93 일동안 ø 러 ó 례해당약을리필할수있습니다. 그동안 처방자는의약품목록에있는약으로변경하거나예외를요청할수있습니다. 비장기간호치료수준변경 비 LTC 거주자의경우, 전환이자동으로이루어질수있습니다.. 그렇지 ô 으면약국에서 치료수준전환요청을제출하기위해조치를취할것입니다. 장기요양시설거주자가아닌경우파트 D 약품에대한최고 30 일까지의비상약품공급 결정이내려질수있습니다. 또최대처방약제미만의분량만을필요로할경우는최고 90 일까지의누적처방분량이허용됩니다. 이러한플랜제한은혜택설계에따라보다클수있으며처방된분량에따라제한을 받습니다. 장기간호치료수준변경 질문이있으시면저희 HealthfirstAbsoluteCare FIDA 플랜으로전화주시기바랍니다. 전화번호는 1-855-675-7630(TTY/TDD: 711) 이고연중무휴오전 8 시에서오후 8 시까지통화가능합니다. 통화는언제나무료이고좀더자세한정보를원하시면저희웹사이트 www.healthfirst.org/mmp 를방문해주세요. x

LTC 거주자의경우약국은전환허가를요청할수있고새로운입원자에대해너무빠른리필거절을하지 ô도록요청할수있습니다. 치료수준전환은 CMS 지침에서요구하는예외가적용되고 31일치조제로제한되는경구투ø 브랜드고형약제를제외하고최소 93일치가허용됩니다. 치료수준변경이적용되는모든가입자의경우투ø량변경이 " 조기리필 " 또는 " 너무빠른리필 " 거절을야기하는경우, 약국은헬프데스크로전화해취소를얻을수있습니다. 이러한플랜제한은혜택설계에따라보다클수있으며처방된분량에따라제한을받습니다. 11. 원하는의약품을보장하도록예외를요청할수있나요? 예. 귀하는 Healthfirst AbsoluteCare FIDA Plan 이나통합팀 (IDT) 에게의약품목록에없는약에대한보장예외를요청할수있습니다. 또한 Healthfirst AbsoluteCare FIDA Plan 이나담당 IDT 에게현재약에대한규칙을변경하도록요청할수도있습니다. 예를들어, Healthfirst AbsoluteCare FIDA Plan 은보장하는의약품의양을제한할수있습니다. 현재의약품에한도가있을경우, 저희나담당 IDT 에게한도를변경하ø 더많은양을보장하도록요청할수있습니다. 기타예 : 저희나담당 IDT 에게단계ñ 치료법제한이나사전승인요건을없애도록요청하실수있습니다. 12. 예외를인정받으려면얼마나걸리나요? 우선 Healthfirst AbsoluteCare FIDA Plan 이나담당통합팀 (IDT) 은예외요청을뒷받침하는진술서를처방자로부터받아야합니다. 저희가의견서를접수한후부터예외신청에대한결정을 72 시간내에받아보실수있습니다. 가입자나처방자가결정을통지받을때까지 72 시간을기다리면건강에해로울수있다고생각할경우, 신속예외를요청할수있습니다. 이것을빠른결정이라고합니다. 귀하의처방약사가귀하의요청을입증하는서류를저희에게제출할경우서류접수후 24 시간내에결정을받아보실수있습니다. 질문이있으시면저희 HealthfirstAbsoluteCare FIDA 플랜으로전화주시기바랍니다. 전화번호는 1-855-675-7630(TTY/TDD: 711) 이고연중무휴오전 8 시에서오후 8 시까지통화가능합니다. 통화는언제나무료이고좀더자세한정보를원하시면저희웹사이트 www.healthfirst.org/mmp 를방문해주세요. xi

13. 예외는어떻게요청하나요? 예외를요청하려면담당건강관리자에게문의하십시오. 담당건강관리자는귀하및서비스 제공자와협력하 ø 예외요청을도와드릴것입니다. 14. 복제약이란무엇인가요? 복제약이란브랜드약ö 동일한 ð분으로만든약입니다. 일반적으로브랜드약보다비용이저렴하며익숙하지 ô은이름을가지고있습니다. 복제약은식품의약국 (FDA) 의승인을받았습니다. Healthfirst AbsoluteCare FIDA Plan 은브랜드약ö 복제약을모두보장합니다. 15. OTC 약이란무엇인가요? OTC 는 ý처방전없이구입가능한약þ(over-the-counter) 을말합니다. Healthfirst AbsoluteCare FIDA Plan 은귀하의서비스제공자가처방약으로처방한일부 OTC 약을보장합니다. 보장되는 OTC 약을확인하려면 Healthfirst AbsoluteCare FIDA Plan 의약품목록을참조해주시기바랍니다. 16. Healthfirst AbsoluteCare FIDA Plan 은 OTC 비의약품품목을보장하나요? HealthfirstAbsoluteCare FIDA 플랜은처방없이살수있는비의약품에대해서도귀하의 의료서비스제공자가이를처방전에기입한경우에는보험커버리지를제공합니다. 처방이 불필요한비의약품의예로는섬 ò 보충제, 거즈, 알코올면봉등입니다. 보장되는 OTC 비의약품품목을확인하려면 Healthfirst AbsoluteCare FIDA Plan 의약품목록을 참조해주시기바랍니다. 17. 자기부담금이란무엇인가요? 질문이있으시면저희 HealthfirstAbsoluteCare FIDA 플랜으로전화주시기바랍니다. 전화번호는 1-855-675-7630(TTY/TDD: 711) 이고연중무휴오전 8 시에서오후 8 시까지통화가능합니다. 통화는언제나무료이고좀더자세한정보를원하시면저희웹사이트 www.healthfirst.org/mmp 를방문해주세요. xii

의약품목록에있는약의자기부담금은귀하에게부 ö 되지 ô 습니다. 18. 약품군이란무엇인가요? 등급 (tiers) 은처방약리스트상에상이한약품들이분류되는방식을의미합니다. 동플랜의 처방약리스트에있는모든약품은세등급으로나뉘어있습니다. 어 ü 등급에속하든모든 약품은무료로제공됩니다. 1 군에는 (Medicare) 복제약이포함됩니다. 2 군에는 (Medicare) 브랜드약이포함됩니다. 3 군에는비 Medicare(Medicaid) 약이포함됩니다. 질문이있으시면저희 HealthfirstAbsoluteCare FIDA 플랜으로전화주시기바랍니다. 전화번호는 1-855-675-7630(TTY/TDD: 711) 이고연중무휴오전 8 시에서오후 8 시까지통화가능합니다. 통화는언제나무료이고좀더자세한정보를원하시면저희웹사이트 www.healthfirst.org/mmp 를방문해주세요. xiii

보장약목록 아래의보장의약품목록은 Healthfirst AbsoluteCare FIDA Plan 이보장하는의약품에대한정 보가포함되어있습니다. 목록에서원하는약을찾지못한경우, 73 페이지에서시작되는색인 에서찾아보시기바랍니다. ó 트의첫번째열에는의약품이름이있습니다. 브랜드약은대문자로표기되어있으며 ( 예 : CIPRO) 복제약은기울임 ù 의소문자 ( 예 : ciprofloxacin hcl) 로표기되어있습니다. 사용열에있는필요한조치, 제한또는한도에대한정보는귀하의약에적용되는 Healthfirst AbsoluteCare FIDA Plan 규칙이있는지알려줍니다. 참고 : 약옆에있는 ý *þ 기호는해당약이 ý 파트 D 의약품 þ 이아니라는것을의미합니다. 이러한 의약품에는서로다른이의제기규칙이있습니다. 이의제기는보장범위에문제가있다고 생각할경우보장범위결정을검토하고변경하도록요청하는공식적인방법입니다. 예를들어, Healthfirst AbsoluteCare FIDA Plan 이나통합팀 (IDT) 은귀하가원하는약을보장하지 ô 도록 결정하거나 Medicare 또는 Medicaid 가보장하지 ô 도록결정할수있습니다. 결정불복에따른 항소를하길원하시고그방법을문의하시려면저희가입자서비스에전화해주시기바랍니다. 전화번호는 1-855-675-7630(TTY/TDD: 711) 이고연중무휴오전 8 시에서오후 8 시까지통화 가능합니다. 또는독립소비자보호네트워크 (ICAN) 에 1-844-614-8800 으로전화하 ø 문의해 주십시오.( TTY 사용자 : 711, 전화를건후녹음메시지를따라 844-614-8800 으로전화하세요.) 또한가입자핸드북을통해이의신청방법을확인하실수도있습니다. ý 필요한조치, 제한또는한도 þ 열에서사용된코드의의미는다음 ö 같습니다. * = Medicaid 의약품이며이의신청시다른규칙이있음 NM = 우편주문불가능 : 우편주문을통해구입할수없는약 B/D = 파트 B 또는파트 D 약일수있음 LA = 사용제한 : 처방전이있어야만하거나약사가약일람표및규약에따라감독이나중재를해야만판매가능한약 PA = 사전허가 ( 승인 ): 약을구입하기전에플랜이나통합팀 (IDT) 의승인을받아야함. QL = 수량한도 : 보장되는약의수량에한도가있는경우 ST = 단계 ñ 치료법 : 이치료법을실시하기전에가입자는다른약을먼저시도해야함 질문이있으시면저희 HealthfirstAbsoluteCare FIDA 플랜으로전화주시기바랍니다. 전화번호는 1-855-675-7630(TTY/TDD: 711) 이고연중무휴오전 8 시에서오후 8 시까지통화가능합니다. 통화는언제나무료이고좀더자세한정보를원하시면저희웹사이트 www.healthfirst.org/mmp 를방문해주세요. xiv

의학적 증상에 따른 의약품 목록이 절의 약들은 치료를 하는 의학적 증상 종류에 따라 범주ñ로 묶ø 있습니다 예를 들어 심장 증상이 있을 경우 해당 카테고리에서 를 û아보아야 합니다 ø기에서 심장 증상을 치료할 의약품을 û을 수 있습니다. 질문이있으시면저희 HealthfirstAbsoluteCare FIDA 플랜으로전화주시기바랍니다. 전화번호는 1-855-675-7630(TTY/TDD: 711) 이고연중무휴오전 8 시에서오후 8 시까지통화가능합니다. 통화는언제나무료이고좀더자세한정보를원하시면저희웹사이트 www.healthfirst.org/mmp 를방문해주세요. xv

NY_CY17_2T_MMP eff 11/01/2017 진통제 - 통증과염증을치료하기위한약 통풍 - 통풍치료약 allopurinol tab 1 $0 colchicine w/ probenecid 1 $0 COLCRYS 2 $0 QL (120 tabs / 30 probenecid 1 $0 ULORIC 2 $0 ST 기타 acetaminophen CAPS 3 $0 NM; * acetaminophen CHEW 3 $0 NM; * acetaminophen LIQD 3 $0 NM; * acetaminophen SOLN 3 $0 NM; * acetaminophen SUPP 120mg, 3 $0 NM; * 325mg, 650mg ACETAMINOPHEN SUPP 120mg, 3 $0 NM; * 325mg, 650mg acetaminophen SUSP 3 $0 NM; * acetaminophen TABS 3 $0 NM; * acetaminophen TBCR 3 $0 NM; * acetaminophen TBDP 3 $0 NM; * aspirin CHEW 3 $0 NM; * aspirin SUPP 300mg, 600mg 3 $0 NM; * aspirin TABS 3 $0 NM; * aspirin TBEC 3 $0 NM; * aspirin buffered (cal carb-mag 3 $0 NM; * carb-mag oxide) FEVERALL INFANTS 3 $0 NM; * NSAIDS -통증과염증을치료하기위한약 celecoxib CAPS 50mg 1 $0 QL (240 caps / 30 celecoxib CAPS 100mg 1 $0 QL (120 caps / 30 celecoxib CAPS 200mg 1 $0 QL (60 caps / 30 celecoxib CAPS 400mg 1 $0 QL (30 caps / 30 diclofenac potassium 1 $0 QL (120 tabs / 30 diclofenac sodium TB24 1 $0 diclofenac sodium TBEC 1 $0 PA -사전허가 ( 승인 ) QL -수량한도 ST -단계별치료법 NM - 우편주문불가능 B/D -파트 B 또는파트 D 약일수있음 LA -사용제한 1

diflunisal 1 $0 etodolac 1 $0 etodolac er 1 $0 flurbiprofen TABS 1 $0 ibuprofen CAPS 3 $0 NM; * ibuprofen SUSP 100mg/5ml 1 $0 ibuprofen SUSP 100mg/5ml 3 $0 NM; * ibuprofen TABS 200mg 3 $0 NM; * ibuprofen TABS 400mg, 600mg, 1 $0 800mg ketoprofen CAPS 1 $0 MELOXICAM SUSP 1 $0 meloxicam TABS 1 $0 nabumetone TABS 1 $0 naproxen SUSP; TABS; TBEC 1 $0 naproxen sodium TABS 275mg, 1 $0 550mg piroxicam CAPS 1 $0 sulindac TABS 1 $0 오피오이드진통제 - 통증치료제 acetaminophen w/ codeine SOLN 1 $0 QL (5000 ml / 30 acetaminophen w/ codeine TABS 1 $0 QL (400 tabs / 30 butorphanol tartrate SOLN 1 $0 1mg/ml, 2mg/ml BUTRANS 5mcg/hr 2 $0 QL (16 patches / 28 BUTRANS 10mcg/hr 2 $0 QL (8 patches / 28 BUTRANS 15mcg/hr, 20mcg/hr 2 $0 QL (4 patches / 28 BUTRANS 7.5MCG/HR 2 $0 QL (8 patches / 28 nalbuphine hcl SOLN 1 $0 tramadol hcl TABS 1 $0 QL (240 tabs / 30 tramadol-acetaminophen 1 $0 QL (240 tabs / 30 오피오이드진통제, CII - 통증치료제 DURAMORPH 1 $0 B/D endocet 1 $0 QL (360 tabs / 30 PA -사전허가 ( 승인 ) QL -수량한도 ST -단계별치료법 NM - 우편주문 불가능 B/D -파트 B 또는파트 D 약일수있음 LA -사용제한 2

fentanyl citrate LPOP 2 $0 QL (120 lozenges / 30, PA fentanyl patch 12 mcg/hr 1 $0 QL (10 patches / 30 fentanyl patch 25 mcg/hr 1 $0 QL (10 patches / 30 fentanyl patch 50 mcg/hr 1 $0 QL (10 patches / 30, PA fentanyl patch 75 mcg/hr 1 $0 QL (10 patches / 30, PA fentanyl patch 100 mcg/hr 1 $0 QL (10 patches / 30, PA FENTORA 2 $0 QL (120 tabs / 30, PA hydroco/apap tab 5-325mg 1 $0 QL (360 tabs / 30 hydroco/apap tab 7.5-325 1 $0 QL (360 tabs / 30 hydroco/apap tab 10-325mg 1 $0 QL (360 tabs / 30 hydrocodone-acetaminophen 7.5-1 $0 QL (5400 ml / 30 325 mg/15ml hydrocodone-ibuprofen tab 7.5-1 $0 QL (150 tabs / 30 200 mg hydromorphone hcl LIQD 1 $0 hydromorphone hcl SOLN 1 $0 B/D 10mg/ml, 50mg/5ml, 500mg/50ml hydromorphone hcl TABS 1 $0 QL (270 tabs / 30 HYSINGLA ER 20mg, 30mg, 2 $0 QL (60 tabs / 30 40mg, 60mg HYSINGLA ER 80mg, 100mg, 2 $0 QL (30 tabs / 30 120mg lorcet hd tab 10-325mg 1 $0 QL (360 tabs / 30 lorcet plus tab 7.5-325 1 $0 QL (360 tabs / 30 lorcet tab 5-325mg 1 $0 QL (360 tabs / 30 methadone hcl CONC 1 $0 QL (120 ml / 30 methadone hcl SOLN 5mg/5ml, 1 $0 QL (600 ml / 30 10mg/5ml methadone hcl 5mg 1 $0 QL (240 tabs / 30 PA -사전허가 ( 승인 ) QL -수량한도 ST -단계별치료법 NM - 우편주문 3 불가능 B/D -파트 B 또는파트 D 약일수있음 LA -사용제한

methadone hcl 10mg 1 $0 QL (240 tabs / 30 morphine ext-rel tab 15mg, 30mg, 1 $0 QL (90 tabs / 30 60mg, 100mg morphine ext-rel tab 200mg 1 $0 QL (60 tabs / 30 MORPHINE SUL INJ 1MG/ML 1 $0 B/D MORPHINE SUL INJ 4MG/ML 1 $0 B/D MORPHINE SUL INJ 10MG/ML 1 $0 B/D MORPHINE SUL INJ 15MG/ML 1 $0 B/D MORPHINE SULFATE SOLN 1 $0 B/D 2mg/ml, 8mg/ml, 150mg/30ml morphine sulfate SOLN.5mg/ml, 1 $0 B/D 1mg/ml, 4mg/ml, 8mg/ml MORPHINE SULFATE TABS 1 $0 QL (180 tabs / 30 MORPHINE SULFATE ORAL SOL 1 $0 oxycodone hcl CAPS 1 $0 QL (180 caps / 30 oxycodone hcl CONC 1 $0 OXYCODONE HCL SOLN 1 $0 oxycodone hcl TABS 1 $0 QL (180 tabs / 30 oxycodone w/ acetaminophen 2.5-1 $0 QL (360 tabs / 30 325mg oxycodone w/ acetaminophen 5-1 $0 QL (360 tabs / 30 325mg oxycodone w/ acetaminophen 7.5-1 $0 QL (360 tabs / 30 325mg oxycodone w/ acetaminophen 10-1 $0 QL (360 tabs / 30 325mg oxycodone w/ acetaminophen soln 1 $0 QL (1800 ml / 30 OXYCONTIN 2 $0 QL (120 tabs / 30 마취제 - 감각을없애는약국부마취제 lidocaine hcl (local anesth.) 1 $0 B/D lidocaine inj 0.5% 1 $0 B/D lidocaine inj 1% 1 $0 B/D lidocaine inj 1.5% 1 $0 B/D lidocaine inj 2% 1 $0 B/D 항감염약 - 감염을치료하기위한약항균제 - 기타 PA -사전허가 ( 승인 ) QL -수량한도 ST -단계별치료법 NM - 우편주문 4 불가능 B/D -파트 B 또는파트 D 약일수있음 LA -사용제한

amikacin sulfate SOLN 1 $0 gentamicin in saline 1 $0 gentamicin sulfate SOLN 1 $0 neomycin sulfate TABS 1 $0 paromomycin sulfate CAPS 1 $0 streptomycin sulfate SOLR 1 $0 sulfadiazine TABS 2 $0 tobramycin NEBU 2 $0 NM, PA tobramycin inj 1.2 gm/30ml 1 $0 tobramycin inj 1.2gm 2 $0 tobramycin inj 10mg/ml 1 $0 tobramycin inj 40mg/ml 1 $0 tobramycin inj 80mg/2ml 1 $0 항감염약 - 기타 ALBENZA 2 $0 ALINIA 2 $0 atovaquone SUSP 2 $0 AZACTAM IN ISO-OSMOTIC DE 2 $0 AZACTAM/DEX INJ 2GM 2 $0 aztreonam 1 $0 BILTRICIDE 2 $0 CAYSTON 2 $0 NM, LA, PA clindamycin cap 75mg 1 $0 clindamycin cap 300mg 1 $0 clindamycin hcl cap 150 mg 1 $0 clindamycin phosphate SOLN 1 $0 clindamycin phosphate in d5w 1 $0 CLINDAMYCIN PHOSPHATE IN 2 $0 NACL clindamycin phosphate inj 1 $0 clindamycin sol 75mg/5ml 1 $0 colistimethate sodium SOLR 1 $0 CUBICIN 2 $0 dapsone TABS 1 $0 daptomycin 2 $0 emverm 2 $0 imipenem-cilastatin 1 $0 INVANZ 2 $0 ivermectin TABS 1 $0 linezolid SOLN 2 $0 LINEZOLID SUSR; TABS 2 $0 PA -사전허가 ( 승인 ) QL -수량한도 ST -단계별치료법 NM - 우편주문불가능 B/D -파트 B 또는파트 D 약일수있음 LA -사용제한 5

LINEZOLID IN SODIUM CHLORIDE 2 $0 meropenem 1 $0 methenamine hippurate 1 $0 metronidazole TABS 1 $0 metronidazole in nacl 1 $0 NEBUPENT 2 $0 B/D nitrofurantoin macrocrystal 50mg, 2 $0 PA; PA applies if 65 100mg years and older after a 90 day supply in a calendar year nitrofurantoin monohyd macro 2 $0 PA; PA applies if 65 years and older after a 90 day supply in a calendar year PENTAM 300 2 $0 SIVEXTRO 2 $0 sulfamethoxazole-trimethop ds 1 $0 sulfamethoxazole-trimethoprim 1 $0 sulfamethoxazole-trimethoprim inj 1 $0 SYNERCID 2 $0 TIGECYCLINE 2 $0 trimethoprim TABS 1 $0 TYGACIL 2 $0 vancomycin hcl CAPS 2 $0 vancomycin hcl SOLR 1 $0 VANCOMYCIN IN NACL 2 $0 항진균제 - 세균감염을치료하기위한약 ABELCET 2 $0 B/D AMBISOME 2 $0 B/D amphotericin b SOLR 1 $0 B/D CANCIDAS 2 $0 CASPOFUNGIN ACETATE 2 $0 fluconazole SUSR; TABS 1 $0 fluconazole in dextrose 1 $0 fluconazole inj nacl 100 1 $0 fluconazole inj nacl 200 1 $0 fluconazole inj nacl 400 1 $0 flucytosine CAPS 2 $0 griseofulvin microsize 1 $0 griseofulvin ultramicrosize 1 $0 itraconazole CAPS 1 $0 PA ketoconazole TABS 1 $0 PA PA -사전허가 ( 승인 ) QL -수량한도 ST -단계별치료법 NM - 우편주문불가능 B/D -파트 B 또는파트 D 약일수있음 LA -사용제한 6

MYCAMINE 2 $0 NOXAFIL SUSP; TBEC 2 $0 nystatin TABS 1 $0 terbinafine hcl TABS 1 $0 QL (90 tabs / 365 voriconazole SOLR 1 $0 voriconazole SUSR; TABS 2 $0 항말라리아제 - 말라리아치료제 atovaquone-proguanil hcl 1 $0 chloroquine phosphate TABS 1 $0 COARTEM 2 $0 mefloquine hcl 1 $0 PRIMAQUINE PHOSPHATE 2 $0 quinine sulfate CAPS 1 $0 PA 항레트로바이러스제 - HIV/AIDS 감염을억제하는약 abacavir sulfate 1 $0 APTIVUS 2 $0 CRIXIVAN 2 $0 didanosine 1 $0 EDURANT 2 $0 EMTRIVA 2 $0 FUZEON 2 $0 NM INTELENCE 2 $0 INVIRASE 2 $0 ISENTRESS 2 $0 ISENTRESS HD 2 $0 lamivudine 1 $0 LEXIVA 2 $0 NEVIRAPINE SUSP 1 $0 nevirapine TABS; TB24 1 $0 NORVIR 2 $0 PREZISTA 2 $0 RESCRIPTOR 2 $0 RETROVIR IV INFUSION 2 $0 REYATAZ 2 $0 SELZENTRY 2 $0 stavudine 1 $0 SUSTIVA 2 $0 TIVICAY 2 $0 TYBOST 2 $0 VIDEX PEDIATRIC 2 $0 PA -사전허가 ( 승인 ) QL -수량한도 ST -단계별치료법 NM - 우편주문불가능 B/D -파트 B 또는파트 D 약일수있음 LA -사용제한 7

VIRACEPT 2 $0 VIRAMUNE SUSP 2 $0 VIREAD 2 $0 ZERIT SOLR 2 $0 ZIAGEN SOLN 2 $0 zidovudine 1 $0 병합항레트로바이러스제 - HIV/AIDS 감염을억제하는약 ABACAVIR SULFATE-LAMIVUDINE 2 $0 abacavir sulfate-lamivudine- 2 $0 zidovudine ATRIPLA 2 $0 COMPLERA 2 $0 DESCOVY 2 $0 EVOTAZ 2 $0 GENVOYA 2 $0 KALETRA SOL 2 $0 KALETRA TAB 100-25MG 2 $0 KALETRA TAB 200-50MG 2 $0 lamivudine-zidovudine 1 $0 lopinavir-ritonavir 2 $0 ODEFSEY 2 $0 PREZCOBIX 2 $0 STRIBILD 2 $0 TRIUMEQ 2 $0 TRUVADA TAB 100-150 2 $0 QL (60 tabs / 30 TRUVADA TAB 133-200 2 $0 QL (30 tabs / 30 TRUVADA TAB 167-250 2 $0 QL (30 tabs / 30 TRUVADA TAB 200-300 2 $0 QL (30 tabs / 30 항결핵제 - 결핵치료제 CAPASTAT SULFATE 2 $0 cycloserine CAPS 2 $0 ethambutol hcl TABS 1 $0 isoniazid TABS 1 $0 isoniazid inj 100 mg/ml 1 $0 isoniazid syp 50mg/5ml 1 $0 paser d/r 2 $0 PRIFTIN 2 $0 pyrazinamide TABS 1 $0 rifabutin 1 $0 rifampin CAPS; SOLR 1 $0 RIFATER 2 $0 PA -사전허가 ( 승인 ) QL -수량한도 ST -단계별치료법 NM - 우편주문불가능 B/D -파트 B 또는파트 D 약일수있음 LA -사용제한 8

SIRTURO 2 $0 LA, PA TRECATOR 2 $0 항바이러스제 -세균감염을치료하는약 acyclovir CAPS 1 $0 acyclovir SUSP 1 $0 acyclovir TABS 1 $0 acyclovir sodium 1 $0 B/D adefovir dipivoxil 2 $0 BARACLUDE SOLN 2 $0 DAKLINZA 2 $0 NM, PA entecavir 2 $0 EPCLUSA 2 $0 NM, PA EPIVIR HBV SOLN 2 $0 famciclovir TABS 1 $0 ganciclovir inj 500mg 1 $0 B/D HARVONI 2 $0 NM, PA lamivudine (hbv) 1 $0 MAVYRET 2 $0 NM, PA moderiba tab 200mg 1 $0 NM oseltamivir phosphate 1 $0 PEGASYS 2 $0 NM, PA PEGASYS PROCLICK 2 $0 NM, PA REBETOL SOLN 2 $0 NM RELENZA DISKHALER 2 $0 ribasphere CAPS 1 $0 NM ribasphere TABS 200mg 1 $0 NM ribasphere TABS 400mg, 600mg 2 $0 NM ribavirin 200mg 1 $0 NM rimantadine hydrochloride 1 $0 SOVALDI 2 $0 NM, PA TAMIFLU SUSR 2 $0 TYZEKA 2 $0 valacyclovir hcl TABS 1 $0 VALCYTE SOLR 2 $0 valganciclovir hcl 2 $0 VEMLIDY 2 $0 VOSEVI 2 $0 NM, PA ZEPATIER 2 $0 NM, PA CEPHALOSPORINS -감염을치료하는약 cefaclor 1 $0 cefaclor monohydrate er 2 $0 PA -사전허가 ( 승인 ) QL -수량한도 ST -단계별치료법 NM - 우편주문불가능 B/D -파트 B 또는파트 D 약일수있음 LA -사용제한 9

cefadroxil 1 $0 CEFAZOLIN IN DEXTROSE 2 $0 2GM/100ML-4% cefazolin inj 1 $0 cefazolin sodium SOLR 1gm, 1 $0 20gm cefazolin sodium 1 gm/50ml 2 $0 cefdinir 1 $0 cefepime hcl 1 $0 cefixime 1 $0 cefotaxime sodium 1gm, 2gm, 1 $0 500mg cefoxitin sodium 1 $0 cefpodoxime proxetil 1 $0 cefprozil 1 $0 ceftazidime SOLR 1 $0 CEFTAZIDIME/DEXTROSE 2 $0 ceftriaxone sodium SOLR 1gm, 1 $0 2gm, 10gm, 250mg, 500mg cefuroxime axetil 1 $0 cefuroxime sodium 1 $0 cephalexin CAPS 250mg, 500mg 1 $0 cephalexin SUSR 1 $0 SUPRAX CAPS 2 $0 suprax CHEW 2 $0 SUPRAX SUSR 500mg/5ml 2 $0 tazicef SOLR 1 $0 tazicef vial 1 $0 TEFLARO 2 $0 ERYTHROMYCINS/MACROLIDES -감염을치료하는약 AZITHROMYCIN PACK 1 $0 azithromycin SOLR; SUSR; TABS 1 $0 clarithromycin TABS 1 $0 clarithromycin er 1 $0 clarithromycin for susp 1 $0 DIFICID 2 $0 e.e.s. 1 $0 ery-tab 1 $0 erythrocin lactobionate 2 $0 erythrocin stearate 1 $0 erythromycin base 1 $0 erythromycin cap 250mg ec 1 $0 PA -사전허가 ( 승인 ) QL -수량한도 ST -단계별치료법 NM - 우편주문불가능 B/D -파트 B 또는파트 D 약일수있음 LA -사용제한 10

erythromycin ethylsuccinate TABS 1 $0 FLUOROQUINOLONES -감염을치료하는약 ciprofloxacin SUSR 1 $0 ciprofloxacin er 1 $0 ciprofloxacin hcl tab 1 $0 ciprofloxacin in d5w 1 $0 ciprofloxacin inj 1 $0 levofloxacin TABS 1 $0 levofloxacin in d5w 1 $0 levofloxacin inj 25mg/ml 1 $0 levofloxacin oral soln 25 mg/ml 1 $0 moxifloxacin hcl TABS 1 $0 PENICILLINS -감염을치료하는약 amoxicillin 1 $0 amoxicillin & pot clavulanate 1 $0 ampicillin & sulbactam sodium 1 $0 ampicillin cap 250 mg 1 $0 ampicillin cap 500 mg 1 $0 ampicillin inj 1 $0 ampicillin sodium 1 $0 ampicillin susp 1 $0 BICILLIN L-A 2 $0 dicloxacillin sodium 1 $0 nafcillin sodium 1 $0 oxacillin sodium 1gm, 2gm 1 $0 oxacillin sodium 10gm 2 $0 PENICILLIN G POT IN DEXTROSE 2 $0 penicillin g procaine 2 $0 penicillin g sodium 1 $0 penicillin v potassium 1 $0 penicilln gk inj 5mu 1 $0 penicilln gk inj 20mu 1 $0 pfizerpen-g 1 $0 piperacillin sodium-tazobactam 1 $0 sodium piperacillin/tazobactam 1 $0 TETRACYCLINES -감염을치료하는약 doxy 1 $0 doxycycline (monohydrate) CAPS 1 $0 50mg, 100mg doxycycline (monohydrate) TABS 1 $0 PA -사전허가 ( 승인 ) QL -수량한도 ST -단계별치료법 NM - 우편주문불가능 B/D -파트 B 또는파트 D 약일수있음 LA -사용제한 11

doxycycline hyclate CAPS 1 $0 doxycycline hyclate SOLR 1 $0 doxycycline hyclate TABS 20mg, 1 $0 100mg minocycline hcl CAPS 1 $0 morgidox cap 1x50mg 1 $0 항종양제 - 암을치료하는약알킬화제 BENDEKA 2 $0 B/D, NM BICNU 2 $0 B/D busulfan 2 $0 B/D BUSULFEX 2 $0 B/D CYCLOPHOSPHAMIDE CAPS 2 $0 B/D cyclophosphamide SOLR 2 $0 B/D dacarbazine 1 $0 B/D EMCYT 2 $0 GLEOSTINE 2 $0 HEXALEN 2 $0 IFEX INJ 3GM 2 $0 B/D ifosfamide inj 1gm 1 $0 B/D ifosfamide inj 1gm/20ml 1 $0 B/D IFOSFAMIDE INJ 3GM 2 $0 B/D ifosfamide inj 3gm/60ml 1 $0 B/D LEUKERAN 2 $0 melphalan hcl 2 $0 B/D MUSTARGEN 2 $0 B/D TREANDA 2 $0 B/D, NM 안트라사이클린 adriamycin 1 $0 B/D daunorubicin hcl 1 $0 B/D doxorubicin hcl 1 $0 B/D doxorubicin hcl liposomal inj 2 $0 B/D 2mg/ml doxorubicin inj 50mg 1 $0 B/D epirubicin hcl 1 $0 B/D idarubicin hcl 2 $0 B/D 항생제 bleomycin sulfate 1 $0 B/D mitomycin SOLR 2 $0 B/D 항대사성물질 PA -사전허가 ( 승인 ) QL -수량한도 ST -단계별치료법 NM - 우편주문불가능 B/D -파트 B 또는파트 D 약일수있음 LA -사용제한 12

adrucil 1 $0 B/D ALIMTA 2 $0 B/D azacitidine 2 $0 B/D, NM cladribine 2 $0 B/D cytarabine 20mg/ml 1 $0 B/D fludarabine phosphate 1 $0 B/D fluorouracil SOLN 1 $0 B/D GEMCITABINE HCL SOLN 2 $0 B/D gemcitabine hcl SOLR 2 $0 B/D mercaptopurine TABS 1 $0 METHOTREXATE SODIUM 1 $0 B/D 50mg/2ml methotrexate sodium 50mg/2ml, 1 $0 B/D 100mg/4ml, 200mg/8ml, 250mg/10ml methotrexate sodium inj 1 $0 B/D NIPENT 2 $0 B/D PURIXAN 2 $0 NM TABLOID 2 $0 항유사분열제, TAXOIDS ABRAXANE 2 $0 B/D DOCEFREZ 2 $0 B/D DOCETAXEL 20mg/ml, 80mg/4ml, 2 $0 B/D 160mg/8ml docetaxel 80mg/4ml, 200mg/10ml2 $0 B/D DOCETAXEL 20MG/2ML 2 $0 B/D DOCETAXEL 160MG/16ML 2 $0 B/D DOCETAXEL SOLN 80MG/8ML 2 $0 B/D paclitaxel 1 $0 B/D TAXOTERE 80mg/4ml 2 $0 B/D 항유사분열제, VINCA ALKALOIDS vinblastine sulfate 2 $0 B/D vincasar 1 $0 B/D vincristine sulfate 1 $0 B/D vinorelbine tartrate 1 $0 B/D 생물학적반응조절제 AVASTIN 2 $0 NM, LA, PA BELEODAQ 2 $0 NM, PA ERIVEDGE 2 $0 NM, LA, PA FARYDAK 2 $0 NM, LA, PA HERCEPTIN 2 $0 NM, PA PA -사전허가 ( 승인 ) QL -수량한도 ST -단계별치료법 NM - 우편주문불가능 B/D -파트 B 또는파트 D 약일수있음 LA -사용제한 13

IBRANCE 2 $0 NM, LA, PA IDHIFA 2 $0 NM, LA, PA ISTODAX (OVERFILL) 2 $0 B/D, NM KADCYLA 2 $0 B/D, NM KEYTRUDA 2 $0 NM, PA KISQALI 2 $0 NM, PA KISQALI FEMARA 200 DOSE 2 $0 NM, PA KISQALI FEMARA 400 DOSE 2 $0 NM, PA KISQALI FEMARA 600 DOSE 2 $0 NM, PA LYNPARZA CAPS 2 $0 NM, LA, PA NINLARO 2 $0 NM, PA PROLEUKIN 2 $0 B/D, NM RITUXAN 2 $0 NM, LA, PA RITUXAN HYCELA 2 $0 NM, LA, PA RUBRACA 2 $0 NM, LA, PA TECENTRIQ 2 $0 NM, LA, PA VELCADE 2 $0 NM, PA VENCLEXTA 2 $0 NM, LA, PA VENCLEXTA STARTING PACK 2 $0 NM, LA, PA YERVOY 2 $0 NM, PA ZEJULA 2 $0 NM, LA, PA ZOLINZA 2 $0 NM, PA 호르몬성항종양제 anastrozole TABS 1 $0 bicalutamide 1 $0 DEPO-PROVERA INJ 400/ML 2 $0 B/D exemestane 1 $0 FARESTON 2 $0 FASLODEX 2 $0 B/D flutamide 1 $0 hydroxyprogesterone caproate 2 $0 B/D (antineoplastic) letrozole TABS 1 $0 leuprolide acetate KIT 1 $0 NM, PA LUPRON DEPOT (1-MONTH) 2 $0 NM, PA 3.75mg LUPRON DEPOT INJ 11.25MG (3-2 $0 NM, PA MONTH) LYSODREN 2 $0 megestrol ac sus 40mg/ml 2 $0 PA; PA if 65 years and older PA -사전허가 ( 승인 ) QL -수량한도 ST -단계별치료법 NM - 우편주문불가능 B/D -파트 B 또는파트 D 약일수있음 LA -사용제한 14

megestrol ac tab 20mg 2 $0 PA; PA if 65 years and older megestrol ac tab 40mg 2 $0 PA; PA if 65 years and older MEGESTROL SUS 625MG/5ML 2 $0 PA nilutamide 2 $0 SOLTAMOX 2 $0 tamoxifen citrate TABS 1 $0 TRELSTAR DEP INJ 3.75MG 2 $0 NM, PA TRELSTAR LA INJ 11.25MG 2 $0 NM, PA XTANDI 2 $0 NM, LA, PA ZYTIGA 2 $0 NM, LA, PA 키나제억제제 AFINITOR 2 $0 NM, PA AFINITOR DISPERZ 2 $0 NM, PA ALECENSA 2 $0 NM, LA, PA ALUNBRIG 2 $0 NM, LA, PA BOSULIF 2 $0 NM, PA CABOMETYX 2 $0 NM, LA, PA CAPRELSA 2 $0 NM, LA, PA COMETRIQ 2 $0 NM, LA, PA COTELLIC 2 $0 NM, LA, PA GILOTRIF TAB 20MG 2 $0 NM, LA, PA GILOTRIF TAB 30MG 2 $0 NM, LA, PA GILOTRIF TAB 40MG 2 $0 NM, LA, PA ICLUSIG 2 $0 NM, LA, PA imatinib mesylate 100mg 2 $0 QL (90 tabs / 30, NM, PA imatinib mesylate 400mg 2 $0 QL (60 tabs / 30, NM, PA IMBRUVICA CAP 140MG 2 $0 NM, LA, PA INLYTA 2 $0 NM, LA, PA IRESSA 2 $0 NM, LA, PA JAKAFI 2 $0 NM, LA, PA LENVIMA 8 MG DAILY DOSE 2 $0 NM, LA, PA LENVIMA 10 MG DAILY DOSE 2 $0 NM, LA, PA LENVIMA 14 MG DAILY DOSE 2 $0 NM, LA, PA LENVIMA 18 MG DAILY DOSE 2 $0 NM, LA, PA LENVIMA 20 MG DAILY DOSE 2 $0 NM, LA, PA LENVIMA 24 MG DAILY DOSE 2 $0 NM, LA, PA MEKINIST 2 $0 NM, LA, PA NERLYNX 2 $0 NM, LA, PA PA -사전허가 ( 승인 ) QL -수량한도 ST -단계별치료법 NM - 우편주문불가능 B/D -파트 B 또는파트 D 약일수있음 LA -사용제한 15

NEXAVAR 2 $0 NM, LA, PA RYDAPT 2 $0 NM, PA SPRYCEL 2 $0 NM, PA STIVARGA 2 $0 NM, LA, PA SUTENT 2 $0 NM, PA TAFINLAR 2 $0 NM, LA, PA TAGRISSO 2 $0 NM, LA, PA TARCEVA 2 $0 NM, LA, PA TASIGNA 2 $0 NM, PA TYKERB 2 $0 NM, LA, PA VOTRIENT 2 $0 NM, LA, PA XALKORI 2 $0 NM, LA, PA ZELBORAF 2 $0 NM, LA, PA ZYDELIG 2 $0 NM, LA, PA ZYKADIA 2 $0 NM, LA, PA 기타 bexarotene 2 $0 NM, PA DROXIA 2 $0 hydroxyurea CAPS 1 $0 LONSURF 2 $0 NM, PA MATULANE 2 $0 LA mitoxantrone hcl 1 $0 B/D, NM ODOMZO 2 $0 NM, LA, PA SYLATRON KIT 200MCG 2 $0 NM, PA SYLATRON KIT 300MCG 2 $0 NM, PA SYLATRON KIT 600MCG 2 $0 NM, PA SYNRIBO 2 $0 NM, PA tretinoin (chemotherapy) 2 $0 TRISENOX 2 $0 B/D 백금계제제 carboplatin 1 $0 B/D cisplatin 1 $0 B/D oxaliplatin 1 $0 B/D 보호제 AMIFOSTINE 2 $0 B/D dexrazoxane 2 $0 B/D ELITEK 2 $0 B/D FUSILEV 2 $0 B/D, NM leucovorin calcium SOLR 1 $0 B/D leucovorin calcium TABS 1 $0 leucovorin calcium for inj 500 mg 1 $0 B/D PA -사전허가 ( 승인 ) QL -수량한도 ST -단계별치료법 NM - 우편주문불가능 B/D -파트 B 또는파트 D 약일수있음 LA -사용제한 16

levoleucovorin calcium SOLN 2 $0 B/D, NM levoleucovorin calcium SOLR 2 $0 B/D, NM 50mg LEVOLEUCOVORIN CALCIUM SOLR 2 $0 B/D, NM 175mg mesna 1 $0 B/D MESNEX TABS 2 $0 국소이성화효소억제제 etoposide SOLN 1 $0 B/D irinotecan inj 40mg/2ml 1 $0 B/D irinotecan inj 100/5ml 1 $0 B/D irinotecan inj 500mg/25ml 1 $0 B/D toposar 1 $0 B/D TOPOTECAN HCL SOLN 2 $0 B/D topotecan hcl SOLR 2 $0 B/D 심혈관계 - 심장및순환질환을치료는약 억제제조합 - 고혈압을치료하는약 amlodipine--benazepril hcl cap 10-1 $0 20 mg amlodipine-benazepril hcl cap 2.5-1 $0 10 mg amlodipine-benazepril hcl cap 5-10 1 $0 mg amlodipine-benazepril hcl cap 5-20 1 $0 mg amlodipine-benazepril hcl cap 5-40 1 $0 mg amlodipine-benazepril hcl cap 10-1 $0 40mg benazepril & hydrochlorothiazide 1 $0 captopril & hydrochlorothiazide 1 $0 enalapril maleate & 1 $0 hydrochlorothiazide fosinopril sodium & 1 $0 hydrochlorothiazide lisinopril & hydrochlorothiazide 1 $0 moexipril-hydrochlorothiazide 1 $0 quinapril-hydrochlorothiazide 1 $0 ACE 억제제 - 고혈압을치료하는약 benazepril hcl TABS 1 $0 captopril TABS 1 $0 enalapril maleate TABS 1 $0 PA -사전허가 ( 승인 ) QL -수량한도 ST -단계별치료법 NM - 우편주문불가능 B/D -파트 B 또는파트 D 약일수있음 LA -사용제한 17

fosinopril sodium 1 $0 lisinopril TABS 1 $0 moexipril hcl 1 $0 perindopril erbumine 1 $0 quinapril hcl 1 $0 ramipril 1 $0 trandolapril 1 $0 ALDOSTERONE 수용체길항제 - 고혈압을치료하는약 eplerenone 1 $0 spironolactone TABS 1 $0 알파차단제 - 고혈압을치료하는약 doxazosin mesylate 1mg, 2mg, 1 $0 QL (30 tabs / 30 4mg doxazosin mesylate 8mg 1 $0 prazosin hcl 1 $0 terazosin hcl 1 $0 수용체길항제 - 고혈압을치료하는약 amlodipine besylate-olmesartan 1 $0 medoxomil amlodipine besylate-valsartan tab 5-1 $0 160 mg amlodipine besylate-valsartan tab 5-1 $0 320 mg amlodipine besylate-valsartan tab 10-1 $0 160 mg amlodipine besylate-valsartan tab 10-1 $0 320 mg amlodipine-valsartan- 1 $0 hydrochlorothiazide 5-160-12.5mg amlodipine-valsartan- 1 $0 hydrochlorothiazide 5-160-25mg amlodipine-valsartan- 1 $0 hydrochlorothiazide 10-160- 12.5mg amlodipine-valsartan- 1 $0 hydrochlorothiazide 10-160-25mg amlodipine-valsartan- 1 $0 hydrochlorothiazide 10-320-25mg candesartan cilexetil- 1 $0 hydrochlorothiazide ENTRESTO 2 $0 irbesartan-hydrochlorothiazide 1 $0 PA -사전허가 ( 승인 ) QL -수량한도 ST -단계별치료법 NM - 우편주문불가능 B/D -파트 B 또는파트 D 약일수있음 LA -사용제한 18

losartan-hydrochlorothiazide 1 $0 olmesartan medoxomil-amlodipine-1 $0 hydrochlorothiazide olmesartan medoxomil- 1 $0 hydrochlorothiazide telmisartan-hydrochlorothiazide 1 $0 valsartan & hctz tab 80-12.5mg 1 $0 valsartan & hctz tab 160-12.5mg 1 $0 valsartan & hctz tab 160-25mg 1 $0 valsartan & hctz tab 320-12.5mg 1 $0 valsartan & hctz tab 320-25mg 1 $0 ANGIOTENSIN II RECEPTOR ANTAGONISTS -수용체길항제 - 고혈압을 치료하는약 candesartan cilexetil 1 $0 irbesartan 1 $0 losartan potassium 1 $0 olmesartan medoxomil TABS 1 $0 telmisartan 1 $0 valsartan 1 $0 항부정맥제 - 심박조절제 amiodarone hcl 1 $0 disopyramide phosphate 2 $0 PA; PA if 65 years and older DOFETILIDE 1 $0 NM flecainide acetate 1 $0 mexiletine hcl 1 $0 MULTAQ 2 $0 NORPACE CR 2 $0 PA; PA if 65 years and older pacerone 1 $0 propafenone hcl 1 $0 propafenone hcl 12hr 1 $0 quinidine gluconate TBCR 1 $0 quinidine sulfate TABS 1 $0 sorine 1 $0 sotalol hcl 1 $0 sotalol hcl (afib/afl) 1 $0 항지혈제, HMG-CoA 환원효소억제제 - 고콜레스테롤을치료하는약 atorvastatin calcium TABS 1 $0 lovastatin 1 $0 pravastatin sodium 1 $0 PA -사전허가 ( 승인 ) QL -수량한도 ST -단계별치료법 NM - 우편주문불가능 B/D -파트 B 또는파트 D 약일수있음 LA -사용제한 19

rosuvastatin calcium 1 $0 QL (30 tabs / 30 simvastatin TABS 5mg, 10mg, 1 $0 20mg, 40mg simvastatin TABS 80mg 1 $0 QL (30 tabs / 30 항지혈제, 기타 - 고콜레스테롤을치료하는약 cholestyramine 1 $0 cholestyramine light 1 $0 colestipol hcl 1 $0 ezetimibe 1 $0 fenofibrate TABS 48mg, 54mg, 1 $0 145mg, 160mg fenofibrate micronized 67mg, 1 $0 134mg, 200mg gemfibrozil TABS 1 $0 JUXTAPID 2 $0 NM, LA, PA KYNAMRO 2 $0 NM, PA niacin er (antihyperlipidemic) 1 $0 QL (90 tabs / 30 500mg niacin er (antihyperlipidemic) 1 $0 750mg, 1000mg niacor 1 $0 omega-3-acid ethyl esters 1 $0 PRALUENT 2 $0 NM, PA prevalite 1 $0 triklo 1 $0 VASCEPA 2 $0 WELCHOL 2 $0 항지혈제, 기타 - 고콜레스테롤을치료하는약 atenolol & chlorthalidone 1 $0 bisoprolol & hydrochlorothiazide 1 $0 metoprolol & hctz tab 50-25mg 1 $0 metoprolol & hctz tab 100-25mg 1 $0 metoprolol & hctz tab 100-50mg 1 $0 propranolol & hydrochlorothiazide 1 $0 베타차단제 - 고혈압및심장질환을치료하는약 acebutolol hcl CAPS 1 $0 atenolol TABS 1 $0 bisoprolol fumarate 1 $0 BYSTOLIC 2 $0 carvedilol 1 $0 labetalol hcl TABS 1 $0 PA -사전허가 ( 승인 ) QL -수량한도 ST -단계별치료법 NM - 우편주문불가능 B/D -파트 B 또는파트 D 약일수있음 LA -사용제한 20

metoprolol succinate 1 $0 metoprolol tartrate SOCT 1 $0 metoprolol tartrate SOLN 1 $0 metoprolol tartrate TABS 25mg, 1 $0 50mg, 100mg nadolol TABS 1 $0 pindolol 1 $0 propranolol cap er 1 $0 propranolol hcl SOLN; TABS 1 $0 propranolol oral sol 1 $0 timolol maleate TABS 1 $0 칼슘통로차단제 - 고혈압및심장질환을치료하는약 afeditab cr 1 $0 amlodipine besylate TABS 1 $0 cartia xt cap 120/24hr 1 $0 cartia xt cap 180/24hr 1 $0 cartia xt cap 240/24hr 1 $0 cartia xt cap 300/24hr 1 $0 dilt-xr cap 1 $0 diltiazem cap 120mg cd 1 $0 diltiazem cap 180mg cd 1 $0 diltiazem cap 240mg cd 1 $0 diltiazem cap 300mg cd 1 $0 DILTIAZEM CAP 360MG CD 1 $0 diltiazem cap er/12hr 1 $0 diltiazem hcl SOLN; TABS 1 $0 diltiazem hcl cap sr 24hr 1 $0 diltiazem hcl coated beads cap sr 1 $0 24hr diltiazem hcl extended release 1 $0 beads cap sr felodipine 1 $0 isradipine 1 $0 nicardipine hcl CAPS 1 $0 nifedical xl 1 $0 nifedipine TB24 1 $0 nifedipine er 1 $0 nimodipine CAPS 2 $0 NYMALIZE 2 $0 taztia 1 $0 verapamil cap er 100mg, 120mg, 1 $0 180mg, 200mg, 240mg, 300mg PA -사전허가 ( 승인 ) QL -수량한도 ST -단계별치료법 NM - 우편주문불가능 B/D -파트 B 또는파트 D 약일수있음 LA -사용제한 21

VERAPAMIL CAP ER 360mg 1 $0 verapamil hcl SOLN; TABS; TBCR 1 $0 verapamil tab er 1 $0 DIGITALIS GLYCOSIDES -심장질환을치료하는약 digitek.25mg 1 $0 PA; PA if 65 years and older digitek.125mg 1 $0 QL (30 tabs / 30 digox 125mcg 1 $0 QL (30 tabs / 30 digox 250mcg 1 $0 PA; PA if 65 years and older digoxin TABS 125mcg 1 $0 QL (30 tabs / 30 digoxin TABS 250mcg 1 $0 PA; PA if 65 years and older digoxin inj 1 $0 DIGOXIN SOL 50MCG/ML 1 $0 PA; PA if 65 years and older 이뇨제 - 심장질환을치료하는약 acetazolamide CP12; TABS 1 $0 amiloride & hydrochlorothiazide 1 $0 amiloride hcl TABS 1 $0 bumetanide 1 $0 chlorothiazide tabs 1 $0 chlorthalidone 1 $0 furosemide SOLN; TABS 1 $0 furosemide inj 10mg/ml 1 $0 FUROSEMIDE INJ 10mg/ml 1 $0 hydrochlorothiazide CAPS; TABS 1 $0 indapamide 1 $0 methazolamide TABS 1 $0 methyclothiazide 1 $0 metolazone 1 $0 spironolactone & 1 $0 hydrochlorothiazide torsemide tabs 1 $0 triamterene & hydrochlorothiazide 1 $0 TABS triamterene & hydrochlorothiazide 1 $0 cap 37.5-25 mg 기타 clonidine hcl PTWK; TABS 1 $0 DEMSER 2 $0 hydralazine hcl SOLN; TABS 1 $0 PA -사전허가 ( 승인 ) QL -수량한도 ST -단계별치료법 NM - 우편주문불가능 B/D -파트 B 또는파트 D 약일수있음 LA -사용제한 22

midodrine hcl 1 $0 minoxidil TABS 1 $0 NORTHERA 2 $0 NM, LA, PA RANEXA 2 $0 NITRATES -심장질환을치료하는 isosorb mononitrate tab 1 $0 isosorbide dinitrate 1 $0 isosorbide dinitrate er 1 $0 isosorbide mononitrate er 1 $0 minitran 1 $0 nitro-bid 2 $0 NITRO-DUR DIS 0.3MG/HR 2 $0 NITRO-DUR DIS 0.8MG/HR 2 $0 nitroglycerin SUBL 1 $0 nitroglycerin td patch 1 $0 폐동맥고혈압 - 폐고혈압을치료하는약 ADCIRCA 2 $0 NM, PA ADEMPAS 2 $0 QL (90 tabs / 30, NM, LA, PA LETAIRIS 2 $0 QL (30 tabs / 30, NM, LA, PA OPSUMIT 2 $0 NM, LA, PA REMODULIN 2 $0 NM, LA, PA REVATIO SUSR 2 $0 QL (224 ml / 30, NM, PA sildenafil citrate (pulmonary 1 $0 QL (90 tabs / 30, hypertension) TABS NM, PA TRACLEER 62.5mg 2 $0 QL (120 tabs / 30, NM, LA, PA TRACLEER 125mg 2 $0 QL (60 tabs / 30, NM, LA, PA UPTRAVI TABS 200mcg 2 $0 QL (480 tabs / 30, NM, LA, PA UPTRAVI TABS 400mcg 2 $0 QL (240 tabs / 30, NM, LA, PA UPTRAVI TABS 600mcg 2 $0 QL (150 tabs / 30, NM, LA, PA UPTRAVI TABS 800mcg 2 $0 QL (120 tabs / 30, NM, LA, PA UPTRAVI TABS 1000mcg 2 $0 QL (90 tabs / 30, NM, LA, PA UPTRAVI TABS 1200mcg, 2 $0 QL (60 tabs / 30, 1400mcg, 1600mcg NM, LA, PA PA -사전허가 ( 승인 ) QL -수량한도 ST -단계별치료법 NM - 우편주문 23 불가능 B/D -파트 B 또는파트 D 약일수있음 LA -사용제한

UPTRAVI TBPK 2 $0 NM, LA, PA VENTAVIS 2 $0 NM, PA 중추신경계 - 신경계질환을치료하는약 항불안제 - 불안증을치료하는약 alprazolam tab 0.5mg 1 $0 QL (240 tabs / 30 alprazolam tab 0.25mg 1 $0 QL (480 tabs / 30 alprazolam tab 1mg 1 $0 QL (120 tabs / 30 alprazolam tab 2mg 1 $0 QL (150 tabs / 30 buspirone hcl TABS 1 $0 fluvoxamine maleate TABS 25mg, 1 $0 QL (45 tabs / 30 50mg fluvoxamine maleate TABS 100mg 1 $0 lorazepam CONC 1 $0 QL (150 ml / 30 lorazepam SOLN 1 $0 lorazepam TABS 1 $0 QL (150 tabs / 30 항경련제 - 발작을치료하는약 APTIOM 200mg 2 $0 QL (180 tabs / 30 APTIOM 400mg 2 $0 QL (90 tabs / 30 APTIOM 600mg, 800mg 2 $0 QL (60 tabs / 30 BANZEL SUS 40MG/ML 2 $0 PA BANZEL TAB 200MG 2 $0 PA BANZEL TAB 400MG 2 $0 PA BRIVIACT 2 $0 PA carbamazepine CHEW; CP12; 1 $0 SUSP; TABS; TB12 CELONTIN 2 $0 clonazepam TABS 1mg 1 $0 QL (120 tabs / 30 clonazepam TABS 2mg 1 $0 QL (300 tabs / 30 clonazepam TABS.5mg 1 $0 QL (240 tabs / 30 clonazepam TBDP 1mg 1 $0 QL (120 tabs / 30 clonazepam TBDP 2mg 1 $0 QL (300 tabs / 30 PA -사전허가 ( 승인 ) QL -수량한도 ST -단계별치료법 NM - 우편주문 24 불가능 B/D -파트 B 또는파트 D 약일수있음 LA -사용제한

clonazepam TBDP.5mg 1 $0 QL (240 tabs / 30 clonazepam TBDP.25mg 1 $0 QL (480 tabs / 30 clonazepam TBDP.125mg 1 $0 QL (960 tabs / 30 clorazepate dipotassium 3.75mg, 1 $0 QL (120 tabs / 30 7.5mg, PA; PA if 65 years and older clorazepate dipotassium 15mg 1 $0 QL (180 tabs / 30, PA; PA if 65 years and older DIASTAT ACUDIAL 2 $0 DIASTAT PEDIATRIC 2 $0 diazepam CONC 1 $0 QL (240 ml / 30, PA; PA if 65 years and older diazepam SOLN 1mg/ml 1 $0 QL (1200 ml / 30, PA; PA if 65 years and older diazepam SOLN 5mg/ml 1 $0 diazepam TABS 1 $0 QL (120 tabs / 30, PA; PA if 65 years and older DIAZEPAM GEL 1 $0 dilantin 2 $0 DILANTIN-125 SUS 125/5ML 2 $0 divalproex sodium CSDR; TB24; 1 $0 TBEC epitol 1 $0 ethosuximide CAPS; SOLN 1 $0 felbamate SUSP 2 $0 felbamate TABS 1 $0 FYCOMPA SUSP 2 $0 QL (720 ml / 30, PA FYCOMPA TABS 2mg 2 $0 QL (180 tabs / 30, PA FYCOMPA TABS 4mg 2 $0 QL (90 tabs / 30, PA FYCOMPA TABS 6mg 2 $0 QL (60 tabs / 30, PA FYCOMPA TABS 8mg, 10mg, 12mg2 $0 QL (30 tabs / 30, PA PA -사전허가 ( 승인 ) QL -수량한도 ST -단계별치료법 NM - 우편주문불가능 B/D -파트 B 또는파트 D 약일수있음 LA -사용제한 25

gabapentin CAPS 100mg 1 $0 QL (1080 caps / 30 gabapentin CAPS 300mg 1 $0 QL (360 caps / 30 gabapentin CAPS 400mg 1 $0 QL (270 caps / 30 gabapentin SOLN 1 $0 QL (2160 ml / 30 gabapentin TABS 600mg 1 $0 QL (180 tabs / 30 gabapentin TABS 800mg 1 $0 QL (120 tabs / 30 GABITRIL 12mg, 16mg 2 $0 lamotrigine CHEW; TABS; TB24 1 $0 levetiracetam SOLN; TABS; TB24 1 $0 LEVETIRACETAM IN SODIUM 2 $0 CHLORIDE LEVETIRACETAM IV 1 $0 levetiracetam oral soln 100 mg/ml 1 $0 LYRICA CAPS 25mg, 50mg, 75mg, 2 $0 QL (120 caps / 30 100mg, 150mg LYRICA CAPS 200mg 2 $0 QL (90 caps / 30 LYRICA CAPS 225mg, 300mg 2 $0 QL (60 caps / 30 LYRICA SOLN 2 $0 QL (946 ml / 30 ONFI 2 $0 PA oxcarbazepine 1 $0 PEGANONE 2 $0 phenobarbital ELIX; TABS 2 $0 PA; PA if 65 years and older PHENOBARBITAL SODIUM SOLN 2 $0 PA; PA if 65 years and 65mg/ml older phenobarbital sodium SOLN 2 $0 PA; PA if 65 years and 130mg/ml older phenytek 2 $0 phenytoin CHEW; SUSP 1 $0 phenytoin sodium SOLN 1 $0 phenytoin sodium extended 1 $0 POTIGA 50mg 2 $0 POTIGA 200mg 2 $0 QL (180 tabs / 30 POTIGA 300mg, 400mg 2 $0 QL (90 tabs / 30 primidone TABS 1 $0 roweepra 1 $0 PA -사전허가 ( 승인 ) QL -수량한도 ST -단계별치료법 NM - 우편주문 26 불가능 B/D -파트 B 또는파트 D 약일수있음 LA -사용제한

SABRIL PACK 2 $0 QL (180 packets / 30, NM, LA, PA SABRIL TABS 2 $0 QL (180 tabs / 30, NM, LA, PA SPRITAM 2 $0 TEGRETOL 2 $0 TEGRETOL-XR 2 $0 tiagabine hcl 1 $0 topiramate CPSP; TABS 1 $0 valproate sodium SOLN 1 $0 valproic acid 1 $0 vigabatrin powd pack 2 $0 QL (180 packets / 30, NM, LA, PA VIMPAT SOLN 10mg/ml 2 $0 QL (1200 ml / 30 VIMPAT SOLN 200mg/20ml 2 $0 VIMPAT TABS 50mg 2 $0 QL (180 tabs / 30 VIMPAT TABS 100mg, 150mg, 2 $0 QL (60 tabs / 30 200mg zonisamide CAPS 1 $0 항치매제 - 치매및기억력상실을치료하는약 donepezil hydrochloride TABS 5mg1 $0 QL (60 tabs / 30 donepezil hydrochloride TABS 1 $0 10mg, 23mg donepezil hydrochloride TBDP 5mg1 $0 QL (60 tabs / 30 donepezil hydrochloride TBDP 1 $0 10mg galantamine hydrobromide SOLN 1 $0 galantamine hydrobromide TABS 1 $0 QL (180 tabs / 30 4mg galantamine hydrobromide TABS 1 $0 QL (90 tabs / 30 8mg galantamine hydrobromide TABS 1 $0 12mg galantamine hydrobromide er 1 $0 QL (30 caps / 30 8mg, 16mg galantamine hydrobromide er 1 $0 24mg memantine hcl SOLN 1 $0 PA; PA if < 30 yrs memantine hcl TABS 5mg 1 $0 PA; PA if < 30 yrs MEMANTINE HCL TABS 10mg 1 $0 PA; PA if < 30 yrs NAMENDA XR 2 $0 PA; PA if < 30 yrs PA -사전허가 ( 승인 ) QL -수량한도 ST -단계별치료법 NM - 우편주문 27 불가능 B/D -파트 B 또는파트 D 약일수있음 LA -사용제한

NAMENDA XR TITRATION PACK 2 $0 PA; PA if < 30 yrs NAMZARIC 2 $0 rivastigmine tartrate 1 $0 rivastigmine td patch 24hr 4.6 1 $0 QL (30 patches / 30 mg/24hr rivastigmine td patch 24hr 9.5 1 $0 QL (30 patches / 30 mg/24hr rivastigmine td patch 24hr 13.3 1 $0 QL (30 patches / 30 mg/24hr 항우울제 - 우울증을치료하는약 amitriptyline hcl TABS 2 $0 PA; PA if 65 years and older amoxapine tab 25mg 1 $0 amoxapine tab 50mg 1 $0 amoxapine tab 100mg 1 $0 amoxapine tab 150mg 1 $0 bupropion hcl TABS 1 $0 bupropion hcl TB12 1 $0 bupropion hcl TB24 150mg 1 $0 QL (90 tabs / 30 bupropion hcl TB24 300mg 1 $0 QL (30 tabs / 30 citalopram hydrobromide SOLN 1 $0 citalopram hydrobromide TABS 1 $0 QL (45 tabs / 30 10mg, 20mg citalopram hydrobromide TABS 1 $0 QL (30 tabs / 30 40mg clomipramine hcl CAPS 2 $0 PA; PA if 65 years and older desipramine hcl TABS 1 $0 desvenlafaxine succinate 1 $0 QL (30 tabs / 30 doxepin hcl CAPS; CONC 2 $0 PA; PA if 65 years and older duloxetine hcl CPEP 20mg 1 $0 QL (180 caps / 30 duloxetine hcl CPEP 30mg 1 $0 QL (120 caps / 30 duloxetine hcl CPEP 60mg 1 $0 QL (60 caps / 30 EMSAM 2 $0 QL (30 patches / 30, PA escitalopram oxalate SOLN 1 $0 QL (600 ml / 30 escitalopram oxalate TABS 5mg, 1 $0 QL (45 tabs / 30 10mg escitalopram oxalate TABS 20mg 1 $0 QL (60 tabs / 30 PA -사전허가 ( 승인 ) QL -수량한도 ST -단계별치료법 NM - 우편주문불가능 B/D -파트 B 또는파트 D 약일수있음 LA -사용제한 28

FETZIMA 20mg 2 $0 QL (180 caps / 30 FETZIMA 40mg 2 $0 QL (90 caps / 30 FETZIMA 80mg, 120mg 2 $0 QL (30 caps / 30 FETZIMA TITRATION PACK 2 $0 fluoxetine cap 10mg 1 $0 QL (30 caps / 30 fluoxetine cap 20mg 1 $0 QL (120 caps / 30 fluoxetine cap 40mg 1 $0 fluoxetine hcl SOLN 1 $0 fluoxetine hcl TABS 10mg 1 $0 QL (45 tabs / 30 fluoxetine hcl TABS 20mg 1 $0 imipramine hcl TABS 2 $0 PA; PA if 65 years and older maprotiline hcl 1 $0 MARPLAN TAB 10MG 2 $0 QL (180 tabs / 30 mirtazapine TABS 7.5mg, 15mg 1 $0 QL (45 tabs / 30 mirtazapine TABS 30mg, 45mg 1 $0 mirtazapine TBDP 15mg 1 $0 QL (30 tabs / 30 mirtazapine TBDP 30mg, 45mg 1 $0 nefazodone hcl 1 $0 nortriptyline hcl CAPS; SOLN 1 $0 paroxetine hcl tabs 10mg, 20mg, 1 $0 QL (45 tabs / 30 40mg paroxetine hcl tabs 30mg 1 $0 QL (60 tabs / 30 PAXIL SUSP 2 $0 QL (900 ml / 30 phenelzine sulfate TABS 1 $0 PRISTIQ 2 $0 QL (30 tabs / 30 protriptyline hcl 1 $0 sertraline hcl CONC 1 $0 sertraline hcl TABS 25mg, 50mg 1 $0 QL (45 tabs / 30 sertraline hcl TABS 100mg 1 $0 tranylcypromine sulfate 1 $0 trazodone hcl TABS 50mg, 1 $0 100mg, 150mg trimipramine maleate CAPS 25mg 2 $0 QL (240 caps / 30, PA; PA if 65 years and older trimipramine maleate CAPS 50mg 2 $0 QL (120 caps / 30, PA; PA if 65 years and older PA -사전허가 ( 승인 ) QL -수량한도 ST -단계별치료법 NM - 우편주문 29 불가능 B/D -파트 B 또는파트 D 약일수있음 LA -사용제한

trimipramine maleate CAPS 2 $0 QL (60 caps / 30, 100mg PA; PA if 65 years and older TRINTELLIX 5mg 2 $0 QL (120 tabs / 30 TRINTELLIX 10mg 2 $0 QL (60 tabs / 30 TRINTELLIX 20mg 2 $0 QL (30 tabs / 30 venlafaxine hcl CP24 37.5mg, 1 $0 QL (30 caps / 30 75mg venlafaxine hcl CP24 150mg 1 $0 QL (60 caps / 30 venlafaxine hcl TABS 1 $0 VIIBRYD STARTER PACK 2 $0 VIIBRYD TAB 2 $0 QL (30 tabs / 30 항파킨슨병제 - 파킨슨병을치료하는약 amantadine hcl CAPS 1 $0 QL (120 caps / 30 amantadine hcl SYRP; TABS 1 $0 APOKYN 2 $0 NM, LA, PA BENZTROPINE MESYLATE SOLN 1 $0 benztropine mesylate TABS 2 $0 PA; PA if 65 years and older bromocriptine mesylate CAPS; 1 $0 TABS carbidopa-levodopa 1 $0 CARBIDOPA/LEVODOPA/ENTACAPO 1 $0 NE ENTACAPONE 1 $0 NEUPRO 2 $0 pramipexole tab 0.5mg 1 $0 pramipexole tab 0.25mg 1 $0 pramipexole tab 0.75mg 1 $0 pramipexole tab 0.125mg 1 $0 pramipexole tab 1.5mg 1 $0 pramipexole tab 1mg 1 $0 rasagiline mesylate TABS 1 $0 ropinirole tab 0.5mg 1 $0 ropinirole tab 0.25mg 1 $0 ropinirole tab 1mg 1 $0 ropinirole tab 2mg 1 $0 ropinirole tab 3mg 1 $0 ropinirole tab 4mg 1 $0 ropinirole tab 5mg 1 $0 PA -사전허가 ( 승인 ) QL -수량한도 ST -단계별치료법 NM - 우편주문 30 불가능 B/D -파트 B 또는파트 D 약일수있음 LA -사용제한

selegiline hcl CAPS; TABS 1 $0 trihexyphenidyl hcl 2 $0 PA; PA if 65 years and older 항정신병제 - 정신병을치료하는약 ABILIFY MAINTENA PRSY 2 $0 QL (1 syringe / 28 ABILIFY MAINTENA SRER 2 $0 QL (1 vial / 28 aripiprazole odt 2 $0 QL (60 tabs / 30 aripiprazole oral solution 1 mg/ml 2 $0 QL (900 ml / 30 aripiprazole tab 2mg, 5mg, 10mg, 1 $0 QL (30 tabs / 30 15mg aripiprazole tab 20mg, 30mg 2 $0 QL (30 tabs / 30 ARISTADA 441mg/1.6ml, 2 $0 QL (1 syringe / 28 662mg/2.4ml, 882mg/3.2ml ARISTADA 1064mg/3.9ml 2 $0 QL (1 syringe / 56 chlorpromazine hcl TABS 1 $0 chlorpromazine inj 2 $0 CLOZAPINE ODT 12.5mg, 25mg 1 $0 PA CLOZAPINE ODT 100mg 1 $0 QL (270 tabs / 30, PA CLOZAPINE ODT 150mg 1 $0 QL (180 tabs / 30, PA CLOZAPINE ODT 200mg 2 $0 QL (135 tabs / 30, PA clozapine tab 25mg 1 $0 clozapine tab 50mg 1 $0 clozapine tab 100mg 1 $0 QL (270 tabs / 30 clozapine tab 200mg 1 $0 QL (135 tabs / 30 FANAPT 2 $0 QL (60 tabs / 30 FANAPT TITRATION PACK 2 $0 fluphenazine decanoate SOLN 1 $0 fluphenazine hcl 1 $0 GEODON SOLR 2 $0 QL (6 ml / 3 haloperidol TABS 1 $0 haloperidol decanoate SOLN 1 $0 haloperidol lactate inj 5 mg/ml 1 $0 haloperidol lactate oral conc 2 1 $0 mg/ml INVEGA SUST INJ 39 MG/0.25 ML 2 $0 QL (1 injection / 28 PA -사전허가 ( 승인 ) QL -수량한도 ST -단계별치료법 NM - 우편주문 31 불가능 B/D -파트 B 또는파트 D 약일수있음 LA -사용제한

INVEGA SUST INJ 78 MG/0.5 ML 2 $0 QL (1 injection / 28 INVEGA SUST INJ 117 MG/0.75 ML 2 $0 QL (1 injection / 28 INVEGA SUST INJ 156MG/ML 2 $0 QL (1 injection / 28 INVEGA SUST INJ 234 MG/1.5 ML 2 $0 QL (1 injection / 28 INVEGA TRINZA 2 $0 QL (1 syringe / 90 LATUDA 20mg 2 $0 QL (240 tabs / 30 LATUDA 40mg, 120mg 2 $0 QL (30 tabs / 30 LATUDA 60mg, 80mg 2 $0 QL (60 tabs / 30 loxapine succinate 1 $0 molindone hcl 10mg 1 $0 molindone hcl 25mg 1 $0 NUPLAZID 2 $0 QL (60 tabs / 30, NM, LA, PA olanzapine SOLR 1 $0 QL (3 vials / 1 day) olanzapine TABS 2.5mg 1 $0 QL (240 tabs / 30 olanzapine TABS 5mg 1 $0 QL (120 tabs / 30 olanzapine TABS 7.5mg 1 $0 QL (30 tabs / 30 olanzapine TABS 10mg, 15mg, 1 $0 QL (60 tabs / 30 20mg olanzapine TBDP 5mg 1 $0 QL (30 tabs / 30 olanzapine TBDP 10mg, 15mg, 1 $0 QL (60 tabs / 30 20mg paliperidone 1.5mg, 3mg, 9mg 2 $0 QL (30 tabs / 30 paliperidone 6mg 2 $0 QL (60 tabs / 30 perphenazine TABS 1 $0 pimozide 1 $0 quetiapine fumarate TABS 1 $0 QL (90 tabs / 30 quetiapine fumarate TB24 50mg 1 $0 QL (120 tabs / 30 quetiapine fumarate TB24 150mg, 1 $0 QL (30 tabs / 30 200mg quetiapine fumarate TB24 300mg, 1 $0 QL (60 tabs / 30 400mg REXULTI 1mg 2 $0 QL (90 tabs / 30 REXULTI 2mg 2 $0 QL (60 tabs / 30 PA -사전허가 ( 승인 ) QL -수량한도 ST -단계별치료법 NM - 우편주문불가능 B/D -파트 B 또는파트 D 약일수있음 LA -사용제한 32

REXULTI 3mg, 4mg 2 $0 QL (30 tabs / 30 REXULTI.5mg 2 $0 QL (180 tabs / 30 REXULTI.25mg 2 $0 QL (360 tabs / 30 RISPERDAL INJ 12.5MG 2 $0 QL (2 injections / 28 RISPERDAL INJ 25MG 2 $0 QL (2 injections / 28 RISPERDAL INJ 37.5MG 2 $0 QL (2 injections / 28 RISPERDAL INJ 50MG 2 $0 QL (2 injections / 28 risperidone SOLN 1 $0 QL (240 ml / 30 risperidone TABS 1mg, 2mg, 3mg 1 $0 QL (60 tabs / 30 risperidone TABS 4mg 1 $0 QL (120 tabs / 30 risperidone TABS.25mg,.5mg 1 $0 QL (90 tabs / 30 risperidone TBDP 1mg, 2mg, 3mg 1 $0 QL (60 tabs / 30 risperidone TBDP 4mg 1 $0 QL (120 tabs / 30 risperidone TBDP.25mg,.5mg 1 $0 QL (90 tabs / 30 SAPHRIS 2.5mg 2 $0 QL (240 tabs / 30 SAPHRIS 5mg 2 $0 QL (120 tabs / 30 SAPHRIS 10mg 2 $0 QL (60 tabs / 30 thioridazine hcl TABS 2 $0 PA; PA if 65 years and older thiothixene 1 $0 trifluoperazine hcl 1 $0 VERSACLOZ 2 $0 QL (600 ml / 30, PA VRAYLAR 1.5mg 2 $0 QL (120 caps / 30 VRAYLAR 3mg 2 $0 QL (60 caps / 30 VRAYLAR 4.5mg, 6mg 2 $0 QL (30 caps / 30 VRAYLAR THERAPY PACK 2 $0 ziprasidone hcl 20mg, 40mg 1 $0 QL (60 caps / 30 ziprasidone hcl 60mg, 80mg 1 $0 QL (90 caps / 30 ZYPREXA RELPREVV 300mg 2 $0 QL (2 vials / 28, PA PA -사전허가 ( 승인 ) QL -수량한도 ST -단계별치료법 NM - 우편주문불가능 B/D -파트 B 또는파트 D 약일수있음 LA -사용제한 33

ZYPREXA RELPREVV 405mg 2 $0 QL (1 vial / 28, PA ZYPREXA RELPREVV INJ 210MG 2 $0 QL (2 vials / 28, PA 주의력결핍과다활동장애 - ADHD 를치료하는약 amphetamine-dextroamphetamine 1 $0 QL (90 caps / 30 cap sr 24hr 5 mg amphetamine-dextroamphetamine 1 $0 QL (90 caps / 30 cap sr 24hr 10 mg amphetamine-dextroamphetamine 1 $0 QL (30 caps / 30 cap sr 24hr 15 mg amphetamine-dextroamphetamine 1 $0 QL (30 caps / 30 cap sr 24hr 20 mg amphetamine-dextroamphetamine 1 $0 QL (30 caps / 30 cap sr 24hr 25 mg amphetamine-dextroamphetamine 1 $0 QL (30 caps / 30 cap sr 24hr 30 mg amphetamine-dextroamphetamine 1 $0 QL (360 tabs / 30 tab 5 mg amphetamine-dextroamphetamine 1 $0 QL (240 tabs / 30 tab 7.5 mg amphetamine-dextroamphetamine 1 $0 QL (180 tabs / 30 tab 10 mg amphetamine-dextroamphetamine 1 $0 QL (144 tabs / 30 tab 12.5 mg amphetamine-dextroamphetamine 1 $0 QL (120 tabs / 30 tab 15 mg amphetamine-dextroamphetamine 1 $0 QL (90 tabs / 30 tab 20 mg amphetamine-dextroamphetamine 1 $0 QL (60 tabs / 30 tab 30 mg atomoxetine hcl 10mg, 18mg, 1 $0 QL (120 caps / 30 25mg atomoxetine hcl 40mg 1 $0 QL (60 caps / 30 atomoxetine hcl 60mg, 80mg, 1 $0 QL (30 caps / 30 100mg guanfacine er (adhd) 2 $0 PA; PA if 65 years and older metadate er tab 20mg 1 $0 QL (90 tabs / 30 methylphenidate hcl TABS 5mg, 1 $0 QL (180 tabs / 30 10mg methylphenidate hcl TABS 20mg 1 $0 QL (90 tabs / 30 methylphenidate hcl TBCR 1 $0 QL (90 tabs / 30 PA -사전허가 ( 승인 ) QL -수량한도 ST -단계별치료법 NM - 우편주문 34 불가능 B/D -파트 B 또는파트 D 약일수있음 LA -사용제한

methylphenidate hcl oral soln 1 $0 QL (1800 ml / 30 5mg/5ml methylphenidate hcl oral soln 1 $0 QL (900 ml / 30 10mg/5ml STRATTERA 10mg, 18mg, 25mg 2 $0 QL (120 caps / 30 STRATTERA 40mg 2 $0 QL (60 caps / 30 STRATTERA 60mg, 80mg, 100mg 2 $0 QL (30 caps / 30 최면제 - 불면증을치료하는약 eszopiclone 2 $0 QL (30 tabs / 30, PA; PA applies if 65 years and older after a 90 day supply in a calendar year HETLIOZ 2 $0 NM, LA, PA SILENOR 3mg 2 $0 QL (60 tabs / 30 SILENOR 6mg 2 $0 QL (30 tabs / 30 temazepam 7.5mg 1 $0 QL (30 caps / 30, PA; PA applies if 65 years and older after a 90 day supply in a calendar year temazepam 15mg 1 $0 QL (60 caps / 30, PA; PA applies if 65 years and older after a 90 day supply in a calendar year zolpidem tartrate TABS 2 $0 QL (30 tabs / 30, PA; PA applies if 65 years and older after a 90 day supply in a calendar year 편두통 - 심각한두통을치료하는약 dihydroergotamine mesylate 1 $0 1mg/ml eletriptan hydrobromide 1 $0 QL (12 tabs / 30 ergotamine w/ caffeine 1 $0 migergot 2 $0 naratriptan hcl 1 $0 QL (12 tabs / 30 RELPAX 2 $0 QL (12 tabs / 30 rizatriptan benzoate 1 $0 QL (18 tabs / 30 SUMATRIPTAN SOLN 5mg/act 1 $0 QL (24 inhalers / 30 PA -사전허가 ( 승인 ) QL -수량한도 ST -단계별치료법 NM - 우편주문 35 불가능 B/D -파트 B 또는파트 D 약일수있음 LA -사용제한

SUMATRIPTAN SOLN 20mg/act 1 $0 QL (12 inhalers / 30 SUMATRIPTAN INJ 4MG/0.5ML 1 $0 QL (18 injections / 30 sumatriptan inj 6mg/0.5ml 1 $0 QL (12 injections / 30 sumatriptan succinate TABS 1 $0 QL (12 tabs / 30 zolmitriptan TABS 1 $0 QL (12 tabs / 30 zolmitriptan odt 1 $0 QL (12 tabs / 30 기타 AUSTEDO 6mg 2 $0 QL (60 tabs / 30, NM, LA, PA AUSTEDO 9mg, 12mg 2 $0 QL (120 tabs / 30, NM, LA, PA lithium carbonate CAPS; TABS 1 $0 lithium carbonate er 1 $0 LITHIUM SOLN 8MEQ/5ML 2 $0 NUEDEXTA 2 $0 PA pyridostigmine tab 60mg 1 $0 riluzole 1 $0 TETRABENAZINE 12.5mg 2 $0 QL (240 tabs / 30, NM, PA TETRABENAZINE 25mg 2 $0 QL (120 tabs / 30, NM, PA 다발성경화증제 - 다발성경화증을치료하는약 AMPYRA 2 $0 NM, LA, PA BETASERON 2 $0 QL (14 syringes / 28, NM, PA COPAXONE INJ 40MG/ML 2 $0 QL (12 syringes / 28, NM, PA GILENYA CAP 0.5MG 2 $0 QL (28 caps / 28, NM, PA glatopa 2 $0 QL (30 syringes / 30, NM, PA TYSABRI 2 $0 NM, LA, PA 근골격치료제 - 근경련을치료하는약 baclofen TABS 1 $0 carisoprodol TABS 350mg 2 $0 QL (120 tabs / 30, PA; PA if 65 years and older cyclobenzaprine hcl TABS 5mg, 2 $0 PA; PA if 65 years and 10mg older dantrolene sodium CAPS 1 $0 PA -사전허가 ( 승인 ) QL -수량한도 ST -단계별치료법 NM - 우편주문불가능 B/D -파트 B 또는파트 D 약일수있음 LA -사용제한 36

methocarbamol TABS 2 $0 PA; PA if 65 years and older tizanidine hcl TABS 1 $0 기면증 / 허탈발작 - 수면장애를치료하는약 armodafinil 50mg 1 $0 QL (150 tabs / 30, PA armodafinil 150mg 1 $0 QL (60 tabs / 30, PA ARMODAFINIL 200mg 1 $0 QL (30 tabs / 30, PA armodafinil 250mg 1 $0 QL (30 tabs / 30, PA XYREM 2 $0 QL (540 ml / 30, LA, PA 심리요법 - 기타 acamprosate calcium 1 $0 buprenorphine hcl SUBL 1 $0 PA buprenorphine hcl-naloxone hcl sl 1 $0 QL (120 tabs / 30, PA buproban tab 150mg 1 $0 bupropion hcl (smoking deterrent) 1 $0 CHANTIX 2 $0 PA CHANTIX CONTINUING MONTH 2 $0 PA CHANTIX STARTER PACK 2 $0 PA diphenhydramine hcl (sleep) 3 $0 NM; * disulfiram TABS 1 $0 naloxone inj 0.4mg/ml 1 $0 naloxone inj 1mg/ml 1 $0 naltrexone hcl TABS 1 $0 nicotine 7mg/24hr, 14mg/24hr, 3 $0 NM; * 21mg/24hr NICOTINE 7mg/24hr, 14mg/24hr, 3 21mg/24hr $0 NM; * nicotine polacrilex GUM; LOZG 3 $0 NM; * NICOTROL INHALER 2 $0 NICOTROL NS 2 $0 SUBOXONE MIS 2-0.5MG 2 $0 QL (120 SL films / 30, PA SUBOXONE MIS 4-1MG 2 $0 QL (120 SL films / 30, PA SUBOXONE MIS 8-2MG 2 $0 QL (120 SL films / 30, PA PA -사전허가 ( 승인 ) QL -수량한도 ST -단계별치료법 NM - 우편주문 37 불가능 B/D -파트 B 또는파트 D 약일수있음 LA -사용제한

SUBOXONE MIS 12-3MG 2 $0 QL (60 SL films / 30, PA 내분비및신진대사 - 당뇨병을치료하고호르몬을제어하는약 ANDROGENS -남성호르몬을조절하는약 ANADROL-50 2 $0 PA ANDRODERM 2 $0 QL (30 patches / 30, PA AXIRON 2 $0 QL (440 ml / 30, PA oxandrolone TABS 1 $0 PA testosterone SOLN 1 $0 QL (440 ml / 30, PA testosterone cypionate SOLN 1 $0 PA testosterone enanthate SOLN 1 $0 PA 당뇨병치료제, 주사제 - 당뇨병을치료하는약 ALCOHOL SWABS 2 $0 BYDUREON INJ 2 $0 QL (4 vials / 28 BYDUREON PEN 2 $0 QL (4 pens / 28 BYETTA 2 $0 QL (1 pen / 30 GAUZE PADS 2" X 2" 2 $0 HUMULIN R INJ U-500 2 $0 B/D HUMULIN R U-500 KWIKPEN 2 $0 INSULIN PEN NEEDLE 2 $0 INSULIN SAFETY NEEDLES 2 $0 INSULIN SYRINGE 2 $0 LANTUS 2 $0 LANTUS SOLOSTAR 2 $0 LEVEMIR 2 $0 LEVEMIR FLEXTOUCH 2 $0 NOVOLIN 70/30 2 $0 (brand RELION not covered) NOVOLIN N 2 $0 (brand RELION not covered) NOVOLIN R 2 $0 (brand RELION not covered) NOVOLOG 2 $0 NOVOLOG FLEXPEN 2 $0 NOVOLOG MIX 70/30 2 $0 NOVOLOG MIX 70/30 PREFILL 2 $0 NOVOLOG PENFILL 2 $0 SYMLINPEN 60 2 $0 QL (8 pens / 30, PA PA -사전허가 ( 승인 ) QL -수량한도 ST -단계별치료법 NM - 우편주문불가능 B/D -파트 B 또는파트 D 약일수있음 LA -사용제한 38

SYMLINPEN 120 2 $0 QL (4 pens / 30, PA TOUJEO SOLOSTAR 2 $0 TRESIBA FLEXTOUCH 2 $0 TRULICITY 2 $0 QL (4 pens / 28 VICTOZA 2 $0 QL (3 pens / 30 경구항당뇨병제 - 당뇨병을치료하는약 acarbose 1 $0 FARXIGA 5mg 2 $0 QL (60 tabs / 30 FARXIGA 10mg 2 $0 QL (30 tabs / 30 glimepiride 1mg 1 $0 QL (240 tabs / 30 glimepiride 2mg 1 $0 QL (120 tabs / 30 glimepiride 4mg 1 $0 QL (60 tabs / 30 glip/metform tab 2.5-250m 1 $0 QL (240 tabs / 30 glip/metform tab 2.5-500m 1 $0 QL (120 tabs / 30 glip/metform tab 5-500mg 1 $0 QL (120 tabs / 30 glipizide TABS 5mg 1 $0 QL (240 tabs / 30 glipizide TABS 10mg 1 $0 QL (120 tabs / 30 glipizide TB24 2.5mg 1 $0 QL (240 tabs / 30 glipizide TB24 5mg 1 $0 QL (120 tabs / 30 glipizide TB24 10mg 1 $0 QL (60 tabs / 30 GLIPIZIDE XL TB24 2.5MG 1 $0 QL (240 tabs / 30 GLIPIZIDE XL TB24 5MG 1 $0 QL (120 tabs / 30 glyburide TABS 1.25mg 2 $0 QL (480 tabs / 30, PA; PA if 65 years and older glyburide TABS 2.5mg 2 $0 QL (240 tabs / 30, PA; PA if 65 years and older glyburide TABS 5mg 2 $0 QL (120 tabs / 30, PA; PA if 65 years and older PA -사전허가 ( 승인 ) QL -수량한도 ST -단계별치료법 NM - 우편주문 39 불가능 B/D -파트 B 또는파트 D 약일수있음 LA -사용제한

glyburide micronized 1.5mg 2 $0 QL (240 tabs / 30, PA; PA if 65 years and older glyburide micronized 3mg 2 $0 QL (120 tabs / 30, PA; PA if 65 years and older glyburide micronized 6mg 2 $0 QL (60 tabs / 30, PA; PA if 65 years and older INVOKAMET TAB 50-500MG 2 $0 QL (120 tabs / 30 INVOKAMET TAB 50-1000MG 2 $0 QL (60 tabs / 30 INVOKAMET TAB 150-500MG 2 $0 QL (60 tabs / 30 INVOKAMET TAB 150-1000MG 2 $0 QL (60 tabs / 30 INVOKAMET XR TAB 50-500MG 2 $0 QL (120 tabs / 30 INVOKAMET XR TAB 50-1000MG 2 $0 QL (60 tabs / 30 INVOKAMET XR TAB 150-500MG 2 $0 QL (60 tabs / 30 INVOKAMET XR TAB 150-1000MG 2 $0 QL (60 tabs / 30 INVOKANA 100mg 2 $0 QL (90 tabs / 30 INVOKANA 300mg 2 $0 QL (30 tabs / 30 JANUMET 2 $0 QL (60 tabs / 30 JANUMET XR TAB 50-500MG 2 $0 QL (60 tabs / 30 JANUMET XR TAB 50-1000 2 $0 QL (60 tabs / 30 JANUMET XR TAB 100-1000 2 $0 QL (30 tabs / 30 JANUVIA 2 $0 QL (30 tabs / 30 JENTADUETO 2 $0 QL (60 tabs / 30 JENTADUETO TAB XR 2.5-1000 MG 2 $0 QL (60 tabs / 30 JENTADUETO TAB XR 5-1000 MG 2 $0 QL (30 tabs / 30 metformin hcl TABS 500mg 1 $0 QL (150 tabs / 30 metformin hcl TABS 850mg 1 $0 QL (90 tabs / 30 metformin hcl TABS 1000mg 1 $0 QL (75 tabs / 30 metformin hcl TB24 500mg 1 $0 QL (120 tabs / 30 ; (generic of GLUCOPHAGE XR) metformin hcl TB24 750mg 1 $0 QL (60 tabs / 30 ; (generic of GLUCOPHAGE XR) nateglinide 1 $0 QL (90 tabs / 30 pioglitazone hcl 1 $0 QL (30 tabs / 30 repaglinide 2mg 1 $0 QL (240 tabs / 30 PA -사전허가 ( 승인 ) QL -수량한도 ST -단계별치료법 NM - 우편주문불가능 B/D -파트 B 또는파트 D 약일수있음 LA -사용제한 40

repaglinide.5mg, 1mg 1 $0 QL (120 tabs / 30 TRADJENTA 2 $0 QL (30 tabs / 30 XIGDUO XR TAB 5-500MG 2 $0 QL (60 tabs / 30 XIGDUO XR TAB 5-1000MG 2 $0 QL (60 tabs / 30 XIGDUO XR TAB 10-500MG 2 $0 QL (30 tabs / 30 XIGDUO XR TAB 10-1000MG 2 $0 QL (30 tabs / 30 BISPHOSPHONATES -골손실을치료하는약 alendronate sodium TABS 5mg, 1 $0 10mg, 40mg alendronate sodium TABS 35mg, 1 $0 QL (4 tabs / 28 70mg pamidronate disodium 1 $0 B/D zoledronic acid SOLN 5mg/100ml 1 $0 B/D, NM zoledronic acid SOLR 1 $0 B/D, NM zoledronic inj 4mg/5ml 1 $0 B/D, NM 칼슘수용체작용제 SENSIPAR 30mg, 90mg 2 $0 QL (120 tabs / 30, NM SENSIPAR 60mg 2 $0 QL (60 tabs / 30, NM 킬레이트제 CHEMET 2 $0 DEPEN TITRATABS 2 $0 EXJADE 2 $0 NM, LA, PA FERRIPROX 2 $0 NM, LA, PA kionex 1 $0 sodium polystyrene sulfonate 1 $0 sps susp 15gm/60ml 1 $0 SYPRINE 2 $0 피임제 - 피임을위한약 altavera tab 1 $0 alyacen 1/35 1 $0 apri 28 day 1 $0 aranelle 28 1 $0 aubra 28 day 1 $0 aviane 28 1 $0 balziva 28 day 1 $0 bekyree 28 day 1 $0 blisovi 21 fe 1.5/30 28 day pack 1 $0 blisovi 21 fe 1/20 28 day pack 1 $0 PA -사전허가 ( 승인 ) QL -수량한도 ST -단계별치료법 NM - 우편주문 41 불가능 B/D -파트 B 또는파트 D 약일수있음 LA -사용제한

briellyn 28 day 1 $0 camila 28 day 1 $0 caziant pak 1 $0 cryselle 28 1 $0 cyclafem 1/35 28 day 1 $0 cyclafem 7/7/7 28 day 1 $0 cyred tab 1 $0 deblitane 28 day 1 $0 delyla 28 day 1 $0 desogestrel & ethinyl estradiol 1 $0 desogestrel-ethinyl estradiol 1 $0 (biphasic) drospirenone-ethinyl estradiol 1 $0 ELLA 2 $0 emoquette 1 $0 enpresse 28 day 1 $0 errin 28 day 1 $0 estarylla tab 0.25-35 1 $0 ethynodiol tab 1-50 1 $0 falmina 28 day 1 $0 femynor 28 day 1 $0 GIANVI 1 $0 gildagia 1 $0 gildess tab 1.5/30 1 $0 heather 1 $0 introvale 91 day 1 $0 isibloom 28 day 1 $0 JOLESSA TAB 0.15-0.03 MG 1 $0 JOLIVETTE 1 $0 juleber 28 day 1 $0 junel 1.5/30 21 day 1 $0 junel 1/20 21 day 1 $0 junel fe 1.5/30 28 day 1 $0 junel fe 1/20 28 day 1 $0 kariva 28 day 1 $0 kelnor 1/35 28 day 1 $0 kimidess 28 day 1 $0 larin 1.5/30 1 $0 larin 1/20 1 $0 larin fe 1.5/30 1 $0 larin fe 1/20 1 $0 larissia tab 1 $0 PA -사전허가 ( 승인 ) QL -수량한도 ST -단계별치료법 NM - 우편주문불가능 B/D -파트 B 또는파트 D 약일수있음 LA -사용제한 42

LEENA 1 $0 lessina 28 day 1 $0 levonest 28 day 1 $0 levonor/ethi tab 1 $0 levonorgestrel & eth estradiol 1 $0 levonorgestrel (emergency oc) 1 $0 1.5mg levonorgestrel (emergency oc) 3 $0 NM; * 1.5mg LEVONORGESTREL (EMERGENCY 3 $0 NM; * OC) 1.5mg levonorgestrel-ethinyl estradiol 1 $0 (91-day) levora 0.15/30 28 day 1 $0 loryna 28 day 1 $0 low-ogestrel 1 $0 lutera 28 day 1 $0 lyza 1 $0 marlissa 28 day 1 $0 medroxyprogesterone acetate 1 $0 (contraceptive) SUSP MEDROXYPROGESTERONE 1 $0 ACETATE (CONTRACEPTIVE) SUSY MICROGESTIN 1.5/30 1 $0 MICROGESTIN 1/20 1 $0 MICROGESTIN FE 1.5/30 1 $0 MICROGESTIN FE 1/20 1 $0 mono-linyah tab 0.25-35 1 $0 MONONESSA 1 $0 myzilra 1 $0 necon 0.5/35 28 day 1 $0 NECON 7/7/7 1 $0 necon 10/11-28 2 $0 necon tab 1/35 1 $0 NECON TAB 1/50-28 1 $0 nikki 28 day 1 $0 NORA-BE TAB 1 $0 norethindrone (contraceptive) 1 $0 norethindrone acet & eth estra 1 $0 norgest/ethi tab 0.25/35 1 $0 norgestimate-ethinyl estradiol 1 $0 (triphasic) PA -사전허가 ( 승인 ) QL -수량한도 ST -단계별치료법 NM - 우편주문불가능 B/D -파트 B 또는파트 D 약일수있음 LA -사용제한 43

norlyroc 28 day 1 $0 nortrel 0.5/35 28 day 1 $0 nortrel 1/35 21 day 1 $0 nortrel 1/35 28 day 1 $0 nortrel 7/7/7 28 day 1 $0 NUVARING 2 $0 OCELLA TAB 3-0.03MG 1 $0 orsythia 28 day 1 $0 philith 1 $0 pimtrea pack 1 $0 pirmella 1/35 28 day 1 $0 portia 28 day 1 $0 previfem 28 day 1 $0 quasense 91 day 1 $0 reclipsen 28 day 1 $0 setlakin tab 1 $0 sharobel 28 day 1 $0 sprintec 28 day 1 $0 sronyx 1 $0 syeda 1 $0 tarina fe 1/20 28 day 1 $0 TILIA FE 1 $0 tri-legest 28 day 1 $0 tri-linyah 1 $0 tri-lo marzia 1 $0 tri-lo-estarylla 1 $0 tri-lo-sprintec 28 day 1 $0 tri-previfem 28 day 1 $0 tri-sprintec 28 day 1 $0 TRINESSA 1 $0 TRINESSA LO TAB 1 $0 trivora 28 day 1 $0 velivet 28 day 1 $0 vestura 1 $0 vienva 28 day 1 $0 viorele 1 $0 vyfemla 28 day 1 $0 xulane 1 $0 zarah 1 $0 zenchent 28 day 1 $0 zovia 1/35e 28 day 1 $0 PA -사전허가 ( 승인 ) QL -수량한도 ST -단계별치료법 NM - 우편주문불가능 B/D -파트 B 또는파트 D 약일수있음 LA -사용제한 44

zovia 1/50e 28 day 1 $0 자궁내막증 danazol CAPS 1 $0 SYNAREL 2 $0 효소대체제 - 효소결핍제를치료하는약 ADAGEN 2 $0 NM, LA, PA ALDURAZYME 2 $0 NM, LA, PA BUPHENYL TABS 2 $0 NM, LA, PA CARBAGLU 2 $0 NM, LA, PA CERDELGA 2 $0 NM, PA CEREZYME 2 $0 NM, LA, PA CYSTADANE 2 $0 NM, LA CYSTAGON 2 $0 NM, LA, PA FABRAZYME 2 $0 NM, LA, PA KUVAN 2 $0 NM, LA, PA levocarnitine (metabolic modifiers) 1 $0 B/D LUMIZYME 2 $0 NM, LA, PA NAGLAZYME 2 $0 NM, LA, PA ORFADIN 2 $0 NM, LA, PA RAVICTI 2 $0 NM, PA sodium phenylbutyrate 2 $0 NM, PA ZAVESCA 2 $0 NM, LA, PA ESTROGENS -여성호르몬을조절하는약 DELESTROGEN 10mg/ml 2 $0 estrace CREA 2 $0 estradiol PTWK 2 $0 PA; PA if 65 years and older estradiol TABS 2 $0 PA; PA if 65 years and older estradiol vaginal tab 10 mcg 1 $0 estradiol valerate OIL 1 $0 fyavolv tab 1-5mg 2 $0 PA; PA if 65 years and older jinteli 2 $0 PA; PA if 65 years and older norethindrone acetate-ethinyl 2 $0 PA; PA if 65 years and estradiol 1mg-5mcg older yuvafem vaginal tablet 10 mcg 1 $0 GLUCOCORTICOIDS -염증반응을치료하는약 cortisone acetate TABS 1 $0 dexamethasone CONC; ELIX; 1 $0 SOLN; TABS PA -사전허가 ( 승인 ) QL -수량한도 ST -단계별치료법 NM - 우편주문 45 불가능 B/D -파트 B 또는파트 D 약일수있음 LA -사용제한

dexamethasone sodium phosphate 1 $0 fludrocortisone acetate TABS 1 $0 hydrocortisone TABS 1 $0 methylpr ace inj 40mg/ml 1 $0 B/D methylpr ace inj 80mg/ml 1 $0 B/D methylpr ss inj 1gm 1 $0 B/D methylpr ss inj 40mg 1 $0 B/D methylpr ss inj 125 mg 1 $0 B/D methylpred pak 4mg 1 $0 methylpred tab 4mg 1 $0 B/D methylpred tab 8mg 1 $0 B/D methylpred tab 16mg 1 $0 B/D methylpred tab 32mg 1 $0 B/D pred sod pho sol 5mg/5ml 1 $0 B/D prednisolone sol 15mg/5ml 1 $0 B/D prednisolone sol 25mg/5ml 1 $0 B/D prednisolone syp 15mg/5ml 1 $0 B/D prednisone con 5mg/ml 2 $0 B/D prednisone pak 5mg 1 $0 prednisone pak 10mg 1 $0 prednisone sol 5mg/5ml 1 $0 B/D prednisone tab 1mg 1 $0 B/D prednisone tab 2.5mg 1 $0 B/D prednisone tab 5mg 1 $0 B/D prednisone tab 10mg 1 $0 B/D prednisone tab 20mg 1 $0 B/D prednisone tab 50mg 1 $0 B/D SOLU-CORTEF 250mg 2 $0 혈당상승제 - 저혈당을치료하는약 GLUCAGEN HYPOKIT 2 $0 GLUCAGON EMERGENCY KIT 2 $0 HM GLUCOSE 3 $0 NM; * PROGLYCEM SUS 50MG/ML 2 $0 SM GLUCOSE 3 $0 NM; * 인간성장호르몬 - 뇌하수체호르몬을조절하는약 NORDITROPIN FLEXPRO 2 $0 NM, PA 기타 cabergoline 1 $0 calcitonin (salmon) 1 $0 B/D FORTICAL 2 $0 B/D INCRELEX 2 $0 NM, LA, PA PA -사전허가 ( 승인 ) QL -수량한도 ST -단계별치료법 NM - 우편주문불가능 B/D -파트 B 또는파트 D 약일수있음 LA -사용제한 46

KORLYM 2 $0 NM, LA, PA LUPRON DEP-PED INJ 7.5MG 2 $0 NM, PA LUPRON DEP-PED INJ 11.25MG 2 $0 NM, PA LUPRON DEP-PED INJ 11.25MG (3-2 $0 NM, PA MONTH) LUPRON DEP-PED INJ 15MG 2 $0 NM, PA LUPRON DEP-PED INJ 30MG (3-2 $0 NM, PA MONTH) methergine 0.2 mg tab 1 $0 methylergonovine maleate TABS 1 $0 MIACALCIN 200 UNIT/ML 2 $0 B/D octreotide acetate 50mcg/ml, 1 $0 NM, PA 100mcg/ml, 200mcg/ml octreotide acetate 500mcg/ml, 2 $0 NM, PA 1000mcg/ml PROLIA 2 $0 QL (1 syringe / 180, NM raloxifene hcl 1 $0 SANDOSTATIN LAR DEPOT 2 $0 NM, PA SIGNIFOR 2 $0 NM, LA, PA SOMATULINE DEPOT 2 $0 NM, PA SOMAVERT 2 $0 NM, LA, PA XGEVA 2 $0 NM, PA 부갑상선호르몬 - 부갑상선농도를조절하는약 FORTEO 2 $0 QL (1 pen / 28, NM, PA NATPARA 2 $0 NM, PA 인접착제 - 칼슘과인농도를조절하는약 AURYXIA 2 $0 calcium acetate (phosphate binder)1 $0 RENVELA PAK 0.8GM 2 $0 RENVELA PAK 2.4GM 2 $0 RENVELA TAB 800MG 2 $0 PROGESTINS -여성호르몬을조절하는약 medroxyprogesterone acetate tab 1 $0 norethindrone acetate TABS 1 $0 갑상선제 - 갑상선농도를조절하는약 levothyroxine sodium TABS 1 $0 25mcg, 50mcg, 88mcg, 100mcg, 112mcg, 125mcg, 137mcg, 150mcg, 175mcg, 200mcg PA -사전허가 ( 승인 ) QL -수량한도 ST -단계별치료법 NM - 우편주문 47 불가능 B/D -파트 B 또는파트 D 약일수있음 LA -사용제한

LEVOTHYROXINE SODIUM TABS 1 $0 75mcg, 300mcg LEVOXYL 1 $0 liothyronine sodium TABS 1 $0 methimazole TABS 1 $0 propylthiouracil TABS 1 $0 SYNTHROID 2 $0 UNITHROID 1 $0 VASOPRESSINS -뇌하수체호르몬을조절하는약 desmopressin acetate spray 1 $0 desmopressin acetate spray refrigerated desmopressin acetate tabs desmopressin inj 4mcg/ml DESMOPRESSIN SOL 0.01% 1 1 1 1 $0 $0 $0 $0 STIMATE 2 $0 NM 위장약 - 위장및내장질환을치료하는약 제산제 alum & mag hydrox-simethicone 3 $0 NM; * ALUMINUM HYDROXIDE 3 $0 NM; * aluminum hydroxide-mag carb calcium carbonate (antacid) CHEW; TABS 3 3 $0 $0 NM; * NM; * GAVISCON CHEW 3 $0 NM; * GAVISCON EXTRA STRENGTH R 3 $0 NM; * magnesium oxide TABS 420mg mi-acid 3 3 $0 $0 NM; * NM; * sodium bicarbonate (antacid) 3 $0 NM; * 지사제 bismuth subsalicylate CHEW; 3 $0 NM; * SUSP loperamide hcl LIQD; TABS 3 $0 NM; * 제토제 - 구역질과구토를위한약 aprepitant compro dimenhydrinate TABS dronabinol 1 1 3 1 $0 $0 $0 $0 B/D NM; * B/D, QL (60 caps / 30 EMEND SUSR EMEND CAP 40MG 2 2 $0 $0 B/D B/D PA -사전허가 ( 승인 ) QL -수량한도 ST -단계별치료법 NM - 우편주문불가능 B/D -파트 B 또는파트 D 약일수있음 LA -사용제한 48

EMEND CAP 80MG 2 $0 B/D EMEND CAP 125MG 2 $0 B/D EMEND PAK 80 & 125 2 $0 B/D granisetron hcl SOLN 1 $0 granisetron hcl TABS 1 $0 B/D meclizine hcl CHEW 3 $0 NM; * meclizine hcl TABS 12.5mg 3 $0 NM; * meclizine hcl TABS 12.5mg, 25mg 1 $0 metoclopramide hcl SOLN; TABS 1 $0 metoclopramide inj 1 $0 ondansetron hcl TABS 1 $0 B/D ondansetron hcl inj 1 $0 ondansetron hcl oral soln 1 $0 B/D ondansetron odt 1 $0 B/D phenadoz 2 $0 PA; PA if 65 years and older phenergan SUPP 2 $0 PA; PA if 65 years and older prochlorperazine inj 1 $0 prochlorperazine maleate TABS 1 $0 prochlorperazine supp 1 $0 promethazine hcl SOLN; SUPP; 2 $0 PA; PA if 65 years and SYRP; TABS older promethegan 2 $0 PA; PA if 65 years and older scopolamine 2 $0 QL (10 patches / 30, PA; PA if 65 years and older TRANSDERM-SCOP 2 $0 QL (10 patches / 30, PA; PA if 65 years and older 진경약 - 위경련을위한약 dicyclomine hcl CAPS 1 $0 dicyclomine hcl SOLN 10mg/5ml 1 $0 dicyclomine hcl TABS 1 $0 glycopyrrolate TABS 1 $0 glycopyrrolate soln 4mg/20ml 1 $0 H2-수용체길항제 - 위궤양및위산을위한약 cimetidine TABS 200mg 3 $0 NM; * famotidine SOLN 1 $0 famotidine SUSR 1 $0 famotidine TABS 10mg, 20mg 3 $0 NM; * PA -사전허가 ( 승인 ) QL -수량한도 ST -단계별치료법 NM - 우편주문불가능 B/D -파트 B 또는파트 D 약일수있음 LA -사용제한 49

famotidine TABS 20mg, 40mg 1 $0 famotidine inj 1 $0 ranitidine hcl TABS 75mg, 150mg 3 $0 NM; * ranitidine hcl TABS 150mg, 300mg1 $0 ranitidine hcl inj 1 $0 ranitidine syrup 1 $0 염증성장질환 APRISO 2 $0 balsalazide disodium 1 $0 budesonide ec 2 $0 CANASA 2 $0 colocort enema 100mg 1 $0 DELZICOL 2 $0 DIPENTUM 2 $0 HYDROCORTISONE (ENEMA) 1 $0 MESALAMINE TBEC 800mg 1 $0 mesalamine enema 1 $0 mesalamine w/ cleanser 1 $0 sulfasalazine TABS 1 $0 sulfasalazine ec 1 $0 완하제 bisacodyl SUPP; TBEC 3 $0 NM; * calcium polycarbophil 3 $0 NM; * constulose 1 $0 docusate calcium 3 $0 NM; * docusate sodium CAPS; LIQD; 3 $0 NM; * SYRP; TABS docusol mini 3 $0 NM; * enemeez mini 3 $0 NM; * enemeez plus 3 $0 NM; * enulose 1 $0 FLEET BISACODYL 3 $0 NM; * gavilyte-c 1 $0 gavilyte-g 1 $0 gavilyte-h 1 $0 gavilyte-n 1 $0 generlac 1 $0 glycerin (laxative) 3 $0 NM; * GOLYTELY 2 $0 KONSYL PACK 100% 3 $0 NM; * KONSYL POWD 60.3%, 71.67% 3 $0 NM; * PA -사전허가 ( 승인 ) QL -수량한도 ST -단계별치료법 NM - 우편주문불가능 B/D -파트 B 또는파트 D 약일수있음 LA -사용제한 50

KONSYL-D 3 $0 NM; * lactulose 1 $0 lactulose (encephalopathy) 1 $0 magnesium citrate SOLN 3 $0 NM; * magnesium hydroxide SUSP 3 $0 NM; * methylcellulose (laxative) 3 $0 NM; * MINERAL OIL OIL 3 $0 NM; * MOVIPREP 2 $0 NULYTELY/FLAVOR PACKS 2 $0 PEG 3350-KCL-SOD BICARB-SOD 1 $0 CHLORIDE-SOD SULFATE peg 3350-potassium chloride-sod 1 $0 bicarbonate-sod chloride PEG 3350/ELECTROLYTES 1 $0 polyethylene glycol 3350 PACK 1 $0 polyethylene glycol 3350 PACK 3 $0 NM; * polyethylene glycol 3350 POWD 1 $0 polyethylene glycol 3350 POWD 3 $0 NM; * psyllium 3 $0 NM; * sennosides 3 $0 NM; * sennosides-docusate sodium 3 $0 NM; * sodium phosphates 3 $0 NM; * SUPREP BOWEL PREP KIT 2 $0 trilyte 1 $0 기타 alosetron hcl 2 $0 PA AMITIZA CAP 8MCG 2 $0 QL (60 caps / 30 AMITIZA CAP 24MCG 2 $0 QL (60 caps / 30 cromolyn sodium (mastocytosis) 2 $0 diphenoxylate w/ atropine 1 $0 GATTEX 2 $0 NM, LA, PA LINZESS 72mcg, 290mcg 2 $0 QL (30 caps / 30 LINZESS 145mcg 2 $0 QL (60 caps / 30 loperamide hcl CAPS 1 $0 misoprostol TABS 1 $0 MOVANTIK 12.5mg 2 $0 QL (60 tabs / 30 MOVANTIK 25mg 2 $0 QL (30 tabs / 30 RELISTOR SOLN 2 $0 PA SUCRAID 2 $0 LA sucralfate TABS 1 $0 ursodiol CAPS; TABS 1 $0 XIFAXAN 550mg 2 $0 PA PA -사전허가 ( 승인 ) QL -수량한도 ST -단계별치료법 NM - 우편주문불가능 B/D -파트 B 또는파트 D 약일수있음 LA -사용제한 51

췌장효소 CREON 2 $0 ZENPEP 2 $0 양성자펌프억제제 - 위궤양및위산을위한약 DEXILANT 2 $0 QL (30 caps / 30 esomeprazole magnesium 1 $0 QL (30 caps / 30 esomeprazole sodium inj 1 $0 GNP OMEPRAZOLE 3 $0 NM; * HM OMEPRAZOLE 3 $0 NM; * lansoprazole CPDR 15mg 3 $0 NM; * lansoprazole CPDR 15mg, 30mg 1 $0 QL (30 caps / 30 NEXIUM GRA 2.5MG DR 2 $0 NEXIUM GRA 5MG DR 2 $0 NEXIUM GRA 10MG DR 2 $0 QL (30 packets / 30 NEXIUM GRA 20MG DR 2 $0 QL (30 packets / 30 NEXIUM GRA 40MG DR 2 $0 QL (30 packets / 30 OMEPRAZOLE TBEC 3 $0 NM; * omeprazole cap 10mg 1 $0 QL (30 caps / 30 omeprazole cap 20mg 1 $0 QL (60 caps / 30 omeprazole cap 40mg 1 $0 QL (30 caps / 30 pantoprazole sodium tbec 1 $0 QL (30 tabs / 30 PRILOSEC OTC 3 $0 NM; * rabeprazole sodium 1 $0 QL (30 tabs / 30 SM OMEPRAZOLE 3 $0 NM; * 비뇨생ð기 - 생ð관및요로질환을치료하는약 전ñ선비대 - 비대한전ñ선을치료하는약 alfuzosin hcl 1 $0 QL (30 tabs / 30 dutasteride 1 $0 QL (30 caps / 30 dutasteride-tamsulosin hcl 1 $0 QL (30 caps / 30 finasteride TABS 5mg 1 $0 tamsulosin hcl 1 $0 기타 bethanechol chloride TABS 1 $0 ELMIRON 2 $0 potassium citrate (alkalinizer) 1 $0 15meq POTASSIUM CITRATE 1 $0 (ALKALINIZER) 540mg, 1080mg PA -사전허가 ( 승인 ) QL -수량한도 ST -단계별치료법 NM - 우편주문불가능 B/D -파트 B 또는파트 D 약일수있음 LA -사용제한 52

비뇨기진경제 - 요실금을치료하는약 MYRBETRIQ 25mg 2 $0 QL (60 tabs / 30 MYRBETRIQ 50mg 2 $0 QL (30 tabs / 30 oxybutynin chloride SYRP 1 $0 oxybutynin chloride TABS 1 $0 oxybutynin chloride TB24 5mg 1 $0 QL (30 tabs / 30 oxybutynin chloride TB24 10mg, 1 $0 QL (60 tabs / 30 15mg tolterodine tartrate cap er 1 $0 QL (30 caps / 30 tolterodine tartrate tabs 1 $0 TOVIAZ 2 $0 QL (30 tabs / 30 trospium chloride TABS 1 $0 QL (60 tabs / 30 VESICARE 2 $0 QL (30 tabs / 30 질항염증제 clindamycin phosphate vaginal 1 $0 clotrimazole vaginal 3 $0 NM; * metronidazole vaginal 1 $0 miconazole nitrate vaginal CREA 3 $0 NM; * miconazole nitrate vaginal SUPP 3 $0 NM; * 100mg terconazole vaginal 1 $0 VANDAZOLE 1 $0 혈ò학 - 혈ò 장애를치료하는약항응고제 - 혈ò óô제 COUMADIN 2 $0 ELIQUIS 2 $0 PA enoxaparin sodium 30mg/0.3ml, 1 $0 40mg/0.4ml, 60mg/0.6ml, 80mg/0.8ml, 100mg/ml, 120mg/0.8ml, 150mg/ml ENOXAPARIN SODIUM 300mg/3ml1 $0 fondaparinux sodium 2.5mg/0.5ml1 $0 fondaparinux sodium 5mg/0.4ml, 2 $0 7.5mg/0.6ml, 10mg/0.8ml heparin sod (porcine) in d5w 2 $0 HEPARIN SOD (PORCINE) IN D5W 2 $0 heparin sod inj 1000/ml 1 $0 B/D heparin sod inj 5000/ml 1 $0 B/D heparin sod inj 10000/ml 1 $0 B/D heparin sod inj 20000/ml 1 $0 B/D HEPARIN SODIUM/D5W 2 $0 HEPARIN SODIUM/NACL 0.45% 2 $0 PA -사전허가 ( 승인 ) QL -수량한도 ST -단계별치료법 NM - 우편주문 53 불가능 B/D -파트 B 또는파트 D 약일수있음 LA -사용제한

jantoven 1 $0 PRADAXA 2 $0 warfarin sodium 1 $0 XARELTO 2 $0 XARELTO STARTER PACK 2 $0 조혈성장인자 GRANIX 2 $0 NM, PA LEUKINE 2 $0 NM, PA MOZOBIL 2 $0 NM, PA NEUPOGEN 2 $0 NM, PA PROCRIT 2 $0 NM, PA õ ferrous gluconate TABS 27mg, 3 $0 NM; * 324mg FERROUS GLUCONATE TABS 3 $0 NM; * 324mg ferrous sulfate ELIX 3 $0 NM; * FERROUS SULFATE LIQD 3 $0 NM; * ferrous sulfate SOLN 3 $0 NM; * FERROUS SULFATE SYRP 3 $0 NM; * ferrous sulfate TABS 325mg 3 $0 NM; * FERROUS SULFATE TBEC 324mg 3 $0 NM; * ferrous sulfate TBEC 325mg 3 $0 NM; * INFED 3 $0 NM; * polysaccharide iron complex 3 $0 NM; * sodium ferric gluconate complex in 3 $0 NM; * sucrose VENOFER 3 $0 NM; * 기타 anagrelide hcl 1 $0 cilostazol 1 $0 CINRYZE 2 $0 NM, LA, PA FIRAZYR 2 $0 NM, PA HAEGARDA 2 $0 NM, LA, PA pentoxifylline TBCR 1 $0 PROMACTA 12.5mg 2 $0 QL (360 tabs / 30, NM, LA, PA PROMACTA 25mg 2 $0 QL (180 tabs / 30, NM, LA, PA PROMACTA 50mg 2 $0 QL (90 tabs / 30, NM, LA, PA PA -사전허가 ( 승인 ) QL -수량한도 ST -단계별치료법 NM - 우편주문불가능 B/D -파트 B 또는파트 D 약일수있음 LA -사용제한 54

PROMACTA 75mg 2 $0 QL (60 tabs / 30, NM, LA, PA tranexamic acid SOLN; TABS 1 $0 혈소ö 응 억제제 ASPIRIN-DIPYRIDAMOLE 1 $0 BRILINTA 2 $0 clopidogrel bisulfate TABS 75mg 1 $0 EFFIENT 2 $0 prasugrel hcl 1 $0 ZONTIVITY 2 $0 면역학적제제 - 면역체계의장애를치료하는약 질병 ø경항 ù마ú스약물 (DMARDS) -ù마ú스관절염을치료하는약 HUMIRA INJ 10MG/0.2ML 2 $0 QL (2 syringes / 28, NM, PA HUMIRA KIT 20MG/0.4ML 2 $0 QL (2 syringes / 28, NM, PA HUMIRA KIT 40MG/0.8ML 2 $0 QL (6 syringes / 28, NM, PA HUMIRA PEDIATRIC CROHNS 2 $0 NM, PA DISEASE HUMIRA PEN 2 $0 QL (6 pens / 28, NM, PA HUMIRA PEN-CROHNS DISEASE 2 $0 NM, PA HUMIRA PEN-PSORIASIS STAR 2 $0 NM, PA hydroxychloroquine sulfate 1 $0 leflunomide TABS 1 $0 methotrexate sodium tabs 1 $0 REMICADE 2 $0 NM, PA XATMEP 2 $0 B/D XELJANZ 2 $0 QL (60 tabs / 30, NM, PA XELJANZ XR 2 $0 QL (30 tabs / 30, NM, PA 면역 û로불린 BIVIGAM 2 $0 NM, PA CARIMUNE NANOFILTERED 2 $0 NM, PA FLEBOGAMMA DIF 2 $0 NM, PA GAMASTAN S/D 2 $0 B/D, NM GAMMAGARD LIQUID 2 $0 NM, PA GAMMAGARD S/D 2 $0 NM, PA GAMMAKED 2 $0 NM, PA PA -사전허가 ( 승인 ) QL -수량한도 ST -단계별치료법 NM - 우편주문불가능 B/D -파트 B 또는파트 D 약일수있음 LA -사용제한 55

GAMMAPLEX 5gm/100ml, 2 $0 NM, PA 5gm/50ml, 10gm/200ml, 20gm/200ml GAMMAPLEX 10GM/100ML 2 $0 NM, PA GAMUNEX-C 2 $0 NM, PA OCTAGAM 1gm/20ml, 2gm/20ml, 2 $0 NM, PA 2.5gm/50ml, 5gm/100ml, 10gm/200ml, 25gm/500ml PRIVIGEN 2 $0 NM, PA 면역조절물질 ACTIMMUNE 2 $0 NM, LA, PA ARCALYST 2 $0 NM, PA INTRON-A INJ 10MU 2 $0 B/D, NM INTRON-A INJ 18MU 2 $0 B/D, NM INTRON-A INJ 25MU 2 $0 B/D, NM INTRON-A INJ 50MU 2 $0 B/D, NM POMALYST CAP 1MG 2 $0 NM, LA, PA POMALYST CAP 2MG 2 $0 NM, LA, PA POMALYST CAP 3MG 2 $0 NM, LA, PA POMALYST CAP 4MG 2 $0 NM, LA, PA REVLIMID 2 $0 NM, LA, PA THALOMID 2 $0 NM, PA 면역억제제 azathioprine SOLR; TABS 1 $0 B/D BENLYSTA SOLR 2 $0 NM, PA cyclosporine CAPS; SOLN 1 $0 B/D cyclosporine modified (for 1 $0 B/D microemulsion) gengraf 1 $0 B/D mycophenolate mofetil CAPS; 1 $0 B/D TABS mycophenolate mofetil SUSR 2 $0 B/D mycophenolate sodium 1 $0 B/D NEORAL 2 $0 B/D NULOJIX 2 $0 B/D PROGRAF CAPS 2 $0 B/D RAPAMUNE SOLN 2 $0 B/D SANDIMMUNE SOLN 100mg/ml 2 $0 B/D sirolimus TABS 2mg 2 $0 B/D sirolimus TABS.5mg, 1mg 1 $0 B/D tacrolimus CAPS 1 $0 B/D ZORTRESS TAB 0.5MG 2 $0 B/D PA -사전허가 ( 승인 ) QL -수량한도 ST -단계별치료법 NM - 우편주문불가능 B/D -파트 B 또는파트 D 약일수있음 LA -사용제한 56

ZORTRESS TAB 0.25MG 2 $0 B/D ZORTRESS TAB 0.75MG 2 $0 B/D 백신 ACTHIB 2 $0 ADACEL 2 $0 BCG VACCINE 2 $0 BEXSERO 2 $0 BOOSTRIX 2 $0 DAPTACEL 2 $0 DIPHTHERIA/TETANUS TOXOID 2 $0 B/D ENGERIX-B SUSP 2 $0 B/D GARDASIL 2 $0 GARDASIL 9 2 $0 HAVRIX 2 $0 HIBERIX 2 $0 IMOVAX RABIES (H.D.C.V.) 2 $0 INFANRIX 2 $0 IPOL INACTIVATED IPV 2 $0 IXIARO 2 $0 KINRIX 2 $0 M-M-R II 2 $0 MENACTRA 2 $0 MENOMUNE-A/C/Y/W-135 2 $0 MENVEO 2 $0 PEDIARIX 2 $0 PEDVAX HIB 2 $0 PENTACEL 2 $0 PROQUAD 2 $0 QUADRACEL 2 $0 RABAVERT 2 $0 RECOMBIVAX HB 2 $0 B/D ROTARIX 2 $0 ROTATEQ 2 $0 SYNAGIS 2 $0 NM TENIVAC 2 $0 B/D TETANUS/DIPHTHERIA TOXOID 2 $0 B/D TRUMENBA 2 $0 TWINRIX INJ 2 $0 TYPHIM VI 2 $0 VAQTA 2 $0 VARIVAX 2 $0 PA -사전허가 ( 승인 ) QL -수량한도 ST -단계별치료법 NM - 우편주문불가능 B/D -파트 B 또는파트 D 약일수있음 LA -사용제한 57

YF-VAX 2 $0 ZOSTAVAX 2 $0 QL (1 vial per lifetime) ü양제 / ü양보조제 - 비타ý 및 ü양보조제 전þ질 KLOR-CON 8 1 $0 KLOR-CON 10 1 $0 klor-con m10 1 $0 klor-con m15 1 $0 klor-con m20 1 $0 klor-con spr cap 8meq 1 $0 klor-con spr cap 10meq 1 $0 MAGNESIUM SULFATE SOLN 2 $0 2gm/50ml, 4gm/100ml, 4gm/50ml, 20gm/500ml, 40gm/1000ml magnesium sulfate SOLN 1 $0 2gm/50ml, 50% MAGNESIUM SULFATE SOLN 50% 1 $0 magnesium sulfate in d5w 1 $0 MAGNESIUM SULFATE IN D5W 2 $0 oral electrolytes 3 $0 NM; * potassium chloride CPCR 1 $0 POTASSIUM CHLORIDE PACK 1 $0 POTASSIUM CHLORIDE SOLN 1 $0 10%, 20% potassium chloride TBCR 1 $0 potassium chloride 1 $0 microencapsulated crystals er SODIUM CHLORIDE SOLN 1 $0 2.5meq/ml sodium fluoride chew; tab; 1.1 1 $0 (0.5 f) mg/ml soln TPN ELECTROLYTES 2 $0 B/D 정맥주사 ü양제 AMINOSYN 2 $0 B/D AMINOSYN 7%/ELECTROLYTES 2 $0 B/D AMINOSYN 8.5%/ELECTROLYTE 2 $0 B/D AMINOSYN II 8.5% 2 $0 B/D AMINOSYN II 8.5%/ELECTROL 2 $0 B/D AMINOSYN II 10% 2 $0 B/D AMINOSYN M 2 $0 B/D AMINOSYN-HBC 2 $0 B/D PA -사전허가 ( 승인 ) QL -수량한도 ST -단계별치료법 NM - 우편주문 58 불가능 B/D -파트 B 또는파트 D 약일수있음 LA -사용제한

AMINOSYN-PF 7% 2 $0 B/D AMINOSYN-PF INJ 10% 2 $0 B/D AMINOSYN-RF 2 $0 B/D CLINIMIX 2.75%/DEXTROSE 5% 2 $0 B/D CLINIMIX 4.25%/DEXTROSE 5% 2 $0 B/D CLINIMIX 4.25%/DEXTROSE 25% 2 $0 B/D CLINIMIX 5%/DEXTROSE 15% 2 $0 B/D CLINIMIX 5%/DEXTROSE 20% 2 $0 B/D CLINIMIX 5%/DEXTROSE 25% 2 $0 B/D CLINIMIX INJ 4.25/D10 2 $0 B/D CLINIMIX INJ 4.25/D20 2 $0 B/D FREAMINE HBC 6.9% 2 $0 B/D FREAMINE III 2 $0 B/D HEPATAMINE 2 $0 B/D INTRALIPID INJ 20% 2 $0 B/D INTRALIPID INJ 30% 2 $0 B/D NEPHRAMINE 2 $0 B/D nutrilipid inj 20% 2 $0 B/D premasol sol 6% 1 $0 B/D premasol sol 10% 2 $0 B/D PROCALAMINE 2 $0 B/D PROSOL 2 $0 B/D TRAVASOL 2 $0 B/D TROPHAMINE INJ 10% 2 $0 B/D 정맥주사보ÿ ò DEXTROSE 2.5%/NACL 0.45% 1 $0 DEXTROSE 5% 1 $0 DEXTROSE 5% /ELECTROLYTE 2 $0 DEXTROSE 5%/LACTATED RING 1 $0 DEXTROSE 5%/NACL 0.2% 1 $0 DEXTROSE 5%/NACL 0.3% 1 $0 DEXTROSE 5%/NACL 0.9% 1 $0 DEXTROSE 5%/NACL 0.33% 1 $0 DEXTROSE 5%/NACL 0.45% 1 $0 DEXTROSE 5%/NACL 0.225% 1 $0 DEXTROSE 5%/POTASSIUM CHL 1 $0 DEXTROSE 10% FLEX CONTAIN 1 $0 DEXTROSE 10%/NACL 0.2% 2 $0 DEXTROSE 10%/NACL 0.45% 1 $0 DEXTROSE 50% 1 $0 DEXTROSE INJ 70% 1 $0 PA -사전허가 ( 승인 ) QL -수량한도 ST -단계별치료법 NM - 우편주문불가능 B/D -파트 B 또는파트 D 약일수있음 LA -사용제한 59

IONOSOL-B/DEXTROSE 5% 2 $0 IONOSOL-MB/DEXTROSE 5% 2 $0 ISOLYTE P 2 $0 ISOLYTE S 2 $0 KCL0.15%/D5W/NACL0.2% 1 $0 KCL0.15%/D5W/NACL0.225% 2 $0 KCL 0.3%/D5W/NACL 0.9% 1 $0 KCL 0.3%/D5W/NACL 0.45% 1 $0 KCL 0.15%/D5W/NACL 0.9% 1 $0 KCL 0.075%/D5W/NACL 0.45% 1 $0 KCL IN NACL INJ.15-0.45 1 $0 KCL/D5W INJ 0.3% 1 $0 KCL/D5W/NACL INJ 0.22%/0.45% 1 $0 KCL/D5W/NACL INJ.15/.33% 1 $0 KCL/D5W/NACL INJ.15/.45% 1 $0 KCL/NACL INJ 0.3-0.9 1 $0 KCL/NACL INJ 0.15%-0.9% 1 $0 LACTATED RINGER'S INJ 1 $0 NORMOSOL-M IN D5W 2 $0 NORMOSOL-R 2 $0 NORMOSOL-R IN D5W 2 $0 PLASMA-LYTE A 2 $0 PLASMA-LYTE-148 2 $0 pot chloride inj 2meq/ml 1 $0 POTASSIUM CHLORIDE SOLN 1 $0.4meq/ml, 10meq/100ml, 10meq/50ml, 20meq/100ml, 40meq/100ml potassium chloride in nacl 1 $0 RINGER'S 1 $0 SODIUM CHLORIDE SOLN 3%, 5%1 $0 SODIUM CHLORIDE 0.45% VIA 1 $0 SODIUM CHLORIDE INJ 0.9% 1 $0 무기질 calcium carbonate TABS 3 $0 NM; * calcium carbonate (antacid) SUSP 3 $0 NM; * calcium carbonate-cholecalciferol 3 $0 NM; * calcium carbonate-vitamin d 3 $0 NM; * calcium citrate TABS 950mg 3 $0 NM; * calcium citrate-vitamin d 3 $0 NM; * CALCIUM GLUCONATE TABS 3 $0 NM; * 500mg PA -사전허가 ( 승인 ) QL -수량한도 ST -단계별치료법 NM - 우편주문불가능 B/D -파트 B 또는파트 D 약일수있음 LA -사용제한 60

mag64 3 $0 NM; * MAGNEBIND 300 3 $0 NM; * magnesium TABS 250mg 3 $0 NM; * magnesium oxide (mg supplement)3 $0 NM; * oyster shell 3 $0 NM; * 기타 ORA-BLEND 3 $0 NM; * ORA-BLEND SF 3 $0 NM; * ORA-PLUS 3 $0 NM; * ORA-SWEET 3 $0 NM; * ORA-SWEET SF 3 $0 NM; * SUSPENDOL-S 3 $0 NM; * SYRSPEND SF LIQD 3 $0 NM; * 비타ý AQUADEKS CAPS 3 $0 NM; * ascorbic acid CHEW 3 $0 NM; * ascorbic acid TABS 250mg, 500mg3 $0 NM; * b complex w/ c 3 $0 NM; * b-complex vitamins 3 $0 NM; * b-complex w/ c & e + zn 3 $0 NM; * b-complex w/ c & folic acid 3 $0 NM; * b-complex w/ minerals 3 $0 NM; * biotin CAPS 5mg, 5000mcg 3 $0 NM; * biotin TABS 300mcg 3 $0 NM; * calcitriol CAPS 1 $0 B/D calcitriol inj 1 $0 B/D calcitriol oral soln 1 mcg/ml 1 $0 B/D CERTAVITE SENIOR/ANTIOXID 3 $0 NM; * cholecalciferol LIQD; TABS 3 $0 NM; * cyanocobalamin SOLN; TABS 3 $0 NM; * ELDERTONIC 3 $0 NM; * ergocalciferol CAPS; SOLN 3 $0 NM; * folic acid SOLN 3 $0 NM; * folic acid TABS 1mg, 400mcg 3 $0 NM; * hydroxocobalamin SOLN 3 $0 NM; * MEPHYTON 3 $0 NM; * multiple vitamin 3 $0 NM; * multiple vitamins w/ iron 3 $0 NM; * multiple vitamins w/ minerals 3 $0 NM; * NASCOBAL 3 $0 NM; * niacin CPCR 500mg 3 $0 NM; * PA -사전허가 ( 승인 ) QL -수량한도 ST -단계별치료법 NM - 우편주문불가능 B/D -파트 B 또는파트 D 약일수있음 LA -사용제한 61

niacin TABS 50mg, 500mg 3 $0 NM; * niacin TBCR 3 $0 NM; * niacinamide TABS 500mg 3 $0 NM; * ONCOVITE 3 $0 NM; * paricalcitol CAPS 1 $0 B/D pediatric multiple vitamin w/ c 3 $0 NM; * pediatric multiple vitamin w/ c & fa 3 $0 NM; * pediatric multiple vitamin w/ 3 $0 NM; * minerals & c pediatric multiple vitamins w/ iron 3 $0 NM; * pediatric vitamins adc 3 $0 NM; * phytonadione SOLN 3 $0 NM; * PRENATAL 3 $0 NM; * prenatal vitamin/folic acid > 0.8 1 $0 mg (generic) pyridoxine hcl SOLN 3 $0 NM; * pyridoxine hcl TABS 50mg, 100mg3 $0 NM; * THERA 3 $0 NM; * THERA M PLUS 3 $0 NM; * THERA-M 3 $0 NM; * THERA/BETA-CAROTENE 3 $0 NM; * thiamine hcl SOLN; TABS 3 $0 NM; * TRI-VI-SOL 3 $0 NM; * vitamin a CAPS 8000unit, 3 $0 NM; * 10000unit vitamins w/ lipotropics 3 $0 NM; * 안과 - 눈질환을치료하는약 항감염제 / 항염증제 - 감염과염증을치료하는약 bacitracin-poly-neomycin-hc 1 $0 blephamide OINT 2 $0 neomycin-polymy-dexameth 1 $0 neomycin-polymyxin-hc (ophth) 1 $0 sulfacetamide sod-prednisolone 1 $0 TOBRADEX OINT 2 $0 TOBRADEX ST 2 $0 tobramycin-dexamethasone 1 $0 ZYLET 2 $0 항감염약 - 감염을치료하기위한약 bacitracin (ophthalmic) 1 $0 bacitracin-polymyxin b (ophth) 1 $0 BESIVANCE 2 $0 PA -사전허가 ( 승인 ) QL -수량한도 ST -단계별치료법 NM - 우편주문불가능 B/D -파트 B 또는파트 D 약일수있음 LA -사용제한 62

CILOXAN OINT 2 $0 ciprofloxacin hcl (ophth) 1 $0 erythromycin (ophth) 1 $0 gatifloxacin (ophth) 1 $0 gentak 1 $0 gentamicin sulfate (ophth) 1 $0 MOXEZA 2 $0 moxifloxacin hcl (ophth) 1 $0 NATACYN 2 $0 neomycin-bacitracin zn-polymyxin 1 $0 neomycin-polymyxin-gramicidin 1 $0 ofloxacin (ophth) 1 $0 polymyxin b-trimethoprim 1 $0 sulfacet sod oin 10% op 1 $0 sulfacetamide sodium (ophth) 1 $0 tobramycin (ophth) 1 $0 TOBREX OINT 2 $0 trifluridine SOLN 1 $0 VIGAMOX 2 $0 ZIRGAN 2 $0 항염증제 - 염증을치료하는약 ALREX 2 $0 bromfenac sodium (ophth) 1 $0 BROMSITE 2 $0 dexamethasone sodium phosphate 1 $0 (ophth) diclofenac sodium (ophth) 1 $0 DUREZOL 2 $0 FLUOROMETHOLONE 1 $0 flurbiprofen sodium 1 $0 ILEVRO 2 $0 ketorolac tromethamine (ophth) 1 $0 LOTEMAX 2 $0 MAXIDEX 2 $0 PREDNISOLONE ACETATE (OPHTH) 1 $0 prednisolone sodium phosphate 2 $0 (ophth) 항알레르기제 - 알레르기를치료하는약 azelastine drop 0.05% 1 $0 BEPREVE 2 $0 cromolyn sodium (ophth) 1 $0 PA -사전허가 ( 승인 ) QL -수량한도 ST -단계별치료법 NM - 우편주문 불가능 B/D -파트 B 또는파트 D 약일수있음 LA -사용제한 63

LASTACAFT 2 $0 olopatadine hcl.2% 1 $0 PATADAY 2 $0 PAZEO 2 $0 항녹내장제 - 녹내장을치료하는약 ALPHAGAN P SOL 0.1% 2 $0 AZOPT 2 $0 betaxolol hcl (ophth) 1 $0 BETOPTIC-S 2 $0 brimonidine sol 0.2% 1 $0 BRIMONIDINE SOL 0.15% 1 $0 carteolol hcl (ophth) 1 $0 COMBIGAN 2 $0 dorzolamide hcl 1 $0 dorzolamide hcl-timolol maleate 1 $0 ISTALOL 2 $0 latanoprost SOLN 1 $0 levobunolol hcl 1 $0 LUMIGAN 2 $0 metipranolol 1 $0 PHOSPHOLINE IODIDE 2 $0 PILOCARPINE HCL SOLN 1 $0 SIMBRINZA 2 $0 timolol maleate (ophth) soln 1 $0 TIMOLOL MALEATE GEL 1 $0 TRAVATAN Z 2 $0 기타 artificial tear ointment 3 $0 NM; * artificial tear solution 3 $0 NM; * carboxymethylcellulose sodium 3 $0 NM; * (ophth) carboxymethylcellulose-glycerin 3 $0 NM; * carboxymethylcellulose- 3 $0 NM; * hypromellose CYSTARAN 2 $0 NM, LA, PA GENTEAL SEVERE 3 $0 NM; * MURO 128 OINT 3 $0 NM; * MURO 128 SOLN 2% 3 $0 NM; * naphazoline hcl SOLN 1 $0 polyethylene glycol-propylene 3 $0 NM; * glycol (ophth) polyvinyl alcohol SOLN 3 $0 NM; * PA -사전허가 ( 승인 ) QL -수량한도 ST -단계별치료법 NM - 우편주문 불가능 B/D -파트 B 또는파트 D 약일수있음 LA -사용제한 64

PROLENSA 2 $0 proparacaine hcl SOLN 1 $0 REFRESH CELLUVISC 3 $0 NM; * RESTASIS 2 $0 QL (64 vials / 30 RESTASIS MULTIDOSE 2 $0 QL (1 bottle / 30 sodium chloride hypertonic 3 $0 NM; * SYSTANE OVERNIGHT THERAPY 3 $0 NM; * white petrolatum-mineral oil 3 $0 NM; * 호흡계 - 호흡장애를치료하는약 항알레르기 / 베타작용제조합 ( ANTICHOLINERGIC/BETA - 만성폐쇄성 폐질환 (COPD) 을치료하는약 ANORO ELLIPTA 2 $0 QL (60 blisters / 30 BEVESPI AEROSPHERE 2 $0 QL (1 inhaler / 30 COMBIVENT RESPIMAT 2 $0 QL (2 inhalers / 30 ipratropium-albuterol nebu 1 $0 B/D 항콜린제 - 만성폐쇄성폐질환 (COPD) 을치료하는약 ATROVENT HFA 2 $0 QL (2 inhalers / 30 INCRUSE ELLIPTA 2 $0 QL (1 inhaler / 30 ipratropium bromide SOLN 1 $0 B/D ipratropium bromide (nasal) 1 $0 항히스타ý제 - 알레르기를치료하는약 azelastine spr 0.1% 1 $0 azelastine spr 0.15% 1 $0 cetirizine hcl CHEW 10mg 3 $0 NM; * cetirizine hcl SOLN 3 $0 NM; * cetirizine hcl SYRP 3 $0 NM; * cetirizine hcl TABS 3 $0 NM; * cetirizine syrup 1 $0 chlorpheniramine maleate SYRP; 3 $0 NM; * TABS cyproheptadine hcl SYRP; TABS 2 $0 PA; PA if 65 years and older diphenhydramine hcl CAPS 3 $0 NM; * diphenhydramine hcl LIQD 3 $0 NM; * diphenhydramine hcl SYRP 3 $0 NM; * diphenhydramine hcl TABS 25mg 3 $0 NM; * diphenhydramine inj 1 $0 PA -사전허가 ( 승인 ) QL -수량한도 ST -단계별치료법 NM - 우편주문불가능 B/D -파트 B 또는파트 D 약일수있음 LA -사용제한 65

fexofenadine hcl SUSP; TABS 3 $0 NM; * hydroxyzine hcl SOLN; SYRP; 2 $0 PA; PA if 65 years and TABS older hydroxyzine pamoate CAPS 2 $0 PA; PA if 65 years and older levocetirizine dihydrochloride 1 $0 loratadine SOLN; SYRP; TABS 3 $0 NM; * silphen cough 3 $0 NM; * 베타작용제 - 천ð과만성폐쇄성폐질환 (COPD) 을치료하는약 albuterol sulfate NEBU 1 $0 B/D albuterol sulfate SYRP; TABS; 1 $0 TB12 levalbuterol conc 1.25mg/0.5ml 1 $0 B/D levalbuterol hcl NEBU 1 $0 B/D 1.25mg/0.5ml LEVALBUTEROL TARTRATE HFA 1 $0 QL (2 inhalers / 30 SEREVENT DISKUS 2 $0 QL (60 inhalations / 30 terbutaline sulfate SOLN 2 $0 terbutaline sulfate TABS 1 $0 VENTOLIN HFA 2 $0 QL (2 inhalers / 30 기침및감기 benzonatate 3 $0 NM; * brompheniramine & phenyleph 3 $0 NM; * brompheniramine & pseudoeph 3 $0 NM; * brotapp dm 3 $0 NM; * cetirizine-pseudoephedrine 3 $0 NM; * chlorpheniramine & phenylephrine 3 $0 NM; * chlorpheniramine & pseudoeph 3 $0 NM; * chlorpheniramine-dm 3 $0 NM; * cromolyn sodium (nasal) 3 $0 NM; * dextromethorphan-guaifenesin 3 $0 NM; * guaifenesin LIQD; SOLN; SYRP; 3 $0 NM; * TABS; TB12 loratadine & pseudoephedrine 3 $0 NM; * NASAL DECONGESTANT LIQD 3 $0 NM; * nasal decongestant SYRP 3 $0 NM; * oxymetazoline hcl SOLN 3 $0 NM; * phenylephrine hcl (oral) 3 $0 NM; * phenylephrine w/ dm-gg 3 $0 NM; * PA -사전허가 ( 승인 ) QL -수량한도 ST -단계별치료법 NM - 우편주문불가능 B/D -파트 B 또는파트 D 약일수있음 LA -사용제한 66

phenylephrine-brompheniramine- 3 $0 NM; * dm phenylephrine-chlorpheniramine- 3 $0 NM; * dm w/ apap phenylephrine-guaifenesin 3 $0 NM; * PHENYLHISTINE DH 3 $0 NM; * pseudoephedrine hcl LIQD 3 $0 NM; * pseudoephedrine hcl TABS 30mg 3 $0 NM; * pseudoephedrine-chlorphen-dm 3 $0 NM; * triprolidine & pseudoephedrine 3 $0 NM; * LEUKOTRIENE 수용체길항제 - 천ð과알레르기를치료하는약 montelukast sodium CHEW; PACK; 1 $0 TABS zafirlukast 1 $0 비만세포안정제 - 알레르기를치료하는약 cromolyn sodium nebu 1 $0 B/D 기타 acetylcysteine SOLN 10%, 20% 1 $0 B/D ARALAST NP 2 $0 NM, LA, PA DALIRESP 2 $0 EPIPEN 2-PAK 2 $0 EPIPEN-JR 2-PAK 2 $0 ESBRIET 2 $0 NM, PA KALYDECO 2 $0 NM, PA OFEV 2 $0 NM, PA ORKAMBI 2 $0 NM, PA PROLASTIN-C 2 $0 NM, LA, PA PULMOZYME 2 $0 NM, PA saline.65% 3 $0 NM; * XOLAIR 2 $0 NM, LA, PA ZEMAIRA 2 $0 NM, LA, PA 비강 STEROIDS - 알레르기를치료하는약 flunisolide (nasal) 1 $0 QL (2 bottles / 30 fluticasone propionate (nasal) 1 $0 QL (1 bottle / 30 STEROID 흡입제 - 천ð을치료하는약 ARNUITY ELLIPTA 2 $0 QL (30 inhalations / 30 budesonide (inhalation) 1 $0 B/D.25mg/2ml,.5mg/2ml PA -사전허가 ( 승인 ) QL -수량한도 ST -단계별치료법 NM - 우편주문불가능 B/D -파트 B 또는파트 D 약일수있음 LA -사용제한 67

FLOVENT DISKUS 50mcg/blist, 2 $0 QL (120 inhalations / 100mcg/blist 30 FLOVENT DISKUS 250mcg/blist 2 $0 QL (240 inhalations / 30 FLOVENT HFA 2 $0 QL (2 inhalers / 30 PULMICORT FLEXHALER 2 $0 QL (2 inhalers / 30 베타작용제조합 - 천ð과만성폐쇄성폐질환 (COPD) 을치료하는약 ADVAIR DISKUS 2 $0 QL (60 inhalations / 30 ADVAIR HFA 2 $0 QL (1 inhaler / 30 BREO ELLIPTA 2 $0 QL (60 blisters / 30 SYMBICORT 2 $0 QL (1 inhaler / 30 XANTHINES -만성폐쇄성폐질환 (COPD) 을치료하는약 aminophylline inj 1 $0 elixophyllin 2 $0 theo-24 2 $0 theophylline 1 $0 점안 - 귀와피부질환을치료하는약피부과, 여드름 adapalene CREA 1 $0 adapalene GEL.1% 1 $0 amnesteem 1 $0 PA AVITA 1 $0 PA benzoyl peroxide GEL 5%, 10% 3 $0 NM; * benzoyl peroxide-erythromycin 1 $0 claravis 1 $0 PA clindacin-p pad 1% 1 $0 clindamycin phosphate (topical) 1 $0 GEL; LOTN; SOLN; SWAB ery pad 2% 1 $0 erythromycin (acne aid) 1 $0 myorisan 1 $0 PA sulfacetamide sodium (acne) 1 $0 tretinoin CREA 1 $0 PA TRETINOIN GEL.01% 1 $0 PA tretinoin GEL.025% 1 $0 PA zenatane 1 $0 PA PA -사전허가 ( 승인 ) QL -수량한도 ST -단계별치료법 NM - 우편주문불가능 B/D -파트 B 또는파트 D 약일수있음 LA -사용제한 68

피부과, 항생제 bacitracin (topical) 3 $0 NM; * bacitracin zinc OINT 3 $0 NM; * gentamicin sulfate (topical) 1 $0 mupirocin OINT 1 $0 SILVER SULFADIAZINE CREA 1 $0 SSD 1 $0 SULFAMYLON 2 $0 피부과, 항균제 ALEVAZOL 3 $0 NM; * castellani paint 3 $0 NM; * ciclopirox CREA; GEL; SUSP 1 $0 ciclopirox shampoo 1% 1 $0 clotrimazole (topical) CREA 1% 1 $0 clotrimazole (topical) CREA 1% 3 $0 NM; * clotrimazole (topical) SOLN 1 $0 ketoconazole cream 1 $0 miconazole nitrate (topical) 3 $0 NM; * nyamyc 1 $0 nyata 1 $0 nystatin (topical) 1 $0 nystop 1 $0 terbinafine hcl (topical) 3 $0 NM; * tolnaftate AERP; CREA; POWD 3 $0 NM; * 피부과, 항가려움제 DOXEPIN HCL (ANTIPRURITIC) 1 $0 procto-med 1 $0 procto-pak 1 $0 proctosol hc cre 2.5% 1 $0 proctozone hc 1 $0 피부과, 항건선제 acitretin 2 $0 PA calcipotriene CREA 1 $0 calcipotriene SOLN 1 $0 8-MOP 2 $0 tazarotene CREA 1 $0 PA TAZORAC CREA 2 $0 PA 피부과, 항지루약 ketoconazole shampoo 1 $0 selenium sulfide LOTN 1 $0 피부과, CORTICOSTEROIDS PA -사전허가 ( 승인 ) QL -수량한도 ST -단계별치료법 NM - 우편주문불가능 B/D -파트 B 또는파트 D 약일수있음 LA -사용제한 69

ala-cort 1 $0 alclometasone dipropionate 1 $0 betamethasone dipropionate 1 $0 (topical) betamethasone dipropionate 1 $0 augmented CREA; GEL; LOTN BETAMETHASONE DIPROPIONATE 1 $0 AUGMENTED OINT betamethasone valerate CREA 1 $0 betamethasone valerate LOTN 1 $0 betamethasone valerate OINT 1 $0 desoximetasone CREA 1 $0 desoximetasone GEL 1 $0 DESOXIMETASONE OINT.05% 1 $0 desoximetasone OINT.25% 1 $0 fluocinolone acetonide CREA; OIL; 1 $0 OINT; SOLN fluocinonide CREA.05% 1 $0 fluocinonide GEL 1 $0 fluocinonide SOLN 1 $0 fluocinonide emulsified base 1 $0 fluticasone propionate CREA 1 $0 fluticasone propionate OINT 1 $0 halobetasol propionate 1 $0 hydrocortisone (topical) CREA 1% 3 $0 NM; * hydrocortisone (topical) CREA 1%, 1 $0 2.5% hydrocortisone (topical) LOTN 1% 3 $0 NM; * hydrocortisone (topical) LOTN 1 $0 2.5% hydrocortisone (topical) OINT 1% 3 $0 NM; * hydrocortisone (topical) OINT 1%, 1 $0 2.5% hydrocortisone butyrate 1 $0 hydrocortisone valerate 1 $0 hydrocortisone-aloe vera 3 $0 NM; * mometasone furoate CREA 1 $0 mometasone furoate OINT 1 $0 mometasone furoate SOLN 1 $0 texacort soln 2.5% 2 $0 triamcinolone acetonide (topical) 1 $0 CREA; LOTN; OINT PA -사전허가 ( 승인 ) QL -수량한도 ST -단계별치료법 NM - 우편주문불가능 B/D -파트 B 또는파트 D 약일수있음 LA -사용제한 70

triderm 1 $0 피부과, 국소마취제 lidocaine PTCH 1 $0 QL (3 patches / 1 day), PA lidocaine hcl GEL 1 $0 PA lidocaine hcl SOLN 4% 1 $0 PA lidocaine oint 5% 1 $0 PA lidocaine-prilocaine 1 $0 PA 피부과, 기타피부및점ò 막 ABREVA 3 $0 NM; * ammonium lactate CREA; LOTN 1 $0 diclofenac sodium (topical) 1% gel 1 $0 PA fluorouracil (topical) CREA 5% 1 $0 fluorouracil (topical) SOLN 1 $0 imiquimod CREA 1 $0 metronidazole (topical) CREA; 1 $0 LOTN metronidazole gel 0.75% 1 $0 PANRETIN 2 $0 PICATO 2 $0 podofilox SOLN 1 $0 POLYBASE 3 $0 NM; * rosadan cre 0.75% 1 $0 tacrolimus (topical) 1 $0 TARGRETIN GEL 2 $0 NM, PA VALCHLOR 2 $0 NM, LA, PA zinc oxide (topical) 3 $0 NM; * 피부과, 항개선약및머릿니살 ÿ 제 EURAX 2 $0 malathion 1 $0 permethrin CREA 1 $0 permethrin LIQD; LOTN 3 $0 NM; * pyrethrins-piperonyl butoxide 3 $0 NM; * 피부과, 상처치료제 ACETIC ACID.25% 1 $0 REGRANEX 2 $0 PA SANTYL 2 $0 SODIUM CHLORIDE 0.9% 1 $0 STERILE WATER IRRIGATION 1 $0 입 / 인후 / 치과제제 cevimeline hcl 1 $0 PA -사전허가 ( 승인 ) QL -수량한도 ST -단계별치료법 NM - 우편주문불가능 B/D -파트 B 또는파트 D 약일수있음 LA -사용제한 71

chlorhexidine gluconate (mouth- 1 $0 throat) clotrimazole TROC 1 $0 lidocaine hcl (mouth-throat) 1 $0 nystatin (mouth-throat) 1 $0 paroex sol 0.12% 1 $0 periogard 1 $0 PILOCARPINE HCL (ORAL) 5mg 1 $0 pilocarpine hcl (oral) 7.5mg 1 $0 triamcinolone acetonide (mouth) 1 $0 귀 - 귀질환을치료하는약 ACETIC ACID (OTIC) 1 $0 acetic acid-aluminum acetate 1 $0 CIPRODEX 2 $0 fluocinolone acetonide (otic) 1 $0 neomycin-polymyxin-hc (otic) 1 $0 ofloxacin (otic) 1 $0 의약품이름약품군요구사항 / 제한 파트 B 당뇨병측정기및검사지 Breeze 2 Kits, Strips Contour Kits, Strips Contour Next EZ Kits, Strips Contour Next USB Kits, Strips PA -사전허가 ( 승인 ) QL -수량한도 ST -단계별치료법 NM - 우편주문불가능 B/D -파트 B 또는파트 D 약일수있음 LA -사용제한 72

Index 8 8-MOP...69 A abacavir sulfate... 7 ABACAVIR SULFATE-LAMIVUDINE... 8 abacavir sulfate-lamivudine-zidovudine 8 ABELCET... 6 ABILIFY MAINTENA...31 ABRAXANE...13 ABREVA...71 acamprosate calcium...37 acarbose...39 acebutolol hcl...20 acetaminophen... 1 acetaminophen w/ codeine... 2 acetazolamide...22 ACETIC ACID...71 ACETIC ACID (OTIC)...72 acetic acid-aluminum acetate...72 acetylcysteine...67 acitretin...69 ACTHIB...57 ACTIMMUNE...56 acyclovir... 9 acyclovir sodium... 9 ADACEL...57 ADAGEN...45 adapalene...68 ADCIRCA...23 adefovir dipivoxil... 9 ADEMPAS...23 adriamycin...12 adrucil...13 ADVAIR DISKUS...68 ADVAIR HFA...68 afeditab cr...21 AFINITOR...15 AFINITOR DISPERZ...15 ala-cort...70 ALBENZA... 5 albuterol sulfate...66 alclometasone dipropionate...70 ALCOHOL SWABS...38 ALDURAZYME...45 ALECENSA...15 alendronate sodium...41 ALEVAZOL...69 alfuzosin hcl...52 ALIMTA...13 ALINIA... 5 allopurinol tab... 1 alosetron hcl...51 ALPHAGAN P SOL 0.1%...64 alprazolam tab 0.25mg...24 alprazolam tab 0.5mg...24 alprazolam tab 1mg...24 alprazolam tab 2mg...24 ALREX...63 altavera tab...41 alum & mag hydrox-simethicone...48 ALUMINUM HYDROXIDE...48 aluminum hydroxide-mag carb...48 ALUNBRIG...15 alyacen 1/35...41 amantadine hcl...30 AMBISOME... 6 AMIFOSTINE...16 amikacin sulfate... 5 amiloride & hydrochlorothiazide...22 amiloride hcl...22 aminophylline inj...68 AMINOSYN...58 AMINOSYN 7%/ELECTROLYTES...58 AMINOSYN 8.5%/ELECTROLYTE...58 AMINOSYN II 10%...58 AMINOSYN II 8.5%...58 AMINOSYN II 8.5%/ELECTROL...58 AMINOSYN M...58 AMINOSYN-HBC...58 AMINOSYN-PF 7%...59 AMINOSYN-PF INJ 10%...59 AMINOSYN-RF...59 amiodarone hcl...19 AMITIZA CAP 24MCG...51 AMITIZA CAP 8MCG...51 amitriptyline hcl...28 73

amlodipine besylate...21 amlodipine besylate-olmesartan medoxomil...18 amlodipine besylate-valsartan tab 10-160 mg...18 amlodipine besylate-valsartan tab 10-320 mg...18 amlodipine besylate-valsartan tab 5-160 mg...18 amlodipine besylate-valsartan tab 5-320 mg...18 amlodipine--benazepril hcl cap 10-20 mg...17 amlodipine-benazepril hcl cap 10-40mg...17 amlodipine-benazepril hcl cap 2.5-10 mg...17 amlodipine-benazepril hcl cap 5-10 mg17 amlodipine-benazepril hcl cap 5-20 mg17 amlodipine-benazepril hcl cap 5-40 mg17 amlodipine-valsartan-hydrochlorothiazide 10-160-12.5mg...18 amlodipine-valsartan-hydrochlorothiazide 10-160-25mg...18 amlodipine-valsartan-hydrochlorothiazide 10-320-25mg...18 amlodipine-valsartan-hydrochlorothiazide 5-160-12.5mg...18 amlodipine-valsartan-hydrochlorothiazide 5-160-25mg...18 ammonium lactate...71 amnesteem...68 amoxapine tab 100mg...28 amoxapine tab 150mg...28 amoxapine tab 25mg...28 amoxapine tab 50mg...28 amoxicillin...11 amoxicillin & pot clavulanate...11 amphetamine-dextroamphetamine cap sr 24hr 10 mg...34 amphetamine-dextroamphetamine cap sr 24hr 15 mg...34 amphetamine-dextroamphetamine cap sr 24hr 20 mg...34 amphetamine-dextroamphetamine cap sr 24hr 25 mg...34 amphetamine-dextroamphetamine cap sr 24hr 30 mg...34 amphetamine-dextroamphetamine cap sr 24hr 5 mg...34 amphetamine-dextroamphetamine tab 10 mg...34 amphetamine-dextroamphetamine tab 12.5 mg...34 amphetamine-dextroamphetamine tab 15 mg...34 amphetamine-dextroamphetamine tab 20 mg...34 amphetamine-dextroamphetamine tab 30 mg...34 amphetamine-dextroamphetamine tab 5 mg...34 amphetamine-dextroamphetamine tab 7.5 mg...34 amphotericin b... 6 ampicillin & sulbactam sodium...11 ampicillin cap 250 mg...11 ampicillin cap 500 mg...11 ampicillin inj...11 ampicillin sodium...11 ampicillin susp...11 AMPYRA...36 ANADROL-50...38 anagrelide hcl...54 anastrozole...14 ANDRODERM...38 ANORO ELLIPTA...65 APOKYN...30 aprepitant...48 apri 28 day...41 APRISO...50 APTIOM...24 APTIVUS... 7 AQUADEKS...61 ARALAST NP...67 aranelle 28...41 ARCALYST...56 aripiprazole odt...31 aripiprazole oral solution 1 mg/ml...31 aripiprazole tab...31 74

ARISTADA...31 armodafinil...37 ARNUITY ELLIPTA...67 artificial tear ointment...64 artificial tear solution...64 ascorbic acid...61 aspirin... 1 aspirin buffered (cal carb-mag carb-mag oxide)... 1 ASPIRIN-DIPYRIDAMOLE...55 atenolol...20 atenolol & chlorthalidone...20 atomoxetine hcl...34 atorvastatin calcium...19 atovaquone... 5 atovaquone-proguanil hcl... 7 ATRIPLA... 8 ATROVENT HFA...65 aubra 28 day...41 AURYXIA...47 AUSTEDO...36 AVASTIN...13 aviane 28...41 AVITA...68 AXIRON...38 azacitidine...13 AZACTAM IN ISO-OSMOTIC DE... 5 AZACTAM/DEX INJ 2GM... 5 azathioprine...56 azelastine drop 0.05%...63 azelastine spr 0.1%...65 azelastine spr 0.15%...65 AZITHROMYCIN...10 AZOPT...64 aztreonam... 5 B b complex w/ c...61 bacitracin (ophthalmic)...62 bacitracin (topical)...69 bacitracin zinc...69 bacitracin-polymyxin b (ophth)...62 bacitracin-poly-neomycin-hc...62 baclofen...36 balsalazide disodium...50 balziva 28 day...41 BANZEL SUS 40MG/ML...24 BANZEL TAB 200MG...24 BANZEL TAB 400MG...24 BARACLUDE... 9 BCG VACCINE...57 b-complex vitamins...61 b-complex w/ c & e + zn...61 b-complex w/ c & folic acid...61 b-complex w/ minerals...61 bekyree 28 day...41 BELEODAQ...13 benazepril & hydrochlorothiazide...17 benazepril hcl...17 BENDEKA...12 BENLYSTA...56 benzonatate...66 benzoyl peroxide...68 benzoyl peroxide-erythromycin...68 BENZTROPINE MESYLATE...30 BEPREVE...63 BESIVANCE...62 betamethasone dipropionate (topical).70 betamethasone dipropionate augmented...70 betamethasone valerate...70 BETASERON...36 betaxolol hcl (ophth)...64 bethanechol chloride...52 BETOPTIC-S...64 BEVESPI AEROSPHERE...65 bexarotene...16 BEXSERO...57 bicalutamide...14 BICILLIN L-A...11 BICNU...12 BILTRICIDE... 5 biotin...61 bisacodyl...50 bismuth subsalicylate...48 bisoprolol & hydrochlorothiazide...20 bisoprolol fumarate...20 BIVIGAM...55 bleomycin sulfate...12 blephamide...62 blisovi 21 fe 1.5/30 28 day pack...41 75

blisovi 21 fe 1/20 28 day pack...41 BOOSTRIX...57 BOSULIF...15 BREO ELLIPTA...68 briellyn 28 day...42 BRILINTA...55 BRIMONIDINE SOL 0.15%...64 brimonidine sol 0.2%...64 BRIVIACT...24 bromfenac sodium (ophth)...63 bromocriptine mesylate...30 brompheniramine & phenyleph...66 brompheniramine & pseudoeph...66 BROMSITE...63 brotapp dm...66 budesonide (inhalation)...67 budesonide ec...50 bumetanide...22 BUPHENYL...45 buprenorphine hcl...37 buprenorphine hcl-naloxone hcl sl...37 buproban tab 150mg...37 bupropion hcl...28 bupropion hcl (smoking deterrent)...37 buspirone hcl...24 busulfan...12 BUSULFEX...12 butorphanol tartrate... 2 BUTRANS... 2 BUTRANS 7.5MCG/HR... 2 BYDUREON INJ...38 BYDUREON PEN...38 BYETTA...38 BYSTOLIC...20 C cabergoline...46 CABOMETYX...15 calcipotriene...69 calcitonin (salmon)...46 calcitriol...61 calcitriol inj...61 calcitriol oral soln 1 mcg/ml...61 calcium acetate (phosphate binder)...47 calcium carbonate...60 calcium carbonate (antacid)... 48, 60 calcium carbonate-cholecalciferol...60 calcium carbonate-vitamin d...60 calcium citrate...60 calcium citrate-vitamin d...60 CALCIUM GLUCONATE...60 calcium polycarbophil...50 camila 28 day...42 CANASA...50 CANCIDAS... 6 candesartan cilexetil...19 candesartan cilexetil-hydrochlorothiazide...18 CAPASTAT SULFATE... 8 CAPRELSA...15 captopril...17 captopril & hydrochlorothiazide...17 CARBAGLU...45 carbamazepine...24 CARBIDOPA/LEVODOPA/ENTACAPONE.30 carbidopa-levodopa...30 carboplatin...16 carboxymethylcellulose sodium (ophth)...64 carboxymethylcellulose-glycerin...64 carboxymethylcellulose-hypromellose..64 CARIMUNE NANOFILTERED...55 carisoprodol...36 carteolol hcl (ophth)...64 cartia xt cap 120/24hr...21 cartia xt cap 180/24hr...21 cartia xt cap 240/24hr...21 cartia xt cap 300/24hr...21 carvedilol...20 CASPOFUNGIN ACETATE... 6 castellani paint...69 CAYSTON... 5 caziant pak...42 cefaclor... 9 cefaclor monohydrate er... 9 cefadroxil...10 CEFAZOLIN IN DEXTROSE 2GM/100ML- 4%...10 cefazolin inj...10 cefazolin sodium...10 cefazolin sodium 1 gm/50ml...10 76

cefdinir...10 cefepime hcl...10 cefixime...10 cefotaxime sodium...10 cefoxitin sodium...10 cefpodoxime proxetil...10 cefprozil...10 ceftazidime...10 CEFTAZIDIME/DEXTROSE...10 ceftriaxone sodium...10 cefuroxime axetil...10 cefuroxime sodium...10 celecoxib... 1 CELONTIN...24 cephalexin...10 CERDELGA...45 CEREZYME...45 CERTAVITE SENIOR/ANTIOXID...61 cetirizine hcl...65 cetirizine syrup...65 cetirizine-pseudoephedrine...66 cevimeline hcl...71 CHANTIX...37 CHANTIX CONTINUING MONTH...37 CHANTIX STARTER PACK...37 CHEMET...41 chlorhexidine gluconate (mouth-throat)...72 chloroquine phosphate... 7 chlorothiazide tabs...22 chlorpheniramine & phenylephrine...66 chlorpheniramine & pseudoeph...66 chlorpheniramine maleate...65 chlorpheniramine-dm...66 chlorpromazine hcl...31 chlorpromazine inj...31 chlorthalidone...22 cholecalciferol...61 cholestyramine...20 cholestyramine light...20 ciclopirox...69 ciclopirox shampoo 1%...69 cilostazol...54 CILOXAN...63 cimetidine...49 CINRYZE...54 CIPRODEX...72 ciprofloxacin...11 ciprofloxacin er...11 ciprofloxacin hcl (ophth)...63 ciprofloxacin hcl tab...11 ciprofloxacin in d5w...11 ciprofloxacin inj...11 cisplatin...16 citalopram hydrobromide...28 cladribine...13 claravis...68 clarithromycin...10 clarithromycin er...10 clarithromycin for susp...10 clindacin-p pad 1%...68 clindamycin cap 300mg... 5 clindamycin cap 75mg... 5 clindamycin hcl cap 150 mg... 5 clindamycin phosphate... 5 clindamycin phosphate (topical)...68 clindamycin phosphate in d5w... 5 CLINDAMYCIN PHOSPHATE IN NACL... 5 clindamycin phosphate inj... 5 clindamycin phosphate vaginal...53 clindamycin sol 75mg/5ml... 5 CLINIMIX 2.75%/DEXTROSE 5%...59 CLINIMIX 4.25%/DEXTROSE 25%...59 CLINIMIX 4.25%/DEXTROSE 5%...59 CLINIMIX 5%/DEXTROSE 15%...59 CLINIMIX 5%/DEXTROSE 20%...59 CLINIMIX 5%/DEXTROSE 25%...59 CLINIMIX INJ 4.25/D10...59 CLINIMIX INJ 4.25/D20...59 clomipramine hcl...28 clonazepam... 24, 25 clonidine hcl...22 clopidogrel bisulfate...55 clorazepate dipotassium...25 clotrimazole...72 clotrimazole (topical)...69 clotrimazole vaginal...53 CLOZAPINE ODT...31 clozapine tab 100mg...31 clozapine tab 200mg...31 77

clozapine tab 25mg...31 clozapine tab 50mg...31 COARTEM... 7 colchicine w/ probenecid... 1 COLCRYS... 1 colestipol hcl...20 colistimethate sodium... 5 colocort enema 100mg...50 COMBIGAN...64 COMBIVENT RESPIMAT...65 COMETRIQ...15 COMPLERA... 8 compro...48 constulose...50 COPAXONE INJ 40MG/ML...36 cortisone acetate...45 COTELLIC...15 COUMADIN...53 CREON...52 CRIXIVAN... 7 cromolyn sodium (mastocytosis)...51 cromolyn sodium (nasal)...66 cromolyn sodium (ophth)...63 cromolyn sodium nebu...67 cryselle 28...42 CUBICIN... 5 cyanocobalamin...61 cyclafem 1/35 28 day...42 cyclafem 7/7/7 28 day...42 cyclobenzaprine hcl...36 CYCLOPHOSPHAMIDE...12 cycloserine... 8 cyclosporine...56 cyclosporine modified (for microemulsion)...56 cyproheptadine hcl...65 cyred tab...42 CYSTADANE...45 CYSTAGON...45 CYSTARAN...64 cytarabine...13 D dacarbazine...12 DAKLINZA... 9 DALIRESP...67 danazol...45 dantrolene sodium...36 dapsone... 5 DAPTACEL...57 daptomycin... 5 daunorubicin hcl...12 deblitane 28 day...42 DELESTROGEN...45 delyla 28 day...42 DELZICOL...50 DEMSER...22 DEPEN TITRATABS...41 DEPO-PROVERA INJ 400/ML...14 DESCOVY... 8 desipramine hcl...28 desmopressin acetate spray...48 desmopressin acetate spray refrigerated...48 desmopressin acetate tabs...48 desmopressin inj 4mcg/ml...48 DESMOPRESSIN SOL 0.01%...48 desogestrel & ethinyl estradiol...42 desogestrel-ethinyl estradiol (biphasic)42 desoximetasone...70 desvenlafaxine succinate...28 dexamethasone...45 dexamethasone sodium phosphate...46 dexamethasone sodium phosphate (ophth)...63 DEXILANT...52 dexrazoxane...16 dextromethorphan-guaifenesin...66 DEXTROSE 10% FLEX CONTAIN...59 DEXTROSE 10%/NACL 0.2%...59 DEXTROSE 10%/NACL 0.45%...59 DEXTROSE 2.5%/NACL 0.45%...59 DEXTROSE 5%...59 DEXTROSE 5% /ELECTROLYTE...59 DEXTROSE 5%/LACTATED RING...59 DEXTROSE 5%/NACL 0.2%...59 DEXTROSE 5%/NACL 0.225%...59 DEXTROSE 5%/NACL 0.3%...59 DEXTROSE 5%/NACL 0.33%...59 DEXTROSE 5%/NACL 0.45%...59 DEXTROSE 5%/NACL 0.9%...59 78

DEXTROSE 5%/POTASSIUM CHL...59 DEXTROSE 50%...59 DEXTROSE INJ 70%...59 DIASTAT ACUDIAL...25 DIASTAT PEDIATRIC...25 diazepam...25 DIAZEPAM GEL...25 diclofenac potassium... 1 diclofenac sodium... 1 diclofenac sodium (ophth)...63 diclofenac sodium (topical) 1% gel...71 dicloxacillin sodium...11 dicyclomine hcl...49 didanosine... 7 DIFICID...10 diflunisal... 2 digitek...22 digox...22 digoxin...22 digoxin inj...22 DIGOXIN SOL 50MCG/ML...22 dihydroergotamine mesylate...35 dilantin...25 DILANTIN-125 SUS 125/5ML...25 diltiazem cap 120mg cd...21 diltiazem cap 180mg cd...21 diltiazem cap 240mg cd...21 diltiazem cap 300mg cd...21 DILTIAZEM CAP 360MG CD...21 diltiazem cap er/12hr...21 diltiazem hcl...21 diltiazem hcl cap sr 24hr...21 diltiazem hcl coated beads cap sr 24hr 21 diltiazem hcl extended release beads cap sr...21 dilt-xr cap...21 dimenhydrinate...48 DIPENTUM...50 diphenhydramine hcl...65 diphenhydramine hcl (sleep)...37 diphenhydramine inj...65 diphenoxylate w/ atropine...51 DIPHTHERIA/TETANUS TOXOID...57 disopyramide phosphate...19 disulfiram...37 divalproex sodium...25 DOCEFREZ...13 DOCETAXEL...13 DOCETAXEL 160MG/16ML...13 DOCETAXEL 20MG/2ML...13 DOCETAXEL SOLN 80MG/8ML...13 docusate calcium...50 docusate sodium...50 docusol mini...50 DOFETILIDE...19 donepezil hydrochloride...27 dorzolamide hcl...64 dorzolamide hcl-timolol maleate...64 doxazosin mesylate...18 doxepin hcl...28 DOXEPIN HCL (ANTIPRURITIC)...69 doxorubicin hcl...12 doxorubicin hcl liposomal inj 2mg/ml..12 doxorubicin inj 50mg...12 doxy...11 doxycycline (monohydrate)...11 doxycycline hyclate...12 dronabinol...48 drospirenone-ethinyl estradiol...42 DROXIA...16 duloxetine hcl...28 DURAMORPH... 2 DUREZOL...63 dutasteride...52 dutasteride-tamsulosin hcl...52 E e.e.s...10 EDURANT... 7 EFFIENT...55 ELDERTONIC...61 eletriptan hydrobromide...35 ELIQUIS...53 ELITEK...16 elixophyllin...68 ELLA...42 ELMIRON...52 EMCYT...12 EMEND...48 EMEND CAP 125MG...49 EMEND CAP 40MG...48 79

EMEND CAP 80MG...49 EMEND PAK 80 & 125...49 emoquette...42 EMSAM...28 EMTRIVA... 7 emverm... 5 enalapril maleate...17 enalapril maleate & hydrochlorothiazide...17 endocet... 2 enemeez mini...50 enemeez plus...50 ENGERIX-B...57 enoxaparin sodium...53 enpresse 28 day...42 ENTACAPONE...30 entecavir... 9 ENTRESTO...18 enulose...50 EPCLUSA... 9 EPIPEN 2-PAK...67 EPIPEN-JR 2-PAK...67 epirubicin hcl...12 epitol...25 EPIVIR HBV... 9 eplerenone...18 ergocalciferol...61 ergotamine w/ caffeine...35 ERIVEDGE...13 errin 28 day...42 ery pad 2%...68 ery-tab...10 erythrocin lactobionate...10 erythrocin stearate...10 erythromycin (acne aid)...68 erythromycin (ophth)...63 erythromycin base...10 erythromycin cap 250mg ec...10 erythromycin ethylsuccinate...11 ESBRIET...67 escitalopram oxalate...28 esomeprazole magnesium...52 esomeprazole sodium inj...52 estarylla tab 0.25-35...42 estrace...45 estradiol...45 estradiol vaginal tab 10 mcg...45 estradiol valerate...45 eszopiclone...35 ethambutol hcl... 8 ethosuximide...25 ethynodiol tab 1-50...42 etodolac... 2 etodolac er... 2 etoposide...17 EURAX...71 EVOTAZ... 8 exemestane...14 EXJADE...41 ezetimibe...20 F FABRAZYME...45 falmina 28 day...42 famciclovir... 9 famotidine... 49, 50 famotidine inj...50 FANAPT...31 FANAPT TITRATION PACK...31 FARESTON...14 FARXIGA...39 FARYDAK...13 FASLODEX...14 felbamate...25 felodipine...21 femynor 28 day...42 fenofibrate...20 fenofibrate micronized...20 fentanyl citrate... 3 fentanyl patch 100 mcg/hr... 3 fentanyl patch 12 mcg/hr... 3 fentanyl patch 25 mcg/hr... 3 fentanyl patch 50 mcg/hr... 3 fentanyl patch 75 mcg/hr... 3 FENTORA... 3 FERRIPROX...41 ferrous gluconate...54 ferrous sulfate...54 FETZIMA...29 FETZIMA TITRATION PACK...29 FEVERALL INFANTS... 1 80

fexofenadine hcl...66 finasteride...52 FIRAZYR...54 FLEBOGAMMA DIF...55 flecainide acetate...19 FLEET BISACODYL...50 FLOVENT DISKUS...68 FLOVENT HFA...68 fluconazole... 6 fluconazole in dextrose... 6 fluconazole inj nacl 100... 6 fluconazole inj nacl 200... 6 fluconazole inj nacl 400... 6 flucytosine... 6 fludarabine phosphate...13 fludrocortisone acetate...46 flunisolide (nasal)...67 fluocinolone acetonide...70 fluocinolone acetonide (otic)...72 fluocinonide...70 fluocinonide emulsified base...70 FLUOROMETHOLONE...63 fluorouracil...13 fluorouracil (topical)...71 fluoxetine cap 10mg...29 fluoxetine cap 20mg...29 fluoxetine cap 40mg...29 fluoxetine hcl...29 fluphenazine decanoate...31 fluphenazine hcl...31 flurbiprofen... 2 flurbiprofen sodium...63 flutamide...14 fluticasone propionate...70 fluticasone propionate (nasal)...67 fluvoxamine maleate...24 folic acid...61 fondaparinux sodium...53 FORTEO...47 FORTICAL...46 fosinopril sodium...18 fosinopril sodium & hydrochlorothiazide...17 FREAMINE HBC 6.9%...59 FREAMINE III...59 furosemide...22 furosemide inj...22 FUSILEV...16 FUZEON... 7 fyavolv tab 1-5mg...45 FYCOMPA...25 G gabapentin...26 GABITRIL...26 galantamine hydrobromide...27 galantamine hydrobromide er...27 GAMASTAN S/D...55 GAMMAGARD LIQUID...55 GAMMAGARD S/D...55 GAMMAKED...55 GAMMAPLEX...56 GAMMAPLEX 10GM/100ML...56 GAMUNEX-C...56 ganciclovir inj 500mg... 9 GARDASIL...57 GARDASIL 9...57 gatifloxacin (ophth)...63 GATTEX...51 GAUZE PADS 2...38 gavilyte-c...50 gavilyte-g...50 gavilyte-h...50 gavilyte-n...50 GAVISCON...48 GAVISCON EXTRA STRENGTH R...48 GEMCITABINE HCL...13 gemfibrozil...20 generlac...50 gengraf...56 gentak...63 gentamicin in saline... 5 gentamicin sulfate... 5 gentamicin sulfate (ophth)...63 gentamicin sulfate (topical)...69 GENTEAL SEVERE...64 GENVOYA... 8 GEODON...31 GIANVI...42 gildagia...42 gildess tab 1.5/30...42 81

GILENYA CAP 0.5MG...36 GILOTRIF TAB 20MG...15 GILOTRIF TAB 30MG...15 GILOTRIF TAB 40MG...15 glatopa...36 GLEOSTINE...12 glimepiride...39 glip/metform tab 2.5-250m...39 glip/metform tab 2.5-500m...39 glip/metform tab 5-500mg...39 glipizide...39 GLIPIZIDE XL TB24 2.5MG...39 GLIPIZIDE XL TB24 5MG...39 GLUCAGEN HYPOKIT...46 GLUCAGON EMERGENCY KIT...46 glyburide...39 glyburide micronized...40 glycerin (laxative)...50 glycopyrrolate...49 glycopyrrolate soln 4mg/20ml...49 GNP OMEPRAZOLE...52 GOLYTELY...50 granisetron hcl...49 GRANIX...54 griseofulvin microsize... 6 griseofulvin ultramicrosize... 6 guaifenesin...66 guanfacine er (adhd)...34 H HAEGARDA...54 halobetasol propionate...70 haloperidol...31 haloperidol decanoate...31 haloperidol lactate inj 5 mg/ml...31 haloperidol lactate oral conc 2 mg/ml..31 HARVONI... 9 HAVRIX...57 heather...42 heparin sod (porcine) in d5w...53 heparin sod inj 1000/ml...53 heparin sod inj 10000/ml...53 heparin sod inj 20000/ml...53 heparin sod inj 5000/ml...53 HEPARIN SODIUM/D5W...53 HEPARIN SODIUM/NACL 0.45%...53 HEPATAMINE...59 HERCEPTIN...13 HETLIOZ...35 HEXALEN...12 HIBERIX...57 HM GLUCOSE...46 HM OMEPRAZOLE...52 HUMIRA INJ 10MG/0.2ML...55 HUMIRA KIT 20MG/0.4ML...55 HUMIRA KIT 40MG/0.8ML...55 HUMIRA PEDIATRIC CROHNS DISEASE55 HUMIRA PEN...55 HUMIRA PEN-CROHNS DISEASE...55 HUMIRA PEN-PSORIASIS STAR...55 HUMULIN R INJ U-500...38 HUMULIN R U-500 KWIKPEN...38 hydralazine hcl...22 hydrochlorothiazide...22 hydroco/apap tab 10-325mg... 3 hydroco/apap tab 5-325mg... 3 hydroco/apap tab 7.5-325... 3 hydrocodone-acetaminophen 7.5-325 mg/15ml... 3 hydrocodone-ibuprofen tab 7.5-200 mg 3 hydrocortisone...46 HYDROCORTISONE (ENEMA)...50 hydrocortisone (topical)...70 hydrocortisone butyrate...70 hydrocortisone valerate...70 hydrocortisone-aloe vera...70 hydromorphone hcl... 3 hydroxocobalamin...61 hydroxychloroquine sulfate...55 hydroxyprogesterone caproate (antineoplastic)...14 hydroxyurea...16 hydroxyzine hcl...66 hydroxyzine pamoate...66 HYSINGLA ER... 3 I IBRANCE...14 ibuprofen... 2 ICLUSIG...15 idarubicin hcl...12 IDHIFA...14 82

IFEX INJ 3GM...12 ifosfamide inj 1gm...12 ifosfamide inj 1gm/20ml...12 IFOSFAMIDE INJ 3GM...12 ifosfamide inj 3gm/60ml...12 ILEVRO...63 imatinib mesylate...15 IMBRUVICA CAP 140MG...15 imipenem-cilastatin... 5 imipramine hcl...29 imiquimod...71 IMOVAX RABIES (H.D.C.V.)...57 INCRELEX...46 INCRUSE ELLIPTA...65 indapamide...22 INFANRIX...57 INFED...54 INLYTA...15 INSULIN PEN NEEDLE...38 INSULIN SAFETY NEEDLES...38 INSULIN SYRINGE...38 INTELENCE... 7 INTRALIPID INJ 20%...59 INTRALIPID INJ 30%...59 INTRON-A INJ 10MU...56 INTRON-A INJ 18MU...56 INTRON-A INJ 25MU...56 INTRON-A INJ 50MU...56 introvale 91 day...42 INVANZ... 5 INVEGA SUST INJ 117 MG/0.75 ML...32 INVEGA SUST INJ 156MG/ML...32 INVEGA SUST INJ 234 MG/1.5 ML...32 INVEGA SUST INJ 39 MG/0.25 ML...31 INVEGA SUST INJ 78 MG/0.5 ML...32 INVEGA TRINZA...32 INVIRASE... 7 INVOKAMET TAB 150-1000MG...40 INVOKAMET TAB 150-500MG...40 INVOKAMET TAB 50-1000MG...40 INVOKAMET TAB 50-500MG...40 INVOKAMET XR TAB 150-1000MG...40 INVOKAMET XR TAB 150-500MG...40 INVOKAMET XR TAB 50-1000MG...40 INVOKAMET XR TAB 50-500MG...40 INVOKANA...40 IONOSOL-B/DEXTROSE 5%...60 IONOSOL-MB/DEXTROSE 5%...60 IPOL INACTIVATED IPV...57 ipratropium bromide...65 ipratropium bromide (nasal)...65 ipratropium-albuterol nebu...65 irbesartan...19 irbesartan-hydrochlorothiazide...18 IRESSA...15 irinotecan inj 100/5ml...17 irinotecan inj 40mg/2ml...17 irinotecan inj 500mg/25ml...17 ISENTRESS... 7 ISENTRESS HD... 7 isibloom 28 day...42 ISOLYTE P...60 ISOLYTE S...60 isoniazid... 8 isoniazid inj 100 mg/ml... 8 isoniazid syp 50mg/5ml... 8 isosorb mononitrate tab...23 isosorbide dinitrate...23 isosorbide dinitrate er...23 isosorbide mononitrate er...23 isradipine...21 ISTALOL...64 ISTODAX (OVERFILL)...14 itraconazole... 6 ivermectin... 5 IXIARO...57 J JAKAFI...15 jantoven...54 JANUMET...40 JANUMET XR TAB 100-1000...40 JANUMET XR TAB 50-1000...40 JANUMET XR TAB 50-500MG...40 JANUVIA...40 JENTADUETO...40 JENTADUETO TAB XR 2.5-1000 MG...40 JENTADUETO TAB XR 5-1000 MG...40 jinteli...45 JOLESSA TAB 0.15-0.03 MG...42 JOLIVETTE...42 83

juleber 28 day...42 junel 1.5/30 21 day...42 junel 1/20 21 day...42 junel fe 1.5/30 28 day...42 junel fe 1/20 28 day...42 JUXTAPID...20 K KADCYLA...14 KALETRA SOL... 8 KALETRA TAB 100-25MG... 8 KALETRA TAB 200-50MG... 8 KALYDECO...67 kariva 28 day...42 KCL 0.075%/D5W/NACL 0.45%...60 KCL 0.15%/D5W/NACL 0.9%...60 KCL 0.3%/D5W/NACL 0.45%...60 KCL 0.3%/D5W/NACL 0.9%...60 KCL IN NACL INJ.15-0.45...60 KCL/D5W INJ 0.3%...60 KCL/D5W/NACL INJ.15/.33%...60 KCL/D5W/NACL INJ.15/.45%...60 KCL/D5W/NACL INJ 0.22%/0.45%...60 KCL/NACL INJ 0.15%-0.9%...60 KCL/NACL INJ 0.3-0.9...60 KCL0.15%/D5W/NACL0.2%...60 KCL0.15%/D5W/NACL0.225%...60 kelnor 1/35 28 day...42 ketoconazole... 6 ketoconazole cream...69 ketoconazole shampoo...69 ketoprofen... 2 ketorolac tromethamine (ophth)...63 KEYTRUDA...14 kimidess 28 day...42 KINRIX...57 kionex...41 KISQALI...14 KISQALI FEMARA 200 DOSE...14 KISQALI FEMARA 400 DOSE...14 KISQALI FEMARA 600 DOSE...14 KLOR-CON 10...58 KLOR-CON 8...58 klor-con m10...58 klor-con m15...58 klor-con m20...58 klor-con spr cap 10meq...58 klor-con spr cap 8meq...58 KONSYL...50 KONSYL-D...51 KORLYM...47 KUVAN...45 KYNAMRO...20 L labetalol hcl...20 LACTATED RINGER'S INJ...60 lactulose...51 lactulose (encephalopathy)...51 lamivudine... 7 lamivudine (hbv)... 9 lamivudine-zidovudine... 8 lamotrigine...26 lansoprazole...52 LANTUS...38 LANTUS SOLOSTAR...38 larin 1.5/30...42 larin 1/20...42 larin fe 1.5/30...42 larin fe 1/20...42 larissia tab...42 LASTACAFT...64 latanoprost...64 LATUDA...32 LEENA...43 leflunomide...55 LENVIMA 10 MG DAILY DOSE...15 LENVIMA 14 MG DAILY DOSE...15 LENVIMA 18 MG DAILY DOSE...15 LENVIMA 20 MG DAILY DOSE...15 LENVIMA 24 MG DAILY DOSE...15 LENVIMA 8 MG DAILY DOSE...15 lessina 28 day...43 LETAIRIS...23 letrozole...14 leucovorin calcium...16 leucovorin calcium for inj 500 mg...16 LEUKERAN...12 LEUKINE...54 leuprolide acetate...14 levalbuterol conc 1.25mg/0.5ml...66 levalbuterol hcl...66 84

LEVALBUTEROL TARTRATE HFA...66 LEVEMIR...38 LEVEMIR FLEXTOUCH...38 levetiracetam...26 LEVETIRACETAM IN SODIUM CHLORIDE...26 LEVETIRACETAM IV...26 levetiracetam oral soln 100 mg/ml...26 levobunolol hcl...64 levocarnitine (metabolic modifiers)...45 levocetirizine dihydrochloride...66 levofloxacin...11 levofloxacin in d5w...11 levofloxacin inj 25mg/ml...11 levofloxacin oral soln 25 mg/ml...11 levoleucovorin calcium...17 levonest 28 day...43 levonor/ethi tab...43 levonorgestrel (emergency oc)...43 levonorgestrel & eth estradiol...43 levonorgestrel-ethinyl estradiol (91-day)...43 levora 0.15/30 28 day...43 levothyroxine sodium... 47, 48 LEVOXYL...48 LEXIVA... 7 lidocaine...71 lidocaine hcl...71 lidocaine hcl (local anesth.)... 4 lidocaine hcl (mouth-throat)...72 lidocaine inj 0.5%... 4 lidocaine inj 1.5%... 4 lidocaine inj 1%... 4 lidocaine inj 2%... 4 lidocaine oint 5%...71 lidocaine-prilocaine...71 linezolid... 5 LINEZOLID IN SODIUM CHLORIDE... 6 LINZESS...51 liothyronine sodium...48 lisinopril...18 lisinopril & hydrochlorothiazide...17 lithium carbonate...36 lithium carbonate er...36 LITHIUM SOLN 8MEQ/5ML...36 LONSURF...16 loperamide hcl... 48, 51 lopinavir-ritonavir... 8 loratadine...66 loratadine & pseudoephedrine...66 lorazepam...24 lorcet hd tab 10-325mg... 3 lorcet plus tab 7.5-325... 3 lorcet tab 5-325mg... 3 loryna 28 day...43 losartan potassium...19 losartan-hydrochlorothiazide...19 LOTEMAX...63 lovastatin...19 low-ogestrel...43 loxapine succinate...32 LUMIGAN...64 LUMIZYME...45 LUPRON DEPOT (1-MONTH)...14 LUPRON DEPOT INJ 11.25MG (3-MONTH)...14 LUPRON DEP-PED INJ 11.25MG...47 LUPRON DEP-PED INJ 11.25MG (3- MONTH)...47 LUPRON DEP-PED INJ 15MG...47 LUPRON DEP-PED INJ 30MG (3-MONTH)...47 LUPRON DEP-PED INJ 7.5MG...47 lutera 28 day...43 LYNPARZA...14 LYRICA...26 LYSODREN...14 lyza...43 M mag64...61 MAGNEBIND 300...61 magnesium...61 magnesium citrate...51 magnesium hydroxide...51 magnesium oxide...48 magnesium oxide (mg supplement)...61 MAGNESIUM SULFATE...58 magnesium sulfate in d5w...58 malathion...71 maprotiline hcl...29 85

marlissa 28 day...43 MARPLAN TAB 10MG...29 MATULANE...16 MAVYRET... 9 MAXIDEX...63 meclizine hcl...49 medroxyprogesterone acetate (contraceptive)...43 medroxyprogesterone acetate tab...47 mefloquine hcl... 7 megestrol ac sus 40mg/ml...14 megestrol ac tab 20mg...15 megestrol ac tab 40mg...15 MEGESTROL SUS 625MG/5ML...15 MEKINIST...15 MELOXICAM... 2 melphalan hcl...12 memantine hcl...27 MENACTRA...57 MENOMUNE-A/C/Y/W-135...57 MENVEO...57 MEPHYTON...61 mercaptopurine...13 meropenem... 6 MESALAMINE...50 mesalamine enema...50 mesalamine w/ cleanser...50 mesna...17 MESNEX...17 metadate er tab 20mg...34 metformin hcl...40 methadone hcl... 3 methadone hcl 10mg... 4 methadone hcl 5mg... 3 methazolamide...22 methenamine hippurate... 6 methergine 0.2 mg tab...47 methimazole...48 methocarbamol...37 METHOTREXATE SODIUM...13 methotrexate sodium inj...13 methotrexate sodium tabs...55 methyclothiazide...22 methylcellulose (laxative)...51 methylergonovine maleate...47 methylphenidate hcl...34 methylphenidate hcl oral soln...35 methylpr ace inj 40mg/ml...46 methylpr ace inj 80mg/ml...46 methylpr ss inj 125 mg...46 methylpr ss inj 1gm...46 methylpr ss inj 40mg...46 methylpred pak 4mg...46 methylpred tab 16mg...46 methylpred tab 32mg...46 methylpred tab 4mg...46 methylpred tab 8mg...46 metipranolol...64 metoclopramide hcl...49 metoclopramide inj...49 metolazone...22 metoprolol & hctz tab 100-25mg...20 metoprolol & hctz tab 100-50mg...20 metoprolol & hctz tab 50-25mg...20 metoprolol succinate...21 metoprolol tartrate...21 metronidazole... 6 metronidazole (topical)...71 metronidazole gel 0.75%...71 metronidazole in nacl... 6 metronidazole vaginal...53 mexiletine hcl...19 MIACALCIN 200 UNIT/ML...47 mi-acid...48 miconazole nitrate (topical)...69 miconazole nitrate vaginal...53 MICROGESTIN 1.5/30...43 MICROGESTIN 1/20...43 MICROGESTIN FE 1.5/30...43 MICROGESTIN FE 1/20...43 midodrine hcl...23 migergot...35 MINERAL OIL...51 minitran...23 minocycline hcl...12 minoxidil...23 mirtazapine...29 misoprostol...51 mitomycin...12 mitoxantrone hcl...16 86

M-M-R II...57 moderiba tab 200mg... 9 moexipril hcl...18 moexipril-hydrochlorothiazide...17 molindone hcl 10mg...32 molindone hcl 25mg...32 mometasone furoate...70 mono-linyah tab 0.25-35...43 MONONESSA...43 montelukast sodium...67 morgidox cap 1x50mg...12 morphine ext-rel tab... 4 MORPHINE SUL INJ 10MG/ML... 4 MORPHINE SUL INJ 15MG/ML... 4 MORPHINE SUL INJ 1MG/ML... 4 MORPHINE SUL INJ 4MG/ML... 4 MORPHINE SULFATE... 4 MORPHINE SULFATE ORAL SOL... 4 MOVANTIK...51 MOVIPREP...51 MOXEZA...63 moxifloxacin hcl...11 moxifloxacin hcl (ophth)...63 MOZOBIL...54 MULTAQ...19 multiple vitamin...61 multiple vitamins w/ iron...61 multiple vitamins w/ minerals...61 mupirocin...69 MURO 128...64 MUSTARGEN...12 MYCAMINE... 7 mycophenolate mofetil...56 mycophenolate sodium...56 myorisan...68 MYRBETRIQ...53 myzilra...43 N nabumetone... 2 nadolol...21 nafcillin sodium...11 NAGLAZYME...45 nalbuphine hcl... 2 naloxone inj 0.4mg/ml...37 naloxone inj 1mg/ml...37 naltrexone hcl...37 NAMENDA XR...27 NAMENDA XR TITRATION PACK...28 NAMZARIC...28 naphazoline hcl...64 naproxen... 2 naproxen sodium... 2 naratriptan hcl...35 NASAL DECONGESTANT...66 NASCOBAL...61 NATACYN...63 nateglinide...40 NATPARA...47 NEBUPENT... 6 necon 0.5/35 28 day...43 necon 10/11-28...43 NECON 7/7/7...43 necon tab 1/35...43 NECON TAB 1/50-28...43 nefazodone hcl...29 neomycin sulfate... 5 neomycin-bacitracin zn-polymyxin...63 neomycin-polymy-dexameth...62 neomycin-polymyxin-gramicidin...63 neomycin-polymyxin-hc (ophth)...62 neomycin-polymyxin-hc (otic)...72 NEORAL...56 NEPHRAMINE...59 NERLYNX...15 NEUPOGEN...54 NEUPRO...30 NEVIRAPINE... 7 NEXAVAR...16 NEXIUM GRA 10MG DR...52 NEXIUM GRA 2.5MG DR...52 NEXIUM GRA 20MG DR...52 NEXIUM GRA 40MG DR...52 NEXIUM GRA 5MG DR...52 niacin... 61, 62 niacin er (antihyperlipidemic)...20 niacinamide...62 niacor...20 nicardipine hcl...21 nicotine...37 nicotine polacrilex...37 87

NICOTROL INHALER...37 NICOTROL NS...37 nifedical xl...21 nifedipine...21 nifedipine er...21 nikki 28 day...43 nilutamide...15 nimodipine...21 NINLARO...14 NIPENT...13 nitro-bid...23 NITRO-DUR DIS 0.3MG/HR...23 NITRO-DUR DIS 0.8MG/HR...23 nitrofurantoin macrocrystal... 6 nitrofurantoin monohyd macro... 6 nitroglycerin...23 nitroglycerin td patch...23 NORA-BE TAB...43 NORDITROPIN FLEXPRO...46 norethindrone (contraceptive)...43 norethindrone acet & eth estra...43 norethindrone acetate...47 norethindrone acetate-ethinyl estradiol 1mg-5mcg...45 norgest/ethi tab 0.25/35...43 norgestimate-ethinyl estradiol (triphasic)...43 norlyroc 28 day...44 NORMOSOL-M IN D5W...60 NORMOSOL-R...60 NORMOSOL-R IN D5W...60 NORPACE CR...19 NORTHERA...23 nortrel 0.5/35 28 day...44 nortrel 1/35 21 day...44 nortrel 1/35 28 day...44 nortrel 7/7/7 28 day...44 nortriptyline hcl...29 NORVIR... 7 NOVOLIN 70/30...38 NOVOLIN N...38 NOVOLIN R...38 NOVOLOG...38 NOVOLOG FLEXPEN...38 NOVOLOG MIX 70/30...38 NOVOLOG MIX 70/30 PREFILL...38 NOVOLOG PENFILL...38 NOXAFIL... 7 NUEDEXTA...36 NULOJIX...56 NULYTELY/FLAVOR PACKS...51 NUPLAZID...32 nutrilipid inj 20%...59 NUVARING...44 nyamyc...69 nyata...69 NYMALIZE...21 nystatin... 7 nystatin (mouth-throat)...72 nystatin (topical)...69 nystop...69 O OCELLA TAB 3-0.03MG...44 OCTAGAM...56 octreotide acetate...47 ODEFSEY... 8 ODOMZO...16 OFEV...67 ofloxacin (ophth)...63 ofloxacin (otic)...72 olanzapine...32 olmesartan medoxomil...19 olmesartan medoxomil-amlodipinehydrochlorothiazide...19 olmesartan medoxomilhydrochlorothiazide...19 olopatadine hcl...64 omega-3-acid ethyl esters...20 OMEPRAZOLE...52 omeprazole cap 10mg...52 omeprazole cap 20mg...52 omeprazole cap 40mg...52 ONCOVITE...62 ondansetron hcl...49 ondansetron hcl inj...49 ondansetron hcl oral soln...49 ondansetron odt...49 ONFI...26 OPSUMIT...23 ORA-BLEND...61 88

ORA-BLEND SF...61 oral electrolytes...58 ORA-PLUS...61 ORA-SWEET...61 ORA-SWEET SF...61 ORFADIN...45 ORKAMBI...67 orsythia 28 day...44 oseltamivir phosphate... 9 oxacillin sodium...11 oxaliplatin...16 oxandrolone...38 oxcarbazepine...26 oxybutynin chloride...53 oxycodone hcl... 4 oxycodone w/ acetaminophen 10-325mg... 4 oxycodone w/ acetaminophen 2.5-325mg... 4 oxycodone w/ acetaminophen 5-325mg 4 oxycodone w/ acetaminophen 7.5-325mg... 4 oxycodone w/ acetaminophen soln... 4 OXYCONTIN... 4 oxymetazoline hcl...66 oyster shell...61 P pacerone...19 paclitaxel...13 paliperidone...32 pamidronate disodium...41 PANRETIN...71 pantoprazole sodium tbec...52 paricalcitol...62 paroex sol 0.12%...72 paromomycin sulfate... 5 paroxetine hcl tabs...29 paser d/r... 8 PATADAY...64 PAXIL...29 PAZEO...64 PEDIARIX...57 pediatric multiple vitamin w/ c...62 pediatric multiple vitamin w/ c & fa...62 pediatric multiple vitamin w/ minerals & c...62 pediatric multiple vitamins w/ iron...62 pediatric vitamins adc...62 PEDVAX HIB...57 PEG 3350/ELECTROLYTES...51 PEG 3350-KCL-SOD BICARB-SOD CHLORIDE-SOD SULFATE...51 peg 3350-potassium chloride-sod bicarbonate-sod chloride...51 PEGANONE...26 PEGASYS... 9 PEGASYS PROCLICK... 9 PENICILLIN G POT IN DEXTROSE...11 penicillin g procaine...11 penicillin g sodium...11 penicillin v potassium...11 penicilln gk inj 20mu...11 penicilln gk inj 5mu...11 PENTACEL...57 PENTAM 300... 6 pentoxifylline...54 perindopril erbumine...18 periogard...72 permethrin...71 perphenazine...32 pfizerpen-g...11 phenadoz...49 phenelzine sulfate...29 phenergan...49 phenobarbital...26 PHENOBARBITAL SODIUM...26 phenylephrine hcl (oral)...66 phenylephrine w/ dm-gg...66 phenylephrine-brompheniramine-dm...67 phenylephrine-chlorpheniramine-dm w/ apap...67 phenylephrine-guaifenesin...67 PHENYLHISTINE DH...67 phenytek...26 phenytoin...26 phenytoin sodium...26 phenytoin sodium extended...26 philith...44 PHOSPHOLINE IODIDE...64 phytonadione...62 89

PICATO...71 PILOCARPINE HCL...64 PILOCARPINE HCL (ORAL)...72 pimozide...32 pimtrea pack...44 pindolol...21 pioglitazone hcl...40 piperacillin sodium-tazobactam sodium11 piperacillin/tazobactam...11 pirmella 1/35 28 day...44 piroxicam... 2 PLASMA-LYTE A...60 PLASMA-LYTE-148...60 podofilox...71 POLYBASE...71 polyethylene glycol 3350...51 polyethylene glycol-propylene glycol (ophth)...64 polymyxin b-trimethoprim...63 polysaccharide iron complex...54 polyvinyl alcohol...64 POMALYST CAP 1MG...56 POMALYST CAP 2MG...56 POMALYST CAP 3MG...56 POMALYST CAP 4MG...56 portia 28 day...44 pot chloride inj 2meq/ml...60 potassium chloride... 58, 60 potassium chloride in nacl...60 potassium chloride microencapsulated crystals er...58 potassium citrate (alkalinizer)...52 POTIGA...26 PRADAXA...54 PRALUENT...20 pramipexole tab 0.125mg...30 pramipexole tab 0.25mg...30 pramipexole tab 0.5mg...30 pramipexole tab 0.75mg...30 pramipexole tab 1.5mg...30 pramipexole tab 1mg...30 prasugrel hcl...55 pravastatin sodium...19 prazosin hcl...18 pred sod pho sol 5mg/5ml...46 PREDNISOLONE ACETATE (OPHTH)...63 prednisolone sodium phosphate (ophth)...63 prednisolone sol 15mg/5ml...46 prednisolone sol 25mg/5ml...46 prednisolone syp 15mg/5ml...46 prednisone con 5mg/ml...46 prednisone pak 10mg...46 prednisone pak 5mg...46 prednisone sol 5mg/5ml...46 prednisone tab 10mg...46 prednisone tab 1mg...46 prednisone tab 2.5mg...46 prednisone tab 20mg...46 prednisone tab 50mg...46 prednisone tab 5mg...46 premasol sol 10%...59 premasol sol 6%...59 PRENATAL...62 prenatal vitamin/folic acid > 0.8 mg (generic)...62 prevalite...20 previfem 28 day...44 PREZCOBIX... 8 PREZISTA... 7 PRIFTIN... 8 PRILOSEC OTC...52 PRIMAQUINE PHOSPHATE... 7 primidone...26 PRISTIQ...29 PRIVIGEN...56 probenecid... 1 PROCALAMINE...59 prochlorperazine inj...49 prochlorperazine maleate...49 prochlorperazine supp...49 PROCRIT...54 procto-med...69 procto-pak...69 proctosol hc cre 2.5%...69 proctozone hc...69 PROGLYCEM SUS 50MG/ML...46 PROGRAF...56 PROLASTIN-C...67 PROLENSA...65 90

PROLEUKIN...14 PROLIA...47 PROMACTA... 54, 55 promethazine hcl...49 promethegan...49 propafenone hcl...19 propafenone hcl 12hr...19 proparacaine hcl...65 propranolol & hydrochlorothiazide...20 propranolol cap er...21 propranolol hcl...21 propranolol oral sol...21 propylthiouracil...48 PROQUAD...57 PROSOL...59 protriptyline hcl...29 pseudoephedrine hcl...67 pseudoephedrine-chlorphen-dm...67 psyllium...51 PULMICORT FLEXHALER...68 PULMOZYME...67 PURIXAN...13 pyrazinamide... 8 pyrethrins-piperonyl butoxide...71 pyridostigmine tab 60mg...36 pyridoxine hcl...62 Q QUADRACEL...57 quasense 91 day...44 quetiapine fumarate...32 quinapril hcl...18 quinapril-hydrochlorothiazide...17 quinidine gluconate...19 quinidine sulfate...19 quinine sulfate... 7 R RABAVERT...57 rabeprazole sodium...52 raloxifene hcl...47 ramipril...18 RANEXA...23 ranitidine hcl...50 ranitidine hcl inj...50 ranitidine syrup...50 RAPAMUNE...56 rasagiline mesylate...30 RAVICTI...45 REBETOL SOLN... 9 reclipsen 28 day...44 RECOMBIVAX HB...57 REFRESH CELLUVISC...65 REGRANEX...71 RELENZA DISKHALER... 9 RELISTOR...51 RELPAX...35 REMICADE...55 REMODULIN...23 RENVELA PAK 0.8GM...47 RENVELA PAK 2.4GM...47 RENVELA TAB 800MG...47 repaglinide... 40, 41 RESCRIPTOR... 7 RESTASIS...65 RESTASIS MULTIDOSE...65 RETROVIR IV INFUSION... 7 REVATIO...23 REVLIMID...56 REXULTI... 32, 33 REYATAZ... 7 ribasphere... 9 ribavirin 200mg... 9 rifabutin... 8 rifampin... 8 RIFATER... 8 riluzole...36 rimantadine hydrochloride... 9 RINGER'S...60 RISPERDAL INJ 12.5MG...33 RISPERDAL INJ 25MG...33 RISPERDAL INJ 37.5MG...33 RISPERDAL INJ 50MG...33 risperidone...33 RITUXAN...14 RITUXAN HYCELA...14 rivastigmine tartrate...28 rivastigmine td patch 24hr 13.3 mg/24hr...28 rivastigmine td patch 24hr 4.6 mg/24hr...28 rivastigmine td patch 24hr 9.5 mg/24hr 91

...28 rizatriptan benzoate...35 ropinirole tab 0.25mg...30 ropinirole tab 0.5mg...30 ropinirole tab 1mg...30 ropinirole tab 2mg...30 ropinirole tab 3mg...30 ropinirole tab 4mg...30 ropinirole tab 5mg...30 rosadan cre 0.75%...71 rosuvastatin calcium...20 ROTARIX...57 ROTATEQ...57 roweepra...26 RUBRACA...14 RYDAPT...16 S SABRIL...27 saline...67 SANDIMMUNE...56 SANDOSTATIN LAR DEPOT...47 SANTYL...71 SAPHRIS...33 scopolamine...49 selegiline hcl...31 selenium sulfide...69 SELZENTRY... 7 sennosides...51 sennosides-docusate sodium...51 SENSIPAR...41 SEREVENT DISKUS...66 sertraline hcl...29 setlakin tab...44 sharobel 28 day...44 SIGNIFOR...47 sildenafil citrate (pulmonary hypertension)...23 SILENOR...35 silphen cough...66 SILVER SULFADIAZINE...69 SIMBRINZA...64 simvastatin...20 sirolimus...56 SIRTURO... 9 SIVEXTRO... 6 SM GLUCOSE...46 SM OMEPRAZOLE...52 sodium bicarbonate (antacid)...48 SODIUM CHLORIDE... 58, 60 SODIUM CHLORIDE 0.45% VIA...60 SODIUM CHLORIDE 0.9%...71 sodium chloride hypertonic...65 SODIUM CHLORIDE INJ 0.9%...60 sodium ferric gluconate complex in sucrose...54 sodium fluoride chew; tab; 1.1 (0.5 f) mg/ml soln...58 sodium phenylbutyrate...45 sodium phosphates...51 sodium polystyrene sulfonate...41 SOLTAMOX...15 SOLU-CORTEF...46 SOMATULINE DEPOT...47 SOMAVERT...47 sorine...19 sotalol hcl...19 sotalol hcl (afib/afl)...19 SOVALDI... 9 spironolactone...18 spironolactone & hydrochlorothiazide..22 sprintec 28 day...44 SPRITAM...27 SPRYCEL...16 sps susp 15gm/60ml...41 sronyx...44 SSD...69 stavudine... 7 STERILE WATER IRRIGATION...71 STIMATE...48 STIVARGA...16 STRATTERA...35 streptomycin sulfate... 5 STRIBILD... 8 SUBOXONE MIS 12-3MG...38 SUBOXONE MIS 2-0.5MG...37 SUBOXONE MIS 4-1MG...37 SUBOXONE MIS 8-2MG...37 SUCRAID...51 sucralfate...51 sulfacet sod oin 10% op...63 92

sulfacetamide sodium (acne)...68 sulfacetamide sodium (ophth)...63 sulfacetamide sod-prednisolone...62 sulfadiazine... 5 sulfamethoxazole-trimethop ds... 6 sulfamethoxazole-trimethoprim... 6 sulfamethoxazole-trimethoprim inj... 6 SULFAMYLON...69 sulfasalazine...50 sulfasalazine ec...50 sulindac... 2 SUMATRIPTAN... 35, 36 SUMATRIPTAN INJ 4MG/0.5ML...36 sumatriptan inj 6mg/0.5ml...36 sumatriptan succinate...36 SUPRAX...10 SUPREP BOWEL PREP KIT...51 SUSPENDOL-S...61 SUSTIVA... 7 SUTENT...16 syeda...44 SYLATRON KIT 200MCG...16 SYLATRON KIT 300MCG...16 SYLATRON KIT 600MCG...16 SYMBICORT...68 SYMLINPEN 120...39 SYMLINPEN 60...38 SYNAGIS...57 SYNAREL...45 SYNERCID... 6 SYNRIBO...16 SYNTHROID...48 SYPRINE...41 SYRSPEND SF...61 SYSTANE OVERNIGHT THERAPY...65 T TABLOID...13 tacrolimus...56 tacrolimus (topical)...71 TAFINLAR...16 TAGRISSO...16 TAMIFLU SUSR... 9 tamoxifen citrate...15 tamsulosin hcl...52 TARCEVA...16 TARGRETIN...71 tarina fe 1/20 28 day...44 TASIGNA...16 TAXOTERE...13 tazarotene...69 tazicef...10 tazicef vial...10 TAZORAC...69 taztia...21 TECENTRIQ...14 TEFLARO...10 TEGRETOL...27 TEGRETOL-XR...27 telmisartan...19 telmisartan-hydrochlorothiazide...19 temazepam...35 TENIVAC...57 terazosin hcl...18 terbinafine hcl... 7 terbinafine hcl (topical)...69 terbutaline sulfate...66 terconazole vaginal...53 testosterone...38 testosterone cypionate...38 testosterone enanthate...38 TETANUS/DIPHTHERIA TOXOID...57 TETRABENAZINE...36 texacort soln 2.5%...70 THALOMID...56 theo-24...68 theophylline...68 THERA...62 THERA M PLUS...62 THERA/BETA-CAROTENE...62 THERA-M...62 thiamine hcl...62 thioridazine hcl...33 thiothixene...33 tiagabine hcl...27 TIGECYCLINE... 6 TILIA FE...44 timolol maleate...21 timolol maleate (ophth) soln...64 TIMOLOL MALEATE GEL...64 TIVICAY... 7 93

tizanidine hcl...37 TOBRADEX...62 TOBRADEX ST...62 tobramycin... 5 tobramycin (ophth)...63 tobramycin inj 1.2 gm/30ml... 5 tobramycin inj 1.2gm... 5 tobramycin inj 10mg/ml... 5 tobramycin inj 40mg/ml... 5 tobramycin inj 80mg/2ml... 5 tobramycin-dexamethasone...62 TOBREX...63 tolnaftate...69 tolterodine tartrate cap er...53 tolterodine tartrate tabs...53 topiramate...27 toposar...17 TOPOTECAN HCL...17 torsemide tabs...22 TOUJEO SOLOSTAR...39 TOVIAZ...53 TPN ELECTROLYTES...58 TRACLEER...23 TRADJENTA...41 tramadol hcl... 2 tramadol-acetaminophen... 2 trandolapril...18 tranexamic acid...55 TRANSDERM-SCOP...49 tranylcypromine sulfate...29 TRAVASOL...59 TRAVATAN Z...64 trazodone hcl...29 TREANDA...12 TRECATOR... 9 TRELSTAR DEP INJ 3.75MG...15 TRELSTAR LA INJ 11.25MG...15 TRESIBA FLEXTOUCH...39 tretinoin...68 tretinoin (chemotherapy)...16 triamcinolone acetonide (mouth)...72 triamcinolone acetonide (topical)...70 triamterene & hydrochlorothiazide...22 triamterene & hydrochlorothiazide cap 37.5-25 mg...22 triderm...71 trifluoperazine hcl...33 trifluridine...63 trihexyphenidyl hcl...31 triklo...20 tri-legest 28 day...44 tri-linyah...44 tri-lo marzia...44 tri-lo-estarylla...44 tri-lo-sprintec 28 day...44 trilyte...51 trimethoprim... 6 trimipramine maleate... 29, 30 TRINESSA...44 TRINESSA LO TAB...44 TRINTELLIX...30 tri-previfem 28 day...44 triprolidine & pseudoephedrine...67 TRISENOX...16 tri-sprintec 28 day...44 TRIUMEQ... 8 TRI-VI-SOL...62 trivora 28 day...44 TROPHAMINE INJ 10%...59 trospium chloride...53 TRULICITY...39 TRUMENBA...57 TRUVADA TAB 100-150... 8 TRUVADA TAB 133-200... 8 TRUVADA TAB 167-250... 8 TRUVADA TAB 200-300... 8 TWINRIX INJ...57 TYBOST... 7 TYGACIL... 6 TYKERB...16 TYPHIM VI...57 TYSABRI...36 TYZEKA... 9 U ULORIC... 1 UNITHROID...48 UPTRAVI... 23, 24 ursodiol...51 V valacyclovir hcl... 9 94

VALCHLOR...71 VALCYTE... 9 valganciclovir hcl... 9 valproate sodium...27 valproic acid...27 valsartan...19 valsartan & hctz tab 160-12.5mg...19 valsartan & hctz tab 160-25mg...19 valsartan & hctz tab 320-12.5mg...19 valsartan & hctz tab 320-25mg...19 valsartan & hctz tab 80-12.5mg...19 vancomycin hcl... 6 VANCOMYCIN IN NACL... 6 VANDAZOLE...53 VAQTA...57 VARIVAX...57 VASCEPA...20 VELCADE...14 velivet 28 day...44 VEMLIDY... 9 VENCLEXTA...14 VENCLEXTA STARTING PACK...14 venlafaxine hcl...30 VENOFER...54 VENTAVIS...24 VENTOLIN HFA...66 verapamil cap er... 21, 22 verapamil hcl...22 verapamil tab er...22 VERSACLOZ...33 VESICARE...53 vestura...44 VICTOZA...39 VIDEX PEDIATRIC... 7 vienva 28 day...44 vigabatrin powd pack...27 VIGAMOX...63 VIIBRYD STARTER PACK...30 VIIBRYD TAB...30 VIMPAT...27 vinblastine sulfate...13 vincasar...13 vincristine sulfate...13 vinorelbine tartrate...13 viorele...44 VIRACEPT... 8 VIRAMUNE... 8 VIREAD... 8 vitamin a...62 vitamins w/ lipotropics...62 voriconazole... 7 VOSEVI... 9 VOTRIENT...16 VRAYLAR...33 VRAYLAR THERAPY PACK...33 vyfemla 28 day...44 W warfarin sodium...54 WELCHOL...20 white petrolatum-mineral oil...65 X XALKORI...16 XARELTO...54 XARELTO STARTER PACK...54 XATMEP...55 XELJANZ...55 XELJANZ XR...55 XGEVA...47 XIFAXAN...51 XIGDUO XR TAB 10-1000MG...41 XIGDUO XR TAB 10-500MG...41 XIGDUO XR TAB 5-1000MG...41 XIGDUO XR TAB 5-500MG...41 XOLAIR...67 XTANDI...15 xulane...44 XYREM...37 Y YERVOY...14 YF-VAX...58 yuvafem vaginal tablet 10 mcg...45 Z zafirlukast...67 zarah...44 ZAVESCA...45 ZEJULA...14 ZELBORAF...16 ZEMAIRA...67 zenatane...68 zenchent 28 day...44 95

ZENPEP...52 ZEPATIER... 9 ZERIT... 8 ZIAGEN... 8 zidovudine... 8 zinc oxide (topical)...71 ziprasidone hcl...33 ZIRGAN...63 zoledronic acid...41 zoledronic inj 4mg/5ml...41 ZOLINZA...14 zolmitriptan...36 zolmitriptan odt...36 zolpidem tartrate...35 zonisamide...27 ZONTIVITY...55 ZORTRESS TAB 0.25MG...57 ZORTRESS TAB 0.5MG...56 ZORTRESS TAB 0.75MG...57 ZOSTAVAX...58 zovia 1/35e 28 day...44 zovia 1/50e 28 day...45 ZYDELIG...16 ZYKADIA...16 ZYLET...62 ZYPREXA RELPREVV... 33, 34 ZYPREXA RELPREVV INJ 210MG...34 ZYTIGA...15 96

Call Healthfirst toll free today at: Healthfirst FIDA Participant Services PO Box 5165 New York, NY 10274-5165 가입자서비스부 1.855.675.7630 TTY/TDD 711 ( 청각또는언어장애인용 ) 주 7 일, 오전 8 시 오후 8 시 본처방집은 2017-10-24 에갱신되었습니다. 다른최신정보가필요하시거나궁금하신사항은 Healthfirst FIDA 가입자서비스부에 1-855-675-7630 번으로, TTY 사용자는 711 번으로주 7 일, 오전 8 시 - 오후 8 시중에연락하여문의해주십시오. 온라인으로 healthfirst.org/mmp 를방문하실수도있습니다. www.healthfirst.org/mmp

HF NY_CY17_2T_MMP_NOV_17_2_Comprehensive_Formulary-v1_KOR-508