2021年加州Medi-Cal管理式護 理承付藥物手冊

（承保藥物清單） 請閱讀：本文件包含當您參與由KAISER PERMANENTE所提供的MEDI-CAL管理式保健計劃 時，屬於計劃承保範圍的藥物相關資訊。

本承付處方藥物手冊是於 09/01/2021 更新且自 September 7, 2021, 起生效。本承付藥物 手冊文件可能會有變更且內容可能會隨您的保健計劃而異。如需最新資訊或對哪份承付藥 物手冊適用於您的計劃有疑問，請瀏覽kp.org/formulary（英文）或致電會員服務聯絡中心 ，服務時間為每週七天，每天24小時（假日休息）。英文1-800-464-4000（並提供超過 150種語言的服務）、西班牙文1-800-788-0616、華語方言1-800-757-7585以及供失聰或 聽障人士使用的聽障及語障電話專線711。

什麼是Kaiser Permanente《加州Medi-Cal管理式護理承付藥物手冊》？ 《加州Medi-Cal管理式護理承付藥物手冊》(California Medi-Cal Managed Care Formulary) 是一份承保藥物清單，這些藥物是由Kaiser Permanente醫生和藥劑師所組成的藥事委員會 所挑選。藥事委員會將會定期舉行會議，以替會員評估和選擇安全有效的藥物。本承付藥物 手冊符合州法律的規定、條例以及Medi-Cal管理式保健計劃的準則。

哪些藥物屬於承保範圍？ Kaiser Permanente承保列於《加州Medi-Cal管理式護理承付藥物手冊》的品牌藥、非品牌藥及 專科藥物， 但條件是該藥物是醫療上必要的藥物、處方是在Kaiser Permanente或附屬藥房配領且有遵守其 他保險規定。

如果醫生開立《加州Medi-Cal管理式護理承付藥物手冊》中的藥物給您，該藥物將會根據 您的藥物理賠條款獲得承保。

獲得承付藥物手冊例外處理 未列於承付藥物手冊中的藥物稱為非承付藥物手冊藥物。當Kaiser Permanente醫生認定非承付 藥物手冊藥物是醫療上適當且必要的藥物，該藥物將會根據您的理賠條款獲得承保（如果您享 有處方藥理賠）。如果您未享有特定類型的處方藥（如性功能障礙及不孕）保險，您將需為該 藥物支付零售價的全額。

您可向醫生洽詢是否需要進行承付藥物手冊例外處理。您和醫生最能確定您的藥物需求。

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您也可與會員服務部聯絡，服務時間為每週7天，每天24小時。 如果您想使用醫生認定為非醫療上必 要的非承付藥物手冊藥物，您可能必須向會員服務部提出抱怨。

承付藥物手冊中的承保藥物有任何限制嗎？ 有些承保藥物可能有其他承保範圍規定或限制，如藥量限制。Kaiser Permanente可能會將特 定藥物的發配藥量限制在一定天數的藥量。此外，當某項藥物在全國發生短缺時，我們也可能 會限制該藥物的發配藥量。

什麼是品牌藥？ 品牌藥通常是由最初研發藥物的製藥公司所製造和販售。當品牌藥的專利到期之後，其他製藥 公司便可使用相同的活性成分並以較低的價格製造和販售經由食品及藥物管理署 (Food and Drug Administration, FDA) 核准的非品牌藥版本。

什麼是非品牌藥？ 非品牌藥是經由FDA核准且與品牌藥具備相同活性成分的藥物。非品牌藥的費用通常低於品 牌藥。

什麼是專科藥物？ 專科藥物是非常高價位、經由FDA核准且列於承付藥物手冊中，用於治療如風濕性關節炎、 多發性硬化症或癌症等複雜慢性病的藥物。

哪些藥物有資格透過郵購藥房郵寄？ 大多數藥物皆可透過郵購藥房郵寄。某些藥物（如非常高價位或需要特殊處理的藥物）可能 不符合郵寄資格。藥物無法郵寄至美國以外的地區。

您可透過郵購服務在kp.org/refill（英文）網站訂購續配藥物，或者透過電話或行動裝置應用 程式訂購。郵購無需額外收費。適當的成本分擔（依據您的處方藥理賠）將適用。

請參閱《承保範圍說明書》(Evidence of Coverage) 以瞭解處方藥理賠的完整詳細資訊。

Kaiser Permanente《加州Medi-Cal管理式護理承付藥物手冊》 Kaiser Permanente可能會在一年當中新增或移除《加州Medi-Cal管理式護理承付藥物手冊》 中的藥物。我們會依據可用的新資訊或新藥物修改承付藥物手冊。

如何使用承付藥物手冊？ 您可以透過以下兩種方法在承付藥物手冊中尋找您的藥物：

病症 承付藥物手冊正文從第 4 頁開始。本承付藥物手冊中的藥物是根據其用於治療的病症類型加 以分類。例如，用於治療心臟病症的藥物列於「Cardiovascular Drugs」（心血管藥物）類 別。如果您知道您所使用的藥物適用的病症，請在從第 4 頁開始的清單中查找該類別名稱， 然後在該類別名稱下查找您的藥物。

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按字母順序排列 如果您不確定應該查找哪個類別，您應在從第 95頁開始的索引中查找您的藥物。索引按字 母順序列出本文件所包含的所有藥物。請在索引中查找您的藥物。您將會在您的藥物旁看到 提供保險資訊的頁碼。翻到索引所列的頁面並在清單的第一欄中查找您的藥物名稱。

表格第一欄所列的是藥物名稱。品牌藥使用英文大寫字母標示（如ALBENZA），非品 牌藥使用斜體英文小寫字母標示（如amoxicillin）。

承付藥物手冊可能並未列出特定藥物的所有劑型和劑量。某些藥物有多種劑型。在此類情況下 ，某些劑型可能有列於承付藥物手冊中，有些劑型則沒有。 注意：這些藥物當中的某些藥物可能僅可在診所使用。

第二欄的「藥物等級」將會列出藥物所屬的等級號碼。《加州Medi-Cal管理式護理承付 藥物手冊》中的藥物均歸屬於等級1。

表格的第三欄將會列出適用於該藥物的所有規定或限制： QL = 藥量限制 (Quantity Limits) -針對特定藥物，我們可能會限制您可領取的藥量。此 外，當某項藥物在全國發生短缺時，我們也可能會限制該藥物的發配藥量。

LD = 發配受限的藥物只能透過特定專科藥房配取。如欲尋找專科藥房，請參閱 kp.org/eguidebook（英文）（位於設施名錄之下）的電子版會員健康服務指南或與會 員服務部聯絡。

OTC = Over-the-Counter

請參閱kp.org/eguidebook的電子版會員健康服務指南，以查看您可使用的網絡藥房完 整清單或與會員服務部聯絡。

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藥物等 藥物等 藥物名稱 規定／限制 藥物名稱 規定／限制 級 級 INTELENCE TABS 25 MG ANTI-INFECTIVE AGENTS 1 ANTHELMINTICS [etravirine] ALBENZA TABS 200 MG INVIRASE TABS 500 MG 1 1 [albendazole] [saquinavir mesylate] BILTRICIDE TABS 600 ISENTRESS CHEW 100 1 MG [praziquantel] MG [raltegravir 1 ivermectin tabs 3 mg 1 potassium] ISENTRESS CHEW 25 ANTI-HIV AGENTS MG [raltegravir 1 abacavir sulfate tabs 300 1 potassium] mg ISENTRESS HD TABS abacavir sulfate- 600 MG [raltegravir 1 1 lamivudine tabs 600-300 potassium] mg ISENTRESS TABS 400 abacavir-lamivudine- MG [raltegravir 1 1 zidovudine tabs 300-150- potassium] 300 mg KALETRA SOLN 400-100 APTIVUS CAPS 250 MG 1 MG/5ML [lopinavir- 1

[tipranavir] ritonavir] BIKTARVY TABS 50-200- KALETRA TABS 100-25 25 MG [bictegravir- 1 1 MG [lopinavir-ritonavir] emtricitabine-tenofovir KALETRA TABS 200-50 alafenamide fumarate] 1 MG [lopinavir-ritonavir] CIMDUO TABS 300-300 lamivudine soln 10 MG [lamivudine- 1 1 mg/ml tenofovir disoproxil lamivudine tabs 150 mg 1 fumarate] COMPLERA TABS 200- lamivudine tabs 300 mg 1 lamivudine-zidovudine 25-300 MG 1 [emtricitabine-rilpivirine- 1 tabs 150-300 mg LEXIVA TABS 700 MG tenofovir disoproxil 1 fumarate] [fosamprenavir calcium] CRIXIVAN CAPS 200 MG nevirapine er tb24 400 1 1 [indinavir sulfate] mg CRIXIVAN CAPS 400 MG nevirapine susp 50 1 1 [indinavir sulfate] mg/5ml didanosine cap 125mg 1 nevirapine tabs 200 mg 1 NORVIR SOLN 80 MG/ML DOVATO TABS 50-300 1 MG [dolutegravir 1 [ritonavir] PREZISTA TABS 150 MG sodium-lamivudine] 1 EDURANT TABS 25 MG [darunavir ethanolate] 1 PREZISTA TABS 600 MG [rilpivirine hcl] 1 EMTRIVA SOLN 10 [darunavir ethanolate] 1 PREZISTA TABS 75 MG MG/ML [emtricitabine] 1 FUZEON SOLR 90 MG [darunavir ethanolate] 1 QL - 30 day(s) PREZISTA TABS 800 MG [enfuvirtide] 1 INTELENCE TABS 100 [darunavir ethanolate] 1 MG [etravirine] RESCRIPTOR TABS 100 INTELENCE TABS 200 MG [delavirdine 1 1 MG [etravirine] mesylate]

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藥物等 藥物等 藥物名稱 規定／限制 藥物名稱 規定／限制 級 級 RESCRIPTOR TABS 200 zidovudine syrp 50 1 MG [delavirdine 1 mg/5ml mesylate] zidovudine tabs 300 mg 1 SELZENTRY TABS 150 1 ANTIBACTERIALS MG [maraviroc] amikacin sulfate soln SELZENTRY TABS 25 1 1 500 mg/2ml MG [maraviroc] amoxicillin caps 250 mg 1 SELZENTRY TABS 300 1 amoxicillin caps 500 mg 1 MG [maraviroc] amoxicillin chew 125 mg 1 SELZENTRY TABS 75 1 1 MG [maraviroc] amoxicillin chew 250 mg amoxicillin susr 125 stavudine caps 15 mg 1 1 mg/5ml stavudine caps 20 mg 1 amoxicillin susr 200 1 1 stavudine caps 30 mg mg/5ml stavudine caps 40 mg 1 amoxicillin susr 250 1 STRIBILD TABS 150-150- mg/5ml 200-300 MG [elvitegravir- amoxicillin susr 400 1 1 cobicistat-emtricitabine- mg/5ml tenofovir df] amoxicillin-pot SYMFI LO TABS 400-300- clavulanate chew 200- 1 300 MG [efavirenz- 1 28.5 mg lamivudine-tenofovir amoxicillin-pot disoproxil fumarate] clavulanate chew 400-57 1 SYMFI TABS 600-300-300 mg MG [efavirenz- 1 amoxicillin-pot lamivudine-tenofovir clavulanate susr 200- 1 disoproxil fumarate] 28.5 mg/5ml SYMTUZA TABS 800-150- amoxicillin-pot 200-10 MG [darunavir- 1 clavulanate susr 250- 1 cobicistat-emtricitabine- 62.5 mg/5ml tenofovir alafenamide] amoxicillin-pot TIVICAY TABS 50 MG 1 clavulanate susr 400-57 1 [dolutegravir sodium] mg/5ml TRIUMEQ TABS 600-50- amoxicillin-pot 300 MG [abacavir- 1 clavulanate susr 600- 1 dolutegravir-lamivudine] 42.9 mg/5ml VIDEX SOLR 2 GM 1 amoxicillin-pot [didanosine] clavulanate tabs 250-125 1 VIDEX SOLR 4 GM 1 mg [didanosine] amoxicillin-pot VIRACEPT TABS 250 MG 1 clavulanate tabs 500-125 1 [nelfinavir mesylate] mg VIRACEPT TABS 625 MG 1 amoxicillin-pot [nelfinavir mesylate] clavulanate tabs 875-125 1 VIRAMUNE SUSP 50 1 mg MG/5ML [nevirapine] amp-sulbacta inj 1.5gm 1 ZIAGEN SOLN 20 MG/ML 1 ampicillin cap 250mg 1 [abacavir sulfate] ampicillin caps 500 mg 1 zidovudine caps 100 mg 1

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藥物等 藥物等 藥物名稱 規定／限制 藥物名稱 規定／限制 級 級 ampicillin sodium solr 1 bacitracin solr 50000 1 1 gm unit ampicillin sodium solr 10 BICILLIN L-A SUSP 1 gm 1200000 UNIT/2ML 1 ampicillin sodium solr [penicillin g benzathine] 1 125 mg BICILLIN L-A SUSP ampicillin sodium solr 2 2400000 UNIT/4ML 1 1 gm [penicillin g benzathine] ampicillin sodium solr BICILLIN L-A SUSP 1 250 mg 600000 UNIT/ML 1 ampicillin sodium solr [penicillin g benzathine] 1 CAYSTON SOLR 75 MG QL - 30 500 mg 1 ampicillin sus 125/5ml 1 [aztreonam lysine] day(s),LD ampicillin sus 250/5ml 1 cefaclor caps 250 mg 1 ampicillin-sulbactam cefaclor caps 500 mg 1 sodium solr 1.5 (1-0.5) 1 cefadroxil caps 500 mg 1 gm cefazolin sodium solr 1 1 ampicillin-sulbactam 1 gm sodium solr 15 (10-5) gm cefazolin sodium solr 10 1 ampicillin-sulbactam 1 gm sodium solr 3 (2-1) gm cefazolin sodium solr 20 1 AUGMENTIN SUSR 125- gm 31.25 MG/5ML cefazolin sodium solr 1 1 [amoxicillin & pot 500 mg clavulanate] CEFAZOLIN SODIUM- AVELOX SOLN 400 DEXTROSE SOLN 1-4 1 MG/250ML [moxifloxacin 1 GM/50ML-% [cefazolin hcl in sodium chloride] sodium-dextrose] AZACTAM IN DEXTROSE CEFAZOLIN SODIUM- SOLN 1 GM/50ML 1 DEXTROSE SOLR 1-4 1 [aztreonam-dextrose] GM-%(50ML) [cefazolin AZACTAM IN DEXTROSE sodium-dextrose] SOLN 2 GM/50ML 1 cefdinir susr 125 mg/5ml 1 [aztreonam-dextrose] cefdinir susr 250 mg/5ml 1 azithromycin solr 500 1 cefepime hcl solr 1 gm 1 mg cefepime hcl solr 2 gm 1 azithromycin susr 100 1 CEFEPIME-DEXTROSE mg/5ml SOLR 1-5 GM-%(50ML) 1 azithromycin susr 200 1 [cefepime hcl-dextrose] mg/5ml CEFEPIME-DEXTROSE azithromycin tabs 250 1 SOLR 2-5 GM-%(50ML) 1 mg [cefepime hcl-dextrose] azithromycin tabs 500 1 cefixime caps 400 mg 1 mg cefotaxime sodium inj azithromycin tabs 600 1 1 10gm mg cefotaxime sodium solr aztreonam solr 1 gm 1 1 1 gm aztreonam solr 2 gm 1

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藥物等 藥物等 藥物名稱 規定／限制 藥物名稱 規定／限制 級 級 cefotaxime sodium solr ceftriaxone sodium solr 1 1 2 gm 10 gm cefotaxime sodium solr ceftriaxone sodium solr 1 1 500 mg 2 gm cefotetan disodium solr ceftriaxone sodium solr 1 1 1 gm 250 mg cefotetan disodium solr ceftriaxone sodium solr 1 1 2 gm 500 mg CEFOTETAN DISODIUM- CEFTRIAXONE SODIUM- DEXTROSE SOLR 1-3.58 DEXTROSE SOLR 1-3.74 1 1 GM-%(50ML) [cefotetan GM-%(50ML) [ceftriaxone disodium and dextrose] sodium and dextrose] CEFOTETAN DISODIUM- CEFTRIAXONE SODIUM- DEXTROSE SOLR 2-2.08 DEXTROSE SOLR 2-2.22 1 1 GM-%(50ML) [cefotetan GM-%(50ML) [ceftriaxone disodium and dextrose] sodium and dextrose] cefoxitin sodium solr 1 cefuroxime axetil tabs 1 1 gm 250 mg cefoxitin sodium solr 10 cefuroxime axetil tabs 1 1 gm 500 mg cefoxitin sodium solr 2 cefuroxime sodium solr 1 1 gm 1.5 gm CEFOXITIN SODIUM- cefuroxime sodium solr 1 DEXTROSE SOLR 1-4 7.5 gm 1 GM-%(50ML) [cefoxitin cefuroxime sodium solr 1 sodium and dextrose] 750 mg CEFOXITIN SODIUM- cephalexin caps 250 mg 1 DEXTROSE SOLR 2-2.2 1 cephalexin caps 500 mg 1 GM-%(50ML) [cefoxitin cephalexin susr 125 1 sodium and dextrose] mg/5ml cefpodoxime proxetil cephalexin susr 250 1 1 susr 100 mg/5ml mg/5ml cefpodoxime proxetil 1 cephalexin tabs 500 mg 1 susr 50 mg/5ml chloramphenicol sod cefpodoxime proxetil 1 1 succinate solr 1 gm tabs 100 mg CIPRO SUSR 250 cefpodoxime proxetil 1 MG/5ML (5%) 1 tabs 200 mg [ciprofloxacin] ceftazidime solr 6 gm 1 CIPRO SUSR 500 CEFTIN SUSR 125 MG/5ML (10%) 1 MG/5ML [cefuroxime 1 [ciprofloxacin] axetil] ciprofloxacin hcl tabs ceftriaxone sodium in 1 1 250 mg dextrose soln 20 mg/ml ciprofloxacin hcl tabs ceftriaxone sodium in 1 1 500 mg dextrose soln 40 mg/ml ciprofloxacin hcl tabs ceftriaxone sodium solr 1 1 750 mg 1 gm ciprofloxacin in d5w soln 1 200 mg/100ml

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藥物等 藥物等 藥物名稱 規定／限制 藥物名稱 規定／限制 級 級 ciprofloxacin in d5w soln demeclocycline hcl tabs 1 1 400 mg/200ml 300 mg clarithromycin susr 125 dicloxacillin sodium 1 1 mg/5ml caps 250 mg clarithromycin susr 250 dicloxacillin sodium 1 1 mg/5ml caps 500 mg clarithromycin tabs 250 [Doxycycline Hyclate] 1 1 mg DOXY 100 SOLR 100 MG clarithromycin tabs 500 doxycycline hyclate 1 1 mg caps 100 mg CLEOCIN IN D5W SOLN doxycycline hyclate 1 300 MG/50ML caps 50 mg 1 [clindamycin phosphate doxycycline hyclate tabs 1 in d5w] 100 mg CLEOCIN IN D5W SOLN doxycycline hyclate tabs 1 600 MG/50ML 1 20 mg [clindamycin phosphate doxycycline in d5w] monohydrate susr 25 1 CLEOCIN IN D5W SOLN mg/5ml 900 MG/50ML 1 doxycycline [clindamycin phosphate monohydrate tabs 100 1 in d5w] mg [Clindamycin Phosphate] doxycycline 1 CLEOCIN PHOSPHATE 1 monohydrate tabs 50 mg SOLN 300 MG/2ML ERYTHROCIN [Clindamycin Phosphate] LACTOBIONATE SOLR 1 CLEOCIN PHOSPHATE 1 500 MG [erythromycin SOLN 900 MG/6ML lactobionate] [Clindamycin Palmitate FIRVANQ SOLR 25 1 Hydrochloride] CLEOCIN 1 MG/ML [vancomycin hcl] SOLR 75 MG/5ML FIRVANQ SOLR 50 1 clindamycin hcl caps 1 MG/ML [vancomycin hcl] 150 mg fluconazole in sodium clindamycin hcl caps 1 chloride soln 100-0.9 1 300 mg mg/50ml-% clindamycin palmitate 1 FORTAZ IN D5W SOLN 1- hcl solr 75 mg/5ml 5 GM/50ML-% 1 clindamycin phosphate 1 [ceftazidime sodium in soln 300 mg/2ml d5w] CLINDAMYCIN FORTAZ IN D5W SOLN 2- PHOSPHATE SOLN 600 5 GM/50ML-% 1 1 MG/4ML [clindamycin [ceftazidime sodium in phosphate] d5w] clindamycin phosphate FORTAZ SOLR 500 MG 1 1 soln 9000 mg/60ml [ceftazidime] CUBICIN SOLR 500 MG gentamicin in saline soln 1 1 [daptomycin] 0.8-0.9 mg/ml-% demeclocycline hcl tabs gentamicin in saline soln 1 1 150 mg 0.9-0.9 mg/ml-%

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藥物等 藥物等 藥物名稱 規定／限制 藥物名稱 規定／限制 級 級 gentamicin in saline soln GM/100ML [nafcillin 1 1-0.9 mg/ml-% sodium in dextrose] gentamicin in saline soln nafcillin sodium solr 1 1 1 1.2-0.9 mg/ml-% gm gentamicin in saline soln nafcillin sodium solr 10 1 1 1.4-0.9 mg/ml-% gm gentamicin in saline soln nafcillin sodium solr 2 1 1 1.6-0.9 mg/ml-% gm gentamicin in saline soln neomycin sulfate tabs 1 1 2-0.9 mg/ml-% 500 mg gentamicin sulfate soln OXACILLIN SODIUM IN 1 DEXTROSE SOLN 1 10 mg/ml 1 gentamicin sulfate soln GM/50ML [oxacillin 1 40 mg/ml sodium in dextrose] INVANZ SOLR 1 GM OXACILLIN SODIUM IN 1 DEXTROSE SOLN 2 [ertapenem sodium] 1 levofloxacin in d5w soln GM/50ML [oxacillin 1 250 mg/50ml sodium in dextrose] levofloxacin in d5w soln oxacillin sodium solr 1 1 1 500 mg/100ml gm levofloxacin in d5w soln OXACILLIN SODIUM 1 750 mg/150ml SOLR 2 GM [oxacillin 1 levofloxacin soln 25 sodium] 1 mg/ml PENICILLIN G POT IN DEXTROSE SOLN 20000 levofloxacin tabs 250 mg 1 1 levofloxacin tabs 500 mg 1 UNIT/ML [penicillin g pot levofloxacin tabs 750 mg 1 in dextrose] PENICILLIN G POT IN linezolid soln 600 1 DEXTROSE SOLN 40000 mg/300ml 1 UNIT/ML [penicillin g pot linezolid susr 100 1 in dextrose] mg/5ml PENICILLIN G POT IN 1 meropenem solr 1 gm DEXTROSE SOLN 60000 1 meropenem solr 500 mg 1 UNIT/ML [penicillin g pot MINOCIN SOLR 100 MG 1 in dextrose] [minocycline hcl] penicillin g potassium minocycline hcl caps 1 1 solr 20000000 unit 100 mg penicillin g potassium minocycline hcl caps 50 1 1 solr 5000000 unit mg penicillin g procaine minocycline hcl caps 75 1 1 susp 600000 unit/ml mg penicillin g sodium solr moxifloxacin hcl tabs 1 1 5000000 unit 400 mg penicillin v potassium 1 NAFCILLIN SODIUM IN solr 125 mg/5ml DEXTROSE SOLN 1 penicillin v potassium 1 1 GM/50ML [nafcillin solr 250 mg/5ml sodium in dextrose] penicillin v potassium NAFCILLIN SODIUM IN 1 1 tabs 250 mg DEXTROSE SOLN 2

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藥物等 藥物等 藥物名稱 規定／限制 藥物名稱 規定／限制 級 級 penicillin v potassium SYNERCID SOLR 150- 1 tabs 500 mg 350 MG [quinupristin- 1 [Penicillin G Potassium] dalfopristin] PFIZERPEN SOLR 1 [Ceftazidime] TAZICEF 1 20000000 UNIT SOLR 1 GM piperacillin sod- [Ceftazidime] TAZICEF 1 tazobactam so solr 2.25 1 SOLR 2 GM (2-0.25) gm TETRACYCLINE HCL piperacillin sod- CAPS 250 MG 1 tazobactam so solr 3.375 1 [tetracycline hcl] (3-0.375) gm TETRACYCLINE HCL piperacillin sod- CAPS 500 MG 1 tazobactam so solr 4.5 1 [tetracycline hcl] (4-0.5) gm TOBI PODHALER CAPS 1 piperacillin sod- 28 MG [tobramycin] tazobactam so solr 40.5 1 tobramycin nebu 300 1 (36-4.5) gm mg/5ml PRIMAXIN IV SOLR 250- tobramycin sulfate soln 1 250 MG [imipenem- 1 10 mg/ml cilastatin] tobramycin sulfate soln 1 PRIMAXIN IV SOLR 500- 80 mg/2ml 500 MG [imipenem- 1 tobramycin sulfate solr 1 cilastatin] 1.2 gm PRIMSOL SOLN 50 vancomycin hcl caps 1 MG/5ML [trimethoprim 1 125 mg hcl] vancomycin hcl caps 1 streptomycin sulfate solr 1 250 mg 1 gm VANCOMYCIN HCL IN sulfadiazine tabs 500 mg 1 DEXTROSE SOLN 1-5 sulfamethoxazole- GM/200ML-% 1 trimethoprim soln 400-80 1 [vancomycin hcl- mg/5ml dextrose] sulfamethoxazole- VANCOMYCIN HCL IN trimethoprim susp 200- 1 DEXTROSE SOLN 500-5 40 mg/5ml MG/100ML-% 1 sulfamethoxazole- [vancomycin hcl- trimethoprim tabs 400-80 1 dextrose] vancomycin hcl solr 1 mg 1 sulfamethoxazole- gm 1 vancomycin hcl solr 10 trimethoprim tabs 800- 1 160 mg gm sulfasalazine tabs 500 vancomycin hcl solr 5 1 1 mg gm sulfasalazine tbec 500 vancomycin hcl solr 500 1 1 mg mg [Cefixime] SUPRAX SUSR XIFAXAN TABS 550 MG 1 1 QL - 30 day(s) 100 MG/5ML [rifaximin] ZITHROMAX PACK 1 GM 1 [azithromycin]

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 10 of 144

藥物等 藥物等 藥物名稱 規定／限制 藥物名稱 規定／限制 級 級 ZOSYN SOLN 2-0.25 griseofulvin microsize 1 GM/50ML [piperacillin susp 125 mg/5ml 1 sodium-tazobactam griseofulvin microsize 1 sodium in dextrose] tabs 500 mg ZOSYN SOLN 3-0.375 griseofulvin GM/50ML [piperacillin 1 1 ultramicrosize tabs 125 sodium-tazobactam mg sodium in dextrose] griseofulvin ZYVOX SUSR 100 1 1 ultramicrosize tabs 250 MG/5ML [linezolid] mg ZYVOX TABS 600 MG itraconazole caps 100 1 1 [linezolid] mg ketoconazole tabs 200 ANTIFUNGALS 1 ABELCET SUSP 5 MG/ML mg 1 nystatin susp 100000 [amphotericin b lipid] 1 AMBISOME SUSR 50 MG unit/ml [amphotericin b 1 nystatin tabs 500000 unit 1 liposome] SPORANOX SOLN 10 1 amphotericin b solr 50 MG/ML [itraconazole] 1 mg terbinafine hcl tabs 250 1 CANCIDAS SOLR 50 MG mg 1 [caspofungin acetate] VFEND IV SOLR 200 MG 1 CANCIDAS SOLR 70 MG [voriconazole] 1 [caspofungin acetate] voriconazole tabs 200 1 fluconazole in dextrose mg 1 inj dex 200 voriconazole tabs 50 mg 1 fluconazole in dextrose 1 ANTIHEPATITIS C AGENTS soln 400 mg/200ml HARVONI TABS 45-200 fluconazole in nacl inj 1 MG [ledipasvir- 1 QL - 30 day(s) nacl 200 sofosbuvir] fluconazole in nacl inj 1 HARVONI TABS 90-400 nacl 400 MG [ledipasvir- 1 QL - 30 day(s) fluconazole in sodium sofosbuvir] chloride soln 200-0.9 1 PEG-INTRON REDIPEN mg/100ml-% KIT 120 RP 1 QL - 30 day(s) fluconazole in sodium [peginterferon alfa-2b] chloride soln 400-0.9 1 PEG-INTRON REDIPEN mg/200ml-% KIT 150 RP 1 QL - 30 day(s) fluconazole susr 10 1 [peginterferon alfa-2b] mg/ml PEGASYS PROCLICK fluconazole susr 40 1 SOLN 135 MCG/0.5ML 1 QL - 30 day(s) mg/ml [peginterferon alfa-2a] fluconazole tabs 100 mg 1 PEGASYS PROCLICK fluconazole tabs 150 mg 1 SOLN 180 MCG/0.5ML 1 QL - 30 day(s) fluconazole tabs 200 mg 1 [peginterferon alfa-2a] fluconazole tabs 50 mg 1 PEGASYS SOLN 180 flucytosine caps 250 mg 1 MCG/0.5ML 1 QL - 30 day(s) flucytosine caps 500 mg 1 [peginterferon alfa-2a]

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 11 of 144

藥物等 藥物等 藥物名稱 規定／限制 藥物名稱 規定／限制 級 級 PEGASYS SOLN 180 ALINIA TABS 500 MG 1 MCG/ML [peginterferon 1 QL - 30 day(s) [nitazoxanide] alfa-2a] atovaquone susp 750 1 PEGINTRON KIT 50 mg/5ml MCG/0.5ML 1 QL - 30 day(s) atovaquone-proguanil 1 [peginterferon alfa-2b] hcl tabs 250-100 mg ribavirin caps 200 mg 1 atovaquone-proguanil 1 SOVALDI PACK 150 MG hcl tabs 62.5-25 mg 1 QL - 30 day(s) chloroquine phosphate [sofosbuvir] 1 SOVALDI PACK 200 MG tabs 250 mg 1 QL - 30 day(s) chloroquine phosphate [sofosbuvir] 1 SOVALDI TABS 200 MG tabs 500 mg 1 QL - 30 day(s) [sofosbuvir] COARTEM TABS 20-120 SOVALDI TABS 400 MG MG [artemether- 1 1 QL - 30 day(s) [sofosbuvir] lumefantrine] DARAPRIM TABS 25 MG ANTIMYCOBACTERIALS 1 CAPASTAT SULFATE [pyrimethamine] hydroxychloroquine SOLR 1 GM 1 1 [capreomycin sulfate] sulfate tabs 200 mg cycloserine caps 250 mg 1 KRINTAFEL TABS 150 dapsone tabs 100 mg 1 MG [tafenoquine 1 succinate] dapsone tabs 25 mg 1 mefloquine hcl tabs 250 ethambutol hcl tabs 100 1 1 mg mg METRONIDAZOLE IN ethambutol hcl tabs 400 1 NACL SOLN 5-0.79 mg 1 MG/ML-% [metronidazole 1 isoniazid soln 100 mg/ml in nacl] isoniazid syrp 50 mg/5ml 1 METRONIDAZOLE IN isoniazid tabs 100 mg 1 NACL SOLN 500-0.74 1 isoniazid tabs 300 mg 1 MG/100ML-% PRETOMANID TABS 200 [metronidazole in nacl] 1 MG [pretomanid] metronidazole tabs 250 1 PRIFTIN TABS 150 MG mg 1 [rifapentine] metronidazole tabs 500 1 pyrazinamide tabs 500 mg 1 mg NEBUPENT SOLR 300 rifabutin caps 150 mg 1 MG [pentamidine 1 [Isoniazid & Rifampin] isethionate] RIFAMATE CAPS 150- 1 paromomycin sulfate 1 300 MG caps 250 mg rifampin caps 150 mg 1 PENTAM SOLR 300 MG rifampin caps 300 mg 1 [pentamidine 1 rifampin solr 600 mg 1 isethionate] TRECATOR TABS 250 PRIMAQUINE 1 PHOSPHATE TABS 26.3 MG [ethionamide] 1 (15 Base) MG ANTIPROTOZOALS [primaquine phosphate] ALINIA SUSR 100 1 ANTIVIRALS MG/5ML [nitazoxanide]

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 12 of 144

藥物等 藥物等 藥物名稱 規定／限制 藥物名稱 規定／限制 級 級 1 emtricitabine-tenofovir acyclovir caps 200 mg 1 acyclovir sodium inj df tabs 200-300 mg 1 1000mg entecavir tabs 0.5 mg 1 acyclovir sodium soln 50 1 1 entecavir tabs 1 mg mg/ml EPCLUSA TABS 200-50 acyclovir susp 200 1 MG [sofosbuvir- 1 QL - 30 day(s) mg/5ml velpatasvir] acyclovir tabs 400 mg 1 EPCLUSA TABS 400-100 acyclovir tabs 800 mg 1 MG [sofosbuvir- 1 QL - 30 day(s) adefovir dipivoxil tabs 10 velpatasvir] 1 mg EPIVIR HBV SOLN 5 atazanavir sulfate caps MG/ML [lamivudine 1 1 150 mg (hbv)] atazanavir sulfate caps EPIVIR HBV TABS 100 1 1 200 mg MG [lamivudine (hbv)] atazanavir sulfate caps EVOTAZ TABS 300-150 1 300 mg MG [atazanavir sulfate- 1 BARACLUDE SOLN 0.05 cobicistat] 1 MG/ML [entecavir] famciclovir tabs 500 mg 1 fosamprenavir calcium cidofovir soln 75 mg/ml 1 1 DAKLINZA TABS 30 MG tabs 700 mg [daclatasvir 1 FOSCAVIR SOLN 6000 dihydrochloride] MG/250ML [foscarnet 1 DAKLINZA TABS 60 MG sodium] ganciclovir sodium solr [daclatasvir 1 1 dihydrochloride] 500 mg DESCOVY TABS 200-25 GENVOYA TABS 150- MG [emtricitabine- 150-200-10 MG 1 tenofovir alafenamide [elvitegravir-cobicistat- 1 fumarate] emtricitabine-tenofovir didanosine cpdr 200 mg 1 alafenamide] didanosine cpdr 250 mg 1 JULUCA TABS 50-25 MG 1 didanosine cpdr 400 mg 1 [dolutegravir sodium- rilpivirine hcl] efavirenz caps 200 mg 1 lamivudine tabs 100 mg 1 efavirenz caps 50 mg 1 ODEFSEY TABS 200-25- efavirenz tabs 600 mg 1 25 MG [emtricitabine- 1 efavirenz-emtricitab- rilpivirine-tenofovir tenofovir tabs 600-200- 1 alafenamide fumarate] 300 mg oseltamivir phosphate emtricitabine caps 200 1 1 caps 30 mg mg oseltamivir phosphate emtricitabine-tenofovir 1 1 caps 45 mg df tabs 100-150 mg oseltamivir phosphate emtricitabine-tenofovir 1 1 caps 75 mg df tabs 133-200 mg oseltamivir phosphate emtricitabine-tenofovir 1 1 susr 6 mg/ml df tabs 167-250 mg PREVYMIS SOLN 240 1 QL - 30 day(s) MG/12ML [letermovir]

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 13 of 144

藥物等 藥物等 藥物名稱 規定／限制 藥物名稱 規定／限制 級 級 PREVYMIS SOLN 480 valganciclovir hcl tabs 1 QL - 30 day(s) 1 MG/24ML [letermovir] 450 mg PREVYMIS TABS 240 MG VEKLURY SOLN 100 1 QL - 30 day(s) 1 [letermovir] MG/20ML [remdesivir] PREVYMIS TABS 480 MG VEKLURY SOLR 100 MG 1 QL - 30 day(s) 1 [letermovir] [remdesivir] PREZCOBIX TABS 800- VIRAZOLE SOLR 6 GM 1 150 MG [darunavir- 1 [ribavirin] cobicistat] voriconazole solr 200 mg 1 RELENZA DISKHALER VOSEVI TABS 400-100- AEPB 5 MG/BLISTER 1 100 MG [sofosbuvir- 1 QL - 30 day(s) [zanamivir] velpatasvir-voxilaprevir] RETROVIR SOLN 10 1 URINARY ANTI-INFECTIVES MG/ML [zidovudine] MACRODANTIN CAPS 25 rimantadine hcl tabs 100 1 MG [nitrofurantoin 1 mg macrocrystal] ritonavir tabs 100 mg 1 methenamine hippurate SYNAGIS SOLN 100 1 1 tabs 1 gm MG/ML [palivizumab] NITROFURANTOIN SYNAGIS SOLN 50 MACROCRYSTAL CAPS 1 1 MG/0.5ML [palivizumab] 100 MG [nitrofurantoin TAMIFLU CAPS 30 MG 1 macrocrystal] [oseltamivir phosphate] NITROFURANTOIN TAMIFLU CAPS 45 MG MACROCRYSTAL CAPS 1 1 [oseltamivir phosphate] 25 MG [nitrofurantoin TAMIFLU CAPS 75 MG 1 macrocrystal] [oseltamivir phosphate] NITROFURANTOIN TAMIFLU SUSR 6 MG/ML MACROCRYSTAL CAPS 1 1 [oseltamivir phosphate] 50 MG [nitrofurantoin tenofovir disoproxil macrocrystal] 1 fumarate tabs 300 mg nitrofurantoin monohyd 1 TIVICAY PD TBSO 5 MG 1 macro caps 100 mg [dolutegravir sodium] nitrofurantoin susp 25 1 TIVICAY TABS 10 MG mg/5ml 1 [dolutegravir sodium] trimethoprim tabs 100 1 TIVICAY TABS 25 MG mg 1 [dolutegravir sodium] ANTIHISTAMINE DRUGS TRIZIVIR TABS 300-150- FIRST GENERATION ANTIHISTAMINES 300 MG [abacavir cyproheptadine hcl syrp 1 1 sulfate-lamivudine- 2 mg/5ml zidovudine] cyproheptadine hcl tabs valacyclovir hcl tabs 1 1 1 4 mg gm diphenhydramine hcl valacyclovir hcl tabs 500 1 1 soln 50 mg/ml mg promethazine hcl soln 25 1 VALCYTE SOLR 50 mg/ml MG/ML 1 QL - 30 day(s) [valganciclovir promethazine hcl tabs 1 hcl] 12.5 mg

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 14 of 144

藥物等 藥物等 藥物名稱 規定／限制 藥物名稱 規定／限制 級 級 promethazine hcl tabs 25 bleomycin sulfate solr 30 1 1 mg unit [Promethazine Hcl] BLINCYTO SOLR 35 1 QL - 30 day(s) PROMETHEGAN SUPP 1 MCG [blinatumomab] 12.5 MG BRUKINSA CAPS 80 MG 1 QL - 30 day(s) [Promethazine Hcl] [zanubrutinib] PROMETHEGAN SUPP 1 CABOMETYX TABS 20 25 MG MG [cabozantinib s- 1 QL - 30 day(s) ANTINEOPLASTIC AGENTS malate] ANTINEOPLASTIC AGENTS CABOMETYX TABS 40 abiraterone acetate tabs MG [cabozantinib s- 1 QL - 30 day(s) 1 QL - 30 day(s) 250 mg malate] ABRAXANE SUSR 100 CABOMETYX TABS 60 MG [paclitaxel protein- 1 MG [cabozantinib s- 1 QL - 30 day(s) bound particles] malate] ADCETRIS SOLR 50 MG CALQUENCE CAPS 100 1 1 QL - 30 day(s) [brentuximab vedotin] MG [acalabrutinib] AFINITOR TABS 10 MG CAMPTOSAR SOLN 100 1 QL - 30 day(s) 1 [everolimus] MG/5ML [irinotecan hcl] ALECENSA CAPS 150 CAMPTOSAR SOLN 40 1 QL - 30 day(s) 1 MG [alectinib hcl] MG/2ML [irinotecan hcl] ALIMTA SOLR 500 MG capecitabine tabs 150 1 1 QL - 30 day(s) [pemetrexed disodium] mg ALKERAN TABS 2 MG capecitabine tabs 500 1 1 QL - 30 day(s) [melphalan] mg ALUNBRIG TABS 180 MG CAPRELSA TABS 100 1 QL - 30 day(s) 1 QL - 30 day(s) [brigatinib] MG [vandetanib] ALUNBRIG TABS 30 MG CAPRELSA TABS 300 1 QL - 30 day(s) 1 QL - 30 day(s) [brigatinib] MG [vandetanib] ALUNBRIG TABS 90 MG carmustine solr 100 mg 1 1 QL - 30 day(s) cisplatin soln 100 [brigatinib] 1 ALUNBRIG TBPK 90 & mg/100ml 1 QL - 30 day(s) cisplatin soln 50 180 MG [brigatinib] 1 anastrozole tabs 1 mg 1 mg/50ml ARRANON SOLN 5 cladribine soln 10 1 1 MG/ML [nelarabine] mg/10ml AVASTIN SOLN 100 COMETRIQ (100 MG 1 DAILY DOSE) KIT 80 & 20 QL - 30 MG/4ML [bevacizumab] 1 AVASTIN SOLN 400 MG [cabozantinib s- day(s),LD 1 MG/16ML [bevacizumab] malate] COMETRIQ (140 MG azacitidine susr 100 mg 1 DAILY DOSE) KIT 3 x 20 QL - 30 BENDEKA SOLN 100 1 MG & 80 MG day(s),LD MG/4ML [bendamustine 1 QL - 30 day(s) [cabozantinib s-malate] hcl] COMETRIQ (60 MG bicalutamide tabs 50 mg 1 QL - 30 DAILY DOSE) KIT 20 MG 1 BICNU SOLR 100 MG day(s),LD 1 [cabozantinib s-malate] [carmustine] COPIKTRA CAPS 15 MG bleomycin sulfate solr 15 1 QL - 30 day(s) 1 [duvelisib] unit

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 15 of 144

藥物等 藥物等 藥物名稱 規定／限制 藥物名稱 規定／限制 級 級 COPIKTRA CAPS 25 MG doxorubicin hcl 1 QL - 30 day(s) 1 [duvelisib] liposomal inj 2 mg/ml COSMEGEN SOLR 0.5 doxorubicin hcl soln 2 1 1 MG [dactinomycin] mg/ml COTELLIC TABS 20 MG doxorubicin hcl solr 10 1 QL - 30 day(s) 1 [cobimetinib fumarate] mg CYCLOPHOSPHAMIDE doxorubicin hcl solr 50 1 CAPS 25 MG 1 mg [cyclophosphamide] EMCYT CAPS 140 MG CYCLOPHOSPHAMIDE [estramustine phosphate 1 QL - 30 day(s) CAPS 50 MG 1 sodium] [cyclophosphamide] ERBITUX SOLN 100 1 cyclophosphamide solr MG/50ML [cetuximab] 1 1 gm ERBITUX SOLN 200 1 cyclophosphamide solr MG/100ML [cetuximab] 1 2 gm ERIVEDGE CAPS 150 1 QL - 30 day(s) cyclophosphamide solr MG [vismodegib] 1 500 mg erlotinib hcl tabs 100 mg 1 QL - 30 day(s) CYRAMZA SOLN 100 1 QL - 30 day(s) erlotinib hcl tabs 150 mg 1 QL - 30 day(s) MG/10ML [ramucirumab] erlotinib hcl tabs 25 mg 1 QL - 30 day(s) CYRAMZA SOLN 500 1 QL - 30 day(s) ERWINAZE SOLR 10000 MG/50ML [ramucirumab] UNIT [asparaginase 1 cytarabine (pf) soln 100 1 erwinia chrysanthemi] mg/ml etoposide caps 50 mg 1 cytarabine (pf) soln 20 1 everolimus tabs 2.5 mg 1 QL - 30 day(s) mg/ml everolimus tabs 5 mg 1 QL - 30 day(s) cytarabine soln 20 mg/ml 1 everolimus tabs 7.5 mg 1 QL - 30 day(s) dacarbazine solr 100 mg 1 exemestane tabs 25 mg 1 dacarbazine solr 200 mg 1 fludarabine phosphate DACOGEN SOLR 50 MG 1 1 solr 50 mg [decitabine] fluorouracil soln 1 DARZALEX SOLN 100 1 1 QL - 30 day(s) gm/20ml MG/5ML [daratumumab] fluorouracil soln 2.5 DARZALEX SOLN 400 1 1 QL - 30 day(s) gm/50ml MG/20ML [daratumumab] fluorouracil soln 5 daunorubicin hcl soln 20 1 1 gm/100ml mg/4ml fluorouracil soln 500 DOCETAXEL (NON- 1 mg/10ml ALCOHOL) SOLN 160 1 QL - 30 day(s) flutamide caps 125 mg 1 MG/8ML [docetaxel] fulvestrant soln 250 DOCETAXEL (NON- 1 QL - 30 day(s) ALCOHOL) SOLN 20 1 QL - 30 day(s) mg/5ml MG/ML [docetaxel] GAZYVA SOLN 1000 MG/40ML 1 QL - 30 day(s) docetaxel conc 80 1 mg/4ml [obinutuzumab] gemcitabine hcl solr 200 DOXIL INJ 2 MG/ML 1 [doxorubicin hcl 1 mg GEMZAR SOLR 1 GM liposomal] 1 [gemcitabine hcl]

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 16 of 144

藥物等 藥物等 藥物名稱 規定／限制 藥物名稱 規定／限制 級 級 GLEOSTINE CAPS 10 IMBRUVICA TABS 140 1 1 QL - 30 day(s) MG [lomustine] MG [ibrutinib] GLEOSTINE CAPS 100 IMBRUVICA TABS 280 1 1 QL - 30 day(s) MG [lomustine] MG [ibrutinib] GLEOSTINE CAPS 40 IMBRUVICA TABS 420 1 1 QL - 30 day(s) MG [lomustine] MG [ibrutinib] GLEOSTINE CAPS 5 MG IMBRUVICA TABS 560 1 1 QL - 30 day(s) [lomustine] MG [ibrutinib] HALAVEN SOLN 1 INTRON A SOLN MG/2ML [eribulin 1 10000000 UNIT/ML 1 QL - 30 day(s) mesylate] [interferon alfa-2b] HERCEPTIN SOLR 150 INTRON A SOLN 6000000 1 QL - 30 day(s) MG [trastuzumab] UNIT/ML [interferon alfa- 1 QL - 30 day(s) HEXALEN CAPS 50 MG 2b] 1 QL - 30 day(s) [altretamine] INTRON A SOLR HYCAMTIN CAPS 0.25 10000000 UNIT 1 QL - 30 day(s) 1 QL - 30 day(s) MG [topotecan hcl] [interferon alfa-2b] HYCAMTIN CAPS 1 MG INTRON A SOLR 1 QL - 30 day(s) [topotecan hcl] 18000000 UNIT 1 QL - 30 day(s) hydroxyurea caps 500 [interferon alfa-2b] 1 mg INTRON A SOLR IBRANCE CAPS 100 MG 50000000 UNIT 1 QL - 30 day(s) 1 QL - 30 day(s) [palbociclib] [interferon alfa-2b] IBRANCE CAPS 125 MG IRESSA TABS 250 MG 1 QL - 30 day(s) 1 QL - 30 day(s) [palbociclib] [gefitinib] IBRANCE CAPS 75 MG irinotecan hcl soln 500 1 QL - 30 day(s) 1 [palbociclib] mg/25ml IBRANCE TABS 100 MG ISTODAX (OVERFILL) 1 QL - 30 day(s) [palbociclib] SOLR 10 MG 1 IBRANCE TABS 125 MG [romidepsin] 1 QL - 30 day(s) IXEMPRA KIT SOLR 15 [palbociclib] 1 QL - 30 day(s) IBRANCE TABS 75 MG MG [ixabepilone] 1 QL - 30 day(s) IXEMPRA KIT SOLR 45 [palbociclib] 1 QL - 30 day(s) IDAMYCIN PFS SOLN 10 MG [ixabepilone] 1 JAKAFI TABS 10 MG MG/10ML [idarubicin hcl] 1 QL - 30 day(s) IDAMYCIN PFS SOLN 20 [ruxolitinib phosphate] 1 JAKAFI TABS 15 MG MG/20ML [idarubicin hcl] 1 QL - 30 day(s) idarubicin hcl soln 5 [ruxolitinib phosphate] 1 JAKAFI TABS 20 MG mg/5ml 1 QL - 30 day(s) IFOSFAMIDE SOLR 1 GM [ruxolitinib phosphate] 1 JAKAFI TABS 25 MG [ifosfamide] 1 QL - 30 day(s) imatinib mesylate tabs [ruxolitinib phosphate] 1 JAKAFI TABS 5 MG 100 mg 1 QL - 30 day(s) imatinib mesylate tabs [ruxolitinib phosphate] 1 JEVTANA SOLN 60 400 mg 1 IMBRUVICA CAPS 140 MG/1.5ML [cabazitaxel] 1 QL - 30 day(s) MG [ibrutinib] KADCYLA SOLR 100 MG IMBRUVICA CAPS 70 MG [ado-trastuzumab 1 QL - 30 day(s) 1 QL - 30 day(s) [ibrutinib] emtansine]

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 17 of 144

藥物等 藥物等 藥物名稱 規定／限制 藥物名稱 規定／限制 級 級 KADCYLA SOLR 160 MG LUPRON DEPOT (3- [ado-trastuzumab 1 QL - 30 day(s) MONTH) KIT 11.25 MG 1 emtansine] [leuprolide acetate (3 KANJINTI SOLR 420 MG month)] 1 [trastuzumab-anns] LUPRON DEPOT (3- KEYTRUDA SOLN 100 MONTH) KIT 22.5 MG 1 MG/4ML 1 QL - 30 day(s) [leuprolide acetate (3 [pembrolizumab] month)] KYPROLIS SOLR 10 MG LUPRON DEPOT (4- 1 QL - 30 day(s) MONTH) KIT 30 MG [carfilzomib] 1 KYPROLIS SOLR 30 MG [leuprolide acetate (4 1 QL - 30 day(s) [carfilzomib] month)] KYPROLIS SOLR 60 MG LUPRON DEPOT (6- 1 QL - 30 day(s) MONTH) KIT 45 MG [carfilzomib] 1 LENVIMA (10 MG DAILY [leuprolide acetate (6 DOSE) CPPK 10 MG 1 QL - 30 day(s) month)] [lenvatinib mesylate] LUPRON DEPOT-PED (1- LENVIMA (12 MG DAILY MONTH) KIT 11.25 MG 1 DOSE) CPPK 3 x 4 MG 1 [leuprolide acetate (cpp)] [lenvatinib mesylate] LUPRON DEPOT-PED (1- LENVIMA (14 MG DAILY MONTH) KIT 15 MG 1 DOSE) CPPK 10 & 4 MG 1 QL - 30 day(s) [leuprolide acetate (cpp)] [lenvatinib mesylate] LUPRON DEPOT-PED (1- LENVIMA (20 MG DAILY MONTH) KIT 7.5 MG 1 DOSE) CPPK 2 x 10 MG 1 QL - 30 day(s) [leuprolide acetate (cpp)] [lenvatinib mesylate] LUPRON DEPOT-PED (3- MONTH) KIT 11.25 MG LENVIMA (24 MG DAILY 1 DOSE) CPPK 2 x 10 MG (PED) [leuprolide acetate 1 QL - 30 day(s) & 4 MG [lenvatinib (cpp) (3 month)] mesylate] LUPRON DEPOT-PED (3- MONTH) KIT 30 MG letrozole tabs 2.5 mg 1 1 LEUKERAN TABS 2 MG (PED) [leuprolide acetate 1 [chlorambucil] (cpp) (3 month)] leuprolide acetate kit 1 LYNPARZA TABS 100 1 1 QL - 30 day(s) mg/0.2ml MG [olaparib] LONSURF TABS 15-6.14 LYNPARZA TABS 150 1 QL - 30 day(s) 1 QL - 30 day(s) MG [trifluridine-tipiracil] MG [olaparib] LONSURF TABS 20-8.19 LYSODREN TABS 500 1 QL - 30 day(s) 1 QL - 30 day(s) MG [trifluridine-tipiracil] MG [mitotane] LORBRENA TABS 100 MARQIBO SUSP 5 1 QL - 30 day(s) MG [lorlatinib] MG/31ML [vincristine 1 QL - 30 day(s) LORBRENA TABS 25 MG sulfate liposome] 1 QL - 30 day(s) MATULANE CAPS 50 MG [lorlatinib] 1 QL - 30 day(s) LUPRON DEPOT (1- [procarbazine hcl] megestrol acetate susp MONTH) KIT 3.75 MG 1 1 [leuprolide acetate] 40 mg/ml megestrol acetate susp LUPRON DEPOT (1- 1 MONTH) KIT 7.5 MG 1 400 mg/10ml [leuprolide acetate]

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 18 of 144

藥物等 藥物等 藥物名稱 規定／限制 藥物名稱 規定／限制 級 級 megestrol acetate tabs OPDIVO SOLN 100 1 1 QL - 30 day(s) 20 mg MG/10ML [nivolumab] megestrol acetate tabs OPDIVO SOLN 40 1 1 QL - 30 day(s) 40 mg MG/4ML [nivolumab] MEKINIST TABS 0.5 MG oxaliplatin soln 100 1 [trametinib dimethyl 1 QL - 30 day(s) mg/20ml sulfoxide] oxaliplatin soln 50 1 MEKINIST TABS 2 MG mg/10ml [trametinib dimethyl 1 QL - 30 day(s) paclitaxel conc 300 1 sulfoxide] mg/50ml melphalan hcl solr 50 mg 1 PADCEV SOLR 20 MG mercaptopurine tabs 50 [enfortumab vedotin- 1 1 mg ejfv] methotrexate sodium PADCEV SOLR 30 MG 1 (pf) soln 50 mg/2ml [enfortumab vedotin- 1 METHOTREXATE ejfv] SODIUM SOLN 50 pentostatin inj 10mg 1 1 MG/2ML [methotrexate PERJETA SOLN 420 1 QL - 30 day(s) sodium] MG/14ML [pertuzumab] methotrexate sodium POMALYST CAPS 1 MG 1 1 QL - 30 day(s) solr 1 gm [pomalidomide] methotrexate tabs 2.5 POMALYST CAPS 2 MG 1 1 QL - 30 day(s) mg [pomalidomide] mitomycin solr 20 mg 1 POMALYST CAPS 3 MG 1 QL - 30 day(s) mitomycin solr 40 mg 1 [pomalidomide] POMALYST CAPS 4 MG mitomycin solr 5 mg 1 1 QL - 30 day(s) mitoxantrone hcl conc [pomalidomide] 1 25 mg/12.5ml PROLEUKIN SOLR MUSTARGEN SOLR 10 22000000 UNIT 1 QL - 30 day(s) MG [mechlorethamine 1 [aldesleukin] hcl] PURIXAN SUSP 2000 MVASI SOLN 100 MG/100ML 1 QL - 30 day(s) MG/4ML [bevacizumab- 1 [mercaptopurine] REVLIMID CAPS 10 MG awwb] 1 QL - 30 day(s) MYLERAN TABS 2 MG [lenalidomide] 1 REVLIMID CAPS 15 MG [busulfan] 1 QL - 30 day(s) NEXAVAR TABS 200 MG [lenalidomide] 1 QL - 30 day(s) REVLIMID CAPS 2.5 MG [sorafenib tosylate] 1 QL - 30 day(s) NINLARO CAPS 2.3 MG [lenalidomide] 1 QL - 30 day(s) REVLIMID CAPS 20 MG [ixazomib citrate] 1 QL - 30 day(s) NINLARO CAPS 3 MG [lenalidomide] 1 QL - 30 day(s) REVLIMID CAPS 25 MG [ixazomib citrate] 1 QL - 30 day(s) NINLARO CAPS 4 MG [lenalidomide] 1 QL - 30 day(s) REVLIMID CAPS 5 MG [ixazomib citrate] 1 QL - 30 day(s) ODOMZO CAPS 200 MG [lenalidomide] 1 QL - 30 day(s) RITUXAN SOLN 100 [sonidegib phosphate] 1 ONCASPAR SOLN 750 MG/10ML [rituximab] 1 RITUXAN SOLN 500 UNIT/ML [pegaspargase] 1 MG/50ML [rituximab]

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 19 of 144

藥物等 藥物等 藥物名稱 規定／限制 藥物名稱 規定／限制 級 級 1 tamoxifen citrate tabs 10 romidepsin solr 10 mg 1 ROZLYTREK CAPS 100 mg 1 QL - 30 day(s) tamoxifen citrate tabs 20 MG [entrectinib] 1 ROZLYTREK CAPS 200 mg 1 QL - 30 day(s) TARGRETIN CAPS 75 MG [entrectinib] 1 RYDAPT CAPS 25 MG MG [bexarotene] 1 QL - 30 day(s) TASIGNA CAPS 150 MG [midostaurin] 1 QL - 30 day(s) SARCLISA SOLN 100 [nilotinib hcl] 1 QL - 30 day(s) TASIGNA CAPS 200 MG MG/5ML [isatuximab-irfc] 1 QL - 30 day(s) SARCLISA SOLN 500 [nilotinib hcl] TAXOTERE INJ MG/25ML [isatuximab- 1 QL - 30 day(s) 1 irfc] 80MG/2ML [docetaxel] SPRYCEL TABS 100 MG TECENTRIQ SOLN 1200 1 QL - 30 day(s) 1 QL - 30 day(s) [dasatinib] MG/20ML [atezolizumab] SPRYCEL TABS 140 MG temozolomide caps 100 1 QL - 30 day(s) 1 [dasatinib] mg SPRYCEL TABS 20 MG temozolomide caps 140 1 QL - 30 day(s) 1 [dasatinib] mg SPRYCEL TABS 50 MG temozolomide caps 180 1 QL - 30 day(s) 1 [dasatinib] mg SPRYCEL TABS 70 MG temozolomide caps 20 1 QL - 30 day(s) 1 [dasatinib] mg SPRYCEL TABS 80 MG temozolomide caps 250 1 QL - 30 day(s) 1 [dasatinib] mg STIVARGA TABS 40 MG temozolomide caps 5 mg 1 1 QL - 30 day(s) [regorafenib] TENIPOSIDE SOLN 10 1 SUTENT CAPS 12.5 MG MG/ML [teniposide] 1 QL - 30 day(s) [sunitinib malate] thiotepa solr 15 mg 1 SUTENT CAPS 25 MG [Etoposide] TOPOSAR 1 QL - 30 day(s) 1 [sunitinib malate] SOLN 100 MG/5ML SUTENT CAPS 37.5 MG 1 QL - 30 day(s) topotecan hcl solr 4 mg 1 [sunitinib malate] TORISEL SOLN 25 SUTENT CAPS 50 MG 1 1 QL - 30 day(s) MG/ML [temsirolimus] [sunitinib malate] TREANDA SOLR 100 MG SYLVANT SOLR 100 MG 1 1 QL - 30 day(s) [bendamustine hcl] [siltuximab] tretinoin caps 10 mg 1 QL - 30 day(s) SYLVANT SOLR 400 MG 1 QL - 30 day(s) TRISENOX SOLN 12 [siltuximab] MG/6ML [arsenic 1 QL - 30 day(s) TABLOID TABS 40 MG 1 trioxide] [thioguanine] TUKYSA TABS 150 MG TAFINLAR CAPS 50 MG 1 QL - 30 day(s) 1 QL - 30 day(s) [tucatinib] [dabrafenib mesylate] TUKYSA TABS 50 MG TAFINLAR CAPS 75 MG 1 QL - 30 day(s) 1 QL - 30 day(s) [tucatinib] [dabrafenib mesylate] TYKERB TABS 250 MG TAGRISSO TABS 40 MG 1 QL - 30 day(s) 1 QL - 30 day(s) [lapatinib ditosylate] [osimertinib mesylate] UNITUXIN SOLN 17.5 TAGRISSO TABS 80 MG 1 QL - 30 day(s) 1 QL - 30 day(s) MG/5ML [dinutuximab] [osimertinib mesylate] VELCADE SOLR 3.5 MG 1 [bortezomib]

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 20 of 144

藥物等 藥物等 藥物名稱 規定／限制 藥物名稱 規定／限制 級 級 VENCLEXTA STARTING ZYDELIG TABS 150 MG 1 QL - 30 day(s) PACK TBPK 10 & 50 & 1 QL - 30 day(s) [idelalisib] 100 MG [venetoclax] ZYKADIA CAPS 150 MG 1 QL - 30 day(s) VENCLEXTA TABS 10 [ceritinib] 1 QL - 30 day(s) MG [venetoclax] ZYKADIA TABS 150 MG 1 QL - 30 day(s) VENCLEXTA TABS 100 [ceritinib] 1 QL - 30 day(s) MG [venetoclax] ZYTIGA TABS 500 MG 1 QL - 30 day(s) VENCLEXTA TABS 50 [abiraterone acetate] 1 QL - 30 day(s) MG [venetoclax] AUTONOMIC DRUGS vinblastine sulfate soln 1 1 ANTICHOLINERGIC AGENTS mg/ml atropine sulfate inj vincristine sulfate soln 1 1 1 1mg/ml mg/ml ATROPINE SULFATE vinorelbine tartrate soln 1 SOLN 0.4 MG/ML 1 10 mg/ml [atropine sulfate] vinorelbine tartrate soln 1 ATROPINE SULFATE 50 mg/5ml SOLN 8 MG/20ML 1 VOTRIENT TABS 200 MG 1 QL - 30 day(s) [atropine sulfate] [pazopanib hcl] ATROPINE SULFATE VYXEOS SUSR 44-100 SOSY 0.5 MG/5ML 1 MG [daunorubicin- 1 QL - 30 day(s) [atropine sulfate] cytarabine liposome] ATROVENT HFA AERS XALKORI CAPS 200 MG 17 MCG/ACT 1 QL - 30 day(s) 1 [crizotinib] [ipratropium bromide XALKORI CAPS 250 MG 1 QL - 30 day(s) hfa] [crizotinib] BELLADONNA XGEVA SOLN 120 1 QL - 30 day(s) ALKALOIDS-OPIUM MG/1.7ML [denosumab] SUPP 16.2-30 MG 1 XTANDI CAPS 40 MG 1 QL - 30 day(s) [belladonna alkaloids & [enzalutamide] opium] XTANDI TABS 40 MG 1 QL - 30 day(s) BELLADONNA [enzalutamide] ALKALOIDS-OPIUM XTANDI TABS 80 MG 1 QL - 30 day(s) SUPP 16.2-60 MG 1 [enzalutamide] [belladonna alkaloids & YERVOY SOLN 200 1 opium] MG/40ML [ipilimumab] BENTYL SOLN 10 MG/ML YERVOY SOLN 50 1 1 [dicyclomine hcl] MG/10ML [ipilimumab] CHLORDIAZEPOXIDE- YONDELIS SOLR 1 MG CLIDINIUM CAPS 5-2.5 1 QL - 30 day(s) 1 [trabectedin] MG [chlordiazepoxide ZANOSAR SOLR 1 GM 1 hcl-clidinium bromide] [streptozocin] CUVPOSA SOLN 1 1 ZEJULA CAPS 100 MG 1 QL - 30 day(s) MG/5ML [glycopyrrolate] [niraparib tosylate] dicyclomine hcl caps 10 ZELBORAF TABS 240 1 1 QL - 30 day(s) mg MG [vemurafenib] dicyclomine hcl soln 10 1 ZYDELIG TABS 100 MG 1 QL - 30 day(s) mg/5ml [idelalisib] dicyclomine hcl tabs 20 1 mg

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 21 of 144

藥物等 藥物等 藥物名稱 規定／限制 藥物名稱 規定／限制 級 級 DONNATAL ELIX 16.2 SPIRIVA RESPIMAT MG/5ML [phenobarbital- AERS 2.5 MCG/ACT 1 1 hyoscyamine-atropine- [tiotropium bromide scopolamine] monohydrate] DONNATAL TABS 16.2 STIOLTO RESPIMAT MG [phenobarbital- AERS 2.5-2.5 MCG/ACT 1 1 hyoscyamine-atropine- [tiotropium bromide- scopolamine] olodaterol hcl] glycopyrrolate soln 0.2 1 AUTONOMIC DRUGS, MISCELLANEOUS mg/ml CHANTIX CONTINUING glycopyrrolate soln 0.4 1 MONTH PAK TABS 1 MG 1 mg/2ml [varenicline tartrate] glycopyrrolate soln 1 1 CHANTIX STARTING mg/5ml MONTH PAK TABS 0.5 1 glycopyrrolate soln 4 1 MG X 11 & 1 MG X 42 mg/20ml [varenicline tartrate] glycopyrrolate tabs 1 mg 1 CHANTIX TABS 0.5 MG 1 glycopyrrolate tabs 2 mg 1 [varenicline tartrate] CHANTIX TABS 1 MG HYOSCYAMINE 1 SULFATE ER TB12 0.375 [varenicline tartrate] 1 MG [hyoscyamine PARASYMPATHOMIMETIC (CHOLINERGIC) sulfate] AGENTS HYOSCYAMINE bethanechol chloride 1 SULFATE SUBL 0.125 tabs 10 mg 1 MG bethanechol chloride [hyoscyamine 1 sulfate] tabs 25 mg HYOSCYAMINE bethanechol chloride 1 SULFATE TABS 0.125 tabs 5 mg 1 MG [hyoscyamine bethanechol chloride 1 sulfate] tabs 50 mg HYOSCYAMINE donepezil hcl tabs 10 mg 1 SULFATE TBDP 0.125 1 DONEPEZIL HCL TABS 5 MG [hyoscyamine MG [donepezil 1 sulfate] hydrochloride] HYOSYNE ELIX 0.125 donepezil hcl tbdp 10 mg 1 MG/5ML [hyoscyamine 1 donepezil hcl tbdp 5 mg 1 sulfate] [Edrophonium Chloride] 1 HYOSYNE SOLN 0.125 ENLON SOLN 10 MG/ML MG/ML [hyoscyamine 1 galantamine sulfate] hydrobromide er cp24 16 1 ipratropium bromide 1 mg soln 0.02 % galantamine ipratropium bromide 1 hydrobromide er cp24 24 1 soln 0.03 % mg LEVSIN SOLN 0.5 MG/ML 1 GALANTAMINE [hyoscyamine sulfate] HYDROBROMIDE ER propantheline bromide 1 1 CP24 8 MG [galantamine tabs 15 mg hydrobromide]

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 22 of 144

藥物等 藥物等 藥物名稱 規定／限制 藥物名稱 規定／限制 級 級 galantamine cyclobenzaprine hcl tabs 1 hydrobromide tabs 12 1 10 mg mg cyclobenzaprine hcl tabs 1 galantamine 5 mg 1 hydrobromide tabs 4 mg dantrolene sodium caps 1 galantamine 100 mg 1 hydrobromide tabs 8 mg dantrolene sodium caps 1 GUANIDINE HCL TABS 25 mg 1 125 MG [guanidine hcl] dantrolene sodium caps 1 MESTINON SOLN 60 50 mg MG/5ML [pyridostigmine 1 GABLOFEN SOLN 10000 1 bromide] MCG/20ML [baclofen] MESTINON TBCR 180 GABLOFEN SOLN 20000 1 MG [pyridostigmine 1 MCG/20ML [baclofen] bromide] GABLOFEN SOLN 40000 1 neostigmine MCG/20ML [baclofen] methylsulfate soln 0.5 1 GABLOFEN SOSY 10000 1 mg/ml MCG/20ML [baclofen] NEOSTIGMINE GABLOFEN SOSY 20000 1 METHYLSULFATE SOLN MCG/20ML [baclofen] 10 MG/10ML 1 GABLOFEN SOSY 40000 1 [neostigmine MCG/20ML [baclofen] methylsulfate] GABLOFEN SOSY 50 1 PHYSOSTIGMINE MCG/ML [baclofen] SALICYLATE SOLN 1 methocarbamol tabs 500 1 1 MG/ML [physostigmine mg salicylate] methocarbamol tabs 750 pilocarpine hcl tabs 5 1 1 mg mg pancuronium bromide pyridostigmine bromide 1 1 soln 1 mg/ml er tbcr 180 mg QUELICIN SOLN 20 pyridostigmine bromide 1 MG/ML [succinylcholine 1 tabs 60 mg chloride] REGONOL SOLN 10 rocuronium bromide 1 MG/2ML [pyridostigmine 1 soln 100 mg/10ml bromide] rocuronium bromide 1 SKELETAL MUSCLE RELAXANTS soln 50 mg/5ml atracurium besylate soln RYANODEX SUSR 250 1 1 100 mg/10ml MG [dantrolene sodium] atracurium besylate soln 1 1 tizanidine hcl tabs 2 mg 50 mg/5ml tizanidine hcl tabs 4 mg 1 baclofen tabs 10 mg 1 vecuronium bromide 1 baclofen tabs 20 mg 1 solr 10 mg cisatracurium besylate vecuronium bromide 1 1 (pf) soln 10 mg/5ml solr 20 mg cisatracurium besylate SYMPATHOLYTIC (ADRENERGIC BLOCKING) 1 (pf) soln 200 mg/20ml AGENTS cisatracurium besylate dihydroergotamine 1 1 soln 20 mg/10ml mesylate soln 1 mg/ml

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 23 of 144

藥物等 藥物等 藥物名稱 規定／限制 藥物名稱 規定／限制 級 級 [Ergotamine Tartrate] DOPAMINE IN D5W 1 ERGOMAR SUBL 2 MG SOLN 0.8-5 MG/ML-% 1 guanfacine hcl tabs 1 mg 1 [dopamine in d5w] guanfacine hcl tabs 2 mg 1 DOPAMINE IN D5W MIGRANAL SOLN 4 SOLN 1.6-5 MG/ML-% 1 MG/ML [dopamine in d5w] 1 [dihydroergotamine DOPAMINE IN D5W mesylate] SOLN 3.2-5 MG/ML-% 1 phenoxybenzamine hcl [dopamine in d5w] 1 caps 10 mg EPHEDRINE SULFATE phentolamine mesylate SOLN 50 MG/ML 1 1 solr 5 mg [ephedrine sulfate SYMPATHOMIMETIC (ADRENERGIC) AGENTS (pressors)] albuterol sulfate hfa aers epinephrine hcl inj 1 1 108 (90 base) mcg/act 1mg/ml EPINEPHRINE PF SOLN albuterol sulfate nebu 1 1 1 MG/ML (2.5 mg/3ml) 0.083% [epinephrine] albuterol sulfate nebu (5 epinephrine soaj 0.15 1 1 mg/ml) 0.5% mg/0.15ml EPINEPHRINE SOLN 30 albuterol sulfate nebu 1 1 MG/30ML 0.63 mg/3ml [epinephrine] EPINEPHRINE SOSY 1 albuterol sulfate nebu 1 1 MG/10ML 1.25 mg/3ml [epinephrine] EPIPEN 2-PAK SOAJ 0.3 albuterol sulfate nebu 1 MG/0.3ML 1 2.5 mg/0.5ml [epinephrine albuterol sulfate syrp 2 (anaphylaxis)] 1 EPIPEN JR 2-PAK SOAJ mg/5ml 0.15 MG/0.3ML albuterol sulfate tabs 2 1 1 [epinephrine mg (anaphylaxis)] albuterol sulfate tabs 4 1 ipratropium-albuterol mg 1 soln 0.5-2.5 (3) mg/3ml dobutamine hcl soln 250 1 isoproterenol hcl soln mg/20ml 1 DOBUTAMINE IN D5W 0.2 mg/ml metaproterenol sulfate SOLN 1-5 MG/ML-% 1 1 syrp 10 mg/5ml [dobutamine in d5w] metaproterenol sulfate DOBUTAMINE IN D5W 1 SOLN 2 MG/ML 1 tabs 10 mg metaproterenol sulfate [dobutamine in d5w] 1 tabs 20 mg dopamine hcl inj 1 midodrine hcl tabs 10 80mg/ml 1 mg dopamine hcl soln 160 1 midodrine hcl tabs 2.5 mg/ml 1 DOPAMINE HCL SOLN mg 40 MG/ML [dopamine 1 midodrine hcl tabs 5 mg 1 norepinephrine bitartrate hcl] 1 dopamine hcl soln 80 soln 1 mg/ml 1 mg/ml

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 24 of 144

藥物等 藥物等 藥物名稱 規定／限制 藥物名稱 規定／限制 級 級 SEREVENT DISKUS ANTIHEMORRHAGIC AGENTS AEPB 50 MCG/DOSE 1 ADVATE SOLR 1000 [salmeterol xinafoate] UNIT [antihemophilic STRIVERDI RESPIMAT factor (rcmb) 1 QL - 30 day(s) AERS 2.5 MCG/ACT 1 plasma/albumin free [olodaterol hcl] (rahf-pfm)] terbutaline sulfate inj 1 ADVATE SOLR 1500 1mg/ml UNIT [antihemophilic terbutaline sulfate soln 1 1 factor (rcmb) 1 QL - 30 day(s) mg/ml plasma/albumin free terbutaline sulfate tabs 1 (rahf-pfm)] 2.5 mg ADVATE SOLR 2000 terbutaline sulfate tabs 5 1 UNIT [antihemophilic mg factor (rcmb) 1 QL - 30 day(s) VENTOLIN HFA AERS plasma/albumin free 108 (90 Base) MCG/ACT 1 (rahf-pfm)] [albuterol sulfate] ADVATE SOLR 250 UNIT [Fluticasone-salmeterol] [antihemophilic factor 1 QL - 30 day(s) WIXELA INHUB AEPB 1 (rcmb) plasma/albumin 100-50 MCG/DOSE free (rahf-pfm)] [Fluticasone-salmeterol] ADVATE SOLR 3000 WIXELA INHUB AEPB 1 UNIT [antihemophilic 250-50 MCG/DOSE factor (rcmb) 1 [Fluticasone-salmeterol] plasma/albumin free WIXELA INHUB AEPB 1 (rahf-pfm)] 500-50 MCG/DOSE ADVATE SOLR 4000 BLOOD DERIVATIVES UNIT [antihemophilic BLOOD DERIVATIVES factor (rcmb) 1 QL - 30 day(s) ALBUMIN HUMAN SOLN plasma/albumin free 1 25 % [albumin, human] (rahf-pfm)] ALBURX SOLN 5 % ADVATE SOLR 500 UNIT 1 [antihemophilic factor [albumin, human] 1 QL - 30 day(s) ALBUTEIN SOLN 25 % (rcmb) plasma/albumin 1 [albumin, human] free (rahf-pfm)] AFSTYLA KIT 1000 UNIT BUMINATE SOLN 5 % 1 [antihemophilic factor [albumin, human] 1 QL - 30 day(s) (recombinant) single PLASMANATE SOLN 5 % 1 chain] [plasma protein fraction] AFSTYLA KIT 1500 UNIT BLOOD FORMATION, COAGULATION, AND [antihemophilic factor 1 QL - 30 day(s) THROMBOSIS (recombinant) single ANTIANEMIA DRUGS chain] INFED SOLN 50 MG/ML 1 AFSTYLA KIT 2000 UNIT [iron dextran] [antihemophilic factor 1 PROFERRIN-FORTE (recombinant) single TABS 12-1 MG [iron 1 chain] heme polypeptide-folic AFSTYLA KIT 250 UNIT 1 QL - 30 day(s) acid] [antihemophilic factor VENOFER SOLN 20 1 MG/ML [iron sucrose]

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 25 of 144

藥物等 藥物等 藥物名稱 規定／限制 藥物名稱 規定／限制 級 級 (recombinant) single BENEFIX KIT 500 UNIT chain] [coagulation factor ix 1 AFSTYLA KIT 2500 UNIT (recombinant)] [antihemophilic factor ELOCTATE SOLR 1000 1 QL - 30 day(s) (recombinant) single UNIT [antihemophilic 1 QL - 30 day(s) chain] factor (rcmb) fc fusion AFSTYLA KIT 3000 UNIT protein(bdd-rfviiifc)] [antihemophilic factor ELOCTATE SOLR 1500 1 QL - 30 day(s) (recombinant) single UNIT [antihemophilic 1 QL - 30 day(s) chain] factor (rcmb) fc fusion AFSTYLA KIT 500 UNIT protein(bdd-rfviiifc)] [antihemophilic factor ELOCTATE SOLR 2000 1 QL - 30 day(s) (recombinant) single UNIT [antihemophilic 1 QL - 30 day(s) chain] factor (rcmb) fc fusion ALPHANATE/VWF protein(bdd-rfviiifc)] COMPLEX/HUMAN SOLR ELOCTATE SOLR 250 1000 UNIT UNIT [antihemophilic 1 1 QL - 30 day(s) [antihemophilic factor (rcmb) fc fusion factor/von willebrand protein(bdd-rfviiifc)] factor complex (human)] ELOCTATE SOLR 3000 ALPHANATE/VWF UNIT [antihemophilic 1 QL - 30 day(s) COMPLEX/HUMAN SOLR factor (rcmb) fc fusion 1500 UNIT 1 protein(bdd-rfviiifc)] [antihemophilic ELOCTATE SOLR 4000 factor/von willebrand UNIT [antihemophilic 1 QL - 30 day(s) factor complex (human)] factor (rcmb) fc fusion ALPHANINE SD SOLR protein(bdd-rfviiifc)] 1000 UNIT [coagulation 1 QL - 30 day(s) ELOCTATE SOLR 500 factor ix] UNIT [antihemophilic 1 QL - 30 day(s) ALPHANINE SD SOLR factor (rcmb) fc fusion 1500 UNIT [coagulation 1 QL - 30 day(s) protein(bdd-rfviiifc)] factor ix] ELOCTATE SOLR 5000 ALPHANINE SD SOLR UNIT [antihemophilic 1 QL - 30 day(s) 500 UNIT [coagulation 1 QL - 30 day(s) factor (rcmb) fc fusion factor ix] protein(bdd-rfviiifc)] aminocaproic acid soln ELOCTATE SOLR 6000 1 250 mg/ml UNIT [antihemophilic 1 QL - 30 day(s) BENEFIX KIT 1000 UNIT factor (rcmb) fc fusion [coagulation factor ix 1 protein(bdd-rfviiifc)] (recombinant)] ELOCTATE SOLR 750 BENEFIX KIT 2000 UNIT UNIT [antihemophilic 1 QL [coagulation factor ix 1 factor (rcmb) fc fusion (recombinant)] protein(bdd-rfviiifc)] BENEFIX KIT 250 UNIT GELFILM FILM [gelatin 1 [coagulation factor ix 1 adsorbable (ophth)] (recombinant)] GELFOAM SPONGE BENEFIX KIT 3000 UNIT MISC 12-7 MM [gelatin 1 [coagulation factor ix 1 absorbable] (recombinant)]

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 26 of 144

藥物等 藥物等 藥物名稱 規定／限制 藥物名稱 規定／限制 級 級 GELFOAM SPONGE SIZE IDELVION SOLR 1000 100 MISC [gelatin 1 UNIT [coagulation factor 1 QL - 30 day(s) absorbable] ix recomb albumin GELFOAM SPONGE SIZE fusion protein (rix-fp)] 50 MISC [gelatin 1 IDELVION SOLR 2000 absorbable] UNIT [coagulation factor 1 QL - 30 day(s) HELIXATE FS KIT 250 ix recomb albumin UNIT [antihemophilic fusion protein (rix-fp)] 1 QL - 30 day(s) factor (recombinant) IDELVION SOLR 250 (rfviii)] UNIT [coagulation factor 1 QL - 30 day(s) HEMLIBRA SOLN 105 ix recomb albumin MG/0.7ML [emicizumab- 1 QL - 30 day(s) fusion protein (rix-fp)] kxwh] IDELVION SOLR 500 HEMLIBRA SOLN 150 UNIT [coagulation factor 1 QL - 30 day(s) MG/ML [emicizumab- 1 QL - 30 day(s) ix recomb albumin kxwh] fusion protein (rix-fp)] HEMLIBRA SOLN 30 KCENTRA KIT 500 UNIT MG/ML [emicizumab- 1 QL - 30 day(s) [prothrombin complex 1 kxwh] concentrate human] HEMLIBRA SOLN 60 KOATE SOLR 1000 UNIT MG/0.4ML [emicizumab- 1 QL - 30 day(s) [antihemophilic factor 1 kxwh] (human)] HEMOFIL M INJ 220-400 KOATE-DVI SOLR 250 [antihemophilic factor 1 QL - 30 day(s) UNIT [antihemophilic 1 (human)] factor (human)] HEMOFIL M SOLR 1000 KOATE-DVI SOLR 500 UNIT [antihemophilic 1 UNIT [antihemophilic 1 factor (human)] factor (human)] HEMOFIL M SOLR 1700 KOGENATE FS KIT 1000 UNIT 1 UNIT [antihemophilic [antihemophilic 1 QL - 30 day(s) factor (human)] factor (recombinant) HEMOFIL M SOLR 500 (rfviii)] UNIT [antihemophilic 1 KOGENATE FS KIT 2000 UNIT [antihemophilic factor (human)] 1 QL - 30 day(s) HUMATE-P SOLR 1000- factor (recombinant) 2400 UNIT (rfviii)] [antihemophilic 1 QL - 30 day(s) KOGENATE FS KIT 500 UNIT [antihemophilic factor/von willebrand 1 QL - 30 day(s) factor complex (human)] factor (recombinant) HUMATE-P SOLR 250- (rfviii)] 600 UNIT [antihemophilic KOVALTRY SOLR 1000 1 QL - 30 day(s) factor/von willebrand UNIT [antihemophilic factor complex (human)] factor (rcmb) 1 QL - 30 day(s) HUMATE-P SOLR 500- plasma/albumin free 1200 UNIT (rahf-pfm)] [antihemophilic 1 QL - 30 day(s) KOVALTRY SOLR 2000 factor/von willebrand UNIT [antihemophilic factor complex (human)] factor (rcmb) 1 QL - 30 day(s) plasma/albumin free (rahf-pfm)]

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 27 of 144

藥物等 藥物等 藥物名稱 規定／限制 藥物名稱 規定／限制 級 級 KOVALTRY SOLR 250 [antihemophilic factor UNIT [antihemophilic (recombinant) (rfviii)] factor (rcmb) 1 QL - 30 day(s) RECOMBINATE SOLR plasma/albumin free 220-400 UNIT 1 QL - 30 day(s) (rahf-pfm)] [antihemophilic factor KOVALTRY SOLR 3000 (recombinant) (rfviii)] UNIT [antihemophilic RECOMBINATE SOLR factor (rcmb) 1 QL - 30 day(s) 401-800 UNIT 1 QL - 30 day(s) plasma/albumin free [antihemophilic factor (rahf-pfm)] (recombinant) (rfviii)] KOVALTRY SOLR 500 RECOMBINATE SOLR UNIT [antihemophilic 801-1240 UNIT 1 QL - 30 day(s) factor (rcmb) 1 QL - 30 day(s) [antihemophilic factor plasma/albumin free (recombinant) (rfviii)] (rahf-pfm)] RECOTHROM SOLR MONONINE SOLR 1000 20000 UNIT [thrombin 1 UNIT [coagulation factor 1 QL - 30 day(s) (recombinant)] ix] RECOTHROM SOLR NOVOSEVEN RT SOLR 1 5000 UNIT [thrombin 1 MG [coagulation factor 1 (recombinant)] viia (recombinant)] THROMBIN-JMI KIT 1 NOVOSEVEN RT SOLR 2 20000 UNIT [thrombin] MG [coagulation factor 1 THROMBIN-JMI SOLR 1 viia (recombinant)] 20000 UNIT [thrombin] NOVOSEVEN RT SOLR 5 THROMBIN-JMI SOLR 1 MG [coagulation factor 1 5000 UNIT [thrombin] viia (recombinant)] tranexamic acid soln 1 NOVOSEVEN RT SOLR 8 1000 mg/10ml MG [coagulation factor 1 tranexamic acid tabs 650 1 viia (recombinant)] mg PHENOL LIQD 89 % 1 QL - 30 day(s) WILATE KIT 1000-1000 [phenol] UNIT [antihemophilic 1 PRAXBIND SOLN 2.5 1 factor/von willebrand GM/50ML [idarucizumab] factor complex (human)] PROFILNINE SOLR 1000 WILATE KIT 500-500 1 UNIT [factor ix complex] UNIT [antihemophilic 1 PROFILNINE SOLR 1500 factor/von willebrand 1 UNIT [factor ix complex] factor complex (human)] PROFILNINE SOLR 500 XYNTHA KIT 1000 UNIT 1 QL - 30 day(s) UNIT [factor ix complex] [antihemophilic factor 1 QL - 30 day(s) protamine sulfate soln (rcmb) moroctocog 1 10 mg/ml alfa(bdd-rfviii,mor)] RECOMBINATE SOLR XYNTHA KIT 2000 UNIT 1241-1800 UNIT [antihemophilic factor 1 QL - 30 day(s) 1 [antihemophilic factor (rcmb) moroctocog (recombinant) (rfviii)] alfa(bdd-rfviii,mor)] RECOMBINATE SOLR XYNTHA KIT 250 UNIT 1 QL - 30 day(s) 1 QL - 30 day(s) 1801-2400 UNIT [antihemophilic factor

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 28 of 144

藥物等 藥物等 藥物名稱 規定／限制 藥物名稱 規定／限制 級 級 (rcmb) moroctocog heparin sodium 1 alfa(bdd-rfviii,mor)] (porcine) lock flush soln XYNTHA KIT 500 UNIT HEPARIN (PORCINE) IN [antihemophilic factor NACL SOLN 1000-0.9 1 QL - 30 day(s) (rcmb) moroctocog UT/500ML-% [heparin 1 alfa(bdd-rfviii,mor)] (porcine) in sodium XYNTHA SOLOFUSE KIT chloride] 3000 UNIT HEPARIN (PORCINE) IN [antihemophilic factor 1 QL - 30 day(s) NACL SOLN 2000-0.9 (rcmb) moroctocog UNIT/L-% [heparin 1 alfa(bdd-rfviii,mor)] (porcine) in sodium ANTITHROMBOTIC AGENTS chloride] ACD-A NOCLOT-50 HEPARIN (PORCINE) IN SOLN 0.73-2.45-2.2 NACL SOLN 25000-0.45 GM/100ML 1 UT/250ML-% [heparin 1 [anticoagulant citrate (porcine) in sodium dextrose solution a] chloride] ACTIVASE SOLR 100 MG HEPARIN LOCK FLUSH 1 SOLN 1 UNIT/ML [alteplase] 1 ACTIVASE SOLR 50 MG [heparin sodium 1 [alteplase] (porcine) lock flush] AGGRENOX CP12 25-200 HEPARIN LOCK FLUSH SOLN 10 UNIT/ML MG [aspirin- 1 1 dipyridamole] [heparin sodium anagrelide hcl caps 0.5 (porcine) lock flush] 1 mg HEPARIN SOD anagrelide hcl caps 1 mg 1 (PORCINE) IN D5W ANGIOMAX SOLR 250 SOLN 100 UNIT/ML 1 MG [bivalirudin 1 [heparin sod (porcine) in trifluoroacetate] d5w] ARGATROBAN IN HEPARIN SOD SODIUM CHLORIDE (PORCINE) IN D5W SOLN 125-0.9 MG/125ML- 1 SOLN 25000-5 UT/500ML- 1 % [argatroban in sodium % [heparin sod (porcine) chloride] in d5w] ARGATROBAN SOLN 250 HEPARIN SOD 1 MG/2.5ML [argatroban] (PORCINE) IN D5W aspirin-dipyridamole er SOLN 40-5 UNIT/ML-% 1 1 cp12 25-200 mg [heparin sod (porcine) in

BRILINTA TABS 90 MG d5w] 1 [ticagrelor] HEPARIN SODIUM CATHFLO ACTIVASE (PORCINE) PF SOLN 1 5000 UNIT/0.5ML 1 SOLR 2 MG [alteplase] [heparin sodium clopidogrel bisulfate 1 (porcine)] tabs 75 mg HEPARIN SODIUM EFFIENT TABS 10 MG 1 (PORCINE) SOLN 1000 [prasugrel hcl] 1 UNIT/ML [heparin EFFIENT TABS 5 MG 1 sodium (porcine)] [prasugrel hcl]

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 29 of 144

藥物等 藥物等 藥物名稱 規定／限制 藥物名稱 規定／限制 級 級 HEPARIN SODIUM PRADAXA CAPS 150 MG (PORCINE) SOLN 10000 [dabigatran etexilate 1 1 UNIT/ML [heparin mesylate] sodium (porcine)] PRADAXA CAPS 75 MG HEPARIN SODIUM [dabigatran etexilate 1 (PORCINE) SOLN 20000 mesylate] 1 UNIT/ML [heparin THROMBATE III SOLR sodium (porcine)] 500 UNIT [antithrombin 1 HEPARIN SODIUM iii (human)] (PORCINE) SOLN 5000 TNKASE KIT 50 MG 1 1 UNIT/ML [heparin [tenecteplase] sodium (porcine)] warfarin sodium tabs 1 1 HEPARIN SODIUM LOCK mg FLUSH SOLN 100 warfarin sodium tabs 10 1 UNIT/ML [heparin 1 mg sodium (porcine) lock warfarin sodium tabs 2 1 flush] mg INTEGRILIN SOLN 20 warfarin sodium tabs 2.5 1 1 MG/10ML [eptifibatide] mg INTEGRILIN SOLN 75 warfarin sodium tabs 3 1 1 MG/100ML [eptifibatide] mg LOVENOX SOLN 100 warfarin sodium tabs 4 1 MG/ML [enoxaparin 1 QL - 30 day(s) mg sodium] warfarin sodium tabs 5 1 LOVENOX SOLN 120 mg MG/0.8ML [enoxaparin 1 QL - 30 day(s) warfarin sodium tabs 6 1 sodium] mg LOVENOX SOLN 150 warfarin sodium tabs 7.5 1 MG/ML [enoxaparin 1 QL - 30 day(s) mg sodium] HEMATOPOIETIC AGENTS LOVENOX SOLN 30 ADAKVEO SOLN 100 MG/0.3ML [enoxaparin 1 QL - 30 day(s) MG/10ML [crizanlizumab- 1 sodium] tmca] LOVENOX SOLN 300 LEUKINE SOLR 250 MCG 1 QL - 30 day(s) MG/3ML [enoxaparin 1 QL - 30 day(s) [sargramostim] sodium] NEUPOGEN SOSY 300 1 QL - 30 day(s) LOVENOX SOLN 40 MCG/0.5ML [filgrastim] MG/0.4ML [enoxaparin 1 QL - 30 day(s) NEUPOGEN SOSY 480 1 QL - 30 day(s) sodium] MCG/0.8ML [filgrastim] LOVENOX SOLN 60 NIVESTYM SOLN 300 1 QL - 30 day(s) MG/0.6ML [enoxaparin 1 QL - 30 day(s) MCG/ML [filgrastim-aafi] sodium] NIVESTYM SOLN 480 LOVENOX SOLN 80 MCG/1.6ML [filgrastim- 1 QL - 30 day(s) MG/0.8ML [enoxaparin 1 QL - 30 day(s) aafi] sodium] NIVESTYM SOSY 300 PRADAXA CAPS 110 MG MCG/0.5ML [filgrastim- 1 [dabigatran etexilate 1 aafi] mesylate]

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 30 of 144

藥物等 藥物等 藥物名稱 規定／限制 藥物名稱 規定／限制 級 級 NIVESTYM SOSY 480 tamsulosin hcl caps 0.4 1 MCG/0.8ML [filgrastim- 1 mg aafi] terazosin hcl caps 1 mg 1 PROCRIT SOLN 10000 1 QL - 30 day(s) terazosin hcl caps 10 mg 1 UNIT/ML [epoetin alfa] terazosin hcl caps 2 mg 1 PROCRIT SOLN 2000 1 QL - 30 day(s) terazosin hcl caps 5 mg 1 UNIT/ML [epoetin alfa] ANTILIPEMIC AGENTS PROCRIT SOLN 20000 1 QL - 30 day(s) atorvastatin calcium UNIT/ML [epoetin alfa] 1 tabs 10 mg PROCRIT SOLN 3000 1 QL - 30 day(s) atorvastatin calcium UNIT/ML [epoetin alfa] 1 tabs 20 mg PROCRIT SOLN 4000 1 QL - 30 day(s) atorvastatin calcium UNIT/ML [epoetin alfa] 1 tabs 40 mg PROCRIT SOLN 40000 1 QL - 30 day(s) atorvastatin calcium UNIT/ML [epoetin alfa] 1 tabs 80 mg PROMACTA PACK 25 MG 1 cholestyramine light [eltrombopag olamine] 1 pack 4 gm PROMACTA TABS 12.5 cholestyramine light MG [eltrombopag 1 QL - 30 day(s) 1 olamine] powd 4 gm/dose cholestyramine pack 4 PROMACTA TABS 25 MG 1 1 QL - 30 day(s) gm [eltrombopag olamine] cholestyramine powd 4 PROMACTA TABS 50 MG 1 QL - 30 day(s) 1 [eltrombopag olamine] gm/dose 1 PROMACTA TABS 75 MG colestipol hcl gran 5 gm 1 QL - 30 day(s) [eltrombopag olamine] colestipol hcl pack 5 gm 1 ZARXIO SOSY 300 colestipol hcl tabs 1 gm 1 MCG/0.5ML [filgrastim- 1 QL - 30 day(s) ezetimibe tabs 10 mg 1 sndz] fenofibrate tabs 160 mg 1 ZARXIO SOSY 480 fenofibrate tabs 54 mg 1 MCG/0.8ML [filgrastim- 1 QL - 30 day(s) gemfibrozil tabs 600 mg 1 sndz] lovastatin tabs 10 mg 1 HEMORRHEOLOGIC AGENTS lovastatin tabs 20 mg 1 pentoxifylline er tbcr 400 1 lovastatin tabs 40 mg 1 mg pravastatin sodium tabs 1 CARDIOVASCULAR DRUGS 10 mg ALPHA-ADRENERGIC BLOCKING AGENTS pravastatin sodium tabs 1 doxazosin mesylate tabs 1 20 mg 1 mg pravastatin sodium tabs 1 doxazosin mesylate tabs 1 40 mg 2 mg pravastatin sodium tabs 1 doxazosin mesylate tabs 1 80 mg 4 mg rosuvastatin calcium 1 doxazosin mesylate tabs 1 tabs 10 mg 8 mg rosuvastatin calcium 1 prazosin hcl caps 1 mg 1 tabs 20 mg 1 rosuvastatin calcium prazosin hcl caps 2 mg 1 prazosin hcl caps 5 mg 1 tabs 40 mg

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 31 of 144

藥物等 藥物等 藥物名稱 規定／限制 藥物名稱 規定／限制 級 級 rosuvastatin calcium metoprolol succinate er 1 1 tabs 5 mg tb24 100 mg 1 metoprolol succinate er simvastatin tabs 10 mg 1 simvastatin tabs 20 mg 1 tb24 200 mg metoprolol succinate er simvastatin tabs 40 mg 1 1 simvastatin tabs 5 mg 1 tb24 25 mg metoprolol succinate er simvastatin tabs 80 mg 1 1 tb24 50 mg BETA-ADRENERGIC BLOCKING AGENTS metoprolol tartrate soln 1 atenolol tabs 100 mg 1 5 mg/5ml atenolol tabs 25 mg 1 metoprolol tartrate tabs 1 atenolol tabs 50 mg 1 100 mg atenolol-chlorthalidone metoprolol tartrate tabs 1 1 tabs 100-25 mg 25 mg atenolol-chlorthalidone metoprolol tartrate tabs 1 1 tabs 50-25 mg 50 mg bisoprolol fumarate tabs 1 metoprolol- 10 mg hydrochlorothiazide tabs 1 bisoprolol fumarate tabs 1 100-50 mg 5 mg nadolol tabs 20 mg 1 bisoprolol- nadolol tabs 40 mg 1 hydrochlorothiazide tabs 1 nadolol tabs 80 mg 1 10-6.25 mg propranolol hcl er cp24 1 bisoprolol- 120 mg 1 hydrochlorothiazide tabs propranolol hcl er cp24 1 2.5-6.25 mg 160 mg bisoprolol- propranolol hcl er cp24 1 1 hydrochlorothiazide tabs 60 mg 5-6.25 mg propranolol hcl er cp24 BREVIBLOC IN NACL 1 80 mg SOLN 2000 MG/100ML 1 propranolol hcl soln 1 [esmolol hcl-sodium 1 mg/ml chloride] propranolol hcl soln 20 BREVIBLOC IN NACL 1 mg/5ml SOLN 2500 MG/250ML 1 propranolol hcl tabs 10 [esmolol hcl-sodium 1 mg chloride] propranolol hcl tabs 20 1 1 carvedilol tabs 12.5 mg mg carvedilol tabs 25 mg 1 propranolol hcl tabs 40 1 carvedilol tabs 3.125 mg 1 mg carvedilol tabs 6.25 mg 1 propranolol hcl tabs 60 1 ESMOLOL HCL SOLN mg 100 MG/10ML [esmolol 1 propranolol hcl tabs 80 1 hcl] mg labetalol hcl soln 5 sotalol hcl (af) tabs 120 1 1 mg/ml mg labetalol hcl tabs 100 mg 1 sotalol hcl (af) tabs 160 1 labetalol hcl tabs 200 mg 1 mg labetalol hcl tabs 300 mg 1

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 32 of 144

藥物等 藥物等 藥物名稱 規定／限制 藥物名稱 規定／限制 級 級 sotalol hcl (af) tabs 80 diltiazem hcl er cp12 90 1 1 mg mg 1 diltiazem hcl er cp24 120 sotalol hcl tabs 120 mg 1 sotalol hcl tabs 160 mg 1 mg diltiazem hcl er cp24 180 sotalol hcl tabs 240 mg 1 1 sotalol hcl tabs 80 mg 1 mg diltiazem hcl er cp24 240 CALCIUM-CHANNEL BLOCKING AGENTS 1 mg amlodipine besylate tabs 1 diltiazem hcl soln 125 10 mg 1 mg/25ml amlodipine besylate tabs 1 diltiazem hcl soln 25 2.5 mg 1 mg/5ml amlodipine besylate tabs 1 diltiazem hcl soln 50 5 mg 1 mg/10ml CARDENE IV SOLN 20- diltiazem hcl tabs 120 0.86 MG/200ML-% 1 1 mg [nicardipine hcl in diltiazem hcl tabs 30 mg 1 sodium chloride] CARDENE IV SOLN 20- diltiazem hcl tabs 60 mg 1 4.8 MG/200ML-% diltiazem hcl tabs 90 mg 1 1 nicardipine hcl soln 2.5 [nicardipine hcl in 1 dextrose] mg/ml CARDENE IV SOLN 40- nifedipine caps 10 mg 1 0.83 MG/200ML-% nifedipine caps 20 mg 1 1 [nicardipine hcl in nifedipine er osmotic 1 sodium chloride] release tb24 30 mg CARDENE IV SOLN 40-5 nifedipine er osmotic 1 MG/200ML-% 1 release tb24 60 mg [nicardipine hcl in nifedipine er osmotic 1 dextrose] release tb24 90 mg [Diltiazem Hcl Coated nifedipine er tb24 30 mg 1 Beads] CARTIA XT CP24 1 nifedipine er tb24 60 mg 1 120 MG nimodipine caps 30 mg 1 [Diltiazem Hcl Coated verapamil hcl er tbcr 120 Beads] CARTIA XT CP24 1 1 mg 240 MG verapamil hcl er tbcr 180 [Diltiazem Hcl Coated 1 mg Beads] CARTIA XT CP24 1 verapamil hcl er tbcr 240 300 MG 1 mg CLEVIPREX EMUL 25 1 verapamil hcl soln 2.5 MG/50ML 1 [clevidipine] mg/ml CLEVIPREX EMUL 50 1 verapamil hcl tabs 120 MG/100ML [clevidipine] 1 mg diltiazem hcl er coated 1 verapamil hcl tabs 40 mg 1 beads cp24 180 mg verapamil hcl tabs 80 mg 1 diltiazem hcl er cp12 120 1 mg CARDIAC DRUGS diltiazem hcl er cp12 60 adenosine inj 6mg/2ml 1 1 adenosine soln 12 mg 1 mg/4ml

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 33 of 144

藥物等 藥物等 藥物名稱 規定／限制 藥物名稱 規定／限制 級 級 adenosine soln 6 mg/2ml 1 milrinone lactate in amiodarone hcl soln 150 dextrose soln 20-5 1 1 mg/3ml mg/100ml-% amiodarone hcl soln 900 milrinone lactate in 1 mg/18ml dextrose soln 40-5 1 amiodarone hcl tabs 200 mg/200ml-% 1 milrinone lactate inj mg 1 DIGOXIN SOLN 0.05 1mg/ml 1 milrinone lactate soln 10 MG/ML [digoxin] 1 digoxin soln 0.25 mg/ml 1 mg/10ml digoxin tabs 125 mcg 1 NORPACE CR CP12 100 digoxin tabs 250 mcg 1 MG [disopyramide 1 phosphate] disopyramide phosphate 1 NORPACE CR CP12 150 caps 100 mg MG [disopyramide 1 disopyramide phosphate 1 phosphate] caps 150 mg procainamide hcl soln dofetilide caps 125 mcg 1 1 100 mg/ml 1 dofetilide caps 250 mcg procainamide hcl soln 1 dofetilide caps 500 mcg 1 500 mg/ml flecainide acetate tabs propafenone hcl tabs 1 1 100 mg 150 mg flecainide acetate tabs propafenone hcl tabs 1 1 150 mg 225 mg flecainide acetate tabs propafenone hcl tabs 1 1 50 mg 300 mg ibutilide fumarate soln 1 quinidine gluconate er 1 1 mg/10ml tbcr 324 mg LANOXIN PEDIATRIC QUINIDINE GLUCONATE SOLN 0.1 MG/ML 1 SOLN 80 MG/ML 1 [digoxin] [quinidine gluconate] lidocaine hcl (cardiac) pf quinidine sulfate tabs 1 1 sosy 100 mg/5ml 200 mg lidocaine hcl (cardiac) quinidine sulfate tabs 1 1 sosy 50 mg/5ml 300 mg LIDOCAINE IN D5W HYPOTENSIVE AGENTS SOLN 4-5 MG/ML-% 1 clonidine hcl tabs 0.1 mg 1 [lidocaine in d5w] 1 LIDOCAINE IN D5W clonidine hcl tabs 0.2 mg SOLN 8-5 MG/ML-% 1 clonidine hcl tabs 0.3 mg 1 clonidine ptwk 0.1 [lidocaine in d5w] 1 mexiletine hcl caps 150 mg/24hr 1 clonidine ptwk 0.2 mg 1 mexiletine hcl caps 200 mg/24hr 1 clonidine ptwk 0.3 mg 1 mexiletine hcl caps 250 mg/24hr 1 hydralazine hcl soln 20 mg 1 mg/ml hydralazine hcl tabs 10 1 mg

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 34 of 144

藥物等 藥物等 藥物名稱 規定／限制 藥物名稱 規定／限制 級 級 hydralazine hcl tabs 100 lisinopril- 1 mg hydrochlorothiazide tabs 1 hydralazine hcl tabs 25 20-12.5 mg 1 mg lisinopril- hydralazine hcl tabs 50 hydrochlorothiazide tabs 1 1 mg 20-25 mg losartan potassium tabs methyldopa tabs 250 mg 1 1 methyldopa tabs 500 mg 1 100 mg methyldopate hcl soln losartan potassium tabs 1 1 250 mg/5ml 25 mg losartan potassium tabs minoxidil tabs 10 mg 1 1 minoxidil tabs 2.5 mg 1 50 mg nitroprusside sodium losartan potassium-hctz 1 1 soln 25 mg/ml tabs 100-12.5 mg PROGLYCEM SUSP 50 losartan potassium-hctz 1 1 MG/ML [diazoxide] tabs 100-25 mg losartan potassium-hctz reserpine tab 0.1mg 1 1 tabs 50-12.5 mg reserpine tab 0.25mg 1 ramipril caps 10 mg 1 RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM ramipril caps 2.5 mg 1 INHIBITORS benazepril hcl tabs 10 ramipril caps 5 mg 1 1 spironolactone tabs 100 mg 1 benazepril hcl tabs 20 mg 1 spironolactone tabs 25 mg 1 benazepril hcl tabs 40 mg 1 spironolactone tabs 50 mg 1 benazepril hcl tabs 5 mg 1 mg spironolactone-hctz tabs captopril tabs 100 mg 1 1 25-25 mg captopril tabs 12.5 mg 1 valsartan tabs 160 mg 1 captopril tabs 25 mg 1 valsartan tabs 320 mg 1 captopril tabs 50 mg 1 valsartan tabs 40 mg 1 enalaprilat inj 1.25 mg/ml 1 valsartan tabs 80 mg 1 ENTRESTO TABS 24-26 1 valsartan- MG [sacubitril-valsartan] hydrochlorothiazide tabs 1 ENTRESTO TABS 49-51 1 160-12.5 mg MG [sacubitril-valsartan] valsartan- ENTRESTO TABS 97-103 1 hydrochlorothiazide tabs 1 MG [sacubitril-valsartan] 160-25 mg 1 lisinopril tabs 10 mg valsartan- lisinopril tabs 2.5 mg 1 hydrochlorothiazide tabs 1 lisinopril tabs 20 mg 1 320-12.5 mg lisinopril tabs 30 mg 1 valsartan- lisinopril tabs 40 mg 1 hydrochlorothiazide tabs 1 lisinopril tabs 5 mg 1 320-25 mg lisinopril- valsartan- hydrochlorothiazide tabs 1 hydrochlorothiazide tabs 1 10-12.5 mg 80-12.5 mg

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 35 of 144

藥物等 藥物等 藥物名稱 規定／限制 藥物名稱 規定／限制 級 級 isosorbide mononitrate SCLEROSING AGENTS 1 ETHAMOLIN SOLN 5 % er tb24 120 mg 1 isosorbide mononitrate [ethanolamine oleate] 1 [Sodium Tetradecyl er tb24 30 mg isosorbide mononitrate Sulfate] SOTRADECOL 1 1 SOLN 1 % er tb24 60 mg LETAIRIS TABS 10 MG QL - 30 [Sodium Tetradecyl 1 Sulfate] SOTRADECOL 1 [ambrisentan] day(s),LD LETAIRIS TABS 5 MG QL - 30 SOLN 3 % 1 VARITHENA FOAM 180 [ambrisentan] day(s),LD [Nitroglycerin] MINITRAN MG/18ML [polidocanol 1 1 (laureth-9)] PT24 0.1 MG/HR [Nitroglycerin] MINITRAN VASODILATING AGENTS 1 alprostadil soln 500 PT24 0.2 MG/HR 1 [Nitroglycerin] MINITRAN mcg/ml 1 QL - 30 PT24 0.6 MG/HR ambrisentan tabs 10 mg 1 [Nitroglycerin] NITRO-BID day(s),LD 1 QL - 30 OINT 2 % ambrisentan tabs 5 mg 1 NITRO-DUR PT24 0.3 day(s),LD 1 CAVERJECT SOLR 20 MG/HR [nitroglycerin] QL - 8/30 MCG [alprostadil 1 NITRO-DUR PT24 0.8 day(s) 1 (vasodilator)] MG/HR [nitroglycerin] CAVERJECT SOLR 40 NITROGLYCERIN ER QL - 8/30 MCG [alprostadil 1 CPCR 2.5 MG 1 day(s) (vasodilator)] [nitroglycerin] dipyridamole soln 5 NITROGLYCERIN ER 1 mg/ml CPCR 6.5 MG 1 dipyridamole tabs 25 mg 1 [nitroglycerin] dipyridamole tabs 50 mg 1 NITROGLYCERIN ER CPCR 9 MG 1 dipyridamole tabs 75 mg 1 [nitroglycerin] EDEX KIT 10 MCG QL - 8/30 NITROGLYCERIN IN [alprostadil 1 day(s) D5W SOLN 100-5 (vasodilator)] 1 MCG/ML-% [nitroglycerin EDEX KIT 20 MCG QL - 8/30 in d5w] [alprostadil 1 day(s) NITROGLYCERIN IN

(vasodilator)] D5W SOLN 200-5 EDEX KIT 40 MCG 1 QL - 8/30 MCG/ML-% [nitroglycerin [alprostadil 1 day(s) in d5w]

(vasodilator)] NITROGLYCERIN IN isosorbide dinitrate er D5W SOLN 400-5 1 1 tbcr 40 mg MCG/ML-% [nitroglycerin isosorbide dinitrate tabs 1 in d5w] 10 mg nitroglycerin pt24 0.4 isosorbide dinitrate tabs 1 1 mg/hr 20 mg nitroglycerin soln 5 isosorbide dinitrate tabs 1 1 mg/ml 30 mg NITROSTAT SUBL 0.3 isosorbide dinitrate tabs 1 1 MG [nitroglycerin] 5 mg

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 36 of 144

藥物等 藥物等 藥物名稱 規定／限制 藥物名稱 規定／限制 級 級 NITROSTAT SUBL 0.4 acetaminophen-codeine 1 1 MG [nitroglycerin] #2 tabs 300-15 mg NITROSTAT SUBL 0.6 acetaminophen-codeine 1 1 MG [nitroglycerin] #3 tabs 300-30 mg PAPAVERINE HCL SOLN acetaminophen-codeine 1 30 MG/ML [papaverine 1 #4 tabs 300-60 mg hcl] acetaminophen-codeine 1 REMODULIN SOLN 100 soln 120-12 mg/5ml 1 LD MG/20ML [treprostinil] alfentanil hcl soln 1000 1 REMODULIN SOLN 20 mcg/2ml 1 LD MG/20ML [treprostinil] buprenorphine hcl soln 1 REMODULIN SOLN 200 0.3 mg/ml 1 LD MG/20ML [treprostinil] buprenorphine hcl- REMODULIN SOLN 50 naloxone hcl subl 2-0.5 1 QL - 30 day(s) 1 LD MG/20ML [treprostinil] mg sildenafil citrate tabs 100 QL - 8/30 buprenorphine hcl- 1 1 QL - 30 day(s) mg day(s) naloxone hcl subl 8-2 mg sildenafil citrate tabs 20 QL - 8/30 butorphanol tartrate soln 1 1 mg day(s) 1 mg/ml tadalafil (pah) tabs 20 butorphanol tartrate soln 1 1 mg 2 mg/ml QL - 8/30 CHOLINE-MAG tadalafil tabs 10 mg 1 day(s) TRISALICYLATE LIQD 1 QL - 8/30 500 MG/5ML [choline & tadalafil tabs 2.5 mg 1 day(s) mag salicylate] tadalafil tabs 20 mg 1 CODEINE SULFATE QL - 8/30 TABS 15 MG [codeine 1 tadalafil tabs 5 mg 1 day(s) sulfate] TRACLEER TABS 125 QL - 30 CODEINE SULFATE 1 MG [bosentan] day(s),LD TABS 30 MG [codeine 1 TRACLEER TABS 62.5 QL - 30 sulfate] 1 MG [bosentan] day(s),LD CODEINE SULFATE treprostinil soln 100 TABS 60 MG [codeine 1 1 LD mg/20ml sulfate] treprostinil soln 20 DURAMORPH SOLN 0.5 1 LD mg/20ml MG/ML [morphine 1 treprostinil soln 200 sulfate] 1 mg/20ml DURAMORPH SOLN 1 treprostinil soln 50 MG/ML [morphine 1 1 LD mg/20ml sulfate] TYVASO SOLN 0.6 QL - 30 etodolac caps 200 mg 1 1 MG/ML [treprostinil] day(s),LD etodolac caps 300 mg 1 VENTAVIS SOLN 10 QL - 30 etodolac tabs 400 mg 1 1 MCG/ML [iloprost] day(s),LD etodolac tabs 500 mg 1 VENTAVIS SOLN 20 QL - 30 fentanyl citrate (pf) soct 1 1 MCG/ML [iloprost] day(s),LD 100 mcg/2ml CENTRAL NERVOUS SYSTEM AGENTS FENTANYL CITRATE ANALGESICS AND ANTIPYRETICS (PF) SOLN 100 MCG/2ML 1 [fentanyl citrate]

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 37 of 144

藥物等 藥物等 藥物名稱 規定／限制 藥物名稱 規定／限制 級 級 FENTANYL CITRATE ibuprofen susp 100 1 (PF) SOLN 500 mg/5ml 1 MCG/10ML [fentanyl [Indomethacin] INDOCIN 1 citrate] SUPP 50 MG fentanyl pt72 100 mcg/hr 1 QL - 30 day(s) indomethacin caps 25 1 fentanyl pt72 12 mcg/hr 1 QL - 30 day(s) mg indomethacin caps 50 fentanyl pt72 25 mcg/hr 1 QL - 30 day(s) 1 fentanyl pt72 50 mcg/hr 1 QL - 30 day(s) mg indomethacin er cpcr 75 fentanyl pt72 75 mcg/hr 1 QL - 30 day(s) 1 mg hydrocodone- INDOMETHACIN acetaminophen soln 7.5- 1 SODIUM SOLR 1 MG 1 325 mg/15ml [indomethacin sodium] hydrocodone- INFUMORPH 200 SOLN acetaminophen tabs 10- 1 200 MG/20ML (10 MG/ML) 325 mg [morphine sulfate for 1 hydrocodone- continuous acetaminophen tabs 5- 1 microinfusion] 325 mg INFUMORPH 500 SOLN hydrocodone- 500 MG/20ML (25 MG/ML) acetaminophen tabs 7.5- 1 [morphine sulfate for 1 325 mg continuous hydromorphone hcl liqd 1 microinfusion] 1 mg/ml ketorolac tromethamine hydromorphone hcl pf 1 1 soln 15 mg/ml soln 500 mg/50ml ketorolac tromethamine HYDROMORPHONE HCL 1 soln 30 mg/ml SOLN 1 MG/ML 1 QL - 30 day(s) ketorolac tromethamine [hydromorphone hcl] 1 soln 60 mg/2ml HYDROMORPHONE HCL [Hydrocodone- SOLN 2 MG/ML 1 acetaminophen] LORTAB 1 [hydromorphone hcl] ELIX 10-300 MG/15ML HYDROMORPHONE HCL meclofenamate sodium SOLN 4 MG/ML 1 1 caps 100 mg [hydromorphone hcl] meclofenamate sodium HYDROMORPHONE HCL 1 caps 50 mg SUPP 3 MG 1 mefenamic acid caps [hydromorphone hcl] 1 250 mg hydromorphone hcl tabs 1 2 mg meloxicam tabs 15 mg 1 hydromorphone hcl tabs meloxicam tabs 7.5 mg 1 1 meperidine hcl soln 100 4 mg 1 hydromorphone hcl tabs mg/ml 1 meperidine hcl soln 25 8 mg 1 [Ibuprofen] IBU TABS 400 mg/ml 1 meperidine hcl soln 50 MG 1 [Ibuprofen] IBU TABS 600 mg/ml 1 methadone hcl soln 10 MG 1 [Ibuprofen] IBU TABS 800 mg/5ml 1 MG

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 38 of 144

藥物等 藥物等 藥物名稱 規定／限制 藥物名稱 規定／限制 級 級 METHADONE HCL SOLN MORPHINE SULFATE 10 MG/ML [methadone 1 SOLN 2 MG/ML 1 hcl] [morphine sulfate] methadone hcl soln 5 MORPHINE SULFATE 1 mg/5ml SOLN 20 MG/5ML 1 METHADONE HCL TABS [morphine sulfate] 1 10 MG [methadone hcl] MORPHINE SULFATE METHADONE HCL TABS SOLN 25 MG/ML 1 1 5 MG [methadone hcl] [morphine sulfate] morphine sulfate MORPHINE SULFATE (concentrate) soln 100 1 SOLN 4 MG/ML 1 mg/5ml [morphine sulfate] morphine sulfate (pf) MORPHINE SULFATE 1 soln 0.5 mg/ml SOLN 5 MG/ML 1 morphine sulfate (pf) [morphine sulfate] 1 soln 1 mg/ml MORPHINE SULFATE MORPHINE SULFATE SOLN 50 MG/ML 1 (PF) SOLN 10 MG/ML 1 [morphine sulfate] [morphine sulfate] MORPHINE SULFATE MORPHINE SULFATE SOLN 8 MG/ML 1 (PF) SOLN 2 MG/ML 1 [morphine sulfate] [morphine sulfate] MORPHINE SULFATE MORPHINE SULFATE SUPP 10 MG [morphine 1 (PF) SOLN 4 MG/ML 1 sulfate] [morphine sulfate] MORPHINE SULFATE morphine sulfate er tbcr SUPP 20 MG [morphine 1 1 100 mg sulfate] morphine sulfate er tbcr MORPHINE SULFATE 1 15 mg SUPP 30 MG [morphine 1 morphine sulfate er tbcr sulfate] 1 200 mg MORPHINE SULFATE morphine sulfate er tbcr SUPP 5 MG [morphine 1 1 30 mg sulfate] morphine sulfate er tbcr MORPHINE SULFATE 1 60 mg TABS 15 MG [morphine 1 MORPHINE SULFATE sulfate] SOLN 1 MG/ML 1 MORPHINE SULFATE [morphine sulfate] TABS 30 MG [morphine 1 MORPHINE SULFATE sulfate] nabumetone tabs 500 SOLN 10 MG/5ML 1 1 [morphine sulfate] mg nabumetone tabs 750 MORPHINE SULFATE 1 SOLN 10 MG/ML 1 mg nalbuphine hcl soln 10 [morphine sulfate] 1 MORPHINE SULFATE mg/ml nalbuphine hcl soln 20 SOLN 15 MG/ML 1 1 [morphine sulfate] mg/ml naproxen sodium tabs 1 275 mg

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 39 of 144

藥物等 藥物等 藥物名稱 規定／限制 藥物名稱 規定／限制 級 級 naproxen sodium tabs amphetamine- 1 550 mg dextroamphet er cp24 15 1 naproxen susp 125 mg 1 mg/5ml amphetamine- naproxen tabs 250 mg 1 dextroamphet er cp24 20 1 naproxen tabs 375 mg 1 mg naproxen tabs 500 mg 1 amphetamine- naproxen tbec 375 mg 1 dextroamphet er cp24 25 1 NEOPROFEN SOLN 10 mg 1 MG/ML [ibuprofen lysine] amphetamine- 1 OFIRMEV SOLN 10 dextroamphet er cp24 30 1 mg MG/ML [acetaminophen] amphetamine- OPANA SOLN 1 MG/ML 1 dextroamphet er cp24 5 1 [oxymorphone hcl] mg oxycodone hcl tabs 5 mg 1 amphetamine- oxycodone- dextroamphetamine tabs 1 1 acetaminophen tabs 10- 10 mg 325 mg amphetamine- oxycodone- dextroamphetamine tabs 1 1 acetaminophen tabs 5- 12.5 mg 325 mg amphetamine- oxycodone- dextroamphetamine tabs 1 1 acetaminophen tabs 7.5- 15 mg 325 mg amphetamine- pentazocine-naloxone 1 dextroamphetamine tabs 1 hcl tabs 50-0.5 mg 20 mg SALSALATE TABS 500 1 amphetamine- MG [salsalate] dextroamphetamine tabs 1 SALSALATE TABS 750 1 30 mg MG [salsalate] amphetamine- sufentanil citrate soln 50 1 dextroamphetamine tabs 1 mcg/ml 5 mg sulindac tabs 150 mg 1 amphetamine- sulindac tabs 200 mg 1 dextroamphetamine tabs 1 tramadol hcl tabs 50 mg 1 7.5 mg tramadol-acetaminophen 1 APTENSIO XR CP24 10 tabs 37.5-325 mg MG [methylphenidate 1 ULTIVA SOLR 1 MG 1 hcl] [remifentanil hcl] APTENSIO XR CP24 15 ULTIVA SOLR 2 MG MG 1 1 [methylphenidate [remifentanil hcl] hcl] ULTIVA SOLR 5 MG APTENSIO XR CP24 20 1 [remifentanil hcl] MG [methylphenidate 1 ANOREXIGENIC AGENTS AND RESPIRATORY hcl] AND CEREBRAL STIMULANTS APTENSIO XR CP24 30 amphetamine- MG [methylphenidate 1 dextroamphet er cp24 10 1 hcl] mg

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 40 of 144

藥物等 藥物等 藥物名稱 規定／限制 藥物名稱 規定／限制 級 級 APTENSIO XR CP24 40 methylphenidate hcl er 1 MG [methylphenidate 1 (cd) cpcr 40 mg hcl] methylphenidate hcl er 1 APTENSIO XR CP24 50 (cd) cpcr 50 mg MG [methylphenidate 1 methylphenidate hcl er 1 hcl] (cd) cpcr 60 mg APTENSIO XR CP24 60 methylphenidate hcl er 1 MG [methylphenidate 1 tbcr 10 mg hcl] methylphenidate hcl er 1 caffeine citrate soln 60 1 tbcr 18 mg mg/3ml methylphenidate hcl er 1 dexmethylphenidate hcl 1 tbcr 20 mg er cp24 10 mg methylphenidate hcl er 1 dexmethylphenidate hcl 1 tbcr 27 mg er cp24 15 mg methylphenidate hcl er 1 dexmethylphenidate hcl 1 tbcr 36 mg er cp24 20 mg methylphenidate hcl er 1 dexmethylphenidate hcl 1 tbcr 54 mg er cp24 25 mg methylphenidate hcl 1 dexmethylphenidate hcl 1 tabs 10 mg er cp24 30 mg methylphenidate hcl 1 dexmethylphenidate hcl 1 tabs 20 mg er cp24 35 mg methylphenidate hcl 1 dexmethylphenidate hcl 1 tabs 5 mg er cp24 40 mg modafinil tabs 100 mg 1 dexmethylphenidate hcl 1 modafinil tabs 200 mg 1 er cp24 5 mg VYVANSE CAPS 10 MG dexmethylphenidate hcl 1 [lisdexamfetamine 1 tabs 10 mg dimesylate] dexmethylphenidate hcl 1 VYVANSE CAPS 20 MG tabs 2.5 mg [lisdexamfetamine 1 dexmethylphenidate hcl 1 dimesylate] tabs 5 mg VYVANSE CAPS 30 MG dextroamphetamine 1 [lisdexamfetamine 1 sulfate er cp24 10 mg dimesylate] dextroamphetamine 1 VYVANSE CAPS 40 MG sulfate er cp24 15 mg [lisdexamfetamine 1 dextroamphetamine 1 dimesylate] sulfate er cp24 5 mg VYVANSE CAPS 50 MG dextroamphetamine 1 [lisdexamfetamine 1 sulfate tabs 10 mg dimesylate] dextroamphetamine 1 VYVANSE CAPS 60 MG sulfate tabs 5 mg [lisdexamfetamine 1 methylphenidate hcl er 1 dimesylate] (cd) cpcr 10 mg VYVANSE CAPS 70 MG methylphenidate hcl er 1 [lisdexamfetamine 1 (cd) cpcr 20 mg dimesylate] methylphenidate hcl er 1 ANTICONVULSANTS (cd) cpcr 30 mg

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 41 of 144

藥物等 藥物等 藥物名稱 規定／限制 藥物名稱 規定／限制 級 級 BANZEL SUSP 40 MG/ML divalproex sodium er 1 1 [rufinamide] tb24 500 mg BANZEL TABS 200 MG divalproex sodium tbec 1 1 [rufinamide] 125 mg BANZEL TABS 400 MG divalproex sodium tbec 1 1 [rufinamide] 250 mg BRIVIACT TABS 10 MG divalproex sodium tbec 1 1 [brivaracetam] 500 mg BRIVIACT TABS 100 MG EQUETRO CP12 200 MG 1 [brivaracetam] [carbamazepine 1 BRIVIACT TABS 25 MG (antipsychotic)] 1 [brivaracetam] ethosuximide caps 250 1 BRIVIACT TABS 50 MG mg 1 [brivaracetam] ethosuximide soln 250 1 BRIVIACT TABS 75 MG mg/5ml 1 [brivaracetam] felbamate susp 600 1 carbamazepine chew 100 mg/5ml 1 mg felbamate tabs 400 mg 1 carbamazepine er cp12 1 felbamate tabs 600 mg 1 100 mg fosphenytoin sodium carbamazepine er cp12 1 1 soln 100 mg pe/2ml 200 mg fosphenytoin sodium carbamazepine er cp12 1 1 soln 500 mg pe/10ml 300 mg gabapentin caps 100 mg 1 carbamazepine er tb12 1 gabapentin caps 300 mg 1 100 mg gabapentin caps 400 mg 1 carbamazepine er tb12 1 gabapentin soln 250 200 mg 1 mg/5ml carbamazepine er tb12 1 gabapentin tabs 600 mg 1 400 mg 1 carbamazepine susp 100 gabapentin tabs 800 mg 1 LAMICTAL STARTER KIT mg/5ml 1 carbamazepine tabs 200 35 x 25 MG [lamotrigine] 1 mg LAMICTAL STARTER KIT CELONTIN CAPS 300 MG 42 x 25 MG & 7 X 100 MG 1 1 [methsuximide] [lamotrigine] LAMICTAL STARTER KIT clonazepam tabs 0.5 mg 1 84 x 25 MG & 14X100 MG 1 clonazepam tabs 1 mg 1 [lamotrigine] 1 clonazepam tabs 2 mg lamotrigine chew 25 mg 1 [Phenytoin Sodium lamotrigine chew 5 mg 1 Extended] DILANTIN 1 CAPS 30 MG lamotrigine tabs 100 mg 1 [Phenytoin] DILANTIN lamotrigine tabs 150 mg 1 1 INFATABS CHEW 50 MG lamotrigine tabs 200 mg 1 divalproex sodium csdr lamotrigine tabs 25 mg 1 1 levetiracetam er tb24 500 125 mg 1 divalproex sodium er mg 1 levetiracetam er tb24 750 tb24 250 mg 1 mg

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 42 of 144

藥物等 藥物等 藥物名稱 規定／限制 藥物名稱 規定／限制 級 級 LEVETIRACETAM IN phenytoin sodium 1 NACL SOLN 1000 extended caps 100 mg 1 MG/100ML [levetiracetam phenytoin sodium soln 1 in sodium chloride] 50 mg/ml LEVETIRACETAM IN phenytoin susp 125 1 NACL SOLN 1500 1 mg/5ml MG/100ML [levetiracetam pregabalin caps 100 mg 1 in sodium chloride] pregabalin caps 150 mg 1 LEVETIRACETAM IN pregabalin caps 200 mg 1 NACL SOLN 500 1 pregabalin caps 225 mg 1 MG/100ML [levetiracetam pregabalin caps 25 mg 1 in sodium chloride] levetiracetam soln 100 pregabalin caps 300 mg 1 1 mg/ml pregabalin caps 50 mg 1 levetiracetam soln 500 pregabalin caps 75 mg 1 1 pregabalin soln 20 mg/5ml 1 levetiracetam tabs 1000 mg/ml 1 mg primidone tab 50mg 1 levetiracetam tabs 250 primidone tabs 250 mg 1 1 mg SABRIL PACK 500 MG QL - 30 1 levetiracetam tabs 500 day(s),LD 1 [vigabatrin] mg topiramate cpsp 15 mg 1 levetiracetam tabs 750 1 topiramate cpsp 25 mg 1 mg topiramate tabs 100 mg 1 MAGNESIUM SULFATE topiramate tabs 200 mg 1 SOLN 20 GM/500ML 1 topiramate tabs 25 mg 1 [magnesium sulfate] MAGNESIUM SULFATE topiramate tabs 50 mg 1 valproate sodium soln SOLN 4 GM/100ML 1 1 [magnesium sulfate] 500 mg/5ml valproic acid caps 250 MAGNESIUM SULFATE 1 SOLN 4 GM/50ML 1 mg valproic acid soln 250 [magnesium sulfate] 1 MAGNESIUM SULFATE mg/5ml [Ethosuximide] ZARONTIN SOLN 40 GM/1000ML 1 1 [magnesium sulfate] SOLN 250 MG/5ML magnesium sulfate soln zonisamide caps 100 mg 1 1 50 % zonisamide caps 25 mg 1 oxcarbazepine susp 300 zonisamide caps 50 mg 1 1 mg/5ml ANTIMANIC AGENTS oxcarbazepine tabs 150 lithium carbonate caps 1 1 mg 150 mg oxcarbazepine tabs 300 1 LITHIUM CARBONATE mg CAPS 300 MG [lithium 1 oxcarbazepine tabs 600 1 carbonate] mg lithium carbonate caps [Phenytoin] PHENYTOIN 1 1 600 mg INFATABS CHEW 50 MG lithium carbonate er tbcr 1 300 mg

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 43 of 144

藥物等 藥物等 藥物名稱 規定／限制 藥物名稱 規定／限制 級 級 lithium carbonate er tbcr sumatriptan succinate 1 1 450 mg tabs 100 mg LITHIUM CARBONATE sumatriptan succinate 1 TABS 300 MG [lithium 1 tabs 25 mg carbonate] sumatriptan succinate 1 LITHIUM SOLN 8 tabs 50 mg 1 MEQ/5ML [lithium] ANTIPARKINSONIAN AGENTS ANTIMIGRAINE AGENTS amantadine hcl caps 100 1 [Ergotamine W/ Caffeine] mg CAFERGOT TABS 1-100 1 amantadine hcl syrp 50 1 MG mg/5ml eletriptan hydrobromide APOKYN SOCT 30 1 tabs 20 mg MG/3ML [apomorphine 1 QL - 30 day(s) eletriptan hydrobromide hydrochloride] 1 tabs 40 mg benztropine mesylate 1 ergoloid mesylates tabs soln 1 mg/ml 1 1 mg benztropine mesylate 1 ergotamine-caffeine tabs tabs 0.5 mg 1 1-100 mg benztropine mesylate 1 ISOMETHEPTENE- tabs 1 mg DICHLORAL-APAP CAPS benztropine mesylate 1 65-100-325 MG 1 tabs 2 mg [isometheptene- bromocriptine mesylate 1 dichloralphenazone- caps 5 mg acetaminophen] bromocriptine mesylate 1 [Ergotamine W/ Caffeine] tabs 2.5 mg MIGERGOT SUPP 2-100 1 cabergoline tabs 0.5 mg 1 MG carbidopa tabs 25 mg 1 naratriptan hcl tabs 1 mg 1 carbidopa-levodopa er naratriptan hcl tabs 2.5 1 1 tbcr 25-100 mg mg carbidopa-levodopa er rizatriptan benzoate tabs 1 1 tbcr 50-200 mg 10 mg carbidopa-levodopa tabs rizatriptan benzoate tabs 1 1 10-100 mg 5 mg carbidopa-levodopa tabs rizatriptan benzoate tbdp 1 1 25-100 mg 10 mg carbidopa-levodopa tabs rizatriptan benzoate tbdp 1 1 25-250 mg 5 mg carbidopa-levodopa- sumatriptan soln 20 1 entacapone tabs 12.5-50- 1 mg/act 200 mg sumatriptan succinate 1 carbidopa-levodopa- refill soct 6 mg/0.5ml entacapone tabs 18.75- 1 sumatriptan succinate 1 75-200 mg soaj 6 mg/0.5ml carbidopa-levodopa- sumatriptan succinate 1 entacapone tabs 25-100- 1 soln 6 mg/0.5ml 200 mg sumatriptan succinate 1 sosy 6 mg/0.5ml

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 44 of 144

藥物等 藥物等 藥物名稱 規定／限制 藥物名稱 規定／限制 級 級 carbidopa-levodopa- pramipexole entacapone tabs 31.25- 1 dihydrochloride tabs 1 1 125-200 mg mg carbidopa-levodopa- pramipexole entacapone tabs 37.5- 1 dihydrochloride tabs 1.5 1 150-200 mg mg carbidopa-levodopa- rasagiline mesylate tabs 1 entacapone tabs 50-200- 1 0.5 mg 200 mg rasagiline mesylate tabs 1 DUOPA SUSP 4.63-20 1 mg MG/ML [carbidopa- 1 ropinirole hcl er tb24 12 1 levodopa] mg ENTACAPONE TABS 200 ropinirole hcl er tb24 2 1 1 MG [entacapone] mg KYNMOBI FILM 10 MG ropinirole hcl er tb24 4 1 [apomorphine 1 QL - 30 day(s) mg hydrochloride] ropinirole hcl er tb24 6 1 KYNMOBI FILM 15 MG mg [apomorphine 1 QL - 30 day(s) ropinirole hcl er tb24 8 1 hydrochloride] mg KYNMOBI FILM 20 MG ropinirole hcl tabs 0.25 1 [apomorphine 1 QL - 30 day(s) mg hydrochloride] ropinirole hcl tabs 0.5 1 KYNMOBI FILM 25 MG mg [apomorphine 1 QL - 30 day(s) ropinirole hcl tabs 1 mg 1 hydrochloride] ropinirole hcl tabs 2 mg 1 KYNMOBI FILM 30 MG ropinirole hcl tabs 3 mg 1 [apomorphine 1 QL - 30 day(s) ropinirole hcl tabs 4 mg 1 hydrochloride] 1 KYNMOBI TITRATION ropinirole hcl tabs 5 mg KIT KIT 10/15/20/25/30 selegiline hcl tabs 5 mg 1 1 QL - 30 day(s) trihexyphenidyl hcl soln MG [apomorphine 1 hydrochloride] 0.4 mg/ml LODOSYN TABS 25 MG trihexyphenidyl hcl tabs 1 1 [carbidopa] 2 mg trihexyphenidyl hcl tabs pramipexole 1 dihydrochloride tabs 1 5 mg 0.125 mg ANXIOLYTICS, SEDATIVES, AND HYPNOTICS pramipexole alprazolam tabs 0.25 mg 1 QL - 30 day(s) dihydrochloride tabs 1 alprazolam tabs 0.5 mg 1 QL - 30 day(s) 0.25 mg alprazolam tabs 1 mg 1 QL - 30 day(s) pramipexole alprazolam tabs 2 mg 1 QL - 30 day(s) dihydrochloride tabs 0.5 1 buspirone hcl tabs 10 1 mg mg pramipexole buspirone hcl tabs 15 1 dihydrochloride tabs 1 mg 0.75 mg buspirone hcl tabs 30 1 mg buspirone hcl tabs 5 mg 1

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 45 of 144

藥物等 藥物等 藥物名稱 規定／限制 藥物名稱 規定／限制 級 級 buspirone hcl tabs 7.5 hydroxyzine pamoate 1 1 mg caps 50 mg chlordiazepoxide hcl [Lorazepam] 1 caps 10 mg LORAZEPAM INTENSOL 1 QL - 30 day(s) chlordiazepoxide hcl CONC 2 MG/ML 1 caps 25 mg lorazepam soln 2 mg/ml 1 chlordiazepoxide hcl 1 lorazepam soln 4 mg/ml 1 caps 5 mg lorazepam tabs 0.5 mg 1 QL - 30 day(s) clorazepate dipotassium 1 lorazepam tabs 1 mg 1 tabs 15 mg lorazepam tabs 2 mg 1 QL - 30 day(s) clorazepate dipotassium 1 midazolam hcl (pf) soln tabs 3.75 mg 1 10 mg/2ml clorazepate dipotassium 1 midazolam hcl (pf) soln 2 tabs 7.5 mg 1 mg/2ml DIASTAT ACUDIAL GEL midazolam hcl (pf) soln 5 10 MG [diazepam 1 1 mg/ml (anticonvulsant)] midazolam hcl soln 10 DIASTAT ACUDIAL GEL 1 mg/2ml 20 MG [diazepam 1 midazolam hcl soln 2 (anticonvulsant)] 1 mg/2ml DIASTAT PEDIATRIC midazolam hcl syrp 2 GEL 2.5 MG [diazepam 1 1 mg/ml (anticonvulsant)] [Pentobarbital Sodium] [Diazepam] DIAZEPAM NEMBUTAL SOLN 50 1 INTENSOL CONC 5 1 MG/ML MG/ML oxazepam caps 10 mg 1 QL - 30 day(s) diazepam soln 5 mg/5ml 1 oxazepam caps 15 mg 1 QL - 30 day(s) diazepam soln 5 mg/ml 1 oxazepam caps 30 mg 1 QL - 30 day(s) diazepam tabs 10 mg 1 PHENOBARBITAL ELIX diazepam tabs 2 mg 1 20 MG/5ML 1 diazepam tabs 5 mg 1 [phenobarbital] droperidol soln 2.5 1 PHENOBARBITAL mg/ml SODIUM SOLN 130 hydroxyzine hcl soln 25 1 1 MG/ML [phenobarbital mg/ml sodium] hydroxyzine hcl soln 50 1 PHENOBARBITAL mg/ml SODIUM SOLN 65 MG/ML 1 hydroxyzine hcl syrp 10 1 [phenobarbital sodium] mg/5ml PHENOBARBITAL TABS hydroxyzine hcl tabs 10 1 1 100 MG [phenobarbital] mg PHENOBARBITAL TABS hydroxyzine hcl tabs 25 1 1 15 MG [phenobarbital] mg PHENOBARBITAL TABS hydroxyzine hcl tabs 50 1 1 16.2 MG [phenobarbital] mg PHENOBARBITAL TABS hydroxyzine pamoate 1 1 30 MG [phenobarbital] caps 100 mg PHENOBARBITAL TABS hydroxyzine pamoate 1 1 32.4 MG [phenobarbital] caps 25 mg

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 46 of 144

藥物等 藥物等 藥物名稱 規定／限制 藥物名稱 規定／限制 級 級 PHENOBARBITAL TABS FORANE SOLN 1 1 60 MG [phenobarbital] [isoflurane] PHENOBARBITAL TABS ketamine hcl soln 10 1 1 64.8 MG [phenobarbital] mg/ml PHENOBARBITAL TABS ketamine hcl soln 100 1 1 97.2 MG [phenobarbital] mg/ml PRECEDEX SOLN 200 ketamine hcl soln 50 1 MCG/2ML 1 mg/ml [dexmedetomidine hcl] propofol emul 1000 1 SILENOR TABS 3 MG mg/100ml 1 [doxepin hcl (sleep)] propofol emul 200 1 SILENOR TABS 6 MG mg/20ml 1 [doxepin hcl (sleep)] MULTIPLE SCLEROSIS AGENTS temazepam caps 15 mg 1 QL - 30 day(s) AVONEX KIT 30MCG 1 QL - 30 day(s) temazepam caps 30 mg 1 QL - 30 day(s) [interferon beta-1a] zolpidem tartrate tabs 5 EXTAVIA KIT 0.3 MG 1 QL - 30 day(s) 1 QL - 30 day(s) mg [interferon beta-1b] CENTRAL NERVOUS SYSTEM AGENTS, [Glatiramer Acetate] MISCELLANEOUS GLATOPA SOSY 20 1 QL - 30 day(s) acamprosate calcium MG/ML 1 tbec 333 mg OPIATE ANTAGONISTS flumazenil soln 0.5 naloxone hcl soct 0.4 1 1 mg/5ml mg/ml guanfacine hcl er tb24 1 naloxone hcl soln 0.4 1 1 mg mg/ml guanfacine hcl er tb24 2 naloxone hcl sosy 2 1 1 mg mg/2ml guanfacine hcl er tb24 3 1 NALTREXONE HCL mg POWD [naltrexone hcl 1 guanfacine hcl er tb24 4 1 (bulk)] mg naltrexone hcl tabs 50 1 memantine hcl tabs 10 1 mg mg NARCAN LIQD 4 1 memantine hcl tabs 5 mg 1 MG/0.1ML [naloxone hcl] NAMENDA SOL PSYCHOTHERAPEUTIC AGENTS 10MG/5ML [memantine 1 amitriptyline hcl tabs 10 1 hcl] mg NAMENDA TITRATION amitriptyline hcl tabs 100 PAK TABS 28 x 5 MG & 1 1 mg 21 X 10 MG [memantine amitriptyline hcl tabs 150 1 hcl] mg riluzole tabs 50 mg 1 amitriptyline hcl tabs 25 1 selegiline hcl caps 5 mg 1 mg amitriptyline hcl tabs 50 GENERAL ANESTHETICS 1 BREVITAL SODIUM mg amitriptyline hcl tabs 75 SOLR 500 MG 1 1 [methohexital sodium] mg etomidate soln 2 mg/ml 1 amoxapine tabs 100 mg 1

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 47 of 144

藥物等 藥物等 藥物名稱 規定／限制 藥物名稱 規定／限制 級 級 amoxapine tabs 150 mg 1 citalopram amoxapine tabs 25 mg 1 hydrobromide soln 10 1 amoxapine tabs 50 mg 1 mg/5ml aripiprazole tabs 10 mg 1 citalopram hydrobromide tabs 10 1 aripiprazole tabs 15 mg 1 mg aripiprazole tabs 2 mg 1 citalopram aripiprazole tabs 20 mg 1 hydrobromide tabs 20 1 aripiprazole tabs 30 mg 1 mg aripiprazole tabs 5 mg 1 citalopram ARISTADA PRSY 1064 hydrobromide tabs 40 1 MG/3.9ML [aripiprazole 1 mg lauroxil] clomipramine hcl caps 1 ARISTADA PRSY 441 25 mg MG/1.6ML [aripiprazole 1 clomipramine hcl caps 1 lauroxil] 50 mg ARISTADA PRSY 662 clomipramine hcl caps 1 MG/2.4ML [aripiprazole 1 75 mg lauroxil] clozapine tabs 100 mg 1 ARISTADA PRSY 882 clozapine tabs 200 mg 1 MG/3.2ML [aripiprazole 1 clozapine tabs 25 mg 1 lauroxil] clozapine tabs 50 mg 1 bupropion hcl er (sr) 1 [Prochlorperazine] tb12 100 mg 1 COMPRO SUPP 25 MG bupropion hcl er (sr) 1 desipramine hcl tabs 10 tb12 150 mg 1 mg bupropion hcl er (sr) 1 desipramine hcl tabs 100 tb12 200 mg 1 mg bupropion hcl er (xl) 1 desipramine hcl tabs 150 tb24 150 mg 1 mg bupropion hcl er (xl) 1 desipramine hcl tabs 25 tb24 300 mg 1 mg bupropion hcl tabs 100 1 desipramine hcl tabs 50 mg 1 mg bupropion hcl tabs 75 1 desipramine hcl tabs 75 mg 1 mg chlorpromazine hcl soln 1 1 25 mg/ml doxepin hcl caps 10 mg chlorpromazine hcl tabs doxepin hcl caps 100 mg 1 1 10 mg doxepin hcl caps 150 mg 1 chlorpromazine hcl tabs doxepin hcl caps 25 mg 1 1 100 mg doxepin hcl caps 50 mg 1 chlorpromazine hcl tabs 1 1 doxepin hcl caps 75 mg 200 mg doxepin hcl conc 10 1 chlorpromazine hcl tabs 1 mg/ml 25 mg duloxetine hcl cpep 20 1 chlorpromazine hcl tabs 1 mg 50 mg duloxetine hcl cpep 30 1 mg

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 48 of 144

藥物等 藥物等 藥物名稱 規定／限制 藥物名稱 規定／限制 級 級 duloxetine hcl cpep 60 1 1 haloperidol tabs 5 mg mg imipramine hcl tabs 10 1 escitalopram oxalate 1 mg soln 5 mg/5ml imipramine hcl tabs 25 1 escitalopram oxalate 1 mg tabs 10 mg imipramine hcl tabs 50 1 escitalopram oxalate 1 mg tabs 20 mg INVEGA SUSTENNA escitalopram oxalate 1 SUSY 117 MG/0.75ML 1 tabs 5 mg [paliperidone palmitate] fluoxetine hcl caps 10 1 INVEGA SUSTENNA mg SUSY 156 MG/ML 1 fluoxetine hcl caps 20 1 [paliperidone palmitate] mg INVEGA SUSTENNA fluoxetine hcl caps 40 SUSY 234 MG/1.5ML 1 1 mg [paliperidone palmitate] fluoxetine hcl soln 20 INVEGA SUSTENNA 1 mg/5ml SUSY 39 MG/0.25ML 1 fluphenazine decanoate [paliperidone palmitate] 1 soln 25 mg/ml INVEGA SUSTENNA fluphenazine hcl conc 5 SUSY 78 MG/0.5ML 1 1 mg/ml [paliperidone palmitate] fluphenazine hcl tabs 1 loxapine succinate caps 1 1 mg 10 mg fluphenazine hcl tabs 10 loxapine succinate caps 1 1 mg 25 mg fluphenazine hcl tabs 2.5 loxapine succinate caps 1 1 mg 5 mg fluphenazine hcl tabs 5 loxapine succinate caps 1 1 mg 50 mg fluvoxamine maleate maprotiline hcl tabs 25 1 1 tabs 100 mg mg fluvoxamine maleate maprotiline hcl tabs 50 1 1 tabs 25 mg mg fluvoxamine maleate maprotiline hcl tabs 75 1 1 tabs 50 mg mg haloperidol decanoate 1 1 mirtazapine tabs 15 mg soln 100 mg/ml mirtazapine tabs 30 mg 1 haloperidol decanoate 1 mirtazapine tabs 45 mg 1 soln 50 mg/ml nefazodone hcl tabs 100 haloperidol lactate conc 1 1 mg 2 mg/ml nefazodone hcl tabs 150 haloperidol lactate soln 1 1 mg 5 mg/ml nefazodone hcl tabs 200 1 haloperidol tabs 0.5 mg 1 mg haloperidol tabs 1 mg 1 nefazodone hcl tabs 250 1 haloperidol tabs 10 mg 1 mg 1 nefazodone hcl tabs 50 haloperidol tabs 2 mg 1 haloperidol tabs 20 mg 1 mg

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 49 of 144

藥物等 藥物等 藥物名稱 規定／限制 藥物名稱 規定／限制 級 級 nortriptyline hcl caps 10 phenelzine sulfate tabs 1 1 mg 15 mg nortriptyline hcl caps 25 1 1 pimozide tabs 2 mg mg prochlorperazine 1 nortriptyline hcl caps 50 1 edisylate soln 10 mg/2ml mg prochlorperazine 1 nortriptyline hcl caps 75 1 maleate tabs 10 mg mg prochlorperazine 1 nortriptyline hcl soln 10 1 maleate tabs 5 mg mg/5ml protriptyline hcl tabs 10 1 olanzapine solr 10 mg 1 mg 1 protriptyline hcl tabs 5 olanzapine tabs 10 mg 1 olanzapine tabs 15 mg 1 mg quetiapine fumarate tabs olanzapine tabs 2.5 mg 1 1 olanzapine tabs 20 mg 1 100 mg quetiapine fumarate tabs olanzapine tabs 5 mg 1 1 200 mg olanzapine tabs 7.5 mg 1 quetiapine fumarate tabs ORAP TABS 1 MG 1 1 25 mg [pimozide] quetiapine fumarate tabs ORAP TABS 2 MG 1 1 300 mg [pimozide] quetiapine fumarate tabs paroxetine hcl tabs 10 1 1 400 mg mg quetiapine fumarate tabs paroxetine hcl tabs 20 1 1 50 mg mg RISPERDAL CONSTA paroxetine hcl tabs 30 SRER 12.5 MG 1 1 mg [risperidone paroxetine hcl tabs 40 1 microspheres] mg RISPERDAL CONSTA perphenazine tabs 16 mg 1 SRER 25 MG 1 perphenazine tabs 2 mg 1 [risperidone perphenazine tabs 4 mg 1 microspheres] perphenazine tabs 8 mg 1 RISPERDAL CONSTA SRER 37.5 MG perphenazine- 1 amitriptyline tabs 2-10 1 [risperidone mg microspheres] perphenazine- RISPERDAL CONSTA 1 SRER 50 MG amitriptyline tabs 2-25 1 mg [risperidone perphenazine- microspheres] 1 RISPERIDONE SOLN 1 amitriptyline tabs 4-10 1 mg MG/ML [risperidone] RISPERIDONE TABS perphenazine- 1 amitriptyline tabs 4-25 1 0.25 MG [risperidone] mg RISPERIDONE TABS 0.5 1 perphenazine- MG [risperidone] amitriptyline tabs 4-50 1 risperidone tabs 1 mg 1 mg

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 50 of 144

藥物等 藥物等 藥物名稱 規定／限制 藥物名稱 規定／限制 級 級 RISPERIDONE TABS 2 venlafaxine hcl er cp24 1 1 MG [risperidone] 75 mg RISPERIDONE TABS 3 venlafaxine hcl tabs 100 1 1 MG [risperidone] mg RISPERIDONE TABS 4 venlafaxine hcl tabs 25 1 1 MG [risperidone] mg sertraline hcl tabs 100 venlafaxine hcl tabs 37.5 1 1 mg mg 1 venlafaxine hcl tabs 50 sertraline hcl tabs 25 mg 1 sertraline hcl tabs 50 mg 1 mg thioridazine hcl tabs 10 venlafaxine hcl tabs 75 1 1 mg mg thioridazine hcl tabs 100 ziprasidone hcl caps 20 1 1 mg mg thioridazine hcl tabs 25 ziprasidone hcl caps 40 1 1 mg mg thioridazine hcl tabs 50 ziprasidone hcl caps 60 1 1 mg mg ziprasidone hcl caps 80 thiothixene caps 1 mg 1 1 thiothixene caps 10 mg 1 mg thiothixene caps 2 mg 1 CONTRACEPTIVES (FOAMS, DEVICES) thiothixene caps 5 mg 1 CONTRACEPTIVES (FOAMS, DEVICES) tranylcypromine sulfate WIDE-SEAL DIAPHRAGM 1 tabs 10 mg 60 DPRH 2 % [diaphragm 1 trazodone hcl tabs 100 wide seal] 1 mg WIDE-SEAL DIAPHRAGM trazodone hcl tabs 150 65 DPRH 2 % [diaphragm 1 1 mg wide seal] trazodone hcl tabs 50 WIDE-SEAL DIAPHRAGM 1 mg 70 DPRH 2 % [diaphragm 1 trifluoperazine hcl tabs 1 wide seal] 1 mg WIDE-SEAL DIAPHRAGM trifluoperazine hcl tabs 75 DPRH 2 % [diaphragm 1 1 10 mg wide seal] trifluoperazine hcl tabs 2 WIDE-SEAL DIAPHRAGM 1 mg 80 DPRH 2 % [diaphragm 1 trifluoperazine hcl tabs 5 wide seal] 1 mg WIDE-SEAL DIAPHRAGM trimipramine maleate 85 DPRH 2 % [diaphragm 1 1 caps 100 mg wide seal] trimipramine maleate WIDE-SEAL DIAPHRAGM 1 caps 25 mg 90 DPRH 2 % [diaphragm 1 trimipramine maleate wide seal] 1 caps 50 mg WIDE-SEAL DIAPHRAGM 95 DPRH 2 % 1 venlafaxine hcl er cp24 [diaphragm 1 150 mg wide seal] venlafaxine hcl er cp24 DEVICES 1 37.5 mg DEVICES

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 51 of 144

藥物等 藥物等 藥物名稱 規定／限制 藥物名稱 規定／限制 級 級 AEROCHAMBER PLUS AK-FLUOR SOLN 10 % FLO-VU SMALL MISC [fluorescein sodium 1 1 [spacer/aerosol-holding injection] chambers] ALTAFLUOR BENOX AEROCHAMBER Z-STAT SOLN 0.25-0.4 % 1 PLUS MISC [fluorescein w/ 1 [spacer/aerosol-holding benoxinate] chambers] BIO GLO STRP 1 MG AEROCHAMBER Z-STAT [fluorescein sodium 1 PLUS/LARGE MISC topical] 1 [spacer/aerosol-holding CANDIN SOLN [candida chambers] albicans skin test 1 AEROCHAMBER Z-STAT antigen] PLUS/MEDIUM MISC CHIRHOSTIM SOLR 16 1 [spacer/aerosol-holding MCG [secretin acetate 1 chambers] (human)] AEROTRACH PLUS MISC CONRAY 43 INJ 43% 1 [respiratory therapy 1 [iothalamate meglumine] supplies] CONRAY SOLN 60 % 1 BD INSULIN SYRINGE U- [iothalamate meglumine] 500 MISC 31G X 6MM 0.5 CORTROSYN SOLR 0.25 1 1 ML [insulin MG [cosyntropin] syringe/needle u-500] CYSTO-CONRAY II SOLN BD VEO INSULIN SYR 17.2 % [iothalamate 1 U/F 1/2UNIT MISC 31G X 1 meglumine] 15/64" 0.3 ML [insulin CYSTOGRAFIN SOLN 30 syringe/needle u-100] % [diatrizoate 1 MONOJECT INSULIN meglumine] SYRINGE MISC 27G X 1 CYSTOGRAFIN-DILUTE 1/2" 1 ML [insulin SOLN 18 % [diatrizoate 1 syringe/needle u-100] meglumine] MONOJECT INSULIN D-XYLOSE POWD [d- SYRINGE MISC 29G X 1 1 xylose] 1/2" 0.3 ML [insulin E-Z-CAT DRY PACK 2 % 1 syringe/needle u-100] [barium sulfate] MONOJECT INSULIN EOVIST SOLN 0.25 SYRINGE MISC 29G X 1 MOL/L [gadoxetate 1 1/2" 1 ML [insulin disodium] syringe/needle u-100] GADAVIST SOLN 1 1 OMNITROPE PEN 5 INJ MMOL/ML [gadobutrol] DEVICE MISC [injection 1 GASTROGRAFIN SOLN device] 66-10 % [diatrizoate 1 TRUZONE PEAK FLOW meglumine & sodium] METER DEVI [peak flow 1 indigotindisulfonate 1 meter] sodium soln DIAGNOSTIC AGENTS LEXISCAN SOLN 0.4 1 DIAGNOSTIC AGENTS MG/5ML [regadenoson] LUMASON SUSR 60.7-25 adenosine soln 3 mg/ml 1 1 MG [sulfur hexafluoride

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 52 of 144

藥物等 藥物等 藥物名稱 規定／限制 藥物名稱 規定／限制 級 級 lipid-type a NEUT SOLN 4 % [sodium 1 microspheres] bicarbonate] MAGNEVIST SOLN POTASSIUM CITRATE 469.01 MG/ML ER TBCR 10 MEQ (1080 1 1 [gadopentetate MG) [potassium citrate dimeglumine] (alkalinizer)] MD-76 R SOLN 66-10 % POTASSIUM CITRATE [diatrizoate meglumine & 1 ER TBCR 5 MEQ (540 1 sodium] MG) [potassium citrate METOPIRONE CAPS 250 (alkalinizer)] 1 MG [metyrapone] POTASSIUM CITRATE- MULTIHANCE SOLN 529 CITRIC ACID SOLN 1100- 1 MG/ML [gadobenate 1 334 MG/5ML [potassium dimeglumine] citrate-citric acid] OMNIPAQUE INJ SOD CITRATE-CITRIC 1 300MG/ML [iohexol] ACID SOLN 500-334 1 OMNIPAQUE INJ MG/5ML [sodium citrate 1 350MG/ML [iohexol] & citric acid] OMNIPAQUE SOLN 180 SODIUM ACETATE SOLN 1 MG/ML [iohexol] 2 MEQ/ML [sodium 1 OMNIPAQUE SOLN 240 acetate] 1 MG/ML [iohexol] SODIUM BICARBONATE OMNIPAQUE SOLN 300 SOLN 4.2 % [sodium 1 1 MG/ML [iohexol] bicarbonate] OMNIPAQUE SOLN 350 SODIUM BICARBONATE 1 MG/ML [iohexol] SOLN 7.5 % [sodium 1 READI-CAT 2 SUSP 2 % bicarbonate] 1 [barium sulfate] SODIUM BICARBONATE READI-CAT 2 SUSP 2.1 SOLN 8.4 % [sodium 1 1 % [barium sulfate] bicarbonate] THYROGEN SOLR 1.1 THAM SOLN 30 1 MG [thyrotropin alfa] MEQ/100ML 1 TISSUEBLUE SOSY [tromethamine] 1 0.025 % [brilliant blue g] TRICITRATES SOLN 550- TUBERSOL SOLN 5 500-334 MG/5ML [pot & 1 UNIT/0.1ML [tuberculin 1 sod citrates w/citric ac] ppd] AMMONIA DETOXICANTS VOLUMEN SUSP 0.1 % BUPHENYL TABS 500 1 [barium sulfate] MG [sodium 1 QL - 30 day(s) ELECTROLYTIC, CALORIC, AND WATER phenylbutyrate] BALANCE lactulose ALKALINIZING AGENTS (encephalopathy) soln 1 CYTRA K CRYSTALS 10 gm/15ml PACK 3300-1002 MG lactulose soln 10 1 1 [potassium citrate-citric gm/15ml acid] LITHOSTAT TABS 250 CYTRA-K SOLN 1100-334 MG [acetohydroxamic 1 MG/5ML [potassium 1 acid] citrate-citric acid]

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 53 of 144

藥物等 藥物等 藥物名稱 規定／限制 藥物名稱 規定／限制 級 級 sodium phenylbutyrate CLINIMIX/DEXTROSE 1 QL - 30 day(s) powd 3 gm/tsp (2.75/5) SOLN 2.75 % 1 CALORIC AGENTS [amino acid infusion in AMINOSYN II SOLN 10 % d5w] 1 [amino acid infusion] CLINIMIX/DEXTROSE (4.25/10) SOLN 4.25 % AMINOSYN 1 II/ELECTROLYTES SOLN [amino acid infusion in 1 8.5 % [amino acid d10w] electrolyte infusion] CLINIMIX/DEXTROSE (4.25/20) SOLN 4.25 % CLINIMIX E/DEXTROSE 1 (2.75/10) SOLN 2.75 % [amino acid infusion in [amino acid electrolyte 1 d20w] w/ calcium infusion in CLINIMIX/DEXTROSE (4.25/25) SOLN 4.25 % d10w] 1 CLINIMIX E/DEXTROSE [amino acid infusion in (2.75/5) SOLN 2.75 % d25w] [amino acid electrolyte 1 CLINIMIX/DEXTROSE (4.25/5) SOLN 4.25 % w/ calcium infusion in 1 d5w] [amino acid infusion in CLINIMIX E/DEXTROSE d5w] (4.25/10) SOLN 4.25 % CLINIMIX/DEXTROSE [amino acid electrolyte 1 (5/15) SOLN 5 % [amino 1 w/ calcium infusion in acid infusion in d15w] d10w] CLINIMIX/DEXTROSE CLINIMIX E/DEXTROSE (5/20) SOLN 5 % [amino 1 (4.25/25) SOLN 4.25 % acid infusion in d20w] [amino acid electrolyte 1 CLINIMIX/DEXTROSE w/ calcium infusion in (5/25) SOLN 5 % [amino 1 d25w] acid infusion in d25w] [Amino Acid Infusion] CLINIMIX E/DEXTROSE 1 (4.25/5) SOLN 4.25 % CLINISOL SF SOLN 15 % DEXTROSE SOLN 10 % [amino acid electrolyte 1 1 w/ calcium infusion in [dextrose] DEXTROSE SOLN 20 % d5w] 1 CLINIMIX E/DEXTROSE [dextrose] (5/15) SOLN 5 % DEXTROSE SOLN 40 % [amino 1 acid electrolyte w/ 1 [dextrose] calcium infusion in DEXTROSE SOLN 5 % 1 d15w] [dextrose] CLINIMIX E/DEXTROSE DEXTROSE SOLN 50 % 1 (5/20) SOLN 5 % [amino [dextrose] acid electrolyte w/ 1 DEXTROSE SOLN 70 % 1 calcium infusion in [dextrose] d20w] INTRALIPID EMUL 20 % CLINIMIX E/DEXTROSE [fat emulsion plant 1 (5/25) SOLN 5 % [amino based] acid electrolyte w/ 1 INTRALIPID EMUL 30 % calcium infusion in [fat emulsion plant 1 d25w] based]

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 54 of 144

藥物等 藥物等 藥物名稱 規定／限制 藥物名稱 規定／限制 級 級 PROCALAMINE SOLN 3 MANNITOL SOLN 25 % 1 % [amino acid 1 [mannitol] electrolyte infusion] metolazone tabs 10 mg 1 PROSOL SOLN 20 % 1 metolazone tabs 2.5 mg 1 [amino acid infusion] metolazone tabs 5 mg 1 TRAVASOL SOLN 10 % OSMITROL SOLN 20 % 1 1 [amino acid infusion] [mannitol] TROPHAMINE SOLN 10 1 SODIUM EDECRIN SOLR % [amino acid infusion] 50 MG [ethacrynate 1 TROPHAMINE SOLN 6 % 1 sodium] [amino acid infusion] torsemide tabs 10 mg 1 DIURETICS torsemide tabs 100 mg 1 amiloride- torsemide tabs 20 mg 1 hydrochlorothiazide tabs 1 torsemide tabs 5 mg 1 5-50 mg triamterene-hctz caps bumetanide soln 0.25 1 1 37.5-25 mg mg/ml TRIAMTERENE-HCTZ bumetanide tabs 0.5 mg 1 TABS 37.5-25 MG 1 bumetanide tabs 1 mg 1 [triamterene & bumetanide tabs 2 mg 1 hydrochlorothiazide] chlorthalidone tabs 25 1 TRIAMTERENE-HCTZ mg TABS 75-50 MG chlorthalidone tabs 50 1 1 [triamterene & mg hydrochlorothiazide] DYRENIUM CAPS 100 1 ION-REMOVING AGENTS MG [triamterene] [Sodium Polystyrene DYRENIUM CAPS 50 MG 1 Sulfonate] KIONEX SUSP 1 [triamterene] 15 GM/60ML EDECRIN TABS 25 MG RENVELA PACK 2.4 GM 1 1 [ethacrynic acid] [sevelamer carbonate] ethacrynic acid tabs 25 RENVELA TABS 800 MG 1 1 mg [sevelamer carbonate] furosemide soln 10 sevelamer carbonate 1 1 mg/ml pack 2.4 gm furosemide soln 8 mg/ml 1 sevelamer carbonate FUROSEMIDE TABS 20 1 1 tabs 800 mg MG [furosemide] sodium polystyrene FUROSEMIDE TABS 40 1 1 sulfonate powd MG [furosemide] sodium polystyrene furosemide tabs 80 mg 1 sulfonate susp 15 1 hydrochlorothiazide tabs 1 gm/60ml 12.5 mg sodium polystyrene hydrochlorothiazide tabs 1 sulfonate susp 30 1 25 mg gm/120ml hydrochlorothiazide tabs 1 [Sodium Polystyrene 50 mg Sulfonate] SPS SUSP 15 1 indapamide tabs 1.25 mg 1 GM/60ML indapamide tabs 2.5 mg 1 IRRIGATING SOLUTIONS

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 55 of 144

藥物等 藥物等 藥物名稱 規定／限制 藥物名稱 規定／限制 級 級 ACETIC ACID SOLN 0.25 CHROMIC CHLORIDE 1 % [acetic acid] SOLN 40 MCG/10ML 1 DIANEAL LOW [chromic chloride] CALCIUM/4.25% DEX CUPRIC CHLORIDE SOLN 483 MOSM/L 1 SOLN 0.4 MG/ML [cupric 1 [peritoneal dialysis chloride] solutions] DEXTROSE DIANEAL PD-2/1.5% 5%/ELECTROLYTE #48 1 DEXTROSE SOLN 346 SOLN [electrolyte-48 in 1 MOSM/L [peritoneal dextrose] dialysis solutions] DEXTROSE IN DIANEAL PD-2/2.5% LACTATED RINGERS 1 DEXTROSE SOLN 396 SOLN 5 % [dextrose in 1 MOSM/L [peritoneal lactated ringers] dialysis solutions] dextrose in ringers soln 1 DIANEAL PD-2/4.25% 5 % DEXTROSE SOLN 485 DEXTROSE-NACL SOLN 1 MOSM/L [peritoneal 10-0.45 % [dextrose w/ 1 dialysis solutions] sodium chloride] LACTATED RINGERS DEXTROSE-NACL SOLN SOLN [lactated ringer's 1 2.5-0.45 % [dextrose w/ 1 (irrigation)] sodium chloride] RINGERS IRRIGATION DEXTROSE-NACL SOLN SOLN [ringer's 1 5-0.2 % [dextrose w/ 1 irrigation] sodium chloride] SODIUM CHLORIDE DEXTROSE-NACL SOLN SOLN 0.9 % [sodium 1 5-0.225 % [dextrose w/ 1 chloride (gu irrigant)] sodium chloride] STERILE WATER FOR DEXTROSE-NACL SOLN IRRIGATION SOLN 5-0.33 % 1 1 [dextrose w/ [water for irrigation, sodium chloride] sterile] DEXTROSE-NACL SOLN ULTRABAG/DIANEAL/1.5 5-0.45 % [dextrose w/ 1 % DEXTROSE SOLN 344 1 sodium chloride] MOSM/L [peritoneal DEXTROSE-NACL SOLN dialysis solutions] 5-0.9 % [dextrose w/ 1 ULTRABAG/DIANEAL/2.5 sodium chloride] % DEXTROSE SOLN 395 EFFER-K TBEF 25 MEQ 1 1 MOSM/L [peritoneal [potassium bicarbonate] dialysis solutions] [Calcium Acetate REPLACEMENT PREPARATIONS (phosphate Binder)] 1 calcium acetate (phos ELIPHOS TABS 667 MG 1 hetastarch-nacl soln 6- binder) caps 667 mg 1 CALCIUM CHLORIDE 0.9 % SOLN 10 % [calcium 1 HEXTEND SOLN 6 % chloride (dihydrate)] [hetastarch in lactated 1 CALCIUM GLUCONATE electrolyte] HYPERLYTE-CR CONC SOLN 10 % [calcium 1 1 gluconate] [parenteral electrolytes]

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 56 of 144

藥物等 藥物等 藥物名稱 規定／限制 藥物名稱 規定／限制 級 級 K-EFFERVESCENT TBEF LACTATED RINGERS 1 25 MEQ [potassium 1 SOLN [lactated ringer's] bicarbonate] [Dextran 40 In D5w] LMD 1 K-PHOS TABS 500 MG IN D5W SOLN 10-5 % [potassium phosphate 1 [Dextran 40 In Saline] monobasic] LMD IN NACL SOLN 10- 1 K-TAB TBCR 10 MEQ 0.9 % 1 [potassium chloride] M.T.E.-5 CONCENTRATE KCL IN DEXTROSE- INJ CONC [trace 1 NACL SOLN 10-5-0.45 minerals (cr-cu-mn-se- MEQ/L-%-% [potassium 1 zn)] chloride in dextrose & MAGNESIUM SULFATE sodium chloride] IN D5W SOLN 1-5 KCL IN DEXTROSE- GM/100ML-% 1 NACL SOLN 20-5-0.2 [magnesium sulfate in MEQ/L-%-% [potassium 1 dextrose] chloride in dextrose & MANGANESE CHLORIDE sodium chloride] SOLN 0.1 MG/ML 1 KCL IN DEXTROSE- [manganese chloride] NACL SOLN 20-5-0.45 MULTITRACE-4 MEQ/L-%-% [potassium 1 CONCENTRATE SOLN chloride in dextrose & 0.01-1-0.5-5 MG/ML 1 sodium chloride] [trace minerals (cr-cu- KCL IN DEXTROSE- mn-zn)] NACL SOLN 20-5-0.9 NORMAL SALINE FLUSH MEQ/L-%-% [potassium 1 SOLN 0.9 % [sodium 1 chloride in dextrose & chloride flush] sodium chloride] PHOSLYRA SOLN 667 KCL IN DEXTROSE- MG/5ML [calcium acetate 1 NACL SOLN 30-5-0.45 (phosphate binder)] MEQ/L-%-% [potassium 1 PLASMA-LYTE A SOLN 1 chloride in dextrose & [electrolyte-a] sodium chloride] POTASSIUM ACETATE KCL IN DEXTROSE- SOLN 2 MEQ/ML 1 NACL SOLN 40-5-0.45 [potassium acetate] MEQ/L-%-% [potassium 1 potassium chloride chloride in dextrose & 0.075%/d5w/nacl 0.225% 1 sodium chloride] inj .075/.2% KCL IN DEXTROSE- potassium chloride crys 1 NACL SOLN 40-5-0.9 er tbcr 10 meq MEQ/L-%-% [potassium 1 potassium chloride crys 1 chloride in dextrose & er tbcr 20 meq sodium chloride] potassium chloride er 1 KCL-LACTATED cpcr 10 meq RINGERS-D5W SOLN 20 potassium chloride er 1 MEQ/L [potassium 1 cpcr 8 meq chloride in d5w lactated POTASSIUM CHLORIDE 1 ringers] IN DEXTROSE SOLN 20- KLOR-CON TBCR 8 MEQ 1 [potassium chloride]

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 57 of 144

藥物等 藥物等 藥物名稱 規定／限制 藥物名稱 規定／限制 級 級 5 MEQ/L-% [potassium MMOLE/15ML chloride in dextrose] [potassium phosphates] POTASSIUM CHLORIDE RINGERS SOLN 1 IN DEXTROSE SOLN 40- [ringer's] 1 5 MEQ/L-% [potassium SELENIUM SOLN 40 1 chloride in dextrose] MCG/ML [selenious acid] POTASSIUM CHLORIDE SODIUM CHLORIDE (PF) IN NACL SOLN 20-0.45 SOLN 0.9 % 1 1 [sodium MEQ/L-% [potassium chloride] chloride in nacl] SODIUM CHLORIDE POTASSIUM CHLORIDE BACTERIOSTATIC SOLN 1 IN NACL SOLN 20-0.9 0.9 % 1 [bacteriostatic MEQ/L-% [potassium sodium chloride] chloride in nacl] SODIUM CHLORIDE POTASSIUM CHLORIDE SOLN 0.45 % [sodium 1 IN NACL SOLN 40-0.9 1 chloride] MEQ/L-% [potassium SODIUM CHLORIDE chloride in nacl] SOLN 0.9 % [sodium 1 POTASSIUM CHLORIDE chloride] PACK 20 MEQ 1 SODIUM CHLORIDE [potassium chloride] SOLN 3 % [sodium 1 potassium chloride sol 1 chloride] 10% sf SODIUM CHLORIDE POTASSIUM CHLORIDE SOLN 4 MEQ/ML [sodium 1 SOLN 10 MEQ/100ML 1 chloride] [potassium chloride] SODIUM CHLORIDE POTASSIUM CHLORIDE SOLN 5 % [sodium 1 SOLN 10 MEQ/50ML 1 chloride] [potassium chloride] SODIUM PHOSPHATES potassium chloride soln SOLN 45 MMOLE/15ML 1 2 meq/ml [sodium phosphates 1 POTASSIUM CHLORIDE (sodium phosphate SOLN 20 MEQ/100ML 1 dibasic & monobasic)] [potassium chloride] TRACE ELEMENTS POTASSIUM CHLORIDE 4/PEDIATRIC SOLN 1- SOLN 20 MEQ/50ML 1 100-30-500 MCG/ML 1 [potassium chloride] [trace minerals (cr-cu- POTASSIUM CHLORIDE mn-zn)] SOLN 40 MEQ/100ML 1 ZINC CHLORIDE SOLN 1 1 [potassium chloride] MG/ML [zinc chloride] POTASSIUM CHLORIDE ZINC SULFATE SOLN 1 1 SOLN 40 MEQ/15ML MG/ML [zinc sulfate] 1 (20%) [potassium URICOSURIC AGENTS chloride] colchicine-probenecid potassium phosphate inj 1 1 tabs 0.5-500 mg 3mm/ml probenecid tabs 500 mg 1 POTASSIUM 1 ENZYMES PHOSPHATES SOLN 45 ENZYMES

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 58 of 144

藥物等 藥物等 藥物名稱 規定／限制 藥物名稱 規定／限制 級 級 ALDURAZYME SOLN 2.9 chlorhexidine gluconate 1 1 MG/5ML [laronidase] soln 0.12 % ARALAST NP SOLR 1000 ciprofloxacin hcl soln 0.3 1 MG [alpha1-proteinase 1 QL - 30 day(s) % inhibitor (human)] erythromycin oint 5 1 CEREZYME SOLR 400 mg/gm 1 UNIT [imiglucerase] gatifloxacin soln 0.5 % 1 ELAPRASE SOLN 6 1 QL - 30 day(s) [Gentamicin Sulfate MG/3ML [idursulfase] (ophth)] GENTAK OINT 1 ELITEK SOLR 1.5 MG 1 0.3 % [rasburicase] gentamicin sulfate soln 1 ELITEK SOLR 7.5 MG 1 0.3 % [rasburicase] MITOSOL KIT 0.2 MG FABRAZYME SOLR 35 1 1 QL - 30 day(s) [mitomycin (ophthalmic)] MG [agalsidase beta] moxifloxacin hcl soln 0.5 1 FABRAZYME SOLR 5 MG 1 QL - 30 day(s) % [agalsidase beta] NATACYN SUSP 5 % 1 HYLENEX SOLN 150 [natamycin] UNIT/ML [hyaluronidase 1 neomycin-bacitracin zn- human] polymyx oint 5-400- 1 LUMIZYME SOLR 50 MG 1 QL - 30 day(s) 10000 [alglucosidase alfa] neomycin-polymyxin- NAGLAZYME SOLN 1 1 QL - 30 day(s) gramicidin soln 1.75- 1 MG/ML [galsulfase] 10000-.025 PULMOZYME SOLN 1 1 QL - 30 day(s) [Neomycin-polymyxin- MG/ML [dornase alfa] gramicidin] NEOSPORIN 1 STRENSIQ SOLN 18 SOLN 1.75-10000-.025 MG/0.45ML [asfotase 1 QL - 30 day(s) ofloxacin soln 0.3 % 1 alfa] polymyxin b- STRENSIQ SOLN 28 1 QL - 30 day(s) trimethoprim soln 10000- 1 MG/0.7ML [asfotase alfa] 0.1 unit/ml-% STRENSIQ SOLN 40 sulfacetamide sodium 1 QL - 30 day(s) 1 MG/ML [asfotase alfa] soln 10 % STRENSIQ SOLN 80 1 QL - 30 day(s) tobramycin soln 0.3 % 1 MG/0.8ML [asfotase alfa] TOBREX OINT 0.3 % VIMIZIM SOLN 5 MG/5ML 1 1 QL - 30 day(s) [tobramycin (ophth)] [elosulfase alfa] trifluridine soln 1 % 1 VORAXAZE SOLR 1000 ZYMAXID SOLN 0.5 % 1 QL - 30 day(s) 1 UNIT [glucarpidase] [gatifloxacin (ophth)] VPRIV SOLR 400 UNIT 1 ANTI-INFLAMMATORY AGENTS [velaglucerase alfa] [Sulfacetamide Sod- EYE, EAR, NOSE, AND THROAT (EENT) prednisolone] 1 PREPARATIONS BLEPHAMIDE S.O.P. ANTI-INFECTIVES OINT 10-0.2 % bacitracin oint 500 1 BLEPHAMIDE SUSP 10- unit/gm 0.2 % [sulfacetamide 1 bacitracin-polymyxin b 1 sod-prednisolone] oint 500-10000 unit/gm CEQUA SOLN 0.09 % 1 [cyclosporine (ophth)]

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 59 of 144

藥物等 藥物等 藥物名稱 規定／限制 藥物名稱 規定／限制 級 級 ciprofloxacin- RETISERT IMPL 0.59 MG dexamethasone susp 1 [fluocinolone acetonide 1 0.3-0.1 % (ophth)] COLY-MYCIN S SUSP sulfacetamide- 3.3-3-10-0.5 MG/ML prednisolone soln 10- 1 1 [neomycin-colistin-hc- 0.23 % thonzonium] TOBRADEX OINT 0.3-0.1 dexamethasone sodium % [tobramycin- 1 1 phosphate soln 0.1 % dexamethasone] diclofenac sodium soln 1 ANTIALLERGIC AGENTS 0.1 % ALOCRIL SOLN 2 % flunisolide soln 25 1 [nedocromil sodium 1 mcg/act (0.025%) (ophth)] fluorometholone susp 1 azelastine hcl soln 0.1 % 1 0.1 % cromolyn sodium soln 4 flurbiprofen sodium soln 1 1 % 0.03 % olopatadine hcl soln 0.1 fluticasone propionate 1 1 % susp 50 mcg/act ANTIGLAUCOMA AGENTS FML FORTE SUSP 0.25 acetazolamide er cp12 1 % [fluorometholone 1 500 mg

(ophth)] acetazolamide sodium 1 FML OINT 0.1 % solr 500 mg 1 [fluorometholone acetazolamide tabs 125 1 (ophth)] mg ketorolac tromethamine acetazolamide tabs 250 1 1 soln 0.4 % mg ketorolac tromethamine 1 betaxolol hcl soln 0.5 % 1 soln 0.5 % bimatoprost soln 0.03 % 1 neomycin-polymyxin- brimonidine tartrate soln dexameth oint 3.5-10000- 1 1 0.1 0.2 % neomycin-polymyxin- dorzolamide hcl soln 2 % 1 dorzolamide hcl-timolol dexameth susp 3.5- 1 1 10000-0.1 mal soln 22.3-6.8 mg/ml neomycin-polymyxin-hc latanoprost soln 0.005 % 1 1 levobunolol hcl soln 0.5 soln 1 % 1 neomycin-polymyxin-hc % 1 methazolamide tabs 25 susp 3.5-10000-1 1 OZURDEX IMPL 0.7 MG mg 1 methazolamide tabs 50 [dexamethasone (ophth)] 1 PRED MILD SUSP 0.12 % mg MIOCHOL-E SOLR 20 MG [prednisolone acetate 1 1 (ophth)] [acetylcholine chloride] prednisolone acetate MIOSTAT SOLN 0.01 % 1 1 susp 1 % [carbachol (ophth)] prednisolone sodium PHOSPHOLINE IODIDE 1 phosphate soln 1 % SOLR 0.125 % 1 [echothiophate iodide]

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 60 of 144

藥物等 藥物等 藥物名稱 規定／限制 藥物名稱 規定／限制 級 級 pilocarpine hcl soln 1 % 1 [riboflavin5-phos sod & pilocarpine hcl soln 2 % 1 riboflavin 5-phosphate pilocarpine hcl soln 4 % 1 sodium-dextran] timolol maleate soln 0.25 VISUDYNE SOLR 15 MG 1 1 % [verteporfin] timolol maleate soln 0.5 LOCAL ANESTHETICS 1 AKTEN GEL 3.5 % % 1 EENT DRUGS, MISCELLANEOUS [lidocaine hcl (ophth)] ACETIC ACID SOLN 2 % [Proparacaine Hcl] 1 1 [acetic acid (otic)] ALCAINE SOLN 0.5 % acetic acid-aluminum C-TOPICAL SOLN 4 % 1 1 acetate soln 2 % [cocaine hcl] apraclonidine hcl soln lidocaine viscous hcl 1 1 0.5 % soln 2 % proparacaine hcl soln BSS PLUS SOLN 1 [ophthalmic irrigation 1 0.5 % solution - intraocular] TETRACAINE HCL SOLN BSS SOLN [ophthalmic 0.5 % [tetracaine hcl 1 irrigation solution - 1 (ophth)] TETRAVISC SOLN 0.5 % intraocular] 1 EYLEA SOLN 2 [tetracaine hcl (ophth)] 1 MG/0.05ML [aflibercept] MYDRIATICS EYLEA SOSY 2 ATROPINE SULFATE 1 MG/0.05ML [aflibercept] OINT 1 % [atropine 1 HEALON5 INJ 23MG/ML sulfate (ophthalmic)] 1 [sodium hyaluronate] ATROPINE SULFATE IOPIDINE SOLN 1 % SOLN 1 % [atropine 1 1 [apraclonidine hcl] sulfate (ophthalmic)] JETREA SOLN 0.5 [Cyclopentolate Hcl] 1 1 MG/0.2ML [ocriplasmin] CYCLOGYL SOLN 0.5 % LACRISERT INST 5 MG [Cyclopentolate W/ 1 Phenylephrine] [artificial tear insert] 1 LUCENTIS SOLN 0.3 CYCLOMYDRIL SOLN MG/0.05ML 1 QL - 30 day(s) 0.2-1 % cyclopentolate hcl soln 1 [ranibizumab] 1 LUCENTIS SOLN 0.5 % cyclopentolate hcl soln 2 MG/0.05ML 1 QL - 30 day(s) 1 [ranibizumab] % LUCENTIS SOSY 0.3 HOMATROPINE HBR MG/0.05ML 1 QL - 30 day(s) SOLN 5 % [homatropine 1 [ranibizumab] hbr] LUCENTIS SOSY 0.5 tropicamide soln 0.5 % 1 MG/0.05ML 1 QL - 30 day(s) tropicamide soln 1 % 1 [ranibizumab] VASOCONSTRICTORS MACUGEN SOLN 0.3 MG 1 naphazoline hcl soln 1 [pegaptanib sodium] PHENYLEPHRINE HCL PHOTREXA-PHOTREXA SOLN 10 % 1 VISCOUS KIT SOSY 1 [phenylephrine hcl 0.146 &0.146-20 % (mydriatic)]

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 61 of 144

藥物等 藥物等 藥物名稱 規定／限制 藥物名稱 規定／限制 級 級 PHENYLEPHRINE HCL ondansetron hcl soln 40 1 SOLN 2.5 % mg/20ml 1 [phenylephrine hcl ondansetron hcl tabs 4 1 (mydriatic)] mg ondansetron hcl tabs 8 GASTROINTESTINAL DRUGS 1 ANTI-INFLAMMATORY AGENTS mg balsalazide disodium ondansetron tbdp 4 mg 1 1 caps 750 mg ondansetron tbdp 8 mg 1 LIALDA TBEC 1.2 GM scopolamine pt72 1 1 1 [mesalamine] mg/3days mesalamine enem 4 gm 1 TRANSDERM-SCOP (1.5 mesalamine supp 1000 MG) PT72 1 MG/3DAYS 1 1 mg [scopolamine] mesalamine tbec 1.2 gm 1 ANTIULCER AGENTS AND ACID PENTASA CPCR 250 MG SUPPRESSANTS 1 CARAFATE SUSP 1 [mesalamine] 1 PENTASA CPCR 500 MG GM/10ML [sucralfate] 1 cimetidine hcl soln 300 [mesalamine] 1 ANTIDIARRHEA AGENTS mg/5ml famotidine premixed diphenoxylate-atropine 1 1 soln 20-0.9 mg/50ml-% liqd 2.5-0.025 mg/5ml famotidine soln 20 diphenoxylate-atropine 1 1 mg/2ml tabs 2.5-0.025 mg famotidine soln 40 PAREGORIC TINC 2 1 1 mg/4ml MG/5ML [paregoric] famotidine susr 40 ANTIEMETICS 1 mg/5ml AKYNZEO CAPS 300-0.5 famotidine tabs 20 mg 1 MG [netupitant- 1 QL - 30 day(s) 1 palonosetron] famotidine tabs 40 mg misoprostol tabs 100 dronabinol caps 10 mg 1 1 mcg dronabinol caps 2.5 mg 1 misoprostol tabs 200 1 dronabinol caps 5 mg 1 mcg EMEND CAPS 125 MG 1 QL - 30 day(s) omeprazole cpdr 10 mg 1 [aprepitant] omeprazole cpdr 20 mg 1 EMEND CAPS 40 MG 1 QL - 30 day(s) 1 [aprepitant] omeprazole cpdr 40 mg EMEND CAPS 80 MG pantoprazole sodium 1 QL - 30 day(s) 1 [aprepitant] tbec 20 mg EMEND TRI-PACK CAPS pantoprazole sodium 1 QL - 30 day(s) 1 80 & 125 MG [aprepitant] tbec 40 mg PROTONIX SOLR 40 MG fosaprepitant 1 dimeglumine solr 150 1 [pantoprazole sodium] mg sucralfate tabs 1 gm 1 meclizine hcl tabs 25 mg 1 CATHARTICS AND LAXATIVES ondansetron hcl soln 4 AMITIZA CAPS 24 MCG 1 1 mg/2ml [lubiprostone] ondansetron hcl soln 4 AMITIZA CAPS 8 MCG 1 1 mg/5ml [lubiprostone]

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 62 of 144

藥物等 藥物等 藥物名稱 規定／限制 藥物名稱 規定／限制 級 級 CASCARA SAGRADA ZENPEP CPEP 20000- EXTR 1 GM/ML [cascara 1 63000 UNIT 1 sagrada] [pancrelipase (lipase- [Peg 3350-kcl-sod Bicarb- protease-amylase)] sod Chloride-sod Sulfate] ZENPEP CPEP 25000- 1 GAVILYTE-G SOLR 236 79000 UNIT 1 GM [pancrelipase (lipase- GOLYTELY SOLR 236 protease-amylase)] GM [peg 3350-kcl-sod ZENPEP CPEP 3000- 1 bicarb-sod chloride-sod 10000 UNIT 1 sulfate] [pancrelipase (lipase- peg 3350-kcl-na bicarb- protease-amylase)] 1 nacl solr 420 gm ZENPEP CPEP 40000- peg 3350/electrolytes 126000 UNIT 1 1 solr 240 gm [pancrelipase (lipase- CHOLELITHOLYTIC AGENTS protease-amylase)] URSO FORTE TABS 500 ZENPEP CPEP 5000- 1 24000 UNIT MG [ursodiol] 1 ursodiol tabs 250 mg 1 [pancrelipase (lipase-

DIGESTANTS protease-amylase)] CREON CPEP 12000- PROKINETIC AGENTS 38000 UNIT metoclopramide hcl soln 1 1 [pancrelipase (lipase- 10 mg/10ml metoclopramide hcl soln protease-amylase)] 1 CREON CPEP 24000- 5 mg/ml 76000 UNIT metoclopramide hcl tabs 1 1 [pancrelipase (lipase- 10 mg metoclopramide hcl tabs protease-amylase)] 1 CREON CPEP 3000-9500 5 mg UNIT [pancrelipase GOLD COMPOUNDS 1 (lipase-protease- GOLD COMPOUNDS amylase)] RIDAURA CAPS 3 MG 1 CREON CPEP 36000- [auranofin] 114000 UNIT 1 HEAVY METAL ANTAGONISTS [pancrelipase (lipase- HEAVY METAL ANTAGONISTS protease-amylase)] BAL IN OIL SOLN 100 CREON CPEP 6000- 1 MG/ML [dimercaprol] 19000 UNIT 1 CHEMET CAPS 100 MG [pancrelipase (lipase- 1 [succimer] protease-amylase)] deferasirox tabs 360 mg 1 QL - 30 day(s) ZENPEP CPEP 10000- 32000 UNIT deferasirox tabs 90 mg 1 QL - 30 day(s) 1 deferoxamine mesylate [pancrelipase (lipase- 1 protease-amylase)] solr 2 gm deferoxamine mesylate ZENPEP CPEP 15000- 1 47000 UNIT solr 500 mg 1 EXJADE TBSO 125 MG [pancrelipase (lipase- 1 QL - 30 day(s) protease-amylase)] [deferasirox]

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 63 of 144

藥物等 藥物等 藥物名稱 規定／限制 藥物名稱 規定／限制 級 級 EXJADE TBSO 250 MG budesonide susp 0.25 1 QL - 30 day(s) 1 [deferasirox] mg/2ml EXJADE TBSO 500 MG budesonide susp 0.5 1 QL - 30 day(s) 1 [deferasirox] mg/2ml JADENU SPRINKLE cortisone acetate tabs 25 1 PACK 180 MG 1 QL - 30 day(s) mg [deferasirox] dexamethasone elix 0.5 1 JADENU SPRINKLE mg/5ml PACK 360 MG 1 QL - 30 day(s) [Dexamethasone] [deferasirox] DEXAMETHASONE 1 JADENU SPRINKLE INTENSOL CONC 1 PACK 90 MG 1 QL - 30 day(s) MG/ML [deferasirox] dexamethasone sodium JADENU TABS 180 MG phosphate soln 10 1 1 QL - 30 day(s) [deferasirox] mg/ml JADENU TABS 360 MG dexamethasone sodium 1 QL - 30 day(s) [deferasirox] phosphate soln 20 1 JADENU TABS 90 MG mg/5ml 1 QL - 30 day(s) [deferasirox] dexamethasone soln 0.5 1 penicillamine caps 250 mg/5ml 1 mg dexamethasone tabs 0.5 1 HORMONES AND SYNTHETIC SUBSTITUTES mg dexamethasone tabs ADRENALS 1 ASMANEX (120 0.75 mg dexamethasone tabs 1 METERED DOSES) AEPB 1 220 MCG/INH 1 mg dexamethasone tabs 1.5 [mometasone furoate 1 (inhalation)] mg dexamethasone tabs 2 ASMANEX (30 METERED 1 DOSES) AEPB 110 mg 1 dexamethasone tabs 4 MCG/INH [mometasone 1 furoate (inhalation)] mg dexamethasone tabs 6 ASMANEX (60 METERED 1 DOSES) AEPB 220 mg 1 MCG/INH [mometasone FLOVENT HFA AERO 44 furoate (inhalation)] MCG/ACT [fluticasone 1 ASMANEX HFA AERO propionate hfa] 100 MCG/ACT fludrocortisone acetate 1 1 [mometasone furoate tabs 0.1 mg hydrocortisone tabs 10 (inhalation)] 1 ASMANEX HFA AERO mg 200 MCG/ACT hydrocortisone tabs 20 1 1 [mometasone furoate mg hydrocortisone tabs 5 (inhalation)] 1 betamethasone sod mg phos & acet susp 6 (3-3) 1 KENALOG SUSP 10 mg/ml MG/ML [triamcinolone 1 budesonide cpep 3 mg 1 acetonide]

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 64 of 144

藥物等 藥物等 藥物名稱 規定／限制 藥物名稱 規定／限制 級 級 KENALOG SUSP 40 prednisone tbpk 5 mg 1 MG/ML [triamcinolone 1 (21) acetonide] PULMICORT MEDROL TABS 2 MG FLEXHALER AEPB 180 1 1 [methylprednisolone] MCG/ACT [budesonide methylprednisolone (inhalation)] 1 acetate susp 40 mg/ml SOLU-CORTEF SOLR methylprednisolone 100 MG [hydrocortisone 1 1 acetate susp 80 mg/ml sod succinate] methylprednisolone SOLU-CORTEF SOLR 1 1000 MG sodium succ solr 1000 1 mg [hydrocortisone sod methylprednisolone succinate] 1 sodium succ solr 125 mg SOLU-CORTEF SOLR methylprednisolone 250 MG [hydrocortisone 1 1 sodium succ solr 40 mg sod succinate] methylprednisolone tabs SOLU-CORTEF SOLR 1 16 mg 500 MG [hydrocortisone 1 methylprednisolone tabs sod succinate] 1 32 mg SOLU-MEDROL SOLR methylprednisolone tabs 125 MG 1 1 4 mg [methylprednisolone sod methylprednisolone tabs succ] 1 8 mg SOLU-MEDROL SOLR methylprednisolone tbpk 500 MG 1 1 4 mg [methylprednisolone sod [Prednisolone] MILLIPRED succ] 1 TABS 5 MG SYMBICORT AERO 160- 4.5 MCG/ACT prednisolone sodium 1 phosphate soln 15 1 [budesonide-formoterol mg/5ml fumarate dihydrate] prednisolone sodium SYMBICORT AERO 80- 4.5 MCG/ACT phosphate soln 6.7 (5 1 1 base) mg/5ml [budesonide-formoterol prednisolone soln 15 fumarate dihydrate] 1 mg/5ml ANDROGENS [Prednisone] ANDRODERM PT24 2 1 PREDNISONE INTENSOL 1 MG/24HR [testosterone] CONC 5 MG/ML ANDRODERM PT24 4 1 prednisone soln 5 MG/24HR [testosterone] 1 mg/5ml [Methyltestosterone] 1 prednisone tabs 1 mg 1 ANDROID CAPS 10 MG [Fluoxymesterone] prednisone tabs 10 mg 1 1 prednisone tabs 2.5 mg 1 ANDROXY TABS 10 MG prednisone tabs 20 mg 1 danazol caps 100 mg 1 prednisone tabs 5 mg 1 danazol caps 200 mg 1 prednisone tabs 50 mg 1 danazol caps 50 mg 1 prednisone tbpk 10 mg 1 (21)

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 65 of 144

藥物等 藥物等 藥物名稱 規定／限制 藥物名稱 規定／限制 級 級 [Testosterone Cypionate] 100 UNIT/ML [insulin DEPO-TESTOSTERONE 1 lispro protamine & SOLN 100 MG/ML lispro] [Testosterone Cypionate] HUMALOG MIX 50/50 DEPO-TESTOSTERONE 1 SUSP (50-50) 100 1 SOLN 200 MG/ML UNIT/ML [insulin lispro methyltestosterone tabs protamine & lispro] 1 HUMALOG SOLN 100 10 mg 1 oxandrolone tabs 10 mg 1 UNIT/ML [insulin lispro] oxandrolone tabs 2.5 mg 1 HUMULIN R U-500 testosterone cypionate (CONCENTRATED) 1 1 soln 200 mg/ml SOLN 500 UNIT/ML testosterone enanthate [insulin regular (human)] 1 soln 200 mg/ml HUMULIN R U-500 testosterone gel 12.5 KWIKPEN SOPN 500 1 1 mg/act (1%) UNIT/ML [insulin regular testosterone gel 20.25 (human)] 1 JARDIANCE TABS 10 MG mg/act (1.62%) 1 testosterone gel 25 [empagliflozin] 1 JARDIANCE TABS 25 MG mg/2.5gm (1%) 1 testosterone gel 50 [empagliflozin] 1 mg/5gm (1%) LANTUS SOLN 100 UNIT/ML 1 ANTIDIABETIC AGENTS [insulin glargine] acarbose tabs 100 mg 1 metformin hcl er tb24 1 acarbose tabs 25 mg 1 500 mg acarbose tabs 50 mg 1 metformin hcl er tb24 BYDUREON BCISE AUIJ 1 1 750 mg 2 MG/0.85ML [exenatide] metformin hcl tabs 1000 1 glimepiride tabs 1 mg 1 mg glimepiride tabs 2 mg 1 metformin hcl tabs 500 1 glimepiride tabs 4 mg 1 mg metformin hcl tabs 850 glipizide tabs 10 mg 1 1 glipizide tabs 5 mg 1 mg pioglitazone hcl tabs 15 glipizide tb24 10 mg 1 1 glipizide tb24 2.5 mg 1 mg pioglitazone hcl tabs 30 glipizide tb24 5 mg 1 1 mg glipizide-metformin hcl 1 pioglitazone hcl tabs 45 tabs 2.5-250 mg 1 mg glipizide-metformin hcl 1 SYMLINPEN 120 SOPN tabs 2.5-500 mg 2700 MCG/2.7ML 1 glipizide-metformin hcl 1 [pramlintide acetate] tabs 5-500 mg tolbutamide tabs 500 mg 1 glyburide tabs 1.25 mg 1 TRADJENTA TABS 5 MG 1 1 glyburide tabs 2.5 mg [linagliptin] glyburide tabs 5 mg 1 VICTOZA SOPN 18 HUMALOG MIX 50/50 1 1 MG/3ML [liraglutide] KWIKPEN SUPN (50-50) ANTIHYPOGLYCEMIC AGENTS

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藥物等 藥物等 藥物名稱 規定／限制 藥物名稱 規定／限制 級 級 BAQSIMI TWO PACK [Norethindrone & Eth POWD 3 MG/DOSE 1 Estradiol] NECON 0.5/35 1 [glucagon] (28) TABS 0.5-35 MG- GLUCAGEN HYPOKIT MCG SOLR 1 MG [glucagon 1 [Norethindrone-eth hcl (rdna)] Estradiol (biphasic)] 1 GLUCAGEN INJ 1MG NECON 10/11-28 TAB 1 [glucagon hcl (rdna)] 10/11-28 glucagon emergency kit NEXPLANON IMPL 68 1 1 1 mg MG [etonogestrel] CONTRACEPTIVES [Norethindrone & Eth [Norethindrone-eth Estradiol] NORTREL 1/35 1 Estradiol (triphasic)] (28) TABS 1-35 MG-MCG 1 ARANELLE TABS [Norethindrone-eth Estradiol (triphasic)] 0.5/1/0.5-35 MG-MCG 1 [Norgestrel & Ethinyl NORTREL 7/7/7 TABS Estradiol] CRYSELLE-28 1 0.5/0.75/1-35 MG-MCG TABS 0.3-30 MG-MCG [Norgestrel & Ethinyl drospirenone-ethinyl Estradiol] OGESTREL 1 1 estradiol tabs 3-0.02 mg TABS 0.5-50 MG-MCG drospirenone-ethinyl [Levonorgestrel & Eth 1 estradiol tabs 3-0.03 mg Estradiol] PORTIA-28 1 ELLA TABS 30 MG TABS 0.15-30 MG-MCG 1 [ulipristal acetate] [Desogestrel & Ethinyl [Etonogestrel-ethinyl Estradiol] RECLIPSEN 1 Estradiol] ELURYNG TABS 0.15-30 MG-MCG 1 RING 0.12-0.015 [Norgestimate-ethinyl MG/24HR Estradiol] SPRINTEC 28 1 JOLIVETTE TABS 0.35 TABS 0.25-35 MG-MCG MG [norethindrone 1 [Norgestimate-ethinyl (contraceptive)] Estradiol (triphasic)] TRI- [Norethin Acet & Estrad-fe] LO-SPRINTEC TABS 1 JUNEL FE 1.5/30 TABS 1 0.18/0.215/0.25 MG-25 1.5-30 MG-MCG MCG [Norethin Acet & Estrad-fe] [Norgestimate-ethinyl JUNEL FE 1/20 TABS 1- 1 Estradiol (triphasic)] TRI- 20 MG-MCG SPRINTEC TABS 1 [Ethynodiol Diacet & Eth 0.18/0.215/0.25 MG-35 Estrad] KELNOR 1/50 1 MCG TABS 1-50 MG-MCG [Levonorgestrel-eth Estradiol (triphasic)] [Norethindrone Acet & Eth 1 Estra] LOESTRIN 1/20 1 TRIVORA (28) TABS 50- (21) TABS 1-20 MG-MCG 30/75-40/ 125-30 MCG [Levonorgestrel & Eth [Norelgestromin-ethinyl Estradiol] LUTERA TABS 1 Estradiol] XULANE PTWK 1 0.1-20 MG-MCG 150-35 MCG/24HR MIRENA (52 MG) IUD 20 [Norelgestromin-ethinyl MCG/24HR 1 Estradiol] ZAFEMY PTWK 1 [levonorgestrel (iud)] 150-35 MCG/24HR

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 67 of 144

藥物等 藥物等 藥物名稱 規定／限制 藥物名稱 規定／限制 級 級 [Ethynodiol Diacet & Eth estradiol ptwk 0.05 1 Estrad] ZOVIA 1/35E (28) 1 mg/24hr TABS 1-35 MG-MCG estradiol ptwk 0.075 1 ESTROGENS AND ESTROGEN AGONISTS- mg/24hr ANTAGONISTS estradiol ptwk 0.1 1 CLIMARA PTWK 0.025 mg/24hr 1 MG/24HR [estradiol] estradiol tabs 0.5 mg 1 CLIMARA PTWK 0.0375 1 estradiol tabs 1 mg 1 MG/24HR [estradiol] estradiol tabs 2 mg 1 CLIMARA PTWK 0.05 estradiol valerate inj 1 1 MG/24HR [estradiol] 10mg/ml CLIMARA PTWK 0.06 estradiol valerate oil 20 1 1 MG/24HR [estradiol] mg/ml CLIMARA PTWK 0.075 estradiol valerate oil 40 1 1 MG/24HR [estradiol] mg/ml CLIMARA PTWK 0.1 ESTRING RING 2 MG 1 1 MG/24HR [estradiol] [estradiol vaginal] clomiphene citrate tabs PREMARIN SOLR 25 MG 1 1 50 mg [estrogens, conjugated] DELESTROGEN OIL 20 raloxifene hcl tabs 60 mg 1 MG/ML 1 [estradiol VAGIFEM TABS 10 MCG 1 valerate] [estradiol vaginal] DELESTROGEN OIL 40 GONADOTROPINS MG/ML [estradiol 1 GONAL-F RFF REDIJECT valerate] SOLN 300 UNIT/0.5ML 1 [Estradiol Cypionate]

DEPO-ESTRADIOL OIL 5 1 [follitropin alfa] MG/ML GONAL-F RFF REDIJECT SOLN 450 UNT/0.75ML 1 EEMT HS TABS 0.625- [follitropin alfa] 1.25 MG [esterified 1 GONAL-F RFF REDIJECT estrogens & SOLN 900 UNIT/1.5ML 1 methyltestosterone] [follitropin alfa] EEMT TABS 1.25-2.5 MG GONAL-F RFF SOLR 75 [esterified estrogens & 1 1 UNIT methyltestosterone] [follitropin alfa] GONAL-F SOLR 1050 [Estradiol Vaginal] 1 ESTRACE CREA 0.1 1 UNIT [follitropin alfa] GONAL-F SOLR 450 MG/GM 1 UNIT estradiol pttw 0.025 [follitropin alfa] 1 MENOPUR SOLR 75 mg/24hr 1 UNIT estradiol pttw 0.0375 [menotropins] 1 mg/24hr NOVAREL SOLR 10000 UNIT 1 estradiol pttw 0.05 [chorionic 1 mg/24hr gonadotropin] OVIDREL INJ 250 estradiol pttw 0.075 1 MCG/0.5ML mg/24hr 1 estradiol pttw 0.1 [choriogonadotropin 1 alfa] mg/24hr

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 68 of 144

藥物等 藥物等 藥物名稱 規定／限制 藥物名稱 規定／限制 級 級 SYNAREL SOLN 2 medroxyprogesterone 1 MG/ML [nafarelin 1 acetate tabs 10 mg acetate] medroxyprogesterone 1 PARATHYROID acetate tabs 2.5 mg calcitonin (salmon) soln medroxyprogesterone 1 1 200 unit/act acetate tabs 5 mg norethindrone acetate FORTEO SOPN 620 1 MCG/2.48ML tabs 5 mg 1 QL - 30 day(s) progesterone caps 100 [teriparatide 1 (recombinant)] mg progesterone caps 200 PITUITARY 1 ACTHAR GEL 80 mg 1 LD PROGESTERONE OIL 50 UNIT/ML [corticotropin] 1 DDAVP RHINAL TUBE MG/ML [progesterone] SOLN 0.01 % SOMATROPIN AGONISTS-ANTAGONISTS 1 [desmopressin acetate NORDITROPIN FLEXPRO refrigerated] SOPN 15 MG/1.5ML 1 QL - 30 day(s) desmopressin ace spray [somatropin] 1 OMNITROPE SOCT 10 refrig soln 0.01 % 1 QL - 30 day(s) desmopressin acetate MG/1.5ML [somatropin] 1 OMNITROPE SOCT 5 soln 4 mcg/ml 1 QL - 30 day(s) desmopressin acetate MG/1.5ML [somatropin] 1 OMNITROPE SOLR 5.8 spray soln 0.01 % 1 desmopressin acetate MG [somatropin] 1 tabs 0.1 mg SEROSTIM SOLR 4 MG desmopressin acetate [somatropin (non- 1 QL - 30 day(s) 1 tabs 0.2 mg refrigerated)] STIMATE SOLN 1.5 SEROSTIM SOLR 5 MG MG/ML [desmopressin 1 [somatropin (non- 1 QL - 30 day(s) acetate] refrigerated)] PROGESTINS SEROSTIM SOLR 6 MG DEPO-PROVERA SUSP [somatropin (non- 1 QL - 30 day(s) 400 MG/ML refrigerated)] 1 [medroxyprogesterone THYROID AND ANTITHYROID AGENTS acetate (antineoplastic)] LEVOTHYROXINE ENDOMETRIN INST 100 SODIUM SOLR 200 MCG 1 MG [progesterone 1 [levothyroxine sodium] (vaginal)] LEVOTHYROXINE hydroxyprogesterone SODIUM SOLR 500 MCG 1 caproate soln 1.25 1 QL - 30 day(s) [levothyroxine sodium] levothyroxine sodium gm/5ml 1 MAKENA OIL 250 MG/ML tabs 100 mcg levothyroxine sodium [hydroxyprogesterone 1 QL - 30 day(s) 1 caproate] tabs 112 mcg medroxyprogesterone levothyroxine sodium 1 1 acetate susp 150 mg/ml tabs 125 mcg medroxyprogesterone levothyroxine sodium 1 1 acetate susy 150 mg/ml tabs 150 mcg

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 69 of 144

藥物等 藥物等 藥物名稱 規定／限制 藥物名稱 規定／限制 級 級 levothyroxine sodium KINERET INJ QL - 30 1 1 tabs 175 mcg [anakinra] day(s),LD levothyroxine sodium 1 1 leflunomide tabs 10 mg tabs 200 mcg leflunomide tabs 20 mg 1 levothyroxine sodium 1 ORENCIA CLICKJECT tabs 25 mcg SOAJ 125 MG/ML 1 QL - 30 day(s) levothyroxine sodium 1 [abatacept] tabs 300 mcg ORENCIA SOLR 250 MG levothyroxine sodium 1 QL - 30 day(s) 1 [abatacept] tabs 50 mcg ORENCIA SOSY 125 levothyroxine sodium 1 1 MG/ML [abatacept] tabs 75 mcg ORENCIA SOSY 50 levothyroxine sodium 1 QL - 30 day(s) 1 MG/0.4ML [abatacept] tabs 88 mcg ORENCIA SOSY 87.5 1 QL - 30 day(s) LEVOXYL TABS 137 MG/0.7ML [abatacept] MCG [levothyroxine 1 OTEZLA TAB 10/20/30 1 QL - 30 day(s) sodium] [apremilast] liothyronine sodium tabs OTEZLA TABS 30 MG 1 1 QL - 30 day(s) 25 mcg [apremilast] liothyronine sodium tabs OTEZLA TBPK 10 & 20 & 1 1 QL - 30 day(s) 5 mcg 30 MG [apremilast] liothyronine sodium tabs 1 RASUVO SOAJ 10 50 mcg MG/0.2ML [methotrexate 1 methimazole tabs 10 mg 1 (antirheumatic)] methimazole tabs 5 mg 1 RASUVO SOAJ 12.5 propylthiouracil tabs 50 MG/0.25ML 1 1 mg [methotrexate SSKI SOLN 1 GM/ML (antirheumatic)] [potassium iodide 1 RASUVO SOAJ 15 (expectorant)] MG/0.3ML [methotrexate 1 IMMUNOLOGICAL AGENTS (antirheumatic)] ANTIRHEUMATIC AGENTS RASUVO SOAJ 17.5 MG/0.35ML ENBREL SOLR 25 MG 1 QL - 30 day(s) 1 [etanercept] [methotrexate ENBREL SOSY 25 (antirheumatic)] 1 QL - 30 day(s) RASUVO SOAJ 20 MG/0.5ML [etanercept] ENBREL SOSY 50 MG/0.4ML [methotrexate 1 1 QL - 30 day(s) (antirheumatic)] MG/ML [etanercept] RASUVO SOAJ 22.5 ENBREL SURECLICK MG/0.45ML SOAJ 50 MG/ML 1 QL - 30 day(s) 1 [etanercept] [methotrexate

HUMIRA PEN PNKT 40 (antirheumatic)] 1 QL - 30 day(s) RASUVO SOAJ 25 MG/0.8ML [adalimumab] MG/0.5ML 1 HUMIRA PSKT 10 [methotrexate 1 QL - 30 day(s) (antirheumatic)] MG/0.2ML [adalimumab] RASUVO SOAJ 30 HUMIRA PSKT 20 1 QL - 30 day(s) MG/0.6ML [methotrexate 1 MG/0.4ML [adalimumab] (antirheumatic)] HUMIRA PSKT 40 1 QL - 30 day(s) MG/0.8ML [adalimumab]

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 70 of 144

藥物等 藥物等 藥物名稱 規定／限制 藥物名稱 規定／限制 級 級 RASUVO SOAJ 7.5 bupivacaine hcl (pf) soln 1 MG/0.15ML 0.75 % 1 [methotrexate bupivacaine hcl inj 1 (antirheumatic)] 0.75% REMICADE SOLR 100 bupivacaine hcl soln 1 1 MG [infliximab] 0.25 % bupivacaine hcl soln 0.5 IMMUNE SUPPRESSANTS 1 ATGAM INJ 50 MG/ML % [lymphocyte immune bupivacaine in dextrose 1 1 globulin,anti-thymocyte soln 0.75-8.25 % bupivacaine-epinephrine globulin (equine)] 1 azathioprine tabs 50 mg 1 (pf) soln 0.25% -1:200000 mycophenolate mofetil bupivacaine-epinephrine 1 1 caps 250 mg (pf) soln 0.5% -1:200000 mycophenolate mofetil bupivacaine-epinephrine 1 1 susr 200 mg/ml soln 0.25% -1:200000 bupivacaine-epinephrine NEORAL SOLN 100 1 MG/ML [cyclosporine soln 0.5% -1:200000 1 chloroprocaine hcl (pf) modified (for 1 microemulsion)] soln 2 % PROGRAF SOLN 5 chloroprocaine hcl inj 1 1 MG/ML [tacrolimus] 3% RAPAMUNE SOLN 1 LIDOCAINE HCL 1 (CARDIAC) PF SOLN 100 MG/ML [sirolimus] 1 SANDIMMUNE CAPS 100 MG/5ML [lidocaine hcl 1 MG [cyclosporine] (cardiac)] SANDIMMUNE CAPS 25 lidocaine hcl (pf) soln 0.5 1 1 MG [cyclosporine] % SANDIMMUNE SOLN 100 lidocaine hcl (pf) soln 1 1 1 MG/ML [cyclosporine] % SANDIMMUNE SOLN 50 lidocaine hcl (pf) soln 2 1 1 MG/ML [cyclosporine] % lidocaine hcl (pf) soln 4 sirolimus tabs 0.5 mg 1 1 sirolimus tabs 1 mg 1 % sirolimus tabs 2 mg 1 lidocaine hcl soln 0.5 % 1 tacrolimus caps 0.5 mg 1 lidocaine hcl soln 1 % 1 tacrolimus caps 1 mg 1 lidocaine hcl soln 2 % 1 lidocaine-epinephrine tacrolimus caps 5 mg 1 1 soln 0.5 %-1:200000 LOCAL ANESTHETICS lidocaine-epinephrine 1 LOCAL ANESTHETICS soln 1 %-1:100000 BUPIVACAINE lidocaine-epinephrine 1 FISIOPHARMA SOLN 2.5 1 soln 1.5 %-1:200000 MG/ML [bupivacaine hcl] lidocaine-epinephrine bupivacaine hcl (pf) soln 1 1 soln 2 %-1:100000 0.25 % lidocaine-epinephrine bupivacaine hcl (pf) soln 1 1 soln 2 %-1:200000 0.5 % NAROPIN SOLN 10 1 MG/ML [ropivacaine hcl]

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 71 of 144

藥物等 藥物等 藥物名稱 規定／限制 藥物名稱 規定／限制 級 級 NAROPIN SOLN 2 MG/ML alendronate sodium tabs 1 1 [ropivacaine hcl] 35 mg NAROPIN SOLN 5 MG/ML alendronate sodium tabs 1 1 [ropivacaine hcl] 40 mg NAROPIN SOLN 7.5 alendronate sodium tabs 1 1 MG/ML [ropivacaine hcl] 70 mg NESACAINE SOLN 1 % 1 1 allopurinol tabs 100 mg [chloroprocaine hcl] allopurinol tabs 300 mg 1 NESACAINE SOLN 2 % [Disulfiram] ANTABUSE 1 1 [chloroprocaine hcl] TABS 250 MG [Mepivacaine Hcl] 1 AVONEX PEN AJKT 30 POLOCAINE SOLN 1 % MCG/0.5ML [interferon 1 QL - 30 day(s) [Mepivacaine Hcl] 1 beta-1a] POLOCAINE SOLN 2 % BOTOX COSMETIC [Mepivacaine Hcl] SOLR 100 UNIT 1 POLOCAINE-MPF SOLN 1 [onabotulinumtoxina 1 % (cosmetic)] [Mepivacaine Hcl] BOTOX SOLR 100 UNIT 1 POLOCAINE-MPF SOLN 1 [onabotulinumtoxina] 1.5 % BOTOX SOLR 200 UNIT 1 [Mepivacaine Hcl] [onabotulinumtoxina] POLOCAINE-MPF SOLN 1 BRIDION SOLN 200 2 % MG/2ML [sugammadex 1 SENSORCAINE- sodium] MPF/EPINEPHRINE CERDELGA CAPS 84 MG 1 QL - 30 day(s) SOLN 0.75-1:200000 % 1 [eliglustat tartrate] [bupivacaine w/ cinacalcet hcl tabs 30 1 epinephrine] mg TETRACAINE HCL SOLN cinacalcet hcl tabs 60 1 1 1 % [tetracaine hcl] mg XYLOCAINE- cinacalcet hcl tabs 90 1 MPF/EPINEPHRINE mg SOLN 1 %-1:200000 1 CINRYZE SOLR 500 UNIT [lidocaine w/ [c1 esterase inhibitor 1 QL - 30 day(s) epinephrine] (human)] MISCELLANEOUS THERAPEUTIC AGENTS colchicine tabs 0.6 mg 1 MISCELLANEOUS THERAPEUTIC AGENTS CYSTADANE POWD 1 QL - 30 day(s) acetylcysteine soln 10 % 1 [betaine] CYSTAGON CAPS 150 acetylcysteine soln 20 % 1 QL - 30 MG [cysteamine 1 ACETYLCYSTEINE SOLN day(s),LD 200 MG/ML bitartrate] 1 CYSTAGON CAPS 50 MG QL - 30 [acetylcysteine 1 (antidote)] [cysteamine bitartrate] day(s),LD dexrazoxane hcl solr 250 ACTIMMUNE SOLN 1 2000000 UNIT/0.5ML 1 QL - 30 day(s) mg dexrazoxane hcl solr 500 [interferon gamma-1b] 1 alendronate sodium tabs mg 1 dimethyl fumarate cpdr 10 mg 1 120 mg

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 72 of 144

藥物等 藥物等 藥物名稱 規定／限制 藥物名稱 規定／限制 級 級 dimethyl fumarate cpdr 80 MG/0.8ML & 1 240 mg 40MG/0.4ML dimethyl fumarate [adalimumab] 1 HUMIRA PEN PNKT 40 starter pack misc 120 & 1 QL - 30 day(s) 240 mg MG/0.4ML [adalimumab] disulfiram tabs 250 mg 1 HUMIRA PEN-CD/UC/HS disulfiram tabs 500 mg 1 STARTER PNKT 80 1 QL - 30 day(s) ELMIRON CAPS 100 MG MG/0.8ML [adalimumab] [pentosan polysulfate 1 HUMIRA PEN- sodium] PSOR/UVEIT STARTER etidronate disodium tabs PNKT 80 MG/0.8ML & 1 QL - 30 day(s) 1 200 mg 40MG/0.4ML etidronate disodium tabs [adalimumab] 1 HUMIRA PSKT 10 400 mg 1 QL - 30 day(s) finasteride tabs 5 mg 1 MG/0.1ML [adalimumab] HUMIRA PSKT 20 FIRAZYR SOLN 30 1 QL - 30 day(s) MG/3ML [icatibant 1 QL - 30 day(s) MG/0.2ML [adalimumab] HUMIRA PSKT 40 acetate] 1 QL - 30 day(s) FLUORITAB CHEW 2.2 (1 MG/0.4ML [adalimumab] 1 icatibant acetate soln 30 F) MG [sodium fluoride] 1 QL - 30 day(s) FLURA-DROPS SOLN mg/3ml INFLECTRA SOLR 100 0.55 (0.25 F) MG/DROP 1 1 [sodium fluoride] MG [infliximab-dyyb] FUSILEV SOLR 50 MG KALYDECO PACK 50 MG 1 1 QL - 30 day(s) [levoleucovorin calcium] [ivacaftor] KALYDECO PACK 75 MG [Cyclosporine Modified (for 1 QL - 30 day(s) Microemulsion)] 1 [ivacaftor] KALYDECO TABS 150 GENGRAF CAPS 100 MG 1 QL - 30 day(s) [Cyclosporine Modified (for MG [ivacaftor] leucovorin calcium solr Microemulsion)] 1 1 GENGRAF CAPS 25 MG 100 mg leucovorin calcium solr [Glatiramer Acetate] 1 GLATOPA SOSY 40 1 350 mg leucovorin calcium solr MG/ML 1 GRASTEK SUBL 2800 50 mg leucovorin calcium tabs BAU [timothy grass 1 1 pollen allergen extract] 25 mg leucovorin calcium tabs HAEGARDA SOLR 2000 1 UNIT [c1 esterase 1 QL - 30 day(s) 5 mg levocarnitine inj inhibitor (human)] 1 HAEGARDA SOLR 3000 200mg/ml UNIT [c1 esterase 1 QL - 30 day(s) LEVOCARNITINE SOLN 1 inhibitor (human)] GM/10ML [levocarnitine 1 HUMIRA PEDIATRIC (metabolic modifiers)] CROHNS START PSKT LEVOCARNITINE TABS 1 QL - 30 day(s) 80 MG/0.8ML 330 MG [levocarnitine 1 [adalimumab] (metabolic modifiers)] HUMIRA PEDIATRIC 1 QL - 30 day(s) CROHNS START PSKT

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 73 of 144

藥物等 藥物等 藥物名稱 規定／限制 藥物名稱 規定／限制 級 級 LUDENT CHEW 0.55 PREVIDENT SOLN 0.2 % (0.25 F) MG [sodium 1 [sodium fluoride 1 fluoride] (dental)] MESNA SOLN 100 RASUVO SOAJ 27.5 1 MG/ML [mesna] MG/0.55ML 1 MESNEX TABS 400 MG [methotrexate 1 QL - 30 day(s) [mesna] (antirheumatic)] METHYLENE BLUE RIMSO-50 SOLN 50 % 1 SOLN 1 % [methylene 1 [dimethyl sulfoxide] blue (antidote)] SANDOSTATIN LAR mycophenolate mofetil DEPOT KIT 10 MG 1 QL - 30 day(s) 1 tabs 500 mg [octreotide acetate] MYOBLOC SOLN 10000 SANDOSTATIN LAR UNIT/2ML 1 DEPOT KIT 20 MG 1 QL - 30 day(s) [rimabotulinumtoxinb] [octreotide acetate] MYOBLOC SOLN 2500 SANDOSTATIN LAR UNIT/0.5ML 1 DEPOT KIT 30 MG 1 QL - 30 day(s) [rimabotulinumtoxinb] [octreotide acetate] MYOBLOC SOLN 5000 SF 5000 PLUS CREA 1.1 UNIT/ML 1 % [sodium fluoride 1 [rimabotulinumtoxinb] (dental)] octreotide acetate soln sirolimus soln 1 mg/ml 1 1 100 mcg/ml SODIUM FLUORIDE octreotide acetate soln CHEW 1.1 (0.5 F) MG 1 1 1000 mcg/ml [sodium fluoride] octreotide acetate soln SODIUM FLUORIDE 1 200 mcg/ml SOLN 1.1 (0.5 F) MG/ML 1 octreotide acetate soln [sodium fluoride] 1 50 mcg/ml SOLIRIS SOLN 300 1 octreotide acetate soln MG/30ML [eculizumab] 1 500 mcg/ml sterile water for injection 1 pamidronate disodium soln 1 soln 30 mg/10ml TAKHZYRO SOLN 300 pamidronate disodium MG/2ML [lanadelumab- 1 QL - 30 day(s) 1 soln 6 mg/ml flyo] pamidronate disodium THALOMID CAPS 100 1 1 QL - 30 day(s) soln 90 mg/10ml MG [thalidomide] pamidronate disodium THALOMID CAPS 150 1 1 QL - 30 day(s) solr 30 mg MG [thalidomide] pamidronate disodium THALOMID CAPS 200 1 1 QL - 30 day(s) solr 90 mg MG [thalidomide] PREVIDENT 5000 PLUS THALOMID CAPS 50 MG 1 QL - 30 day(s) CREA 1.1 % [sodium 1 [thalidomide] fluoride (dental)] THIOLA TABS 100 MG 1 LD PREVIDENT GEL 1.1 % [tiopronin] [sodium fluoride 1 TRI-CHLOR LIQD 80 % 1 (dental)] [trichloroacetic acid] TYSABRI CONC 300 QL - 30 1 MG/15ML [natalizumab] day(s),LD

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 74 of 144

藥物等 藥物等 藥物名稱 規定／限制 藥物名稱 規定／限制 級 級 ULTOMIRIS SOLN 1100 ATROPINE SULFATE MG/11ML [ravulizumab- 1 MONOHYDRATE POW 1 cwvz] MONOHYDT [atropine ULTOMIRIS SOLN 300 sulfate monohydrate] MG/30ML [ravulizumab- 1 BACLOFEN POWD 1 cwvz] [baclofen] ULTOMIRIS SOLN 300 BACTERIOSTATIC MG/3ML [ravulizumab- 1 WATER(BENZ ALC) cwvz] SOLN [water for inject, 1 XELJANZ TABS 10 MG bacteriostatic benzyl 1 [tofacitinib citrate] alcohol] XELJANZ TABS 5 MG CANTHARIDIN POW 1 QL - 30 day(s) 1 [tofacitinib citrate] [cantharidin] XELJANZ XR TB24 11 CARBAMAZEPINE POWD 1 QL - 30 day(s) 1 MG [tofacitinib citrate] [carbamazepine] ZINECARD SOLR 250 MG CHLOROFORM SOL 1 1 [dexrazoxane hcl] [chloroform] ZINECARD SOLR 500 MG CHLORPROMAZINE HCL 1 [dexrazoxane hcl] POW HCL 1 zoledronic acid conc 4 [chlorpromazine hcl] 1 mg/5ml CLINDAMYCIN HCL zoledronic acid soln 5 POWD [clindamycin hcl 1 1 mg/100ml (bulk)] OXYTOCICS CLOBETASOL PROPIONATE POW OXYTOCICS 1 PROPIONA [clobetasol CERVIDIL INST 10 MG 1 [dinoprostone] propionate] CLONIDINE HCL POWD HEMABATE SOLN 250 1

MCG/ML [carboprost 1 [clonidine hcl] CLOTRIMAZOLE CRYS tromethamine] 1 methylergonovine [clotrimazole (topical)] 1 CLOTRIMAZOLE POWD maleate soln 0.2 mg/ml 1 [clotrimazole (topical)] methylergonovine 1 COAL TAR EXTRACT maleate tabs 0.2 mg SOLN 20 % 1 MIFEPREX TABS 200 MG [coal tar 1 (crude)] [mifepristone] CYSTEAMINE HCL OXYTOCIN SOLN 10 1 POWD [cysteamine hcl 1 UNIT/ML [oxytocin]

PREPIDIL GEL 0.5 (bulk)] 1 DEXAMETHASONE MG/3GM [dinoprostone] POWD [dexamethasone 1 PROSTIN E2 SUPP 20 1 (bulk)] MG [dinoprostone] DILTIAZEM HCL POWD 1 PHARMACEUTICAL AIDS [diltiazem hcl (bulk)] PHARMACEUTICAL AIDS ESTRADIOL POW ALOE VERA POWD [aloe 1 1 [estradiol] vera (bulk)] GABAPENTIN POWD ALPROSTADIL POWD 1 1 [gabapentin (bulk)] [alprostadil (bulk)]

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 75 of 144

藥物等 藥物等 藥物名稱 規定／限制 藥物名稱 規定／限制 級 級 GLYCERIN LIQD PAPAVERINE HCL 1 1 [glycerin (bulk)] POWD [papaverine hcl] GLYCOPYRROLATE PHENOBARBITAL POWD 1 POWD [glycopyrrolate 1 [phenobarbital] (bulk)] PHENTOLAMINE HALOPERIDOL POWD MESYLATE POWD 1 1 [haloperidol (bulk)] [phentolamine mesylate HYDROCORTISONE (bulk)] POWD [hydrocortisone 1 PLURONIC F127 GEL 20 1 (topical)] % [pluronic f127 base] HYDROXOCOBALAMIN PODOPHYLLUM RESIN POW POWD [podophyllum 1 1 [hydroxocobalamin resin] (bulk)] POLYETHYLENE HYDROXYPROGESTER GLYCOL 8000 POWD 1 ONE CAPROATE POWD [polyethylene glycol 1 [hydroxyprogesterone 8000] caproate (bulk)] PROGESTERONE INDOMETHACIN POWD MICRONIZED POWD 1 1 [indomethacin] [progesterone ISOSORBIDE POWD micronized (bulk)] 1 [isosorbide (bulk)] PROGESTERONE KETAMINE HCL POWD WETTABLE POWD 1 1 [ketamine hcl (bulk)] [progesterone (bulk)] KETOPROFEN POWD QUINACRINE HCL POWD 1 1 [ketoprofen (bulk)] [quinacrine hcl] L-PROLINE POWD SALICYLIC ACID POWD 1 1 [proline] [salicylic acid (bulk)] LACTOSE SODIUM BENZOATE MONOHYDRATE POWD 1 POWD [sodium 1 [lactose monohydrate] benzoate] LIDOCAINE HCL POWD SORBITOL SOLN 70 % 1 1 [lidocaine hcl (bulk)] [sorbitol] METHADONE HCL SQUARIC ACID 1 POWD DIBUTYLESTER POW [methadone hcl] 1 METOCLOPRAMIDE HCL DIBUTYLS [squaric acid MONOHYDRATE POWD dibutylester] 1 [metoclopramide hcl STERILE WATER FOR monohydrate] INJECTION SOLN [water 1 METRONIDAZOLE for injection, sterile] POWD [metronidazole 1 TESTOSTERONE PROPIONATE POWD (bulk)] 1 MORPHINE SULFATE [testosterone propionate POWD [morphine 1 (bulk)] sulfate] TRANEXAMIC ACID NEOMYCIN SULFATE POWD [tranexamic acid 1 POWD [neomycin 1 (bulk)] TRIAMCINOLONE sulfate (topical)] 1 ACETONIDE POWD

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 76 of 144

藥物等 藥物等 藥物名稱 規定／限制 藥物名稱 規定／限制 級 級 [triamcinolone acetonide promethazine-dm syrp 1 (topical)] 6.25-15 mg/5ml VERAPAMIL HCL POWD [Hydrocodone W/ 1 [verapamil hcl] Homatropine] TUSSIGON 1 ZINC SULFATE GRAN TABS 5-1.5 MG 1 [zinc sulfate] MUCOLYTIC AGENTS RESPIRATORY TRACT AGENTS SODIUM CHLORIDE ANTI-INFLAMMATORY AGENTS NEBU 0.9 % [sodium 1 ADVAIR HFA AERO 115- chloride (inhalant)] 21 MCG/ACT 1 SODIUM CHLORIDE [fluticasone-salmeterol] NEBU 10 % [sodium 1 ADVAIR HFA AERO 230- chloride (inhalant)] 21 MCG/ACT 1 SODIUM CHLORIDE [fluticasone-salmeterol] NEBU 3 % [sodium 1 ADVAIR HFA AERO 45-21 chloride (inhalant)] MCG/ACT [fluticasone- 1 SODIUM CHLORIDE salmeterol] NEBU 7 % [sodium 1 AEROSPAN AERS 80 chloride (inhalant)] MCG/ACT [flunisolide 1 PULMONARY SURFACTANTS hfa] CUROSURF SUSP 120 ALVESCO AERS 160 MG/1.5ML [poractant 1 1 MCG/ACT [ciclesonide] alfa] ALVESCO AERS 80 CUROSURF SUSP 240 1 1 MCG/ACT [ciclesonide] MG/3ML [poractant alfa] COMBIVENT RESPIMAT SURVANTA SUSP 25-0.9 AERS 20-100 MCG/ACT 1 MG/ML-% [beractant in 1 [ipratropium-albuterol] nacl] cromolyn sodium conc 1 RESPIRATORY AGENTS, MISCELLANEOUS 100 mg/5ml ARALAST NP SOLR 500 cromolyn sodium nebu 1 MG [alpha1-proteinase 1 QL - 30 day(s) 20 mg/2ml inhibitor (human)] montelukast sodium DALIRESP TABS 500 1 1 chew 4 mg MCG [roflumilast] montelukast sodium KALYDECO PACK 25 MG 1 1 QL - 30 day(s) chew 5 mg [ivacaftor] montelukast sodium OFEV CAPS 100 MG 1 1 pack 4 mg [nintedanib esylate] montelukast sodium OFEV CAPS 150 MG 1 1 tabs 10 mg [nintedanib esylate] ANTITUSSIVES ORKAMBI PACK 100-125 benzonatate caps 100 MG [lumacaftor- 1 QL - 30 day(s) 1 mg ivacaftor] hydrocodone- ORKAMBI PACK 150-188 homatropine syrp 5-1.5 1 MG [lumacaftor- 1 QL - 30 day(s) mg/5ml ivacaftor] promethazine-codeine ORKAMBI TABS 100-125 1 soln 6.25-10 mg/5ml MG [lumacaftor- 1 QL - 30 day(s) promethazine-dm soln ivacaftor] 1 6.25-15 mg/5ml

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 77 of 144

藥物等 藥物等 藥物名稱 規定／限制 藥物名稱 規定／限制 級 級 ORKAMBI TABS 200-125 DIGIFAB SOLR 40 MG 1 MG [lumacaftor- 1 [digoxin immune fab] ivacaftor] FLEBOGAMMA DIF SOLN SYMDEKO TBPK 100-150 0.5 GM/10ML [immune 1 & 150 MG [tezacaftor- 1 QL - 30 day(s) globulin (human) iv] ivacaftor] FLEBOGAMMA DIF SOLN SYMDEKO TBPK 50-75 & 2.5 GM/50ML [immune 1 75 MG [tezacaftor- 1 globulin (human) iv] ivacaftor] FLEBOGAMMA DIF SOLN TRIKAFTA TBPK 100-50- 20 GM/400ML [immune 1 75 & 150 MG globulin (human) iv] 1 QL - 30 day(s) [elexacaftor-tezacaftor- FLEBOGAMMA DIF SOLN ivacaftor] 5 GM/50ML [immune 1 TRIKAFTA TBPK 50-25- globulin (human) iv] 37.5 & 75 MG GAMASTAN INJ 1 QL - 30 day(s) [elexacaftor-tezacaftor- [immune globulin 1 ivacaftor] (human) im] XOLAIR SOLR 150 MG QL - 30 GAMMAGARD S/D LESS 1 [omalizumab] day(s),LD IGA SOLR 10 GM 1 XOLAIR SOSY 150 [immune globulin 1 QL - 30 day(s) MG/ML [omalizumab] (human) iv] XOLAIR SOSY 75 GAMMAGARD S/D LESS 1 QL - 30 day(s) MG/0.5ML [omalizumab] IGA SOLR 5 GM [immune 1 VASODILATING globulin (human) iv] TRACLEER TBSO 32 MG GAMMAGARD SOLN 1 1 QL - 30 day(s) GM/10ML [immune [bosentan] 1 SERUMS, TOXOIDS, AND VACCINES globulin (human) iv or subcutaneous] SERUMS GAMMAGARD SOLN 30 ANAVIP SOLR GM/300ML [immune [crotalidae immune 1 1 globulin (human) iv or f(ab')2 (equine)] subcutaneous] ANTIVENIN GAMMAKED SOLN 1 LATRODECTUS GM/10ML [immune MACTANS KIT 1 1 globulin (human) iv or [antivenin latrodectus subcutaneous] mactans] GAMMAKED SOLN 10 CARIMUNE NF SOLR 12 GM/100ML [immune GM [immune globulin 1 1 globulin (human) iv or (human) iv] subcutaneous] CARIMUNE NF SOLR 6 GAMMAKED SOLN 2.5 GM [immune globulin 1 GM/25ML [immune (human) iv] 1 globulin (human) iv or CROFAB SOLR subcutaneous] 1 [crotalidae polyvalent GAMMAKED SOLN 20 immune fab (ovine)] GM/200ML [immune CYTOGAM INJ 50 MG/ML 1 globulin (human) iv or [cytomegalovirus 1 subcutaneous] immune globulin (human)]

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 78 of 144

藥物等 藥物等 藥物名稱 規定／限制 藥物名稱 規定／限制 級 級 GAMMAKED SOLN 5 HYPERRAB S/D SOLN GM/50ML [immune 300 UNIT/2ML [rabies 1 1 globulin (human) iv or immune globulin subcutaneous] (human)] GAMMAPLEX SOLN 10 HYPERRAB SOLN 300 GM/200ML [immune 1 UNIT/ML [rabies immune 1 globulin (human) iv] globulin (human)] GAMMAPLEX SOLN 20 HYPERTET S/D INJ 250 GM/400ML [immune 1 UNIT/ML [tetanus 1 globulin (human) iv] immune globulin GAMMAPLEX SOLN 5 (human)] GM/100ML [immune 1 HYQVIA KIT 10 globulin (human) iv] GM/100ML [immune GAMUNEX-C SOLN 1 globulin (human)- 1 QL - 30 day(s) GM/10ML [immune hyaluronidase (human 1 globulin (human) iv or recombinant)] subcutaneous] HYQVIA KIT 2.5 GM/25ML GAMUNEX-C SOLN 10 [immune globulin 1 QL - 30 day(s) GM/100ML [immune (human)-hyaluronidase 1 globulin (human) iv or (human recombinant)] subcutaneous] HYQVIA KIT 20 GAMUNEX-C SOLN 2.5 GM/200ML [immune GM/25ML [immune globulin (human)- 1 QL - 30 day(s) 1 globulin (human) iv or hyaluronidase (human subcutaneous] recombinant)] GAMUNEX-C SOLN 20 HYQVIA KIT 30 GM/200ML [immune GM/300ML [immune 1 globulin (human) iv or globulin (human)- 1 QL - 30 day(s) subcutaneous] hyaluronidase (human GAMUNEX-C SOLN 5 recombinant)] GM/50ML [immune HYQVIA KIT 5 GM/50ML 1 [immune globulin globulin (human) iv or 1 QL - 30 day(s) subcutaneous] (human)-hyaluronidase HIZENTRA SOLN 1 (human recombinant)] GM/5ML [immune IMOGAM RABIES-HT 1 QL - 30 day(s) SOLN 300 UNIT/2ML globulin (human) 1 subcutaneous] [rabies immune globulin HIZENTRA SOLN 10 (human)] GM/50ML [immune MICRHOGAM ULTRA- 1 QL - 30 day(s) FILTERED PLUS SOSY globulin (human) 1 subcutaneous] 250 UNIT [rho d immune HIZENTRA SOLN 2 globulin (human)] GM/10ML [immune NABI-HB SOLN 1 QL - 30 day(s) globulin (human) [hepatitis b immune 1 subcutaneous] globulin (human)] HIZENTRA SOLN 4 OCTAGAM SOLN 1 GM/20ML [immune GM/20ML [immune 1 1 QL - 30 day(s) globulin (human) globulin (human) iv] subcutaneous]

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 79 of 144

藥物等 藥物等 藥物名稱 規定／限制 藥物名稱 規定／限制 級 級 OCTAGAM SOLN 2.5 AFLURIA SUSP GM/50ML [immune 1 [influenza virus vaccine 1 globulin (human) iv] split] OCTAGAM SOLN 25 BEXSERO SUSY GM/500ML [immune 1 [meningococcal vac 1 globulin (human) iv] group b (recombant omv ODACTRA SUBL 12 SQ- adjuvanted)] HDM [dust mite mixed 1 ENGERIX-B SUSP 10 allergen extract] MCG/0.5ML [hepatitis b 1 PRIVIGEN SOLN 10 vaccine (recomb)] GM/100ML [immune 1 ENGERIX-B SUSP 20 globulin (human) iv] MCG/ML [hepatitis b 1 PRIVIGEN SOLN 20 vaccine (recomb)] GM/200ML [immune 1 FLUAD SUSY 0.5 ML globulin (human) iv] [influenza virus vaccine 1 PRIVIGEN SOLN 5 types a & b surface GM/50ML [immune 1 antigen adjuvant] globulin (human) iv] FLUZONE HIGH-DOSE RHOGAM ULTRA- SUSY 0.5 ML [influenza 1 FILTERED PLUS SOSY virus vaccine split high- 1500 UNIT [rho d 1 dose preservative free] immune globulin FLUZONE SUSP (human)] [influenza virus vaccine 1 RHOPHYLAC SOSY 1500 split] UNIT/2ML [rho d immune 1 GARDASIL 9 SUSP globulin (human)] [human papillomavirus 1 TOXOIDS (hpv) 9-valent ADACEL SUSP 5-2-15.5 recombinant vaccine] LF-MCG/0.5 [tetanus GARDASIL 9 SUSY [human papillomavirus toxoid-diphtheria- 1 1 acellular pertussis (hpv) 9-valent adsorb (tdap)] recombinant vaccine] DIPHTHERIA-TETANUS GARDASIL INJ TOXOIDS DT SUSP 25-5 [human papillomavirus 1 1 LFU/0.5ML [diphtheria- (hpv) quadrivalent tetanus toxoids (dt)] recombinant vaccine] INFANRIX SUSP 25-58-10 GARDASIL SUSP [diphtheria, acellular [human papillomavirus 1 1 pertussis & tetanus (hpv) quadrivalent toxoids] recombinant vaccine] TDVAX SUSP 2-2 HAVRIX SUSP 1440 EL LF/0.5ML [tetanus- 1 U/ML [hepatitis a 1 diphtheria toxoids (td)] vaccine] VACCINES HAVRIX SUSP 720 EL ACTHIB SOLR U/0.5ML [hepatitis a 1 [haemophilus b polysac 1 vaccine] conj vac] HIBERIX SOLR 10 MCG [haemophilus b polysac 1 conj vac]

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 80 of 144

藥物等 藥物等 藥物名稱 規定／限制 藥物名稱 規定／限制 級 級 IMOVAX RABIES INJ 2.5 ROTATEQ SOLN UNIT/ML [rabies virus 1 [rotavirus vaccine, live 1 vaccine, hdc] oral pentavalent] IPOL INJ [poliovirus SHINGRIX SUSR 50 1 vaccine, ipv] MCG/0.5ML [zoster 1 IXIARO SUSP [japanese vaccine recombinant encephalitis vaccine 1 adjuvanted] inactivated adsorbed] TICE BCG SUSR 50 MG 1 KINRIX SUSP [diph- [bcg live intravesical] tetanus tox ad-acell TWINRIX SUSY 720-20 1 pertussis & polio virus, ELU-MCG/ML [hepatitis a 1 ipv vac] (inactivated)-hepatitis b M-M-R II SOLR (recombinant) vaccines] [measles, mumps & 1 TYPHIM VI SOLN 25 rubella virus vaccines] MCG/0.5ML [typhoid vi 1 MENVEO SOLR polysaccharide vaccine] [meningococcal VAQTA SUSP 25 (a,c,y&w-135) 1 UNIT/0.5ML [hepatitis a 1 oligosaccharide vaccine] conjugate vac] VAQTA SUSP 50 PEDIARIX SUSP [diph- UNIT/ML [hepatitis a 1 tetanus tox-acell pert- vaccine] 1 hepatitis b recomb-polio VARIVAX INJ 1350 ipv vac] PFU/0.5ML [varicella 1 PNEUMOVAX 23 INJ 25 virus vaccine live] MCG/0.5ML VAXCHORA SUSR 1 [pneumococcal vac [cholera vaccine live 1 polyvalent] attenuated] PREVNAR 13 SUSP VIVOTIF CPDR [typhoid 1 [pneumococcal 13-valent 1 vaccine] conjugate vaccine] YF-VAX INJ [yellow 1 PROQUAD SUSR fever vaccine] [measles-mumps- 1 SKIN AND MUCOUS MEMBRANE AGENTS rubella-varicella virus ANTI-INFECTIVES vaccines] AKTIPAK PACK 5-3 % RABAVERT SUSR 1 [benzoyl peroxide- 1

[rabies vaccine, pcec] erythromycin] RECOMBIVAX HB SUSP benzoyl peroxide- 10 MCG/ML 1 1 [hepatitis b erythromycin gel 5-3 % vaccine (recomb)] clindamycin phos- RECOMBIVAX HB SUSP 1 benzoyl perox gel 1-5 % 40 MCG/ML [hepatitis b 1 clindamycin phos- vaccine (recomb)] benzoyl perox gel 1.2-5 1 RECOMBIVAX HB SUSP % 5 MCG/0.5ML 1 [hepatitis b clindamycin phosphate vaccine (recomb)] 1 crea 2 % ROTARIX SUSR clindamycin phosphate [rotavirus vaccine, live 1 1 gel 1 % oral]

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 81 of 144

藥物等 藥物等 藥物名稱 規定／限制 藥物名稱 規定／限制 級 級 clindamycin phosphate betamethasone 1 lotn 1 % dipropionate aug gel 1 clindamycin phosphate 0.05 % 1 soln 1 % betamethasone clotrimazole troc 10 mg 1 dipropionate aug lotn 1 erythromycin soln 2 % 1 0.05 % gentamicin sulfate crea betamethasone 1 0.1 % dipropionate aug oint 1 gentamicin sulfate oint 0.05 % 1 0.1 % BETAMETHASONE DIPROPIONATE CREA HYDROCORTISONE- 1 IODOQUINOL CREA 1-1 1 0.05 % [betamethasone % [iodoquinol-hc] dipropionate (topical)] ketoconazole sham 2 % 1 BETAMETHASONE VALERATE CREA 0.1 % malathion lotn 0.5 % 1 1 [betamethasone metronidazole crea 0.75 1 valerate] % betamethasone valerate metronidazole gel 0.75 % 1 1 foam 0.12 % metronidazole lotn 0.75 1 BETAMETHASONE % VALERATE LOTN 0.1 % 1 mupirocin oint 2 % 1 [betamethasone neomycin-polymyxin b 1 valerate] gu soln 40-200000 BETAMETHASONE nystatin crea 100000 VALERATE OINT 0.1 % 1 1 unit/gm [betamethasone [Nystatin (topical)] valerate] NYSTOP POWD 100000 1 clobetasol propionate 1 UNIT/GM crea 0.05 % permethrin crea 5 % 1 clobetasol propionate selenium sulfide lotn 2.5 1 1 foam 0.05 % % clobetasol propionate 1 SILVER SULFADIAZINE gel 0.05 % CREA 1 % [silver 1 clobetasol propionate 1 sulfadiazine] lotn 0.05 % SULFAMYLON CREA 85 clobetasol propionate 1 MG/GM [mafenide 1 oint 0.05 % acetate] clobetasol propionate 1 ANTI-INFLAMMATORY AGENTS soln 0.05 % alclometasone CLOBEX LOTN 0.05 % 1 1 dipropionate crea 0.05 % [clobetasol propionate] alclometasone CLOBEX SPRAY LIQD 1 dipropionate oint 0.05 % 0.05 % [clobetasol 1 ANUCORT-HC SUPP 25 propionate] MG [hydrocortisone 1 CORDRAN TAPE 4 acetate (rectal)] MCG/SQCM 1 betamethasone [flurandrenolide] dipropionate aug crea 1 0.05 %

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 82 of 144

藥物等 藥物等 藥物名稱 規定／限制 藥物名稱 規定／限制 級 級 CORTISPORIN CREA nystatin-triamcinolone 3.5-10000-0.5 [neomycin- 1 crea 100000-0.1 unit/gm- 1 polymyxin-hc] % CORTISPORIN OINT 1 % nystatin-triamcinolone [bacitracin-polymyxin- 1 oint 100000-0.1 unit/gm- 1 neomycin hc] % desonide oint 0.05 % 1 [Pramoxine-hc] [Desonide] DESOWEN PRAMOSONE CREA 1-1 1 1 LOTN 0.05 % % desoximetasone crea [Pramoxine-hc] 1 0.25 % PRAMOSONE LOTN 1-1 1 fluocinolone acetonide % 1 body oil 0.01 % [Pramoxine-hc] fluocinolone acetonide PRAMOSONE LOTN 1- 1 1 scalp oil 0.01 % 2.5 % fluocinolone acetonide PRAMOSONE OINT 1-1 1 1 soln 0.01 % % [pramoxine-hc] PRAMOSONE OINT 1-2.5 fluocinonide crea 0.05 % 1 1 fluocinonide gel 0.05 % 1 % [pramoxine-hc] fluocinonide oint 0.05 % 1 [Hydrocortisone (rectal)] PROCTOSOL HC CREA 1 fluocinonide soln 0.05 % 1 2.5 % fluticasone propionate 1 triamcinolone acetonide crea 0.05 % 1 crea 0.025 % fluticasone propionate 1 triamcinolone acetonide oint 0.005 % 1 crea 0.1 % halobetasol propionate 1 triamcinolone acetonide crea 0.05 % 1 crea 0.5 % halobetasol propionate 1 triamcinolone acetonide oint 0.05 % 1 lotn 0.1 % HYDROCORTISONE triamcinolone acetonide ACE-PRAMOXINE CREA 1 1 oint 0.025 % 2.5-1 % [pramoxine-hc] triamcinolone acetonide 1 1 hydrocortisone crea 1 % oint 0.1 % hydrocortisone crea 2.5 triamcinolone acetonide 1 1 % oint 0.5 % hydrocortisone enem triamcinolone acetonide 1 1 100 mg/60ml pste 0.1 % hydrocortisone lotn 2.5 1 ANTIPRURITICS AND LOCAL ANESTHETICS % [Hydrocortisone Acetate hydrocortisone oint 2.5 1 W/ Pramoxine] % 1 ANALPRAM-HC CREA 1- mometasone furoate 1 1 % crea 0.1 % [Hydrocortisone Acetate mometasone furoate oint 1 W/ Pramoxine] 0.1 % 1 ANALPRAM-HC LOTN mometasone furoate 1 2.5-1 % soln 0.1 % HYDROCORT- 1 PRAMOXINE (PERIANAL)

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藥物等 藥物等 藥物名稱 規定／限制 藥物名稱 規定／限制 級 級 CREA 2.5-1 % OXSORALEN ULTRA [hydrocortisone acetate CAPS 10 MG 1 w/ pramoxine] [methoxsalen rapid] hydrocortisone ace- 1 KERATOLYTIC AGENTS pramoxine crea 1-1 % KERALYT GEL 6 % 1 lidocaine hcl soln 4 % 1 [salicylic acid] lidocaine hcl 1 SULFACETAMIDE urethral/mucosal gel 2 % SODIUM-SULFUR EMUL 1 lidocaine hcl 10-5 % [sulfacetamide urethral/mucosal prsy 2 1 sodium w/ sulfur] % SULFACETAMIDE lidocaine oint 5 % 1 SODIUM-SULFUR LOTN 1 lidocaine-prilocaine crea 10-5 % [sulfacetamide 1 2.5-2.5 % sodium w/ sulfur] lidocaine-prilocaine kit SULFACETAMIDE 1 SODIUM-SULFUR SUSP 2.5-2.5 % 1 [Hydrocortisone Acetate 10-5 % [sulfacetamide W/ Pramoxine] sodium w/ sulfur] 1 PROCTOFOAM HC SULFACETAMIDE FOAM 1-1 % SODIUM-SULFUR SUSP 1 ASTRINGENTS 8-4 % [sulfacetamide DRYSOL SOLN 20 % sodium w/ sulfur] 1 [aluminum chloride] SKIN AND MUCOUS MEMBRANE AGENTS, CELL STIMULANTS AND PROLIFERANTS MISCELLANEOUS AVITA CREA 0.025 % acitretin caps 10 mg 1 QL - 30 day(s) 1 [tretinoin] acitretin caps 25 mg 1 QL - 30 day(s) KEPIVANCE SOLR 6.25 adapalene gel 0.1 % 1 1 QL - 30 day(s) MG [palifermin] adapalene gel 0.3 % 1 RETIN-A CREA 0.025 % adapalene-benzoyl 1 1 [tretinoin] peroxide gel 0.1-2.5 % RETIN-A CREA 0.05 % calcipotriene crea 0.005 1 1 [tretinoin] % RETIN-A CREA 0.1 % calcipotriene soln 0.005 1 1 [tretinoin] % RETIN-A GEL 0.01 % [Isotretinoin] CLARAVIS 1 1 QL - 30 day(s) [tretinoin] CAPS 10 MG RETIN-A GEL 0.025 % [Isotretinoin] CLARAVIS 1 1 QL - 30 day(s) [tretinoin] CAPS 20 MG RETIN-A MICRO GEL [Isotretinoin] CLARAVIS 1 QL - 30 day(s) 0.04 % [tretinoin 1 CAPS 30 MG microsphere] [Isotretinoin] CLARAVIS 1 QL - 30 day(s) RETIN-A MICRO GEL 0.1 CAPS 40 MG % [tretinoin 1 CONDYLOX GEL 0.5 % 1 microsphere] [podofilox] DEPIGMENTING AND PIGMENTING AGENTS COSENTYX (300 MG methoxsalen rapid caps DOSE) SOSY 150 MG/ML 1 QL - 30 day(s) 1 10 mg [secukinumab] COSENTYX 1 QL - 30 day(s) SENSOREADY (300 MG)

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 84 of 144

藥物等 藥物等 藥物名稱 規定／限制 藥物名稱 規定／限制 級 級 SOAJ 150 MG/ML TARGRETIN GEL 1 % 1 [secukinumab] [bexarotene (topical)] COSENTYX tazarotene crea 0.1 % 1 SENSOREADY PEN TAZORAC CREA 0.05 % 1 QL - 30 day(s) 1 SOAJ 150 MG/ML [tazarotene] [secukinumab] TAZORAC GEL 0.05 % COSENTYX SOSY 150 1 1 QL - 30 day(s) [tazarotene] MG/ML [secukinumab] TAZORAC GEL 0.1 % diclofenac sodium gel 1 1 1 [tazarotene] % TREMFYA SOPN 100 diclofenac sodium soln 1 1 MG/ML [guselkumab] 1.5 % TREMFYA SOSY 100 DIFFERIN CREA 0.1 % 1 1 MG/ML [guselkumab] [adapalene] VECTICAL OINT 3 DIFFERIN GEL 0.3 % 1 MCG/GM [calcitriol 1 [adapalene] (topical)] DRITHO-CREME HP 1 SMOOTH MUSCLE RELAXANTS CREA 1 % [anthralin] GENITOURINARY SMOOTH MUSCLE EPIDUO FORTE GEL 0.3- RELAXANTS 2.5 % [adapalene- 1 MYRBETRIQ TB24 25 MG 1 benzoyl peroxide] [mirabegron] FLUOROPLEX CREA 1 % MYRBETRIQ TB24 50 MG 1 1 [fluorouracil (topical)] [mirabegron] fluorouracil crea 5 % 1 oxybutynin chloride er 1 fluorouracil soln 2 % 1 tb24 10 mg fluorouracil soln 5 % 1 oxybutynin chloride er 1 imiquimod crea 5 % 1 tb24 15 mg LEVULAN KERASTICK oxybutynin chloride er 1 SOLR 20 % 1 tb24 5 mg [aminolevulinic acid hcl] oxybutynin chloride syrp 1 pimecrolimus crea 1 % 1 5 mg/5ml PODOCON SOLN 25 % oxybutynin chloride tabs 1 1 [podophyllum resin] 5 mg solifenacin succinate podofilox soln 0.5 % 1 1 SANTYL OINT 250 tabs 10 mg 1 solifenacin succinate UNIT/GM [collagenase] 1 SKYRIZI (150 MG DOSE) tabs 5 mg trospium chloride er PSKT 75 MG/0.83ML 1 1 [risankizumab-rzaa] cp24 60 mg STELARA SOLN 45 trospium chloride tabs 1 1 MG/0.5ML [ustekinumab] 20 mg STELARA SOSY 45 RESPIRATORY SMOOTH MUSCLE RELAXANTS 1 MG/0.5ML aminophylline soln 25 [ustekinumab] 1 STELARA SOSY 90 mg/ml 1 MG/ML theophylline er tb12 100 [ustekinumab] 1 TACROLIMUS OINT 0.03 mg 1 % theophylline er tb12 200 [tacrolimus (topical)] 1 TACROLIMUS OINT 0.1 mg 1 % [tacrolimus (topical)]

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 85 of 144

藥物等 藥物等 藥物名稱 規定／限制 藥物名稱 規定／限制 級 級 theophylline er tb12 300 [pediatric multivitamins 1 mg w/fl] theophylline er tb12 450 MVC-FLUORIDE CHEW 1 mg 0.25 MG [pediatric 1 theophylline er tb24 400 multivitamins w/fl] 1 mg MVC-FLUORIDE CHEW THEOPHYLLINE IN D5W 0.5 MG [pediatric 1 SOLN 0.8-5 MG/ML-% multivitamins w/fl] 1 [theophylline in MVC-FLUORIDE CHEW 1 dextrose] MG [pediatric 1 VITAMINS multivitamins w/fl] MULTIVITAMIN PREPARATIONS RENAL CAPS 1 MG [b- 1 INFUVITE ADULT INJ complex w/ c & folic 1 [multiple vitamin] acid] INFUVITE PEDIATRIC TRI-VIT/FLUORIDE SOLN 0.5 MG/ML 1 SOLN [pediatric multiple 1 [pediatric vitamins] vitamins acd w/ fluoride] VITAMINS ACD- pediatric multivitamins 1 FLUORIDE SOLN 0.25 w/fl chew 1 MG/ML pediatric multivitamins [pediatric 1 w/fl chew vitamins acd w/ fluoride] MULTI-VIT/FLUORIDE VITAMIN A SOLN 0.5 MG/ML AQUASOL A SOLN 15 1 1 [pediatric multivitamins MG/ML [vitamin a] w/fl] VITAMIN B COMPLEX cyanocobalamin soln MULTI- 1 VIT/FLUORIDE/IRON 1000 mcg/ml SOLN 0.25-10 MG/ML 1 folic acid soln 5 mg/ml 1 [ped multivitamins w/fl & POTABA CAPS 500 MG iron] [potassium 1 MULTI- aminobenzoate] VIT/IRON/FLUORIDE pyridoxine hcl soln 100 1 SOLN 0.25-10 MG/ML 1 mg/ml [ped multivitamins w/fl & thiamine hcl soln 100 1 iron] mg/ml MULTIVITAMIN/FLUORID VITAMIN C E CHEW 0.25 MG 1 ASCORBIC ACID SOLN [pediatric multivitamins 500 MG/ML [ascorbic 1 w/fl] acid] MULTIVITAMIN/FLUORID VITAMIN D E CHEW 0.5 MG 1 calcitriol caps 0.25 mcg 1 [pediatric multivitamins 1 w/fl] calcitriol caps 0.5 mcg vitamin d (ergocalciferol) MULTIVITAMIN/FLUORID 1 E CHEW 1 MG [pediatric 1 caps 1.25 mg (50000 ut) multivitamins w/fl] VITAMIN K ACTIVITY MULTIVITAMIN/FLUORID MEPHYTON TABS 5 MG 1 1 E SOLN 0.25 MG/ML [phytonadione]

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 86 of 144

藥物等 藥物名稱 規定／限制 級 phytonadione soln 1 1 mg/0.5ml vitamin k1 soln 1 1 mg/0.5ml vitamin k1 soln 10 mg/ml 1

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 87 of 144

藥物等 藥物等 藥物名稱 規定／限制 藥物名稱 規定／限制 級 級 NICORETTE GUM 2 MG ANTI-INFECTIVE AGENTS 1 OTC ANTHELMINTICS [nicotine polacrilex] NICORETTE LOZG 2 MG REESES PINWORM 1 OTC MEDICINE SUSP 144 (50 [nicotine polacrilex] 1 OTC NICORETTE LOZG 4 MG Base) MG/ML [pyrantel 1 OTC pamoate] [nicotine polacrilex] ANTIHISTAMINE DRUGS NICORETTE MINI LOZG FIRST GENERATION ANTIHISTAMINES 2 MG [nicotine 1 OTC polacrilex] loratadine syrp 5 mg/5ml 1 OTC nicotine polacrilex gum CHLORPHENIRAMINE 1 OTC 2 mg MALEATE TABS 4 MG 1 OTC nicotine polacrilex gum [chlorpheniramine 1 OTC 4 mg maleate] nicotine polacrilex lozg 2 DIMAPHEN CHILDRENS 1 OTC mg ELIX 1-2.5 MG/5ML 1 OTC nicotine pt24 14 mg/24hr 1 OTC [brompheniramine & phenyleph] nicotine pt24 21 mg/24hr 1 OTC DIPHENHIST LIQD 12.5 nicotine pt24 7 mg/24hr 1 OTC MG/5ML 1 OTC SYMPATHOMIMETIC (ADRENERGIC) AGENTS [diphenhydramine hcl] KP PSEUDOEPHEDRINE DIPHENHYDRAMINE HCL TABS 60 MG 1 OTC HCL CAPS 25 MG 1 OTC [pseudoephedrine hcl] [diphenhydramine hcl] PSEUDOEPHEDRINE DIPHENHYDRAMINE HCL TABS 30 MG 1 OTC HCL CAPS 50 MG 1 OTC [pseudoephedrine hcl] [diphenhydramine hcl] S2 (RACEPINEPHRINE) ED CHLORPED JR SYRP NEBU 2.25 % 1 OTC 2 MG/5ML [racepinephrine hcl] 1 OTC [chlorpheniramine BLOOD FORMATION, COAGULATION, AND maleate] THROMBOSIS HISTEX-PE SYRP 2.5-10 ANTIANEMIA DRUGS MG/5ML [triprolidine- 1 OTC FERREX 150 CAPS 150 phenylephrine] MG [polysaccharide iron 1 OTC J-TAN PD LIQD 1 MG/ML complex] [brompheniramine 1 OTC FERROUS SULFATE maleate] SOLN 75 (15 Fe) MG/ML 1 OTC loratadine tabs 10 mg 1 OTC [ferrous sulfate] LORTUSS LQ LIQD 6.25- FERROUS SULFATE 30 MG/5ML [doxylamine- 1 OTC TABS 325 (65 Fe) MG 1 OTC pseudoephedrine] [ferrous sulfate] POLY HIST FORTE TABS PROFERRIN ES TABS 12 7.5-10 MG [doxylamine- 1 OTC MG [iron heme 1 OTC phenylephrine] polypeptide] AUTONOMIC DRUGS CENTRAL NERVOUS SYSTEM AGENTS AUTONOMIC DRUGS, MISCELLANEOUS ANALGESICS AND ANTIPYRETICS nicotine polacrilex lozg 4 1 OTC BAYER ADVANCED mg ASPIRIN EX ST TABS 1 OTC 500 MG [aspirin]

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 88 of 144

藥物等 藥物等 藥物名稱 規定／限制 藥物名稱 規定／限制 級 級 GOODSENSE PAIN ML [insulin RELIEF EXTRA ST TABS 1 OTC syringe/needle u-100] 500 MG [acetaminophen] BD INSULIN SYRINGE acetaminophen tbcr 650 U/F MISC 30G X 1/2" 1 1 OTC 1 OTC mg ML [insulin PAIN & FEVER syringe/needle u-100] CHILDRENS SOLN 160 BD INSULIN SYRINGE 1 OTC MG/5ML U/F MISC 31G X 5/16" 0.3 1 OTC [acetaminophen] ML [insulin PAIN RELIEVER TABS syringe/needle u-100] 1 OTC 325 MG [acetaminophen] BD INSULIN SYRINGE U/F MISC 31G X 5/16" 0.5 TRI-BUFFERED ASPIRIN 1 OTC TABS 325 MG [aspirin ML [insulin 1 OTC buffered (cal carb-mag syringe/needle u-100] carb-mag oxide)] BD INSULIN SYRINGE U/F MISC 31G X 5/16" 1 DEVICES 1 OTC DEVICES ML [insulin BD 3ML LUER-LOK syringe/needle u-100] SYRINGE/22G X 1-1/4" [Insulin Syringe/needle U- 100] BD INSULIN MIS 22GX1.25 1 OTC 1 OTC SYRINGE ULTRAFINE [syringe/needle (disp) 3 MISC 31G X 5/16" 0.5 ML ml] BD INSULIN SYRINGE [Insulin Syringe/needle U- MICROFINE MISC 27G X 100] BD INTEGRA 1 OTC INSULIN SYRINGE/U- 1 OTC 5/8" 1 ML [insulin 100/1ML/29G X 1/2" MIS syringe/needle u-100] [Insulin Syringe/needle U- 1ML/29G 100] BD INSULIN BD INTEGRA SYRINGE 1 OTC MISC 25G X 5/8" 3 ML SYRINGE MICROFINE 1 OTC MISC 28G X 1/2" 0.3 ML [syringe/needle (disp) 3

BD INSULIN SYRINGE ml] BD LANCET DEVICE MIS MISC 25G X 1" 1 ML 1 OTC DEVICE 1 OTC [insulin syringe/needle [lancet u-100] devices] BD LANCET ULTRAFINE BD INSULIN SYRINGE 1 OTC 33G MISC MISC 27G X 1/2" 1 ML [lancets] 1 OTC [insulin syringe/needle BD PEN NEEDLE MINI u-100] U/F MISC 31G X 5 MM 1 OTC BD INSULIN SYRINGE [insulin pen needle] U/F 1/2UNIT MISC 31G X BD PEN NEEDLE NANO 1 OTC 5/16" 0.3 ML [insulin U/F MISC 32G X 4 MM 1 OTC syringe/needle u-100] [insulin pen needle] BD INSULIN SYRINGE BD PEN NEEDLE U/F MISC 30G X 1/2" 0.3 ORIGINAL U/F MISC 29G 1 OTC 1 OTC ML [insulin X 12.7MM [insulin pen syringe/needle u-100] needle] BD INSULIN SYRINGE BD PEN NEEDLE SHORT 1 OTC U/F MISC 30G X 1/2" 0.5 U/F MISC 31G X 8 MM 1 OTC [insulin pen needle]

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 89 of 144

藥物等 藥物等 藥物名稱 規定／限制 藥物名稱 規定／限制 級 級 BD SAFETYGLIDE glucose monitoring INSULIN SYRINGE MISC supplies] 29G X 1/2" 0.3 ML 1 OTC ONETOUCH ULTRASOFT [insulin syringe/needle LANCETS MISC 1 OTC u-100] [lancets] BD SAFETYGLIDE ONETOUCH VERIO SYRINGE/NEEDLE MISC SOLN HIGH [blood 1 OTC 27G X 5/8" 1 ML 1 OTC glucose calibration] [syringe/needle (disp) 1 PEDIATRIC SMALL 1 OTC ml] MASK MISC [masks] BD VEO INSULIN SYR PENLET II BLOOD U/F 1/2UNIT MISC 31G X SAMPLER KIT 1 OTC 1 OTC [lancets 15/64" 0.3 ML [insulin misc.] syringe/needle u-100] PRODIGY CONTROL BD VEO INSULIN SOLUTION SOLN LOW 1 OTC SYRINGE U/F MISC 31G 1 OTC [blood glucose X 15/64" 0.3 ML [insulin calibration] syringe/needle u-100] SURE COMFORT BD VEO INSULIN INSULIN SYRINGE MISC SYRINGE U/F MISC 31G 28G X 1/2" 0.5 ML 1 OTC 1 OTC X 15/64" 0.5 ML [insulin [insulin syringe/needle syringe/needle u-100] u-100] BD VEO INSULIN SURE COMFORT SYRINGE U/F MISC 31G INSULIN SYRINGE MISC 1 OTC 1 OTC X 15/64" 1 ML [insulin 28G X 1/2" 1 ML [insulin syringe/needle u-100] syringe/needle u-100] CLICKFINE PEN SURE COMFORT NEEDLES MISC 31G X 6 1 OTC INSULIN SYRINGE MISC MM [insulin pen needle] 29G X 1/2" 0.3 ML 1 OTC CONTOUR NEXT [insulin syringe/needle CONTROL SOLN u-100] 1 OTC NORMAL [blood glucose SURE COMFORT calibration] INSULIN SYRINGE MISC DISPOSABLE POWER 29G X 1/2" 0.5 ML 1 OTC 1 OTC KIT [misc. devices] [insulin syringe/needle ONETOUCH DELICA u-100] LANCETS 33G MISC 1 OTC SURE COMFORT [lancets] INSULIN SYRINGE MISC ONETOUCH FINEPOINT 30G X 1/2" 0.3 ML 1 OTC LANCETS MISC 1 OTC [insulin syringe/needle [lancets] u-100] ONETOUCH SURESOFT SURE COMFORT LANCING DEV MISC 1 OTC INSULIN SYRINGE MISC [lancets misc.] 30G X 1/2" 0.5 ML 1 OTC ONETOUCH ULTRA [insulin syringe/needle CONTROL SOLN [blood 1 OTC u-100] glucose calibration] SURE COMFORT ONETOUCH ULTRA MINI INSULIN SYRINGE MISC 1 OTC 1 OTC KIT W/DEVICE [blood 30G X 1/2" 1 ML [insulin syringe/needle u-100]

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 90 of 144

藥物等 藥物等 藥物名稱 規定／限制 藥物名稱 規定／限制 級 級 SURE COMFORT PHLEXY-10 PACK INSULIN SYRINGE MISC [nutritional 1 OTC 1 OTC 30G X 5/16" 1 ML [insulin supplements] syringe/needle u-100] EYE, EAR, NOSE, AND THROAT (EENT) SURE COMFORT PREPARATIONS INSULIN SYRINGE MISC ANTI-INFLAMMATORY AGENTS 31G X 5/16" 0.3 ML 1 OTC FLONASE SENSIMIST [insulin syringe/needle SUSP 27.5 MCG/SPRAY 1 OTC u-100] [fluticasone furoate] SURE COMFORT fluticasone propionate INSULIN SYRINGE MISC 1 OTC 1 OTC susp 50 mcg/act 31G X 5/16" 1 ML [insulin EENT DRUGS, MISCELLANEOUS syringe/needle u-100] NASAL DECONGESTANT [Insulin Syringe/needle U- PE MAX ST TABS 10 MG 100] TERUMO INSULIN 1 OTC SYRINGE/U- 1 OTC [phenylephrine hcl

100/0.5ML/27G X 1/2" MIS (oral)] 0.5/27G GASTROINTESTINAL DRUGS ULTRA THIN LANCETS ANTACIDS AND ADSORBENTS 1 OTC 30G MISC [lancets] ANTACID SUSP 200-200- ULTRA-COMFORT 20 MG/5ML [alum & mag 1 OTC INSULIN SYRINGE MISC hydrox-simethicone] 31G X 5/16" 0.3 ML 1 OTC BISMATROL MAXIMUM STRENGTH SUSP 525 [insulin syringe/needle 1 OTC u-100] MG/15ML [bismuth DIAGNOSTIC AGENTS subsalicylate] DIAGNOSTIC AGENTS BISMATROL SUSP 262 MG/15ML [bismuth 1 OTC ACETEST TAB TABLETS 1 OTC subsalicylate] [acetone (urine) test] BISMUTH ALBUSTIX STRP 1 OTC SUBSALICYLATE CHEW [albumin (urine) test] 1 OTC 262 MG [bismuth CHEMSTRIP 9 STRP 1 OTC subsalicylate] [multiple urine tests] CALCIUM CARBONATE DIASTIX STRP [glucose TABS 1250 (500 Ca) MG 1 OTC urine test-(glucose 1 OTC [calcium carbonate] oxidase)] CALCIUM GLUCONATE KETO-DIASTIX STRP TABS 500 MG [calcium 1 OTC [urine glucose-ketones 1 OTC gluconate] test] GELUSIL CHEW 200-200- KETOSTIX STRP 1 OTC 25 MG [alum & mag 1 OTC [acetone (urine) test] hydrox-simethicone] ONETOUCH ULTRA 1 OTC MAG-AL LIQD 200-200 STRP [glucose blood] MG/5ML [aluminum & 1 OTC ELECTROLYTIC, CALORIC, AND WATER magnesium hydroxide] BALANCE MAGNEBIND 300 TABS CALORIC AGENTS 250-300 MG [calcium 1 OTC PHENEX-1 POWD carbonate-magnesium [nutritional 1 OTC carbonate] supplements]

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 91 of 144

藥物等 藥物等 藥物名稱 規定／限制 藥物名稱 規定／限制 級 級 MI-ACID MAXIMUM HUMULIN R SOLN 100 STRENGTH SUSP 400- UNIT/ML [insulin regular 1 OTC 400-40 MG/5ML [alum & 1 OTC (human)] mag hydrox- CONTRACEPTIVES simethicone] [Levonorgestrel SM FOAMING ANTACID (emergency Oc)] CHEW 80-20 MG 1 OTC 1 OTC ECONTRA EZ TABS 1.5 [aluminum hydroxide- MG mag trisil] PHARMACEUTICAL AIDS SM STOMACH RELIEF PHARMACEUTICAL AIDS TABS 262 MG [bismuth 1 OTC BIOTIN-D POWD [biotin subsalicylate] 1 OTC (bulk)] ANTIDIARRHEA AGENTS BORIC ACID POWD 1 OTC PEPTIC RELIEF CHEW [boric acid (bulk)] 262 MG 1 OTC [bismuth CHOLESTEROL POWD 1 OTC subsalicylate] [cholesterol] ANTIEMETICS COLLODION FLEXIBLE MECLIZINE HCL TABS 1 OTC 1 OTC LIQD [collodion flexible] 12.5 MG [meclizine hcl] GLYCERIN LIQD MECLIZINE HCL TABS 25 1 OTC 1 OTC [glycerin (bulk)] MG [meclizine hcl] HYDROPHILIC OINT 1 OTC TRAVEL SICKNESS [hydrophilic ointment] CHEW 25 MG [meclizine 1 OTC L-ARGININE POWD 1 OTC hcl] [arginine] CATHARTICS AND LAXATIVES L-CITRULLINE POWD 1 OTC DOCUSATE SODIUM [citrulline (bulk)] CAPS 100 MG [docusate 1 OTC L-ISOLEUCINE POWD 1 OTC sodium] [isoleucine] SORBITOL SOLN 70 % 1 OTC L-VALINE POWD [valine] 1 OTC [sorbitol (laxative)] LACTIC ACID SOLN 1 OTC HORMONES AND SYNTHETIC SUBSTITUTES [lactic acid (bulk)] ANTIDIABETIC AGENTS LACTOSE POWD 1 OTC HUMULIN 70/30 [lactose] KWIKPEN SUPN (70-30) POLYETHYLENE 1 OTC 100 UNIT/ML [insulin nph GLYCOL 400 LIQD 1 OTC isophane & reg (human)] [polyethylene glycol 400] HUMULIN 70/30 SUSP PROPYLENE GLYCOL (70-30) 100 UNIT/ML LIQD [propylene glycol 1 OTC 1 OTC [insulin nph isophane & (bulk)] SULFUR PRECIPITATED reg (human)] 1 OTC HUMULIN N KWIKPEN POWD [sulfur (bulk)] SUPN 100 UNIT/ML THYMOL CRYS [thymol] 1 OTC 1 OTC [insulin nph (human) UREA POWD [urea 1 OTC (isophane)] (bulk)] HUMULIN N SUSP 100 ZINC SULFATE UNIT/ML [insulin nph 1 OTC HEPTAHYDRATE POWD 1 OTC (human) (isophane)] [zinc sulfate]

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 92 of 144

藥物等 藥物等 藥物名稱 規定／限制 藥物名稱 規定／限制 級 級 ZINC SULFATE [Miconazole Nitrate MONOHYDRATE POWD 1 OTC Vaginal] VAGISTAT-3 KIT 1 OTC [zinc sulfate] 200 & 2 MG-% (9GM) RESPIRATORY TRACT AGENTS ANTI-INFLAMMATORY AGENTS ANTITUSSIVES AQUANIL HC LOTN 1 % CHERATUSSIN AC SYRP [hydrocortisone 1 OTC 100-10 MG/5ML 1 OTC (topical)] [guaifenesin-codeine] GNP PHENYLHISTINE DH LIQ HYDROCORTISONE DH [pseudoeph- 1 OTC CREA 0.5 % 1 OTC chlorphen w/ cod] [hydrocortisone phenylephrine- (topical)] 1 OTC chlorphen-dm liqd HYDROCORTISONE CREA 0.5 % VIRTUSSIN DAC SOLN 1 OTC 30-10-100 MG/5ML [hydrocortisone 1 OTC [pseudoephedrine w/ (topical)] codeine-gg] HYDROCORTISONE OINT 0.5 % SKIN AND MUCOUS MEMBRANE AGENTS 1 OTC [hydrocortisone ANTI-INFECTIVES (topical)] clotrimazole crea 1 % 1 OTC HYDROCORTISONE DAKINS (1/4 STRENGTH) OINT 1 % 1 OTC SOLN 0.125 % [sodium 1 OTC [hydrocortisone hypochlorite] (topical)] DAKINS (FULL KP HYDROCORTISONE STRENGTH) SOLN 0.5 % 1 OTC CREA 1 % 1 OTC [sodium hypochlorite] [hydrocortisone DOUBLE ANTIBIOTIC (topical)] OINT 500-10000 UNIT/GM 1 OTC ANTIPRURITICS AND LOCAL ANESTHETICS [bacitracin-polymyxin b] PHENOL LIQD [phenol] 1 OTC EQ MICONAZOLE 7 SARNA LOTN 0.5-0.5 % CREA 2 % [miconazole 1 OTC 1 OTC nitrate vaginal] [camphor & menthol] GENTIAN VIOLET SOLN ASTRINGENTS 1 OTC 1 % [gentian violet] XERAC AC SOLN 6.25 % HYSEPT SOLN 0.25 % [aluminum chloride in 1 OTC 1 OTC [sodium hypochlorite] alcohol] ISAGEL GEL 60 % EMOLLIENTS, DEMULCENTS, AND [antiseptic products, 1 OTC PROTECTANTS CALAMINE LOTN 8-8 % misc.] 1 OTC permethrin lotn 1 % 1 OTC [calamine-zinc oxide] miconazole nitrate KERATOPLASTIC AGENTS 1 OTC ELTA TAR CREA 2 % vaginal supp 100 mg 1 OTC TOLNAFTATE CREA 1 % [coal tar extract] 1 OTC [tolnaftate] SKIN AND MUCOUS MEMBRANE AGENTS, TOLNAFTATE SOLN 1 % MISCELLANEOUS 1 OTC AQUAPHOR OINT [tolnaftate] 1 OTC [emollient]

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 93 of 144

藥物等 藥物等 藥物名稱 規定／限制 藥物名稱 規定／限制 級 級 BENZOIN COMPOUND NIACIN TABS 50 MG 1 OTC TINC [benzoin 1 OTC [niacin] compound] NIACIN TABS 500 MG 1 OTC BENZOIN TINC [niacin] 1 OTC [benzoin] PYRIDOXINE HCL TABS 1 OTC DESITIN PSTE 40 % [zinc 25 MG [pyridoxine hcl] 1 OTC oxide (topical)] SLO-NIACIN TBCR 500 1 OTC DIFFERIN GEL 0.1 % MG [niacin] 1 OTC [adapalene] SLO-NIACIN TBCR 750 1 OTC KP BENZOYL PEROXIDE MG [niacin] GEL 10 % [benzoyl 1 OTC VITAMIN B-6 TABS 100 1 OTC peroxide] MG [pyridoxine hcl] KP BENZOYL PEROXIDE VITAMIN B-6 TABS 50 1 OTC GEL 5 % [benzoyl 1 OTC MG [pyridoxine hcl] peroxide] VITAMIN D SODIUM CHLORIDE ERGOCALCIFEROL TABS 1 GM [sodium 1 OTC SOLN 200 MCG/ML 1 OTC chloride] [ergocalciferol] VITAMINS MULTIVITAMIN PREPARATIONS KP PRENATAL MULTIVITAMINS TABS 28-0.8 MG [prenatal vit 1 OTC w/ ferrous fumarate-folic acid] POLY-VI-SOL SOLN [pediatric multiple 1 OTC vitamins] POLY-VI-SOL/IRON SOLN 11 MG/ML 1 OTC [pediatric multiple vitamins w/ iron] TRI-VI-SOL A/C/D SOLN 250-50-10 [pediatric 1 OTC vitamins adc] VITAMIN B COMPLEX FOLIC ACID TABS 400 1 OTC MCG [folic acid] NIACIN ER CPCR 250 1 OTC MG [niacin] NIACIN ER CPCR 500 1 OTC MG [niacin] NIACIN ER TBCR 250 MG 1 OTC [niacin] NIACIN TABS 100 MG 1 OTC [niacin] NIACIN TABS 250 MG 1 OTC [niacin]

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 94 of 144 abacavir sulfate tabs 300 mg ...... 4 adsorb (tdap)] ...... 80 abacavir sulfate-lamivudine tabs 600-300 mg 4 ADAKVEO SOLN 100 MG/10ML abacavir-lamivudine-zidovudine tabs 300-150- [crizanlizumab-tmca] ...... 30 300 mg ...... 4 adapalene gel 0.1 % ...... 84 ABELCET SUSP 5 MG/ML [amphotericin b adapalene gel 0.3 % ...... 84 lipid] ...... 11 adapalene-benzoyl peroxide gel 0.1-2.5 % ... 84 abiraterone acetate tabs 250 mg ...... 15 ADCETRIS SOLR 50 MG [brentuximab ABRAXANE SUSR 100 MG [paclitaxel protein- vedotin] ...... 15 bound particles] ...... 15 adefovir dipivoxil tabs 10 mg ...... 13 acamprosate calcium tbec 333 mg ...... 47 adenosine inj 6mg/2ml ...... 33 acarbose tabs 100 mg ...... 66 adenosine soln 12 mg/4ml ...... 33 acarbose tabs 25 mg ...... 66 adenosine soln 3 mg/ml ...... 52 acarbose tabs 50 mg ...... 66 adenosine soln 6 mg/2ml ...... 34 ACD-A NOCLOT-50 SOLN 0.73-2.45-2.2 ADVAIR HFA AERO 115-21 MCG/ACT GM/100ML [anticoagulant citrate dextrose [fluticasone-salmeterol] ...... 77 solution a] ...... 29 ADVAIR HFA AERO 230-21 MCG/ACT acetaminophen tbcr 650 mg ...... 89 [fluticasone-salmeterol] ...... 77 acetaminophen-codeine #2 tabs 300-15 mg 37 ADVAIR HFA AERO 45-21 MCG/ACT acetaminophen-codeine #3 tabs 300-30 mg 37 [fluticasone-salmeterol] ...... 77 acetaminophen-codeine #4 tabs 300-60 mg 37 ADVATE SOLR 1000 UNIT [antihemophilic acetaminophen-codeine soln 120-12 mg/5ml factor (rcmb) plasma/albumin free (rahf- ...... 37 pfm)] ...... 25 acetazolamide er cp12 500 mg ...... 60 ADVATE SOLR 1500 UNIT [antihemophilic acetazolamide sodium solr 500 mg ...... 60 factor (rcmb) plasma/albumin free (rahf- acetazolamide tabs 125 mg ...... 60 pfm)] ...... 25 acetazolamide tabs 250 mg ...... 60 ADVATE SOLR 2000 UNIT [antihemophilic ACETEST TAB TABLETS [acetone (urine) factor (rcmb) plasma/albumin free (rahf- test] ...... 91 pfm)] ...... 25 ACETIC ACID SOLN 0.25 % [acetic acid] ...... 56 ADVATE SOLR 250 UNIT [antihemophilic ACETIC ACID SOLN 2 % [acetic acid (otic)] . 61 factor (rcmb) plasma/albumin free (rahf- acetic acid-aluminum acetate soln 2 % ...... 61 pfm)] ...... 25 acetylcysteine soln 10 % ...... 72 ADVATE SOLR 3000 UNIT [antihemophilic acetylcysteine soln 20 % ...... 72 factor (rcmb) plasma/albumin free (rahf- ACETYLCYSTEINE SOLN 200 MG/ML pfm)] ...... 25 [acetylcysteine (antidote)] ...... 72 ADVATE SOLR 4000 UNIT [antihemophilic acitretin caps 10 mg ...... 84 factor (rcmb) plasma/albumin free (rahf- acitretin caps 25 mg ...... 84 pfm)] ...... 25 ACTHAR GEL 80 UNIT/ML [corticotropin] .... 69 ADVATE SOLR 500 UNIT [antihemophilic ACTHIB SOLR [haemophilus b polysac conj factor (rcmb) plasma/albumin free (rahf- vac] ...... 80 pfm)] ...... 25 ACTIMMUNE SOLN 2000000 UNIT/0.5ML AEROCHAMBER PLUS FLO-VU SMALL MISC [interferon gamma-1b] ...... 72 [spacer/aerosol-holding chambers] ...... 52 ACTIVASE SOLR 100 MG [alteplase] ...... 29 AEROCHAMBER Z-STAT PLUS MISC ACTIVASE SOLR 50 MG [alteplase] ...... 29 [spacer/aerosol-holding chambers] ...... 52 acyclovir caps 200 mg ...... 13 AEROCHAMBER Z-STAT PLUS/LARGE MISC acyclovir sodium inj 1000mg ...... 13 [spacer/aerosol-holding chambers] ...... 52 acyclovir sodium soln 50 mg/ml ...... 13 AEROCHAMBER Z-STAT PLUS/MEDIUM MISC acyclovir susp 200 mg/5ml ...... 13 [spacer/aerosol-holding chambers] ...... 52 acyclovir tabs 400 mg ...... 13 AEROSPAN AERS 80 MCG/ACT [flunisolide acyclovir tabs 800 mg ...... 13 hfa] ...... 77 ADACEL SUSP 5-2-15.5 LF-MCG/0.5 [tetanus AEROTRACH PLUS MISC [respiratory toxoid-diphtheria-acellular pertussis therapy supplies] ...... 52

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AFINITOR TABS 10 MG [everolimus] ...... 15 alfentanil hcl soln 1000 mcg/2ml ...... 37 AFLURIA SUSP [influenza virus vaccine split] ALIMTA SOLR 500 MG [pemetrexed disodium] ...... 80 ...... 15 AFSTYLA KIT 1000 UNIT [antihemophilic ALINIA SUSR 100 MG/5ML [nitazoxanide] .... 12 factor (recombinant) single chain] ...... 25 ALINIA TABS 500 MG [nitazoxanide] ...... 12 AFSTYLA KIT 1500 UNIT [antihemophilic ALKERAN TABS 2 MG [melphalan] ...... 15 factor (recombinant) single chain] ...... 25 allopurinol tabs 100 mg ...... 72 AFSTYLA KIT 2000 UNIT [antihemophilic allopurinol tabs 300 mg ...... 72 factor (recombinant) single chain] ...... 25 ALOCRIL SOLN 2 % [nedocromil sodium AFSTYLA KIT 250 UNIT [antihemophilic factor (ophth)] ...... 60 (recombinant) single chain] ...... 25 ALOE VERA POWD [aloe vera (bulk)] ...... 75 AFSTYLA KIT 2500 UNIT [antihemophilic ALPHANATE/VWF COMPLEX/HUMAN SOLR factor (recombinant) single chain] ...... 26 1000 UNIT [antihemophilic factor/von AFSTYLA KIT 3000 UNIT [antihemophilic willebrand factor complex (human)] ...... 26 factor (recombinant) single chain] ...... 26 ALPHANATE/VWF COMPLEX/HUMAN SOLR AFSTYLA KIT 500 UNIT [antihemophilic factor 1500 UNIT [antihemophilic factor/von (recombinant) single chain] ...... 26 willebrand factor complex (human)] ...... 26 AGGRENOX CP12 25-200 MG [aspirin- ALPHANINE SD SOLR 1000 UNIT [coagulation dipyridamole] ...... 29 factor ix] ...... 26 AK-FLUOR SOLN 10 % [fluorescein sodium ALPHANINE SD SOLR 1500 UNIT [coagulation injection] ...... 52 factor ix] ...... 26 AKTEN GEL 3.5 % [lidocaine hcl (ophth)] .... 61 ALPHANINE SD SOLR 500 UNIT [coagulation AKTIPAK PACK 5-3 % [benzoyl peroxide- factor ix] ...... 26 erythromycin] ...... 81 alprazolam tabs 0.25 mg ...... 45 AKYNZEO CAPS 300-0.5 MG [netupitant- alprazolam tabs 0.5 mg ...... 45 palonosetron] ...... 62 alprazolam tabs 1 mg ...... 45 ALBENZA ...... 3 alprazolam tabs 2 mg ...... 45 ALBENZA TABS 200 MG [albendazole]...... 4 ALPROSTADIL POWD [alprostadil (bulk)] ... 75 ALBUMIN HUMAN SOLN 25 % [albumin, alprostadil soln 500 mcg/ml ...... 36 human] ...... 25 ALTAFLUOR BENOX SOLN 0.25-0.4 % ALBURX SOLN 5 % [albumin, human] ...... 25 [fluorescein w/ benoxinate] ...... 52 ALBUSTIX STRP [albumin (urine) test] ...... 91 ALUNBRIG TABS 180 MG [brigatinib] ...... 15 ALBUTEIN SOLN 25 % [albumin, human] ..... 25 ALUNBRIG TABS 30 MG [brigatinib] ...... 15 albuterol sulfate hfa aers 108 (90 base) ALUNBRIG TABS 90 MG [brigatinib] ...... 15 mcg/act ...... 24 ALUNBRIG TBPK 90 & 180 MG [brigatinib] ... 15 albuterol sulfate nebu (2.5 mg/3ml) 0.083% . 24 ALVESCO AERS 160 MCG/ACT [ciclesonide] albuterol sulfate nebu (5 mg/ml) 0.5% ...... 24 ...... 77 albuterol sulfate nebu 0.63 mg/3ml ...... 24 ALVESCO AERS 80 MCG/ACT [ciclesonide] 77 albuterol sulfate nebu 1.25 mg/3ml ...... 24 amantadine hcl caps 100 mg...... 44 albuterol sulfate nebu 2.5 mg/0.5ml ...... 24 amantadine hcl syrp 50 mg/5ml ...... 44 albuterol sulfate syrp 2 mg/5ml ...... 24 AMBISOME SUSR 50 MG [amphotericin b albuterol sulfate tabs 2 mg ...... 24 liposome] ...... 11 albuterol sulfate tabs 4 mg ...... 24 ambrisentan tabs 10 mg ...... 36 alclometasone dipropionate crea 0.05 % ..... 82 ambrisentan tabs 5 mg ...... 36 alclometasone dipropionate oint 0.05 % ...... 82 amikacin sulfate soln 500 mg/2ml ...... 5 ALDURAZYME SOLN 2.9 MG/5ML [laronidase] amiloride-hydrochlorothiazide tabs 5-50 mg ...... 59 ...... 55 ALECENSA CAPS 150 MG [alectinib hcl] ..... 15 aminocaproic acid soln 250 mg/ml ...... 26 alendronate sodium tabs 10 mg ...... 72 aminophylline soln 25 mg/ml ...... 85 alendronate sodium tabs 35 mg ...... 72 AMINOSYN II SOLN 10 % [amino acid alendronate sodium tabs 40 mg ...... 72 infusion] ...... 54 alendronate sodium tabs 70 mg ...... 72 AMINOSYN II/ELECTROLYTES SOLN 8.5 %

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[amino acid electrolyte infusion] ...... 54 amphetamine-dextroamphetamine tabs 15 mg amiodarone hcl soln 150 mg/3ml ...... 34 ...... 40 amiodarone hcl soln 900 mg/18ml ...... 34 amphetamine-dextroamphetamine tabs 20 mg amiodarone hcl tabs 200 mg...... 34 ...... 40 AMITIZA CAPS 24 MCG [lubiprostone] ...... 62 amphetamine-dextroamphetamine tabs 30 mg AMITIZA CAPS 8 MCG [lubiprostone] ...... 62 ...... 40 amitriptyline hcl tabs 10 mg...... 47 amphetamine-dextroamphetamine tabs 5 mg amitriptyline hcl tabs 100 mg ...... 47 ...... 40 amitriptyline hcl tabs 150 mg ...... 47 amphetamine-dextroamphetamine tabs 7.5 amitriptyline hcl tabs 25 mg...... 47 mg ...... 40 amitriptyline hcl tabs 50 mg...... 47 amphotericin b solr 50 mg ...... 11 amitriptyline hcl tabs 75 mg...... 47 ampicillin cap 250mg ...... 5 amlodipine besylate tabs 10 mg ...... 33 ampicillin caps 500 mg ...... 5 amlodipine besylate tabs 2.5 mg ...... 33 ampicillin sodium solr 1 gm ...... 6 amlodipine besylate tabs 5 mg ...... 33 ampicillin sodium solr 10 gm ...... 6 amoxapine tabs 100 mg ...... 47 ampicillin sodium solr 125 mg ...... 6 amoxapine tabs 150 mg ...... 48 ampicillin sodium solr 2 gm ...... 6 amoxapine tabs 25 mg ...... 48 ampicillin sodium solr 250 mg ...... 6 amoxapine tabs 50 mg ...... 48 ampicillin sodium solr 500 mg ...... 6 amoxicillin ...... 3 ampicillin sus 125/5ml ...... 6 amoxicillin caps 250 mg ...... 5 ampicillin sus 250/5ml ...... 6 amoxicillin caps 500 mg ...... 5 ampicillin-sulbactam sodium solr 1.5 (1-0.5) amoxicillin chew 125 mg ...... 5 gm ...... 6 amoxicillin chew 250 mg ...... 5 ampicillin-sulbactam sodium solr 15 (10-5) amoxicillin susr 125 mg/5ml ...... 5 gm ...... 6 amoxicillin susr 200 mg/5ml ...... 5 ampicillin-sulbactam sodium solr 3 (2-1) gm . 6 amoxicillin susr 250 mg/5ml ...... 5 amp-sulbacta inj 1.5gm ...... 5 amoxicillin susr 400 mg/5ml ...... 5 anagrelide hcl caps 0.5 mg ...... 29 amoxicillin-pot clavulanate chew 200-28.5 mg anagrelide hcl caps 1 mg ...... 29 ...... 5 anastrozole tabs 1 mg ...... 15 amoxicillin-pot clavulanate chew 400-57 mg . 5 ANAVIP SOLR [crotalidae immune f(ab')2 amoxicillin-pot clavulanate susr 200-28.5 (equine)] ...... 78 mg/5ml ...... 5 ANDRODERM PT24 2 MG/24HR [testosterone] amoxicillin-pot clavulanate susr 250-62.5 ...... 65 mg/5ml ...... 5 ANDRODERM PT24 4 MG/24HR [testosterone] amoxicillin-pot clavulanate susr 400-57 ...... 65 mg/5ml ...... 5 ANGIOMAX SOLR 250 MG [bivalirudin amoxicillin-pot clavulanate susr 600-42.9 trifluoroacetate] ...... 29 mg/5ml ...... 5 ANTACID SUSP 200-200-20 MG/5ML [alum & amoxicillin-pot clavulanate tabs 250-125 mg 5 mag hydrox-simethicone] ...... 91 amoxicillin-pot clavulanate tabs 500-125 mg 5 ANTIVENIN LATRODECTUS MACTANS KIT amoxicillin-pot clavulanate tabs 875-125 mg 5 [antivenin latrodectus mactans]...... 78 amphetamine-dextroamphet er cp24 10 mg 40 ANUCORT-HC SUPP 25 MG [hydrocortisone amphetamine-dextroamphet er cp24 15 mg 40 acetate (rectal)] ...... 82 amphetamine-dextroamphet er cp24 20 mg 40 APOKYN SOCT 30 MG/3ML [apomorphine amphetamine-dextroamphet er cp24 25 mg 40 hydrochloride] ...... 44 amphetamine-dextroamphet er cp24 30 mg 40 apraclonidine hcl soln 0.5 % ...... 61 amphetamine-dextroamphet er cp24 5 mg .. 40 APTENSIO XR CP24 10 MG [methylphenidate amphetamine-dextroamphetamine tabs 10 mg hcl] ...... 40 ...... 40 APTENSIO XR CP24 15 MG [methylphenidate amphetamine-dextroamphetamine tabs 12.5 hcl] ...... 40 mg ...... 40 APTENSIO XR CP24 20 MG [methylphenidate

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hcl] ...... 40 [mometasone furoate (inhalation)] ...... 64 APTENSIO XR CP24 30 MG [methylphenidate aspirin-dipyridamole er cp12 25-200 mg ...... 29 hcl] ...... 40 atazanavir sulfate caps 150 mg ...... 13 APTENSIO XR CP24 40 MG [methylphenidate atazanavir sulfate caps 200 mg ...... 13 hcl] ...... 41 atazanavir sulfate caps 300 mg ...... 13 APTENSIO XR CP24 50 MG [methylphenidate atenolol tabs 100 mg ...... 32 hcl] ...... 41 atenolol tabs 25 mg...... 32 APTENSIO XR CP24 60 MG [methylphenidate atenolol tabs 50 mg...... 32 hcl] ...... 41 atenolol-chlorthalidone tabs 100-25 mg ...... 32 APTIVUS CAPS 250 MG [tipranavir] ...... 4 atenolol-chlorthalidone tabs 50-25 mg ...... 32 AQUANIL HC LOTN 1 % [hydrocortisone ATGAM INJ 50 MG/ML [lymphocyte immune (topical)] ...... 93 globulin,anti-thymocyte globulin (equine)] AQUAPHOR OINT [emollient] ...... 93 ...... 71 AQUASOL A SOLN 15 MG/ML [vitamin a] ..... 86 atorvastatin calcium tabs 10 mg ...... 31 ARALAST NP SOLR 1000 MG [alpha1- atorvastatin calcium tabs 20 mg ...... 31 proteinase inhibitor (human)] ...... 59 atorvastatin calcium tabs 40 mg ...... 31 ARALAST NP SOLR 500 MG [alpha1- atorvastatin calcium tabs 80 mg ...... 31 proteinase inhibitor (human)] ...... 77 atovaquone susp 750 mg/5ml ...... 12 ARGATROBAN IN SODIUM CHLORIDE SOLN atovaquone-proguanil hcl tabs 250-100 mg . 12 125-0.9 MG/125ML-% [argatroban in sodium atovaquone-proguanil hcl tabs 62.5-25 mg .. 12 chloride] ...... 29 atracurium besylate soln 100 mg/10ml...... 23 ARGATROBAN SOLN 250 MG/2.5ML atracurium besylate soln 50 mg/5ml ...... 23 [argatroban] ...... 29 atropine sulfate inj 1mg/ml ...... 21 aripiprazole tabs 10 mg ...... 48 ATROPINE SULFATE MONOHYDRATE POW aripiprazole tabs 15 mg ...... 48 MONOHYDT [atropine sulfate aripiprazole tabs 2 mg ...... 48 monohydrate] ...... 75 aripiprazole tabs 20 mg ...... 48 ATROPINE SULFATE OINT 1 % [atropine aripiprazole tabs 30 mg ...... 48 sulfate (ophthalmic)] ...... 61 aripiprazole tabs 5 mg ...... 48 ATROPINE SULFATE SOLN 0.4 MG/ML ARISTADA PRSY 1064 MG/3.9ML [aripiprazole [atropine sulfate] ...... 21 lauroxil] ...... 48 ATROPINE SULFATE SOLN 1 % [atropine ARISTADA PRSY 441 MG/1.6ML [aripiprazole sulfate (ophthalmic)] ...... 61 lauroxil] ...... 48 ATROPINE SULFATE SOLN 8 MG/20ML ARISTADA PRSY 662 MG/2.4ML [aripiprazole [atropine sulfate] ...... 21 lauroxil] ...... 48 ATROPINE SULFATE SOSY 0.5 MG/5ML ARISTADA PRSY 882 MG/3.2ML [aripiprazole [atropine sulfate] ...... 21 lauroxil] ...... 48 ATROVENT HFA AERS 17 MCG/ACT ARRANON SOLN 5 MG/ML [nelarabine] ...... 15 [ipratropium bromide hfa] ...... 21 ASCORBIC ACID SOLN 500 MG/ML [ascorbic AUGMENTIN SUSR 125-31.25 MG/5ML acid] ...... 86 [amoxicillin & pot clavulanate] ...... 6 ASMANEX (120 METERED DOSES) AEPB 220 AVASTIN SOLN 100 MG/4ML [bevacizumab] 15 MCG/INH [mometasone furoate (inhalation)] AVASTIN SOLN 400 MG/16ML [bevacizumab] ...... 64 ...... 15 ASMANEX (30 METERED DOSES) AEPB 110 AVELOX SOLN 400 MG/250ML [moxifloxacin MCG/INH [mometasone furoate (inhalation)] hcl in sodium chloride] ...... 6 ...... 64 AVITA CREA 0.025 % [tretinoin] ...... 84 ASMANEX (60 METERED DOSES) AEPB 220 AVONEX KIT 30MCG [interferon beta-1a] .. 47 MCG/INH [mometasone furoate (inhalation)] AVONEX PEN AJKT 30 MCG/0.5ML [interferon ...... 64 beta-1a] ...... 72 ASMANEX HFA AERO 100 MCG/ACT azacitidine susr 100 mg ...... 15 [mometasone furoate (inhalation)] ...... 64 AZACTAM IN DEXTROSE SOLN 1 GM/50ML ASMANEX HFA AERO 200 MCG/ACT [aztreonam-dextrose] ...... 6

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AZACTAM IN DEXTROSE SOLN 2 GM/50ML BD PEN NEEDLE ORIGINAL U/F MISC 29G X [aztreonam-dextrose] ...... 6 12.7MM [insulin pen needle] ...... 89 azathioprine tabs 50 mg ...... 71 BD PEN NEEDLE SHORT U/F MISC 31G X 8 azelastine hcl soln 0.1 % ...... 60 MM [insulin pen needle] ...... 89 azithromycin solr 500 mg ...... 6 BD SAFETYGLIDE INSULIN SYRINGE MISC azithromycin susr 100 mg/5ml ...... 6 29G X 1/2 ...... 90 azithromycin susr 200 mg/5ml ...... 6 BD SAFETYGLIDE SYRINGE/NEEDLE MISC azithromycin tabs 250 mg ...... 6 27G X 5/8 ...... 90 azithromycin tabs 500 mg ...... 6 BD VEO INSULIN SYR U/F 1/2UNIT MISC 31G azithromycin tabs 600 mg ...... 6 X 15/64 ...... 52, 90 aztreonam solr 1 gm ...... 6 BD VEO INSULIN SYRINGE U/F MISC 31G X aztreonam solr 2 gm ...... 6 15/64 ...... 90 bacitracin oint 500 unit/gm ...... 59 BELLADONNA ALKALOIDS-OPIUM SUPP 16.2- bacitracin solr 50000 unit ...... 6 30 MG [belladonna alkaloids & opium] ..... 21 bacitracin-polymyxin b oint 500-10000 BELLADONNA ALKALOIDS-OPIUM SUPP 16.2- unit/gm ...... 59 60 MG [belladonna alkaloids & opium] ..... 21 BACLOFEN POWD [baclofen] ...... 75 benazepril hcl tabs 10 mg ...... 35 baclofen tabs 10 mg ...... 23 benazepril hcl tabs 20 mg ...... 35 baclofen tabs 20 mg ...... 23 benazepril hcl tabs 40 mg ...... 35 BACTERIOSTATIC WATER(BENZ ALC) SOLN benazepril hcl tabs 5 mg ...... 35 [water for inject, bacteriostatic benzyl BENDEKA SOLN 100 MG/4ML [bendamustine alcohol] ...... 75 hcl] ...... 15 BAL IN OIL SOLN 100 MG/ML [dimercaprol] 63 BENEFIX KIT 1000 UNIT [coagulation factor ix balsalazide disodium caps 750 mg ...... 62 (recombinant)] ...... 26 BANZEL SUSP 40 MG/ML [rufinamide] ...... 42 BENEFIX KIT 2000 UNIT [coagulation factor ix BANZEL TABS 200 MG [rufinamide] ...... 42 (recombinant)] ...... 26 BANZEL TABS 400 MG [rufinamide] ...... 42 BENEFIX KIT 250 UNIT [coagulation factor ix BAQSIMI TWO PACK POWD 3 MG/DOSE (recombinant)] ...... 26 [glucagon] ...... 67 BENEFIX KIT 3000 UNIT [coagulation factor ix BARACLUDE SOLN 0.05 MG/ML [entecavir] 13 (recombinant)] ...... 26 BAYER ADVANCED ASPIRIN EX ST TABS 500 BENEFIX KIT 500 UNIT [coagulation factor ix MG [aspirin] ...... 88 (recombinant)] ...... 26 BD 3ML LUER-LOK SYRINGE/22G X 1-1/4 .... 89 BENTYL SOLN 10 MG/ML [dicyclomine hcl] . 21 BD INSULIN SYRINGE MICROFINE MISC 27G BENZOIN COMPOUND TINC [benzoin X 5/8 ...... 89 compound] ...... 94 BD INSULIN SYRINGE MISC 25G X 1 ...... 89 BENZOIN TINC [benzoin] ...... 94 BD INSULIN SYRINGE MISC 27G X 1/2...... 89 benzonatate caps 100 mg ...... 77 BD INSULIN SYRINGE U/F 1/2UNIT MISC 31G benzoyl peroxide-erythromycin gel 5-3 % .... 81 X 5/16 ...... 89 benztropine mesylate soln 1 mg/ml ...... 44 BD INSULIN SYRINGE U/F MISC 30G X 1/2 .. 89 benztropine mesylate tabs 0.5 mg ...... 44 BD INSULIN SYRINGE U/F MISC 31G X 5/16 89 benztropine mesylate tabs 1 mg ...... 44 BD INSULIN SYRINGE U-500 MISC 31G X 6MM benztropine mesylate tabs 2 mg ...... 44 0.5 ML [insulin syringe/needle u-500] ...... 52 betamethasone dipropionate aug crea 0.05 % BD INTEGRA SYRINGE MISC 25G X 5/8 ...... 89 ...... 82 BD LANCET DEVICE MIS DEVICE [lancet betamethasone dipropionate aug gel 0.05 % devices] ...... 89 ...... 82 BD LANCET ULTRAFINE 33G MISC [lancets] betamethasone dipropionate aug lotn 0.05 % ...... 89 ...... 82 BD PEN NEEDLE MINI U/F MISC 31G X 5 MM betamethasone dipropionate aug oint 0.05 % [insulin pen needle] ...... 89 ...... 82 BD PEN NEEDLE NANO U/F MISC 32G X 4 MM BETAMETHASONE DIPROPIONATE CREA [insulin pen needle] ...... 89 0.05 % [betamethasone dipropionate

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(topical)] ...... 82 BORIC ACID POWD [boric acid (bulk)] ...... 92 betamethasone sod phos & acet susp 6 (3-3) BOTOX COSMETIC SOLR 100 UNIT mg/ml ...... 64 [onabotulinumtoxina (cosmetic)] ...... 72 BETAMETHASONE VALERATE CREA 0.1 % BOTOX SOLR 100 UNIT [onabotulinumtoxina] [betamethasone valerate] ...... 82 ...... 72 betamethasone valerate foam 0.12 % ...... 82 BOTOX SOLR 200 UNIT [onabotulinumtoxina] BETAMETHASONE VALERATE LOTN 0.1 % ...... 72 [betamethasone valerate] ...... 82 BREVIBLOC IN NACL SOLN 2000 MG/100ML BETAMETHASONE VALERATE OINT 0.1 % [esmolol hcl-sodium chloride] ...... 32 [betamethasone valerate] ...... 82 BREVIBLOC IN NACL SOLN 2500 MG/250ML betaxolol hcl soln 0.5 % ...... 60 [esmolol hcl-sodium chloride] ...... 32 bethanechol chloride tabs 10 mg ...... 22 BREVITAL SODIUM SOLR 500 MG bethanechol chloride tabs 25 mg ...... 22 [methohexital sodium] ...... 47 bethanechol chloride tabs 5 mg ...... 22 BRIDION SOLN 200 MG/2ML [sugammadex bethanechol chloride tabs 50 mg ...... 22 sodium] ...... 72 BEXSERO SUSY [meningococcal vac group BRILINTA TABS 90 MG [ticagrelor] ...... 29 b (recombant omv adjuvanted)] ...... 80 brimonidine tartrate soln 0.2 % ...... 60 bicalutamide tabs 50 mg ...... 15 BRIVIACT TABS 10 MG [brivaracetam] ...... 42 BICILLIN L-A SUSP 1200000 UNIT/2ML BRIVIACT TABS 100 MG [brivaracetam] ...... 42 [penicillin g benzathine] ...... 6 BRIVIACT TABS 25 MG [brivaracetam] ...... 42 BICILLIN L-A SUSP 2400000 UNIT/4ML BRIVIACT TABS 50 MG [brivaracetam] ...... 42 [penicillin g benzathine] ...... 6 BRIVIACT TABS 75 MG [brivaracetam] ...... 42 BICILLIN L-A SUSP 600000 UNIT/ML [penicillin bromocriptine mesylate caps 5 mg ...... 44 g benzathine] ...... 6 bromocriptine mesylate tabs 2.5 mg ...... 44 BICNU SOLR 100 MG [carmustine] ...... 15 BRUKINSA CAPS 80 MG [zanubrutinib] ...... 15 BIKTARVY TABS 50-200-25 MG [bictegravir- BSS PLUS SOLN [ophthalmic irrigation emtricitabine-tenofovir alafenamide solution - intraocular] ...... 61 fumarate] ...... 4 BSS SOLN [ophthalmic irrigation solution - BILTRICIDE TABS 600 MG [praziquantel] ...... 4 intraocular] ...... 61 bimatoprost soln 0.03 % ...... 60 budesonide cpep 3 mg ...... 64 BIO GLO STRP 1 MG [fluorescein sodium budesonide susp 0.25 mg/2ml ...... 64 topical] ...... 52 budesonide susp 0.5 mg/2ml ...... 64 BIOTIN-D POWD [biotin (bulk)] ...... 92 bumetanide soln 0.25 mg/ml ...... 55 BISMATROL MAXIMUM STRENGTH SUSP 525 bumetanide tabs 0.5 mg ...... 55 MG/15ML [bismuth subsalicylate] ...... 91 bumetanide tabs 1 mg ...... 55 BISMATROL SUSP 262 MG/15ML [bismuth bumetanide tabs 2 mg ...... 55 subsalicylate] ...... 91 BUMINATE SOLN 5 % [albumin, human] ...... 25 BISMUTH SUBSALICYLATE CHEW 262 MG BUPHENYL TABS 500 MG [sodium [bismuth subsalicylate] ...... 91 phenylbutyrate] ...... 53 bisoprolol fumarate tabs 10 mg ...... 32 BUPIVACAINE FISIOPHARMA SOLN 2.5 bisoprolol fumarate tabs 5 mg ...... 32 MG/ML [bupivacaine hcl] ...... 71 bisoprolol-hydrochlorothiazide tabs 10-6.25 bupivacaine hcl (pf) soln 0.25 % ...... 71 mg ...... 32 bupivacaine hcl (pf) soln 0.5 % ...... 71 bisoprolol-hydrochlorothiazide tabs 2.5-6.25 bupivacaine hcl (pf) soln 0.75 % ...... 71 mg ...... 32 bupivacaine hcl inj 0.75% ...... 71 bisoprolol-hydrochlorothiazide tabs 5-6.25 bupivacaine hcl soln 0.25 % ...... 71 mg ...... 32 bupivacaine hcl soln 0.5 % ...... 71 bleomycin sulfate solr 15 unit ...... 15 bupivacaine in dextrose soln 0.75-8.25 % .... 71 bleomycin sulfate solr 30 unit ...... 15 bupivacaine-epinephrine (pf) soln 0.25% -1 BLEPHAMIDE SUSP 10-0.2 % [sulfacetamide 200000 ...... 71 sod-prednisolone] ...... 59 bupivacaine-epinephrine (pf) soln 0.5% -1 BLINCYTO SOLR 35 MCG [blinatumomab] .. 15 200000 ...... 71

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 100 of 144 bupivacaine-epinephrine soln 0.25% -1 CAMPTOSAR SOLN 40 MG/2ML [irinotecan 200000 ...... 71 hcl] ...... 15 bupivacaine-epinephrine soln 0.5% -1 CANCIDAS SOLR 50 MG [caspofungin 200000 ...... 71 acetate] ...... 11 buprenorphine hcl soln 0.3 mg/ml ...... 37 CANCIDAS SOLR 70 MG [caspofungin buprenorphine hcl-naloxone hcl subl 2-0.5 acetate] ...... 11 mg ...... 37 CANDIN SOLN [candida albicans skin test buprenorphine hcl-naloxone hcl subl 8-2 mg antigen] ...... 52 ...... 37 CANTHARIDIN POW [cantharidin] ...... 75 bupropion hcl er (sr) tb12 100 mg ...... 48 CAPASTAT SULFATE SOLR 1 GM bupropion hcl er (sr) tb12 150 mg ...... 48 [capreomycin sulfate] ...... 12 bupropion hcl er (sr) tb12 200 mg ...... 48 capecitabine tabs 150 mg ...... 15 bupropion hcl er (xl) tb24 150 mg ...... 48 capecitabine tabs 500 mg ...... 15 bupropion hcl er (xl) tb24 300 mg ...... 48 CAPRELSA TABS 100 MG [vandetanib] ...... 15 bupropion hcl tabs 100 mg ...... 48 CAPRELSA TABS 300 MG [vandetanib] ...... 15 bupropion hcl tabs 75 mg ...... 48 captopril tabs 100 mg ...... 35 buspirone hcl tabs 10 mg ...... 45 captopril tabs 12.5 mg ...... 35 buspirone hcl tabs 15 mg ...... 45 captopril tabs 25 mg ...... 35 buspirone hcl tabs 30 mg ...... 45 captopril tabs 50 mg ...... 35 buspirone hcl tabs 5 mg ...... 45 CARAFATE SUSP 1 GM/10ML [sucralfate] ... 62 buspirone hcl tabs 7.5 mg ...... 46 carbamazepine chew 100 mg ...... 42 butorphanol tartrate soln 1 mg/ml ...... 37 carbamazepine er cp12 100 mg ...... 42 butorphanol tartrate soln 2 mg/ml ...... 37 carbamazepine er cp12 200 mg ...... 42 BYDUREON BCISE AUIJ 2 MG/0.85ML carbamazepine er cp12 300 mg ...... 42 [exenatide] ...... 66 carbamazepine er tb12 100 mg ...... 42 cabergoline tabs 0.5 mg ...... 44 carbamazepine er tb12 200 mg ...... 42 CABOMETYX TABS 20 MG [cabozantinib s- carbamazepine er tb12 400 mg ...... 42 malate] ...... 15 CARBAMAZEPINE POWD [carbamazepine] 75 CABOMETYX TABS 40 MG [cabozantinib s- carbamazepine susp 100 mg/5ml ...... 42 malate] ...... 15 carbamazepine tabs 200 mg...... 42 CABOMETYX TABS 60 MG [cabozantinib s- carbidopa tabs 25 mg ...... 44 malate] ...... 15 carbidopa-levodopa er tbcr 25-100 mg ...... 44 caffeine citrate soln 60 mg/3ml ...... 41 carbidopa-levodopa er tbcr 50-200 mg ...... 44 CALAMINE LOTN 8-8 % [calamine-zinc oxide] carbidopa-levodopa tabs 10-100 mg ...... 44 ...... 93 carbidopa-levodopa tabs 25-100 mg ...... 44 calcipotriene crea 0.005 % ...... 84 carbidopa-levodopa tabs 25-250 mg ...... 44 calcipotriene soln 0.005 % ...... 84 carbidopa-levodopa-entacapone tabs 12.5-50- calcitonin (salmon) soln 200 unit/act ...... 69 200 mg ...... 44 calcitriol caps 0.25 mcg ...... 86 carbidopa-levodopa-entacapone tabs 18.75- calcitriol caps 0.5 mcg ...... 86 75-200 mg ...... 44 calcium acetate (phos binder) caps 667 mg 56 carbidopa-levodopa-entacapone tabs 25-100- CALCIUM CARBONATE TABS 1250 (500 Ca) 200 mg ...... 44 MG [calcium carbonate] ...... 91 carbidopa-levodopa-entacapone tabs 31.25- CALCIUM CHLORIDE SOLN 10 % [calcium 125-200 mg ...... 45 chloride (dihydrate)] ...... 56 carbidopa-levodopa-entacapone tabs 37.5- CALCIUM GLUCONATE SOLN 10 % [calcium 150-200 mg ...... 45 gluconate] ...... 56 carbidopa-levodopa-entacapone tabs 50-200- CALCIUM GLUCONATE TABS 500 MG 200 mg ...... 45 [calcium gluconate] ...... 91 CARDENE IV SOLN 20-0.86 MG/200ML-% CALQUENCE CAPS 100 MG [acalabrutinib] 15 [nicardipine hcl in sodium chloride] ...... 33 CAMPTOSAR SOLN 100 MG/5ML [irinotecan CARDENE IV SOLN 20-4.8 MG/200ML-% hcl] ...... 15 [nicardipine hcl in dextrose] ...... 33

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 101 of 144

CARDENE IV SOLN 40-0.83 MG/200ML-% 2.08 GM-%(50ML) [cefotetan disodium and [nicardipine hcl in sodium chloride] ...... 33 dextrose] ...... 7 CARDENE IV SOLN 40-5 MG/200ML-% cefoxitin sodium solr 1 gm ...... 7 [nicardipine hcl in dextrose] ...... 33 cefoxitin sodium solr 10 gm ...... 7 CARIMUNE NF SOLR 12 GM [immune cefoxitin sodium solr 2 gm ...... 7 globulin (human) iv] ...... 78 CEFOXITIN SODIUM-DEXTROSE SOLR 1-4 CARIMUNE NF SOLR 6 GM [immune globulin GM-%(50ML) [cefoxitin sodium and (human) iv] ...... 78 dextrose] ...... 7 carmustine solr 100 mg ...... 15 CEFOXITIN SODIUM-DEXTROSE SOLR 2-2.2 carvedilol tabs 12.5 mg ...... 32 GM-%(50ML) [cefoxitin sodium and carvedilol tabs 25 mg ...... 32 dextrose] ...... 7 carvedilol tabs 3.125 mg ...... 32 cefpodoxime proxetil susr 100 mg/5ml ...... 7 carvedilol tabs 6.25 mg ...... 32 cefpodoxime proxetil susr 50 mg/5ml ...... 7 CASCARA SAGRADA EXTR 1 GM/ML [cascara cefpodoxime proxetil tabs 100 mg ...... 7 sagrada] ...... 63 cefpodoxime proxetil tabs 200 mg ...... 7 CATHFLO ACTIVASE SOLR 2 MG [alteplase] ceftazidime solr 6 gm ...... 7 ...... 29 CEFTIN SUSR 125 MG/5ML [cefuroxime CAVERJECT SOLR 20 MCG [alprostadil axetil] ...... 7 (vasodilator)] ...... 36 ceftriaxone sodium in dextrose soln 20 mg/ml CAVERJECT SOLR 40 MCG [alprostadil ...... 7 (vasodilator)] ...... 36 ceftriaxone sodium in dextrose soln 40 mg/ml CAYSTON SOLR 75 MG [aztreonam lysine] ... 6 ...... 7 cefaclor caps 250 mg ...... 6 ceftriaxone sodium solr 1 gm ...... 7 cefaclor caps 500 mg ...... 6 ceftriaxone sodium solr 10 gm ...... 7 cefadroxil caps 500 mg ...... 6 ceftriaxone sodium solr 2 gm ...... 7 cefazolin sodium solr 1 gm ...... 6 ceftriaxone sodium solr 250 mg ...... 7 cefazolin sodium solr 10 gm ...... 6 ceftriaxone sodium solr 500 mg ...... 7 cefazolin sodium solr 20 gm ...... 6 CEFTRIAXONE SODIUM-DEXTROSE SOLR 1- cefazolin sodium solr 500 mg ...... 6 3.74 GM-%(50ML) [ceftriaxone sodium and CEFAZOLIN SODIUM-DEXTROSE SOLN 1-4 dextrose] ...... 7 GM/50ML-% [cefazolin sodium-dextrose] .. 6 CEFTRIAXONE SODIUM-DEXTROSE SOLR 2- CEFAZOLIN SODIUM-DEXTROSE SOLR 1-4 2.22 GM-%(50ML) [ceftriaxone sodium and GM-%(50ML) [cefazolin sodium-dextrose] . 6 dextrose] ...... 7 cefdinir susr 125 mg/5ml ...... 6 cefuroxime axetil tabs 250 mg ...... 7 cefdinir susr 250 mg/5ml ...... 6 cefuroxime axetil tabs 500 mg ...... 7 cefepime hcl solr 1 gm ...... 6 cefuroxime sodium solr 1.5 gm ...... 7 cefepime hcl solr 2 gm ...... 6 cefuroxime sodium solr 7.5 gm ...... 7 CEFEPIME-DEXTROSE SOLR 1-5 GM- cefuroxime sodium solr 750 mg ...... 7 %(50ML) [cefepime hcl-dextrose] ...... 6 CELONTIN CAPS 300 MG [methsuximide] ... 42 CEFEPIME-DEXTROSE SOLR 2-5 GM- cephalexin caps 250 mg ...... 7 %(50ML) [cefepime hcl-dextrose] ...... 6 cephalexin caps 500 mg ...... 7 cefixime caps 400 mg ...... 6 cephalexin susr 125 mg/5ml...... 7 cefotaxime sodium inj 10gm ...... 6 cephalexin susr 250 mg/5ml...... 7 cefotaxime sodium solr 1 gm ...... 6 cephalexin tabs 500 mg ...... 7 cefotaxime sodium solr 2 gm ...... 7 CEQUA SOLN 0.09 % [cyclosporine (ophth)] cefotaxime sodium solr 500 mg ...... 7 ...... 59 cefotetan disodium solr 1 gm ...... 7 CERDELGA CAPS 84 MG [eliglustat tartrate] cefotetan disodium solr 2 gm ...... 7 ...... 72 CEFOTETAN DISODIUM-DEXTROSE SOLR 1- CEREZYME SOLR 400 UNIT [imiglucerase] . 59 3.58 GM-%(50ML) [cefotetan disodium and CERVIDIL INST 10 MG [dinoprostone] ...... 75 dextrose] ...... 7 CHANTIX CONTINUING MONTH PAK TABS 1 CEFOTETAN DISODIUM-DEXTROSE SOLR 2- MG [varenicline tartrate] ...... 22

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CHANTIX STARTING MONTH PAK TABS 0.5 cinacalcet hcl tabs 90 mg ...... 72 MG X 11 & 1 MG X 42 [varenicline tartrate] CINRYZE SOLR 500 UNIT [c1 esterase ...... 22 inhibitor (human)] ...... 72 CHANTIX TABS 0.5 MG [varenicline tartrate] CIPRO SUSR 250 MG/5ML (5%) ...... 22 [ciprofloxacin]...... 7 CHANTIX TABS 1 MG [varenicline tartrate] .. 22 CIPRO SUSR 500 MG/5ML (10%) CHEMET CAPS 100 MG [succimer] ...... 63 [ciprofloxacin]...... 7 CHEMSTRIP 9 STRP [multiple urine tests] . 91 ciprofloxacin hcl soln 0.3 % ...... 59 CHERATUSSIN AC SYRP 100-10 MG/5ML ciprofloxacin hcl tabs 250 mg ...... 7 [guaifenesin-codeine] ...... 93 ciprofloxacin hcl tabs 500 mg ...... 7 CHIRHOSTIM SOLR 16 MCG [secretin acetate ciprofloxacin hcl tabs 750 mg ...... 7 (human)] ...... 52 ciprofloxacin in d5w soln 200 mg/100ml ...... 7 chloramphenicol sod succinate solr 1 gm .... 7 ciprofloxacin in d5w soln 400 mg/200ml ...... 8 chlordiazepoxide hcl caps 10 mg ...... 46 ciprofloxacin-dexamethasone susp 0.3-0.1 % chlordiazepoxide hcl caps 25 mg ...... 46 ...... 60 chlordiazepoxide hcl caps 5 mg ...... 46 cisatracurium besylate (pf) soln 10 mg/5ml . 23 CHLORDIAZEPOXIDE-CLIDINIUM CAPS 5-2.5 cisatracurium besylate (pf) soln 200 mg/20ml MG [chlordiazepoxide hcl-clidinium ...... 23 bromide] ...... 21 cisatracurium besylate soln 20 mg/10ml ...... 23 chlorhexidine gluconate soln 0.12 % ...... 59 cisplatin soln 100 mg/100ml ...... 15 CHLOROFORM SOL [chloroform] ...... 75 cisplatin soln 50 mg/50ml ...... 15 chloroprocaine hcl (pf) soln 2 % ...... 71 citalopram hydrobromide soln 10 mg/5ml ... 48 chloroprocaine hcl inj 3% ...... 71 citalopram hydrobromide tabs 10 mg ...... 48 chloroquine phosphate tabs 250 mg...... 12 citalopram hydrobromide tabs 20 mg ...... 48 chloroquine phosphate tabs 500 mg...... 12 citalopram hydrobromide tabs 40 mg ...... 48 CHLORPHENIRAMINE MALEATE TABS 4 MG cladribine soln 10 mg/10ml ...... 15 [chlorpheniramine maleate] ...... 88 clarithromycin susr 125 mg/5ml ...... 8 CHLORPROMAZINE HCL POW HCL clarithromycin susr 250 mg/5ml ...... 8 [chlorpromazine hcl] ...... 75 clarithromycin tabs 250 mg ...... 8 chlorpromazine hcl soln 25 mg/ml ...... 48 clarithromycin tabs 500 mg ...... 8 chlorpromazine hcl tabs 10 mg ...... 48 CLEOCIN IN D5W SOLN 300 MG/50ML chlorpromazine hcl tabs 100 mg ...... 48 [clindamycin phosphate in d5w] ...... 8 chlorpromazine hcl tabs 200 mg ...... 48 CLEOCIN IN D5W SOLN 600 MG/50ML chlorpromazine hcl tabs 25 mg ...... 48 [clindamycin phosphate in d5w] ...... 8 chlorpromazine hcl tabs 50 mg ...... 48 CLEOCIN IN D5W SOLN 900 MG/50ML chlorthalidone tabs 25 mg ...... 55 [clindamycin phosphate in d5w] ...... 8 chlorthalidone tabs 50 mg ...... 55 CLEVIPREX EMUL 25 MG/50ML [clevidipine] CHOLESTEROL POWD [cholesterol]...... 92 ...... 33 cholestyramine light pack 4 gm ...... 31 CLEVIPREX EMUL 50 MG/100ML [clevidipine] cholestyramine light powd 4 gm/dose ...... 31 ...... 33 cholestyramine pack 4 gm ...... 31 CLICKFINE PEN NEEDLES MISC 31G X 6 MM cholestyramine powd 4 gm/dose ...... 31 [insulin pen needle] ...... 90 CHOLINE-MAG TRISALICYLATE LIQD 500 CLIMARA PTWK 0.025 MG/24HR [estradiol] . 68 MG/5ML [choline & mag salicylate] ...... 37 CLIMARA PTWK 0.0375 MG/24HR [estradiol] CHROMIC CHLORIDE SOLN 40 MCG/10ML ...... 68 [chromic chloride] ...... 56 CLIMARA PTWK 0.05 MG/24HR [estradiol] ... 68 cidofovir soln 75 mg/ml ...... 13 CLIMARA PTWK 0.06 MG/24HR [estradiol] ... 68 CIMDUO TABS 300-300 MG [lamivudine- CLIMARA PTWK 0.075 MG/24HR [estradiol] . 68 tenofovir disoproxil fumarate] ...... 4 CLIMARA PTWK 0.1 MG/24HR [estradiol] ..... 68 cimetidine hcl soln 300 mg/5ml ...... 62 clindamycin hcl caps 150 mg ...... 8 cinacalcet hcl tabs 30 mg ...... 72 clindamycin hcl caps 300 mg ...... 8 cinacalcet hcl tabs 60 mg ...... 72 CLINDAMYCIN HCL POWD [clindamycin hcl

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 103 of 144

(bulk)] ...... 75 acid infusion in d25w] ...... 54 clindamycin palmitate hcl solr 75 mg/5ml ..... 8 clobetasol propionate crea 0.05 % ...... 82 clindamycin phos-benzoyl perox gel 1.2-5 % clobetasol propionate foam 0.05 % ...... 82 ...... 81 clobetasol propionate gel 0.05 % ...... 82 clindamycin phos-benzoyl perox gel 1-5 % . 81 clobetasol propionate lotn 0.05 % ...... 82 clindamycin phosphate crea 2 % ...... 81 clobetasol propionate oint 0.05 % ...... 82 clindamycin phosphate gel 1 % ...... 81 CLOBETASOL PROPIONATE POW PROPIONA clindamycin phosphate lotn 1 % ...... 82 [clobetasol propionate] ...... 75 clindamycin phosphate soln 1 % ...... 82 clobetasol propionate soln 0.05 % ...... 82 clindamycin phosphate soln 300 mg/2ml ...... 8 CLOBEX LOTN 0.05 % [clobetasol propionate] CLINDAMYCIN PHOSPHATE SOLN 600 ...... 82 MG/4ML [clindamycin phosphate] ...... 8 CLOBEX SPRAY LIQD 0.05 % [clobetasol clindamycin phosphate soln 9000 mg/60ml .. 8 propionate] ...... 82 CLINIMIX E/DEXTROSE (2.75/10) SOLN 2.75 % clomiphene citrate tabs 50 mg ...... 68 [amino acid electrolyte w/ calcium infusion clomipramine hcl caps 25 mg ...... 48 in d10w] ...... 54 clomipramine hcl caps 50 mg ...... 48 CLINIMIX E/DEXTROSE (2.75/5) SOLN 2.75 % clomipramine hcl caps 75 mg ...... 48 [amino acid electrolyte w/ calcium infusion clonazepam tabs 0.5 mg ...... 42 in d5w] ...... 54 clonazepam tabs 1 mg ...... 42 CLINIMIX E/DEXTROSE (4.25/10) SOLN 4.25 % clonazepam tabs 2 mg ...... 42 [amino acid electrolyte w/ calcium infusion CLONIDINE HCL POWD [clonidine hcl] ...... 75 in d10w] ...... 54 clonidine hcl tabs 0.1 mg ...... 34 CLINIMIX E/DEXTROSE (4.25/25) SOLN 4.25 % clonidine hcl tabs 0.2 mg ...... 34 [amino acid electrolyte w/ calcium infusion clonidine hcl tabs 0.3 mg ...... 34 in d25w] ...... 54 clonidine ptwk 0.1 mg/24hr ...... 34 CLINIMIX E/DEXTROSE (4.25/5) SOLN 4.25 % clonidine ptwk 0.2 mg/24hr ...... 34 [amino acid electrolyte w/ calcium infusion clonidine ptwk 0.3 mg/24hr ...... 34 in d5w] ...... 54 clopidogrel bisulfate tabs 75 mg ...... 29 CLINIMIX E/DEXTROSE (5/15) SOLN 5 % clorazepate dipotassium tabs 15 mg ...... 46 [amino acid electrolyte w/ calcium infusion clorazepate dipotassium tabs 3.75 mg ...... 46 in d15w] ...... 54 clorazepate dipotassium tabs 7.5 mg ...... 46 CLINIMIX E/DEXTROSE (5/20) SOLN 5 % clotrimazole crea 1 % ...... 93 [amino acid electrolyte w/ calcium infusion CLOTRIMAZOLE CRYS [clotrimazole in d20w] ...... 54 (topical)] ...... 75 CLINIMIX E/DEXTROSE (5/25) SOLN 5 % CLOTRIMAZOLE POWD [clotrimazole [amino acid electrolyte w/ calcium infusion (topical)] ...... 75 in d25w] ...... 54 clotrimazole troc 10 mg ...... 82 CLINIMIX/DEXTROSE (2.75/5) SOLN 2.75 % clozapine tabs 100 mg ...... 48 [amino acid infusion in d5w] ...... 54 clozapine tabs 200 mg ...... 48 CLINIMIX/DEXTROSE (4.25/10) SOLN 4.25 % clozapine tabs 25 mg ...... 48 [amino acid infusion in d10w] ...... 54 clozapine tabs 50 mg ...... 48 CLINIMIX/DEXTROSE (4.25/20) SOLN 4.25 % COAL TAR EXTRACT SOLN 20 % [coal tar [amino acid infusion in d20w] ...... 54 (crude)] ...... 75 CLINIMIX/DEXTROSE (4.25/25) SOLN 4.25 % COARTEM TABS 20-120 MG [artemether- [amino acid infusion in d25w] ...... 54 lumefantrine] ...... 12 CLINIMIX/DEXTROSE (4.25/5) SOLN 4.25 % CODEINE SULFATE TABS 15 MG [codeine [amino acid infusion in d5w] ...... 54 sulfate] ...... 37 CLINIMIX/DEXTROSE (5/15) SOLN 5 % [amino CODEINE SULFATE TABS 30 MG [codeine acid infusion in d15w] ...... 54 sulfate] ...... 37 CLINIMIX/DEXTROSE (5/20) SOLN 5 % [amino CODEINE SULFATE TABS 60 MG [codeine acid infusion in d20w] ...... 54 sulfate] ...... 37 CLINIMIX/DEXTROSE (5/25) SOLN 5 % [amino colchicine tabs 0.6 mg ...... 72

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 104 of 144 colchicine-probenecid tabs 0.5-500 mg ...... 58 (lipase-protease-amylase)] ...... 63 colestipol hcl gran 5 gm ...... 31 CREON CPEP 36000-114000 UNIT colestipol hcl pack 5 gm ...... 31 [pancrelipase (lipase-protease-amylase)] 63 colestipol hcl tabs 1 gm ...... 31 CREON CPEP 6000-19000 UNIT [pancrelipase COLLODION FLEXIBLE LIQD [collodion (lipase-protease-amylase)] ...... 63 flexible] ...... 92 CRIXIVAN CAPS 200 MG [indinavir sulfate] ... 4 COLY-MYCIN S SUSP 3.3-3-10-0.5 MG/ML CRIXIVAN CAPS 400 MG [indinavir sulfate] ... 4 [neomycin-colistin-hc-thonzonium] ...... 60 CROFAB SOLR [crotalidae polyvalent COMBIVENT RESPIMAT AERS 20-100 immune fab (ovine)] ...... 78 MCG/ACT [ipratropium-albuterol] ...... 77 cromolyn sodium conc 100 mg/5ml ...... 77 COMETRIQ (100 MG DAILY DOSE) KIT 80 & 20 cromolyn sodium nebu 20 mg/2ml ...... 77 MG [cabozantinib s-malate] ...... 15 cromolyn sodium soln 4 % ...... 60 COMETRIQ (140 MG DAILY DOSE) KIT 3 x 20 C-TOPICAL SOLN 4 % [cocaine hcl] ...... 61 MG & 80 MG [cabozantinib s-malate] ...... 15 CUBICIN SOLR 500 MG [daptomycin]...... 8 COMETRIQ (60 MG DAILY DOSE) KIT 20 MG CUPRIC CHLORIDE SOLN 0.4 MG/ML [cupric [cabozantinib s-malate] ...... 15 chloride] ...... 56 COMPLERA TABS 200-25-300 MG CUROSURF SUSP 120 MG/1.5ML [poractant [emtricitabine-rilpivirine-tenofovir alfa] ...... 77 disoproxil fumarate] ...... 4 CUROSURF SUSP 240 MG/3ML [poractant CONDYLOX GEL 0.5 % [podofilox] ...... 84 alfa] ...... 77 CONRAY 43 INJ 43% [iothalamate CUVPOSA SOLN 1 MG/5ML [glycopyrrolate]21 meglumine] ...... 52 cyanocobalamin soln 1000 mcg/ml ...... 86 CONRAY SOLN 60 % [iothalamate cyclobenzaprine hcl tabs 10 mg ...... 23 meglumine] ...... 52 cyclobenzaprine hcl tabs 5 mg ...... 23 CONTOUR NEXT CONTROL SOLN NORMAL cyclopentolate hcl soln 1 % ...... 61 [blood glucose calibration] ...... 90 cyclopentolate hcl soln 2 % ...... 61 COPIKTRA CAPS 15 MG [duvelisib] ...... 15 CYCLOPHOSPHAMIDE CAPS 25 MG COPIKTRA CAPS 25 MG [duvelisib] ...... 16 [cyclophosphamide] ...... 16 CORDRAN TAPE 4 MCG/SQCM CYCLOPHOSPHAMIDE CAPS 50 MG [flurandrenolide] ...... 82 [cyclophosphamide] ...... 16 cortisone acetate tabs 25 mg...... 64 cyclophosphamide solr 1 gm ...... 16 CORTISPORIN CREA 3.5-10000-0.5 cyclophosphamide solr 2 gm ...... 16 [neomycin-polymyxin-hc] ...... 83 cyclophosphamide solr 500 mg ...... 16 CORTISPORIN OINT 1 % [bacitracin- cycloserine caps 250 mg ...... 12 polymyxin-neomycin hc] ...... 83 cyproheptadine hcl syrp 2 mg/5ml ...... 14 CORTROSYN SOLR 0.25 MG [cosyntropin] . 52 cyproheptadine hcl tabs 4 mg ...... 14 COSENTYX (300 MG DOSE) SOSY 150 MG/ML CYRAMZA SOLN 100 MG/10ML [ramucirumab] [secukinumab]...... 84 ...... 16 COSENTYX SENSOREADY (300 MG) SOAJ CYRAMZA SOLN 500 MG/50ML [ramucirumab] 150 MG/ML [secukinumab] ...... 84 ...... 16 COSENTYX SENSOREADY PEN SOAJ 150 CYSTADANE POWD [betaine] ...... 72 MG/ML [secukinumab] ...... 85 CYSTAGON CAPS 150 MG [cysteamine COSENTYX SOSY 150 MG/ML [secukinumab] bitartrate] ...... 72 ...... 85 CYSTAGON CAPS 50 MG [cysteamine COSMEGEN SOLR 0.5 MG [dactinomycin] .. 16 bitartrate] ...... 72 COTELLIC TABS 20 MG [cobimetinib CYSTEAMINE HCL POWD [cysteamine hcl fumarate] ...... 16 (bulk)] ...... 75 CREON CPEP 12000-38000 UNIT CYSTO-CONRAY II SOLN 17.2 % [iothalamate [pancrelipase (lipase-protease-amylase)] 63 meglumine] ...... 52 CREON CPEP 24000-76000 UNIT CYSTOGRAFIN SOLN 30 % [diatrizoate [pancrelipase (lipase-protease-amylase)] 63 meglumine] ...... 52 CREON CPEP 3000-9500 UNIT [pancrelipase CYSTOGRAFIN-DILUTE SOLN 18 %

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 105 of 144

[diatrizoate meglumine] ...... 52 tenofovir alafenamide fumarate] ...... 13 cytarabine (pf) soln 100 mg/ml ...... 16 desipramine hcl tabs 10 mg ...... 48 cytarabine (pf) soln 20 mg/ml ...... 16 desipramine hcl tabs 100 mg ...... 48 cytarabine soln 20 mg/ml ...... 16 desipramine hcl tabs 150 mg ...... 48 CYTOGAM INJ 50 MG/ML [cytomegalovirus desipramine hcl tabs 25 mg ...... 48 immune globulin (human)] ...... 78 desipramine hcl tabs 50 mg ...... 48 CYTRA K CRYSTALS PACK 3300-1002 MG desipramine hcl tabs 75 mg ...... 48 [potassium citrate-citric acid] ...... 53 DESITIN PSTE 40 % [zinc oxide (topical)] .... 94 CYTRA-K SOLN 1100-334 MG/5ML [potassium desmopressin ace spray refrig soln 0.01 % . 69 citrate-citric acid] ...... 53 desmopressin acetate soln 4 mcg/ml ...... 69 dacarbazine solr 100 mg ...... 16 desmopressin acetate spray soln 0.01 % ..... 69 dacarbazine solr 200 mg ...... 16 desmopressin acetate tabs 0.1 mg ...... 69 DACOGEN SOLR 50 MG [decitabine] ...... 16 desmopressin acetate tabs 0.2 mg ...... 69 DAKINS (1/4 STRENGTH) SOLN 0.125 % desonide oint 0.05 % ...... 83 [sodium hypochlorite] ...... 93 desoximetasone crea 0.25 %...... 83 DAKINS (FULL STRENGTH) SOLN 0.5 % dexamethasone elix 0.5 mg/5ml ...... 64 [sodium hypochlorite] ...... 93 DEXAMETHASONE POWD [dexamethasone DAKLINZA TABS 30 MG [daclatasvir (bulk)] ...... 75 dihydrochloride] ...... 13 dexamethasone sodium phosphate soln 0.1 DAKLINZA TABS 60 MG [daclatasvir % ...... 60 dihydrochloride] ...... 13 dexamethasone sodium phosphate soln 10 DALIRESP TABS 500 MCG [roflumilast] ...... 77 mg/ml...... 64 danazol caps 100 mg ...... 65 dexamethasone sodium phosphate soln 20 danazol caps 200 mg ...... 65 mg/5ml...... 64 danazol caps 50 mg ...... 65 dexamethasone soln 0.5 mg/5ml ...... 64 dantrolene sodium caps 100 mg ...... 23 dexamethasone tabs 0.5 mg ...... 64 dantrolene sodium caps 25 mg ...... 23 dexamethasone tabs 0.75 mg ...... 64 dantrolene sodium caps 50 mg ...... 23 dexamethasone tabs 1 mg ...... 64 dapsone tabs 100 mg ...... 12 dexamethasone tabs 1.5 mg ...... 64 dapsone tabs 25 mg ...... 12 dexamethasone tabs 2 mg ...... 64 DARAPRIM TABS 25 MG [pyrimethamine] ... 12 dexamethasone tabs 4 mg ...... 64 DARZALEX SOLN 100 MG/5ML dexamethasone tabs 6 mg ...... 64 [daratumumab] ...... 16 dexmethylphenidate hcl er cp24 10 mg ...... 41 DARZALEX SOLN 400 MG/20ML dexmethylphenidate hcl er cp24 15 mg ...... 41 [daratumumab] ...... 16 dexmethylphenidate hcl er cp24 20 mg ...... 41 daunorubicin hcl soln 20 mg/4ml ...... 16 dexmethylphenidate hcl er cp24 25 mg ...... 41 DDAVP RHINAL TUBE SOLN 0.01 % dexmethylphenidate hcl er cp24 30 mg ...... 41 [desmopressin acetate refrigerated] ...... 69 dexmethylphenidate hcl er cp24 35 mg ...... 41 deferasirox tabs 360 mg ...... 63 dexmethylphenidate hcl er cp24 40 mg ...... 41 deferasirox tabs 90 mg ...... 63 dexmethylphenidate hcl er cp24 5 mg...... 41 deferoxamine mesylate solr 2 gm ...... 63 dexmethylphenidate hcl tabs 10 mg ...... 41 deferoxamine mesylate solr 500 mg ...... 63 dexmethylphenidate hcl tabs 2.5 mg ...... 41 DELESTROGEN OIL 20 MG/ML [estradiol dexmethylphenidate hcl tabs 5 mg ...... 41 valerate] ...... 68 dexrazoxane hcl solr 250 mg ...... 72 DELESTROGEN OIL 40 MG/ML [estradiol dexrazoxane hcl solr 500 mg ...... 72 valerate] ...... 68 dextroamphetamine sulfate er cp24 10 mg .. 41 demeclocycline hcl tabs 150 mg ...... 8 dextroamphetamine sulfate er cp24 15 mg .. 41 demeclocycline hcl tabs 300 mg ...... 8 dextroamphetamine sulfate er cp24 5 mg .... 41 DEPO-PROVERA SUSP 400 MG/ML dextroamphetamine sulfate tabs 10 mg ...... 41 [medroxyprogesterone acetate dextroamphetamine sulfate tabs 5 mg ...... 41 (antineoplastic)] ...... 69 DEXTROSE 5%/ELECTROLYTE #48 SOLN DESCOVY TABS 200-25 MG [emtricitabine- [electrolyte-48 in dextrose] ...... 56

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 106 of 144

DEXTROSE IN LACTATED RINGERS SOLN 5 dicyclomine hcl tabs 20 mg ...... 21 % [dextrose in lactated ringers] ...... 56 didanosine cap 125mg ...... 4 dextrose in ringers soln 5 % ...... 56 didanosine cpdr 200 mg ...... 13 DEXTROSE SOLN 10 % [dextrose] ...... 54 didanosine cpdr 250 mg ...... 13 DEXTROSE SOLN 20 % [dextrose] ...... 54 didanosine cpdr 400 mg ...... 13 DEXTROSE SOLN 40 % [dextrose] ...... 54 DIFFERIN CREA 0.1 % [adapalene] ...... 85 DEXTROSE SOLN 5 % [dextrose] ...... 54 DIFFERIN GEL 0.1 % [adapalene] ...... 94 DEXTROSE SOLN 50 % [dextrose] ...... 54 DIFFERIN GEL 0.3 % [adapalene] ...... 85 DEXTROSE SOLN 70 % [dextrose] ...... 54 DIGIFAB SOLR 40 MG [digoxin immune fab]78 DEXTROSE-NACL SOLN 10-0.45 % [dextrose DIGOXIN SOLN 0.05 MG/ML [digoxin]...... 34 w/ sodium chloride] ...... 56 digoxin soln 0.25 mg/ml ...... 34 DEXTROSE-NACL SOLN 2.5-0.45 % [dextrose digoxin tabs 125 mcg ...... 34 w/ sodium chloride] ...... 56 digoxin tabs 250 mcg ...... 34 DEXTROSE-NACL SOLN 5-0.2 % [dextrose w/ dihydroergotamine mesylate soln 1 mg/ml .. 23 sodium chloride] ...... 56 diltiazem hcl er coated beads cp24 180 mg . 33 DEXTROSE-NACL SOLN 5-0.225 % [dextrose diltiazem hcl er cp12 120 mg ...... 33 w/ sodium chloride] ...... 56 diltiazem hcl er cp12 60 mg ...... 33 DEXTROSE-NACL SOLN 5-0.33 % [dextrose diltiazem hcl er cp12 90 mg ...... 33 w/ sodium chloride] ...... 56 diltiazem hcl er cp24 120 mg ...... 33 DEXTROSE-NACL SOLN 5-0.45 % [dextrose diltiazem hcl er cp24 180 mg ...... 33 w/ sodium chloride] ...... 56 diltiazem hcl er cp24 240 mg ...... 33 DEXTROSE-NACL SOLN 5-0.9 % [dextrose w/ DILTIAZEM HCL POWD [diltiazem hcl (bulk)] sodium chloride] ...... 56 ...... 75 DIANEAL LOW CALCIUM/4.25% DEX SOLN diltiazem hcl soln 125 mg/25ml ...... 33 483 MOSM/L [peritoneal dialysis solutions] diltiazem hcl soln 25 mg/5ml ...... 33 ...... 56 diltiazem hcl soln 50 mg/10ml ...... 33 DIANEAL PD-2/1.5% DEXTROSE SOLN 346 diltiazem hcl tabs 120 mg ...... 33 MOSM/L [peritoneal dialysis solutions] ... 56 diltiazem hcl tabs 30 mg ...... 33 DIANEAL PD-2/2.5% DEXTROSE SOLN 396 diltiazem hcl tabs 60 mg ...... 33 MOSM/L [peritoneal dialysis solutions] ... 56 diltiazem hcl tabs 90 mg ...... 33 DIANEAL PD-2/4.25% DEXTROSE SOLN 485 DIMAPHEN CHILDRENS ELIX 1-2.5 MG/5ML MOSM/L [peritoneal dialysis solutions] ... 56 [brompheniramine & phenyleph] ...... 88 DIASTAT ACUDIAL GEL 10 MG [diazepam dimethyl fumarate cpdr 120 mg ...... 72 (anticonvulsant)] ...... 46 dimethyl fumarate cpdr 240 mg ...... 73 DIASTAT ACUDIAL GEL 20 MG [diazepam dimethyl fumarate starter pack misc 120 & (anticonvulsant)] ...... 46 240 mg ...... 73 DIASTAT PEDIATRIC GEL 2.5 MG [diazepam DIPHENHIST LIQD 12.5 MG/5ML (anticonvulsant)] ...... 46 [diphenhydramine hcl] ...... 88 DIASTIX STRP [glucose urine test-(glucose DIPHENHYDRAMINE HCL CAPS 25 MG oxidase)] ...... 91 [diphenhydramine hcl] ...... 88 diazepam soln 5 mg/5ml ...... 46 DIPHENHYDRAMINE HCL CAPS 50 MG diazepam soln 5 mg/ml ...... 46 [diphenhydramine hcl] ...... 88 diazepam tabs 10 mg ...... 46 diphenhydramine hcl soln 50 mg/ml ...... 14 diazepam tabs 2 mg...... 46 diphenoxylate-atropine liqd 2.5-0.025 mg/5ml diazepam tabs 5 mg...... 46 ...... 62 diclofenac sodium gel 1 % ...... 85 diphenoxylate-atropine tabs 2.5-0.025 mg ... 62 diclofenac sodium soln 0.1 % ...... 60 DIPHTHERIA-TETANUS TOXOIDS DT SUSP diclofenac sodium soln 1.5 % ...... 85 25-5 LFU/0.5ML [diphtheria-tetanus toxoids dicloxacillin sodium caps 250 mg ...... 8 (dt)] ...... 80 dicloxacillin sodium caps 500 mg ...... 8 dipyridamole soln 5 mg/ml ...... 36 dicyclomine hcl caps 10 mg ...... 21 dipyridamole tabs 25 mg ...... 36 dicyclomine hcl soln 10 mg/5ml ...... 21 dipyridamole tabs 50 mg ...... 36

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 107 of 144 dipyridamole tabs 75 mg ...... 36 DOVATO TABS 50-300 MG [dolutegravir disopyramide phosphate caps 100 mg ...... 34 sodium-lamivudine] ...... 4 disopyramide phosphate caps 150 mg ...... 34 doxazosin mesylate tabs 1 mg ...... 31 DISPOSABLE POWER KIT [misc. devices] . 90 doxazosin mesylate tabs 2 mg ...... 31 disulfiram tabs 250 mg ...... 73 doxazosin mesylate tabs 4 mg ...... 31 disulfiram tabs 500 mg ...... 73 doxazosin mesylate tabs 8 mg ...... 31 divalproex sodium csdr 125 mg ...... 42 doxepin hcl caps 10 mg ...... 48 divalproex sodium er tb24 250 mg ...... 42 doxepin hcl caps 100 mg ...... 48 divalproex sodium er tb24 500 mg ...... 42 doxepin hcl caps 150 mg ...... 48 divalproex sodium tbec 125 mg ...... 42 doxepin hcl caps 25 mg ...... 48 divalproex sodium tbec 250 mg ...... 42 doxepin hcl caps 50 mg ...... 48 divalproex sodium tbec 500 mg ...... 42 doxepin hcl caps 75 mg ...... 48 dobutamine hcl soln 250 mg/20ml ...... 24 doxepin hcl conc 10 mg/ml ...... 48 DOBUTAMINE IN D5W SOLN 1-5 MG/ML-% DOXIL INJ 2 MG/ML [doxorubicin hcl [dobutamine in d5w] ...... 24 liposomal] ...... 16 DOBUTAMINE IN D5W SOLN 2 MG/ML doxorubicin hcl liposomal inj 2 mg/ml ...... 16 [dobutamine in d5w] ...... 24 doxorubicin hcl soln 2 mg/ml ...... 16 DOCETAXEL (NON-ALCOHOL) SOLN 160 doxorubicin hcl solr 10 mg ...... 16 MG/8ML [docetaxel] ...... 16 doxorubicin hcl solr 50 mg ...... 16 DOCETAXEL (NON-ALCOHOL) SOLN 20 doxycycline hyclate caps 100 mg ...... 8 MG/ML [docetaxel] ...... 16 doxycycline hyclate caps 50 mg ...... 8 docetaxel conc 80 mg/4ml ...... 16 doxycycline hyclate tabs 100 mg ...... 8 DOCUSATE SODIUM CAPS 100 MG [docusate doxycycline hyclate tabs 20 mg ...... 8 sodium] ...... 92 doxycycline monohydrate susr 25 mg/5ml .... 8 dofetilide caps 125 mcg ...... 34 doxycycline monohydrate tabs 100 mg ...... 8 dofetilide caps 250 mcg ...... 34 doxycycline monohydrate tabs 50 mg ...... 8 dofetilide caps 500 mcg ...... 34 DRITHO-CREME HP CREA 1 % [anthralin] ... 85 donepezil hcl tabs 10 mg ...... 22 dronabinol caps 10 mg ...... 62 DONEPEZIL HCL TABS 5 MG [donepezil dronabinol caps 2.5 mg ...... 62 hydrochloride] ...... 22 dronabinol caps 5 mg ...... 62 donepezil hcl tbdp 10 mg ...... 22 droperidol soln 2.5 mg/ml ...... 46 donepezil hcl tbdp 5 mg ...... 22 drospirenone-ethinyl estradiol tabs 3-0.02 mg DONNATAL ELIX 16.2 MG/5ML [phenobarbital- ...... 67 hyoscyamine-atropine-scopolamine] ...... 22 drospirenone-ethinyl estradiol tabs 3-0.03 mg DONNATAL TABS 16.2 MG [phenobarbital- ...... 67 hyoscyamine-atropine-scopolamine] ...... 22 DRYSOL SOLN 20 % [aluminum chloride] ... 84 dopamine hcl inj 80mg/ml ...... 24 duloxetine hcl cpep 20 mg ...... 48 dopamine hcl soln 160 mg/ml ...... 24 duloxetine hcl cpep 30 mg ...... 48 DOPAMINE HCL SOLN 40 MG/ML [dopamine duloxetine hcl cpep 60 mg ...... 49 hcl] ...... 24 DUOPA SUSP 4.63-20 MG/ML [carbidopa- dopamine hcl soln 80 mg/ml ...... 24 levodopa] ...... 45 DOPAMINE IN D5W SOLN 0.8-5 MG/ML-% DURAMORPH SOLN 0.5 MG/ML [morphine [dopamine in d5w] ...... 24 sulfate] ...... 37 DOPAMINE IN D5W SOLN 1.6-5 MG/ML-% DURAMORPH SOLN 1 MG/ML [morphine [dopamine in d5w] ...... 24 sulfate] ...... 37 DOPAMINE IN D5W SOLN 3.2-5 MG/ML-% D-XYLOSE POWD [d-xylose] ...... 52 [dopamine in d5w] ...... 24 DYRENIUM CAPS 100 MG [triamterene] ...... 55 dorzolamide hcl soln 2 % ...... 60 DYRENIUM CAPS 50 MG [triamterene] ...... 55 dorzolamide hcl-timolol mal soln 22.3-6.8 ED CHLORPED JR SYRP 2 MG/5ML mg/ml ...... 60 [chlorpheniramine maleate] ...... 88 DOUBLE ANTIBIOTIC OINT 500-10000 EDECRIN TABS 25 MG [ethacrynic acid] ...... 55 UNIT/GM [bacitracin-polymyxin b] ...... 93 EDEX KIT 10 MCG [alprostadil (vasodilator)]

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...... 36 factor (rcmb) fc fusion protein(bdd-rfviiifc)] EDEX KIT 20 MCG [alprostadil (vasodilator)] ...... 26 ...... 36 ELOCTATE SOLR 750 UNIT [antihemophilic EDEX KIT 40 MCG [alprostadil (vasodilator)] factor (rcmb) fc fusion protein(bdd-rfviiifc)] ...... 36 ...... 26 EDURANT TABS 25 MG [rilpivirine hcl] ...... 4 ELTA TAR CREA 2 % [coal tar extract] ...... 93 EEMT HS TABS 0.625-1.25 MG [esterified EMCYT CAPS 140 MG [estramustine estrogens & methyltestosterone] ...... 68 phosphate sodium] ...... 16 EEMT TABS 1.25-2.5 MG [esterified estrogens EMEND CAPS 125 MG [aprepitant] ...... 62 & methyltestosterone] ...... 68 EMEND CAPS 40 MG [aprepitant] ...... 62 efavirenz caps 200 mg ...... 13 EMEND CAPS 80 MG [aprepitant] ...... 62 efavirenz caps 50 mg ...... 13 EMEND TRI-PACK CAPS 80 & 125 MG efavirenz tabs 600 mg ...... 13 [aprepitant] ...... 62 efavirenz-emtricitab-tenofovir tabs 600-200- emtricitabine caps 200 mg ...... 13 300 mg ...... 13 emtricitabine-tenofovir df tabs 100-150 mg . 13 EFFER-K TBEF 25 MEQ [potassium emtricitabine-tenofovir df tabs 133-200 mg . 13 bicarbonate] ...... 56 emtricitabine-tenofovir df tabs 167-250 mg . 13 EFFIENT TABS 10 MG [prasugrel hcl] ...... 29 emtricitabine-tenofovir df tabs 200-300 mg . 13 EFFIENT TABS 5 MG [prasugrel hcl] ...... 29 EMTRIVA SOLN 10 MG/ML [emtricitabine] ..... 4 ELAPRASE SOLN 6 MG/3ML [idursulfase] ... 59 enalaprilat inj 1.25 mg/ml ...... 35 eletriptan hydrobromide tabs 20 mg ...... 44 ENBREL SOLR 25 MG [etanercept] ...... 70 eletriptan hydrobromide tabs 40 mg ...... 44 ENBREL SOSY 25 MG/0.5ML [etanercept] .... 70 ELITEK SOLR 1.5 MG [rasburicase] ...... 59 ENBREL SOSY 50 MG/ML [etanercept] ...... 70 ELITEK SOLR 7.5 MG [rasburicase] ...... 59 ENBREL SURECLICK SOAJ 50 MG/ML ELLA TABS 30 MG [ulipristal acetate] ...... 67 [etanercept] ...... 70 ELMIRON CAPS 100 MG [pentosan ENDOMETRIN INST 100 MG [progesterone polysulfate sodium] ...... 73 (vaginal)] ...... 69 ELOCTATE SOLR 1000 UNIT [antihemophilic ENGERIX-B SUSP 10 MCG/0.5ML [hepatitis b factor (rcmb) fc fusion protein(bdd-rfviiifc)] vaccine (recomb)] ...... 80 ...... 26 ENGERIX-B SUSP 20 MCG/ML [hepatitis b ELOCTATE SOLR 1500 UNIT [antihemophilic vaccine (recomb)] ...... 80 factor (rcmb) fc fusion protein(bdd-rfviiifc)] ENTACAPONE TABS 200 MG [entacapone] . 45 ...... 26 entecavir tabs 0.5 mg ...... 13 ELOCTATE SOLR 2000 UNIT [antihemophilic entecavir tabs 1 mg...... 13 factor (rcmb) fc fusion protein(bdd-rfviiifc)] ENTRESTO TABS 24-26 MG [sacubitril- ...... 26 valsartan] ...... 35 ELOCTATE SOLR 250 UNIT [antihemophilic ENTRESTO TABS 49-51 MG [sacubitril- factor (rcmb) fc fusion protein(bdd-rfviiifc)] valsartan] ...... 35 ...... 26 ENTRESTO TABS 97-103 MG [sacubitril- ELOCTATE SOLR 3000 UNIT [antihemophilic valsartan] ...... 35 factor (rcmb) fc fusion protein(bdd-rfviiifc)] EOVIST SOLN 0.25 MOL/L [gadoxetate ...... 26 disodium] ...... 52 ELOCTATE SOLR 4000 UNIT [antihemophilic EPCLUSA TABS 200-50 MG [sofosbuvir- factor (rcmb) fc fusion protein(bdd-rfviiifc)] velpatasvir] ...... 13 ...... 26 EPCLUSA TABS 400-100 MG [sofosbuvir- ELOCTATE SOLR 500 UNIT [antihemophilic velpatasvir] ...... 13 factor (rcmb) fc fusion protein(bdd-rfviiifc)] EPHEDRINE SULFATE SOLN 50 MG/ML ...... 26 [ephedrine sulfate (pressors)] ...... 24 ELOCTATE SOLR 5000 UNIT [antihemophilic EPIDUO FORTE GEL 0.3-2.5 % [adapalene- factor (rcmb) fc fusion protein(bdd-rfviiifc)] benzoyl peroxide] ...... 85 ...... 26 epinephrine hcl inj 1mg/ml ...... 24 ELOCTATE SOLR 6000 UNIT [antihemophilic EPINEPHRINE PF SOLN 1 MG/ML

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 109 of 144

[epinephrine] ...... 24 estradiol valerate inj 10mg/ml ...... 68 epinephrine soaj 0.15 mg/0.15ml ...... 24 estradiol valerate oil 20 mg/ml ...... 68 EPINEPHRINE SOLN 30 MG/30ML estradiol valerate oil 40 mg/ml ...... 68 [epinephrine] ...... 24 ESTRING RING 2 MG [estradiol vaginal] ...... 68 EPINEPHRINE SOSY 1 MG/10ML ethacrynic acid tabs 25 mg ...... 55 [epinephrine] ...... 24 ethambutol hcl tabs 100 mg ...... 12 EPIPEN 2-PAK SOAJ 0.3 MG/0.3ML ethambutol hcl tabs 400 mg ...... 12 [epinephrine (anaphylaxis)] ...... 24 ETHAMOLIN SOLN 5 % [ethanolamine oleate] EPIPEN JR 2-PAK SOAJ 0.15 MG/0.3ML ...... 36 [epinephrine (anaphylaxis)] ...... 24 ethosuximide caps 250 mg ...... 42 EPIVIR HBV SOLN 5 MG/ML [lamivudine ethosuximide soln 250 mg/5ml ...... 42 (hbv)] ...... 13 etidronate disodium tabs 200 mg ...... 73 EPIVIR HBV TABS 100 MG [lamivudine (hbv)] etidronate disodium tabs 400 mg ...... 73 ...... 13 etodolac caps 200 mg ...... 37 EQ MICONAZOLE 7 CREA 2 % [miconazole etodolac caps 300 mg ...... 37 nitrate vaginal] ...... 93 etodolac tabs 400 mg ...... 37 EQUETRO CP12 200 MG [carbamazepine etodolac tabs 500 mg ...... 37 (antipsychotic)] ...... 42 etomidate soln 2 mg/ml ...... 47 ERBITUX SOLN 100 MG/50ML [cetuximab] .. 16 etoposide caps 50 mg ...... 16 ERBITUX SOLN 200 MG/100ML [cetuximab] 16 everolimus tabs 2.5 mg ...... 16 ERGOCALCIFEROL SOLN 200 MCG/ML everolimus tabs 5 mg ...... 16 [ergocalciferol] ...... 94 everolimus tabs 7.5 mg ...... 16 ergoloid mesylates tabs 1 mg ...... 44 EVOTAZ TABS 300-150 MG [atazanavir ergotamine-caffeine tabs 1-100 mg ...... 44 sulfate-cobicistat] ...... 13 ERIVEDGE CAPS 150 MG [vismodegib] ...... 16 exemestane tabs 25 mg ...... 16 erlotinib hcl tabs 100 mg ...... 16 EXJADE TBSO 125 MG [deferasirox] ...... 63 erlotinib hcl tabs 150 mg ...... 16 EXJADE TBSO 250 MG [deferasirox] ...... 64 erlotinib hcl tabs 25 mg ...... 16 EXJADE TBSO 500 MG [deferasirox] ...... 64 ERWINAZE SOLR 10000 UNIT [asparaginase EXTAVIA KIT 0.3 MG [interferon beta-1b] ..... 47 erwinia chrysanthemi] ...... 16 EYLEA SOLN 2 MG/0.05ML [aflibercept] ...... 61 ERYTHROCIN LACTOBIONATE SOLR 500 MG EYLEA SOSY 2 MG/0.05ML [aflibercept] ...... 61 [erythromycin lactobionate] ...... 8 E-Z-CAT DRY PACK 2 % [barium sulfate] ..... 52 erythromycin oint 5 mg/gm ...... 59 ezetimibe tabs 10 mg ...... 31 erythromycin soln 2 % ...... 82 FABRAZYME SOLR 35 MG [agalsidase beta] escitalopram oxalate soln 5 mg/5ml ...... 49 ...... 59 escitalopram oxalate tabs 10 mg ...... 49 FABRAZYME SOLR 5 MG [agalsidase beta] . 59 escitalopram oxalate tabs 20 mg ...... 49 famciclovir tabs 500 mg ...... 13 escitalopram oxalate tabs 5 mg ...... 49 famotidine premixed soln 20-0.9 mg/50ml-% ESMOLOL HCL SOLN 100 MG/10ML [esmolol ...... 62 hcl] ...... 32 famotidine soln 20 mg/2ml ...... 62 ESTRADIOL POW [estradiol] ...... 75 famotidine soln 40 mg/4ml ...... 62 estradiol pttw 0.025 mg/24hr...... 68 famotidine susr 40 mg/5ml ...... 62 estradiol pttw 0.0375 mg/24hr ...... 68 famotidine tabs 20 mg ...... 62 estradiol pttw 0.05 mg/24hr ...... 68 famotidine tabs 40 mg ...... 62 estradiol pttw 0.075 mg/24hr...... 68 felbamate susp 600 mg/5ml...... 42 estradiol pttw 0.1 mg/24hr ...... 68 felbamate tabs 400 mg ...... 42 estradiol ptwk 0.05 mg/24hr ...... 68 felbamate tabs 600 mg ...... 42 estradiol ptwk 0.075 mg/24hr ...... 68 fenofibrate tabs 160 mg ...... 31 estradiol ptwk 0.1 mg/24hr ...... 68 fenofibrate tabs 54 mg ...... 31 estradiol tabs 0.5 mg ...... 68 fentanyl citrate (pf) soct 100 mcg/2ml ...... 37 estradiol tabs 1 mg ...... 68 FENTANYL CITRATE (PF) SOLN 100 MCG/2ML estradiol tabs 2 mg ...... 68 [fentanyl citrate] ...... 37

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FENTANYL CITRATE (PF) SOLN 500 flucytosine caps 500 mg ...... 11 MCG/10ML [fentanyl citrate] ...... 38 fludarabine phosphate solr 50 mg ...... 16 fentanyl pt72 100 mcg/hr ...... 38 fludrocortisone acetate tabs 0.1 mg ...... 64 fentanyl pt72 12 mcg/hr ...... 38 flumazenil soln 0.5 mg/5ml ...... 47 fentanyl pt72 25 mcg/hr ...... 38 flunisolide soln 25 mcg/act (0.025%) ...... 60 fentanyl pt72 50 mcg/hr ...... 38 fluocinolone acetonide body oil 0.01 % ...... 83 fentanyl pt72 75 mcg/hr ...... 38 fluocinolone acetonide scalp oil 0.01 % ...... 83 FERREX 150 CAPS 150 MG [polysaccharide fluocinolone acetonide soln 0.01 % ...... 83 iron complex] ...... 88 fluocinonide crea 0.05 % ...... 83 FERROUS SULFATE SOLN 75 (15 Fe) MG/ML fluocinonide gel 0.05 % ...... 83 [ferrous sulfate]...... 88 fluocinonide oint 0.05 % ...... 83 FERROUS SULFATE TABS 325 (65 Fe) MG fluocinonide soln 0.05 % ...... 83 [ferrous sulfate]...... 88 FLUORITAB CHEW 2.2 (1 F) MG [sodium finasteride tabs 5 mg ...... 73 fluoride] ...... 73 FIRAZYR SOLN 30 MG/3ML [icatibant acetate] fluorometholone susp 0.1 % ...... 60 ...... 73 FLUOROPLEX CREA 1 % [fluorouracil FIRVANQ SOLR 25 MG/ML [vancomycin hcl] 8 (topical)] ...... 85 FIRVANQ SOLR 50 MG/ML [vancomycin hcl] 8 fluorouracil crea 5 % ...... 85 FLEBOGAMMA DIF SOLN 0.5 GM/10ML fluorouracil soln 1 gm/20ml...... 16 [immune globulin (human) iv] ...... 78 fluorouracil soln 2 % ...... 85 FLEBOGAMMA DIF SOLN 2.5 GM/50ML fluorouracil soln 2.5 gm/50ml ...... 16 [immune globulin (human) iv] ...... 78 fluorouracil soln 5 % ...... 85 FLEBOGAMMA DIF SOLN 20 GM/400ML fluorouracil soln 5 gm/100ml ...... 16 [immune globulin (human) iv] ...... 78 fluorouracil soln 500 mg/10ml ...... 16 FLEBOGAMMA DIF SOLN 5 GM/50ML fluoxetine hcl caps 10 mg ...... 49 [immune globulin (human) iv] ...... 78 fluoxetine hcl caps 20 mg ...... 49 flecainide acetate tabs 100 mg ...... 34 fluoxetine hcl caps 40 mg ...... 49 flecainide acetate tabs 150 mg ...... 34 fluoxetine hcl soln 20 mg/5ml ...... 49 flecainide acetate tabs 50 mg ...... 34 fluphenazine decanoate soln 25 mg/ml ...... 49 FLONASE SENSIMIST SUSP 27.5 fluphenazine hcl conc 5 mg/ml ...... 49 MCG/SPRAY [fluticasone furoate] ...... 91 fluphenazine hcl tabs 1 mg ...... 49 FLOVENT HFA AERO 44 MCG/ACT fluphenazine hcl tabs 10 mg ...... 49 [fluticasone propionate hfa] ...... 64 fluphenazine hcl tabs 2.5 mg ...... 49 FLUAD SUSY 0.5 ML [influenza virus vaccine fluphenazine hcl tabs 5 mg ...... 49 types a & b surface antigen adjuvant] ...... 80 FLURA-DROPS SOLN 0.55 (0.25 F) MG/DROP fluconazole in dextrose inj dex 200 ...... 11 [sodium fluoride] ...... 73 fluconazole in dextrose soln 400 mg/200ml 11 flurbiprofen sodium soln 0.03 % ...... 60 fluconazole in nacl inj nacl 200 ...... 11 flutamide caps 125 mg ...... 16 fluconazole in nacl inj nacl 400 ...... 11 fluticasone propionate crea 0.05 % ...... 83 fluconazole in sodium chloride soln 100-0.9 fluticasone propionate oint 0.005 % ...... 83 mg/50ml-% ...... 8 fluticasone propionate susp 50 mcg/act 60, 91 fluconazole in sodium chloride soln 200-0.9 fluvoxamine maleate tabs 100 mg ...... 49 mg/100ml-% ...... 11 fluvoxamine maleate tabs 25 mg ...... 49 fluconazole in sodium chloride soln 400-0.9 fluvoxamine maleate tabs 50 mg ...... 49 mg/200ml-% ...... 11 FLUZONE HIGH-DOSE SUSY 0.5 ML fluconazole susr 10 mg/ml ...... 11 [influenza virus vaccine split high-dose fluconazole susr 40 mg/ml ...... 11 preservative free] ...... 80 fluconazole tabs 100 mg ...... 11 FLUZONE SUSP [influenza virus vaccine fluconazole tabs 150 mg ...... 11 split] ...... 80 fluconazole tabs 200 mg ...... 11 FML FORTE SUSP 0.25 % [fluorometholone fluconazole tabs 50 mg ...... 11 (ophth)] ...... 60 flucytosine caps 250 mg ...... 11 FML OINT 0.1 % [fluorometholone (ophth)] . 60

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 111 of 144 folic acid soln 5 mg/ml ...... 86 galantamine hydrobromide tabs 8 mg ...... 23 FOLIC ACID TABS 400 MCG [folic acid] ...... 94 GAMASTAN INJ [immune globulin (human) FORANE SOLN [isoflurane]...... 47 im] ...... 78 FORTAZ IN D5W SOLN 1-5 GM/50ML-% GAMMAGARD S/D LESS IGA SOLR 10 GM [ceftazidime sodium in d5w] ...... 8 [immune globulin (human) iv] ...... 78 FORTAZ IN D5W SOLN 2-5 GM/50ML-% GAMMAGARD S/D LESS IGA SOLR 5 GM [ceftazidime sodium in d5w] ...... 8 [immune globulin (human) iv] ...... 78 FORTAZ SOLR 500 MG [ceftazidime] ...... 8 GAMMAGARD SOLN 1 GM/10ML [immune FORTEO SOPN 620 MCG/2.48ML [teriparatide globulin (human) iv or subcutaneous] ..... 78 (recombinant)] ...... 69 GAMMAGARD SOLN 30 GM/300ML [immune fosamprenavir calcium tabs 700 mg ...... 13 globulin (human) iv or subcutaneous] ..... 78 fosaprepitant dimeglumine solr 150 mg ...... 62 GAMMAKED SOLN 1 GM/10ML [immune FOSCAVIR SOLN 6000 MG/250ML [foscarnet globulin (human) iv or subcutaneous] ..... 78 sodium] ...... 13 GAMMAKED SOLN 10 GM/100ML [immune fosphenytoin sodium soln 100 mg pe/2ml ... 42 globulin (human) iv or subcutaneous] ..... 78 fosphenytoin sodium soln 500 mg pe/10ml . 42 GAMMAKED SOLN 2.5 GM/25ML [immune fulvestrant soln 250 mg/5ml...... 16 globulin (human) iv or subcutaneous] ..... 78 furosemide soln 10 mg/ml ...... 55 GAMMAKED SOLN 20 GM/200ML [immune furosemide soln 8 mg/ml ...... 55 globulin (human) iv or subcutaneous] ..... 78 FUROSEMIDE TABS 20 MG [furosemide] .... 55 GAMMAKED SOLN 5 GM/50ML [immune FUROSEMIDE TABS 40 MG [furosemide] .... 55 globulin (human) iv or subcutaneous] ..... 79 furosemide tabs 80 mg ...... 55 GAMMAPLEX SOLN 10 GM/200ML [immune FUSILEV SOLR 50 MG [levoleucovorin globulin (human) iv] ...... 79 calcium] ...... 73 GAMMAPLEX SOLN 20 GM/400ML [immune FUZEON SOLR 90 MG [enfuvirtide] ...... 4 globulin (human) iv] ...... 79 gabapentin caps 100 mg ...... 42 GAMMAPLEX SOLN 5 GM/100ML [immune gabapentin caps 300 mg ...... 42 globulin (human) iv] ...... 79 gabapentin caps 400 mg ...... 42 GAMUNEX-C SOLN 1 GM/10ML [immune GABAPENTIN POWD [gabapentin (bulk)] ... 75 globulin (human) iv or subcutaneous] ..... 79 gabapentin soln 250 mg/5ml ...... 42 GAMUNEX-C SOLN 10 GM/100ML [immune gabapentin tabs 600 mg ...... 42 globulin (human) iv or subcutaneous] ..... 79 gabapentin tabs 800 mg ...... 42 GAMUNEX-C SOLN 2.5 GM/25ML [immune GABLOFEN SOLN 10000 MCG/20ML globulin (human) iv or subcutaneous] ..... 79 [baclofen] ...... 23 GAMUNEX-C SOLN 20 GM/200ML [immune GABLOFEN SOLN 20000 MCG/20ML globulin (human) iv or subcutaneous] ..... 79 [baclofen] ...... 23 GAMUNEX-C SOLN 5 GM/50ML [immune GABLOFEN SOLN 40000 MCG/20ML globulin (human) iv or subcutaneous] ..... 79 [baclofen] ...... 23 ganciclovir sodium solr 500 mg ...... 13 GABLOFEN SOSY 10000 MCG/20ML GARDASIL 9 SUSP [human papillomavirus [baclofen] ...... 23 (hpv) 9-valent recombinant vaccine] ...... 80 GABLOFEN SOSY 20000 MCG/20ML GARDASIL 9 SUSY [human papillomavirus [baclofen] ...... 23 (hpv) 9-valent recombinant vaccine] ...... 80 GABLOFEN SOSY 40000 MCG/20ML GARDASIL INJ [human papillomavirus [baclofen] ...... 23 (hpv) quadrivalent recombinant vaccine] . 80 GABLOFEN SOSY 50 MCG/ML [baclofen] .... 23 GARDASIL SUSP [human papillomavirus GADAVIST SOLN 1 MMOL/ML [gadobutrol] . 52 (hpv) quadrivalent recombinant vaccine] . 80 galantamine hydrobromide er cp24 16 mg .. 22 GASTROGRAFIN SOLN 66-10 % [diatrizoate galantamine hydrobromide er cp24 24 mg .. 22 meglumine & sodium] ...... 52 GALANTAMINE HYDROBROMIDE ER CP24 8 gatifloxacin soln 0.5 % ...... 59 MG [galantamine hydrobromide] ...... 22 GAZYVA SOLN 1000 MG/40ML galantamine hydrobromide tabs 12 mg ...... 23 [obinutuzumab] ...... 16 galantamine hydrobromide tabs 4 mg ...... 23 GELFILM FILM [gelatin adsorbable (ophth)] 26

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 112 of 144

GELFOAM SPONGE MISC 12-7 MM [gelatin (bulk)] ...... 76 absorbable] ...... 26 glycopyrrolate soln 0.2 mg/ml ...... 22 GELFOAM SPONGE SIZE 100 MISC [gelatin glycopyrrolate soln 0.4 mg/2ml ...... 22 absorbable] ...... 27 glycopyrrolate soln 1 mg/5ml...... 22 GELFOAM SPONGE SIZE 50 MISC [gelatin glycopyrrolate soln 4 mg/20ml ...... 22 absorbable] ...... 27 glycopyrrolate tabs 1 mg ...... 22 GELUSIL CHEW 200-200-25 MG [alum & mag glycopyrrolate tabs 2 mg ...... 22 hydrox-simethicone] ...... 91 GNP HYDROCORTISONE CREA 0.5 % gemcitabine hcl solr 200 mg ...... 16 [hydrocortisone (topical)] ...... 93 gemfibrozil tabs 600 mg ...... 31 GOLYTELY SOLR 236 GM [peg 3350-kcl-sod GEMZAR SOLR 1 GM [gemcitabine hcl] ...... 16 bicarb-sod chloride-sod sulfate] ...... 63 gentamicin in saline soln 0.8-0.9 mg/ml-% .... 8 GONAL-F RFF REDIJECT SOLN 300 gentamicin in saline soln 0.9-0.9 mg/ml-% .... 8 UNIT/0.5ML [follitropin alfa] ...... 68 gentamicin in saline soln 1.2-0.9 mg/ml-% .... 9 GONAL-F RFF REDIJECT SOLN 450 gentamicin in saline soln 1.4-0.9 mg/ml-% .... 9 UNT/0.75ML [follitropin alfa] ...... 68 gentamicin in saline soln 1.6-0.9 mg/ml-% .... 9 GONAL-F RFF REDIJECT SOLN 900 gentamicin in saline soln 1-0.9 mg/ml-% ...... 9 UNIT/1.5ML [follitropin alfa] ...... 68 gentamicin in saline soln 2-0.9 mg/ml-% ...... 9 GONAL-F RFF SOLR 75 UNIT [follitropin alfa] gentamicin sulfate crea 0.1 % ...... 82 ...... 68 gentamicin sulfate oint 0.1 %...... 82 GONAL-F SOLR 1050 UNIT [follitropin alfa] . 68 gentamicin sulfate soln 0.3 % ...... 59 GONAL-F SOLR 450 UNIT [follitropin alfa] ... 68 gentamicin sulfate soln 10 mg/ml ...... 9 GOODSENSE PAIN RELIEF EXTRA ST TABS gentamicin sulfate soln 40 mg/ml ...... 9 500 MG [acetaminophen] ...... 89 GENTIAN VIOLET SOLN 1 % [gentian violet]93 GRASTEK SUBL 2800 BAU [timothy grass GENVOYA TABS 150-150-200-10 MG pollen allergen extract] ...... 73 [elvitegravir-cobicistat-emtricitabine- griseofulvin microsize susp 125 mg/5ml ...... 11 tenofovir alafenamide] ...... 13 griseofulvin microsize tabs 500 mg ...... 11 GLEOSTINE CAPS 10 MG [lomustine] ...... 17 griseofulvin ultramicrosize tabs 125 mg ...... 11 GLEOSTINE CAPS 100 MG [lomustine] ...... 17 griseofulvin ultramicrosize tabs 250 mg ...... 11 GLEOSTINE CAPS 40 MG [lomustine] ...... 17 guanfacine hcl er tb24 1 mg ...... 47 GLEOSTINE CAPS 5 MG [lomustine] ...... 17 guanfacine hcl er tb24 2 mg ...... 47 glimepiride tabs 1 mg ...... 66 guanfacine hcl er tb24 3 mg ...... 47 glimepiride tabs 2 mg ...... 66 guanfacine hcl er tb24 4 mg ...... 47 glimepiride tabs 4 mg ...... 66 guanfacine hcl tabs 1 mg ...... 24 glipizide tabs 10 mg...... 66 guanfacine hcl tabs 2 mg ...... 24 glipizide tabs 5 mg...... 66 GUANIDINE HCL TABS 125 MG [guanidine glipizide tb24 10 mg...... 66 hcl] ...... 23 glipizide tb24 2.5 mg ...... 66 HAEGARDA SOLR 2000 UNIT [c1 esterase glipizide tb24 5 mg...... 66 inhibitor (human)] ...... 73 glipizide-metformin hcl tabs 2.5-250 mg ...... 66 HAEGARDA SOLR 3000 UNIT [c1 esterase glipizide-metformin hcl tabs 2.5-500 mg ...... 66 inhibitor (human)] ...... 73 glipizide-metformin hcl tabs 5-500 mg ...... 66 HALAVEN SOLN 1 MG/2ML [eribulin mesylate] GLUCAGEN HYPOKIT SOLR 1 MG [glucagon ...... 17 hcl (rdna)] ...... 67 halobetasol propionate crea 0.05 % ...... 83 GLUCAGEN INJ 1MG [glucagon hcl (rdna)] halobetasol propionate oint 0.05 % ...... 83 ...... 67 haloperidol decanoate soln 100 mg/ml ...... 49 glucagon emergency kit 1 mg ...... 67 haloperidol decanoate soln 50 mg/ml ...... 49 glyburide tabs 1.25 mg ...... 66 haloperidol lactate conc 2 mg/ml ...... 49 glyburide tabs 2.5 mg ...... 66 haloperidol lactate soln 5 mg/ml ...... 49 glyburide tabs 5 mg ...... 66 HALOPERIDOL POWD [haloperidol (bulk)] . 76 GLYCERIN LIQD [glycerin (bulk)] ...... 76, 92 haloperidol tabs 0.5 mg ...... 49 GLYCOPYRROLATE POWD [glycopyrrolate haloperidol tabs 1 mg ...... 49

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 113 of 144 haloperidol tabs 10 mg ...... 49 HEPARIN SOD (PORCINE) IN D5W SOLN 40-5 haloperidol tabs 2 mg ...... 49 UNIT/ML-% [heparin sod (porcine) in d5w] haloperidol tabs 20 mg ...... 49 ...... 29 haloperidol tabs 5 mg ...... 49 heparin sodium (porcine) lock flush soln .... 29 HARVONI TABS 45-200 MG [ledipasvir- HEPARIN SODIUM (PORCINE) PF SOLN 5000 sofosbuvir] ...... 11 UNIT/0.5ML [heparin sodium (porcine)] .... 29 HARVONI TABS 90-400 MG [ledipasvir- HEPARIN SODIUM (PORCINE) SOLN 1000 sofosbuvir] ...... 11 UNIT/ML [heparin sodium (porcine)] ...... 29 HAVRIX SUSP 1440 EL U/ML [hepatitis a HEPARIN SODIUM (PORCINE) SOLN 10000 vaccine] ...... 80 UNIT/ML [heparin sodium (porcine)] ...... 30 HAVRIX SUSP 720 EL U/0.5ML [hepatitis a HEPARIN SODIUM (PORCINE) SOLN 20000 vaccine] ...... 80 UNIT/ML [heparin sodium (porcine)] ...... 30 HEALON5 INJ 23MG/ML [sodium HEPARIN SODIUM (PORCINE) SOLN 5000 hyaluronate] ...... 61 UNIT/ML [heparin sodium (porcine)] ...... 30 HELIXATE FS KIT 250 UNIT [antihemophilic HEPARIN SODIUM LOCK FLUSH SOLN 100 factor (recombinant) (rfviii)] ...... 27 UNIT/ML [heparin sodium (porcine) lock HEMABATE SOLN 250 MCG/ML [carboprost flush] ...... 30 tromethamine] ...... 75 HERCEPTIN SOLR 150 MG [trastuzumab] ... 17 HEMLIBRA SOLN 105 MG/0.7ML [emicizumab- hetastarch-nacl soln 6-0.9 % ...... 56 kxwh] ...... 27 HEXALEN CAPS 50 MG [altretamine]...... 17 HEMLIBRA SOLN 150 MG/ML [emicizumab- HEXTEND SOLN 6 % [hetastarch in lactated kxwh] ...... 27 electrolyte] ...... 56 HEMLIBRA SOLN 30 MG/ML [emicizumab- HIBERIX SOLR 10 MCG [haemophilus b kxwh] ...... 27 polysac conj vac] ...... 80 HEMLIBRA SOLN 60 MG/0.4ML [emicizumab- HISTEX-PE SYRP 2.5-10 MG/5ML [triprolidine- kxwh] ...... 27 phenylephrine]...... 88 HEMOFIL M INJ 220-400 [antihemophilic HIZENTRA SOLN 1 GM/5ML [immune globulin factor (human)]...... 27 (human) subcutaneous] ...... 79 HEMOFIL M SOLR 1000 UNIT [antihemophilic HIZENTRA SOLN 10 GM/50ML [immune factor (human)]...... 27 globulin (human) subcutaneous] ...... 79 HEMOFIL M SOLR 1700 UNIT [antihemophilic HIZENTRA SOLN 2 GM/10ML [immune factor (human)]...... 27 globulin (human) subcutaneous] ...... 79 HEMOFIL M SOLR 500 UNIT [antihemophilic HIZENTRA SOLN 4 GM/20ML [immune factor (human)]...... 27 globulin (human) subcutaneous] ...... 79 HEPARIN (PORCINE) IN NACL SOLN 1000-0.9 HOMATROPINE HBR SOLN 5 % [homatropine UT/500ML-% [heparin (porcine) in sodium hbr] ...... 61 chloride] ...... 29 HUMALOG MIX 50/50 KWIKPEN SUPN (50-50) HEPARIN (PORCINE) IN NACL SOLN 2000-0.9 100 UNIT/ML [insulin lispro protamine & UNIT/L-% [heparin (porcine) in sodium lispro] ...... 66 chloride] ...... 29 HUMALOG MIX 50/50 SUSP (50-50) 100 HEPARIN (PORCINE) IN NACL SOLN 25000- UNIT/ML [insulin lispro protamine & lispro] 0.45 UT/250ML-% [heparin (porcine) in ...... 66 sodium chloride] ...... 29 HUMALOG SOLN 100 UNIT/ML [insulin lispro] HEPARIN LOCK FLUSH SOLN 1 UNIT/ML ...... 66 [heparin sodium (porcine) lock flush] ...... 29 HUMATE-P SOLR 1000-2400 UNIT HEPARIN LOCK FLUSH SOLN 10 UNIT/ML [antihemophilic factor/von willebrand factor [heparin sodium (porcine) lock flush] ...... 29 complex (human)] ...... 27 HEPARIN SOD (PORCINE) IN D5W SOLN 100 HUMATE-P SOLR 250-600 UNIT UNIT/ML [heparin sod (porcine) in d5w] ... 29 [antihemophilic factor/von willebrand factor HEPARIN SOD (PORCINE) IN D5W SOLN complex (human)] ...... 27 25000-5 UT/500ML-% [heparin sod (porcine) HUMATE-P SOLR 500-1200 UNIT in d5w] ...... 29 [antihemophilic factor/von willebrand factor

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 114 of 144

complex (human)] ...... 27 hydrocodone-acetaminophen tabs 7.5-325 mg HUMIRA PEDIATRIC CROHNS START PSKT ...... 38 80 MG/0.8ML & 40MG/0.4ML [adalimumab] hydrocodone-homatropine syrp 5-1.5 mg/5ml ...... 73 ...... 77 HUMIRA PEDIATRIC CROHNS START PSKT hydrocortisone ace-pramoxine crea 1-1 % .. 84 80 MG/0.8ML [adalimumab] ...... 73 HYDROCORTISONE ACE-PRAMOXINE CREA HUMIRA PEN PNKT 40 MG/0.4ML 2.5-1 % [pramoxine-hc] ...... 83 [adalimumab] ...... 73 HYDROCORTISONE CREA 0.5 % HUMIRA PEN PNKT 40 MG/0.8ML [hydrocortisone (topical)] ...... 93 [adalimumab] ...... 70 hydrocortisone crea 1 % ...... 83 HUMIRA PEN-CD/UC/HS STARTER PNKT 80 hydrocortisone crea 2.5 % ...... 83 MG/0.8ML [adalimumab] ...... 73 hydrocortisone enem 100 mg/60ml ...... 83 HUMIRA PEN-PSOR/UVEIT STARTER PNKT hydrocortisone lotn 2.5 % ...... 83 80 MG/0.8ML & 40MG/0.4ML [adalimumab] HYDROCORTISONE OINT 0.5 % ...... 73 [hydrocortisone (topical)] ...... 93 HUMIRA PSKT 10 MG/0.1ML [adalimumab] . 73 HYDROCORTISONE OINT 1 % HUMIRA PSKT 10 MG/0.2ML [adalimumab] . 70 [hydrocortisone (topical)] ...... 93 HUMIRA PSKT 20 MG/0.2ML [adalimumab] . 73 hydrocortisone oint 2.5 % ...... 83 HUMIRA PSKT 20 MG/0.4ML [adalimumab] . 70 HYDROCORTISONE POWD [hydrocortisone HUMIRA PSKT 40 MG/0.4ML [adalimumab] . 73 (topical)] ...... 76 HUMIRA PSKT 40 MG/0.8ML [adalimumab] . 70 hydrocortisone tabs 10 mg ...... 64 HUMULIN 70/30 KWIKPEN SUPN (70-30) 100 hydrocortisone tabs 20 mg ...... 64 UNIT/ML [insulin nph isophane & reg hydrocortisone tabs 5 mg ...... 64 (human)] ...... 92 HYDROCORTISONE-IODOQUINOL CREA 1-1 HUMULIN 70/30 SUSP (70-30) 100 UNIT/ML % [iodoquinol-hc] ...... 82 [insulin nph isophane & reg (human)] ...... 92 HYDROCORT-PRAMOXINE (PERIANAL) CREA HUMULIN N KWIKPEN SUPN 100 UNIT/ML 2.5-1 % [hydrocortisone acetate w/ [insulin nph (human) (isophane)] ...... 92 pramoxine] ...... 83 HUMULIN N SUSP 100 UNIT/ML [insulin nph hydromorphone hcl liqd 1 mg/ml ...... 38 (human) (isophane)] ...... 92 hydromorphone hcl pf soln 500 mg/50ml .... 38 HUMULIN R SOLN 100 UNIT/ML [insulin HYDROMORPHONE HCL SOLN 1 MG/ML regular (human)] ...... 92 [hydromorphone hcl] ...... 38 HUMULIN R U-500 (CONCENTRATED) SOLN HYDROMORPHONE HCL SOLN 2 MG/ML 500 UNIT/ML [insulin regular (human)] ..... 66 [hydromorphone hcl] ...... 38 HUMULIN R U-500 KWIKPEN SOPN 500 HYDROMORPHONE HCL SOLN 4 MG/ML UNIT/ML [insulin regular (human)] ...... 66 [hydromorphone hcl] ...... 38 HYCAMTIN CAPS 0.25 MG [topotecan hcl] .. 17 HYDROMORPHONE HCL SUPP 3 MG HYCAMTIN CAPS 1 MG [topotecan hcl] ...... 17 [hydromorphone hcl] ...... 38 hydralazine hcl soln 20 mg/ml ...... 34 hydromorphone hcl tabs 2 mg ...... 38 hydralazine hcl tabs 10 mg ...... 34 hydromorphone hcl tabs 4 mg ...... 38 hydralazine hcl tabs 100 mg ...... 35 hydromorphone hcl tabs 8 mg ...... 38 hydralazine hcl tabs 25 mg ...... 35 HYDROPHILIC OINT [hydrophilic ointment] 92 hydralazine hcl tabs 50 mg ...... 35 HYDROXOCOBALAMIN POW hydrochlorothiazide tabs 12.5 mg ...... 55 [hydroxocobalamin (bulk)] ...... 76 hydrochlorothiazide tabs 25 mg ...... 55 hydroxychloroquine sulfate tabs 200 mg ..... 12 hydrochlorothiazide tabs 50 mg ...... 55 HYDROXYPROGESTERONE CAPROATE hydrocodone-acetaminophen soln 7.5-325 POWD [hydroxyprogesterone caproate mg/15ml ...... 38 (bulk)] ...... 76 hydrocodone-acetaminophen tabs 10-325 mg hydroxyprogesterone caproate soln 1.25 ...... 38 gm/5ml...... 69 hydrocodone-acetaminophen tabs 5-325 mg hydroxyurea caps 500 mg ...... 17 ...... 38 hydroxyzine hcl soln 25 mg/ml ...... 46

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 115 of 144 hydroxyzine hcl soln 50 mg/ml ...... 46 IBRANCE TABS 75 MG [palbociclib] ...... 17 hydroxyzine hcl syrp 10 mg/5ml ...... 46 ibuprofen susp 100 mg/5ml ...... 38 hydroxyzine hcl tabs 10 mg ...... 46 ibutilide fumarate soln 1 mg/10ml ...... 34 hydroxyzine hcl tabs 25 mg ...... 46 icatibant acetate soln 30 mg/3ml ...... 73 hydroxyzine hcl tabs 50 mg ...... 46 IDAMYCIN PFS SOLN 10 MG/10ML [idarubicin hydroxyzine pamoate caps 100 mg ...... 46 hcl] ...... 17 hydroxyzine pamoate caps 25 mg ...... 46 IDAMYCIN PFS SOLN 20 MG/20ML [idarubicin hydroxyzine pamoate caps 50 mg ...... 46 hcl] ...... 17 HYLENEX SOLN 150 UNIT/ML [hyaluronidase idarubicin hcl soln 5 mg/5ml ...... 17 human] ...... 59 IDELVION SOLR 1000 UNIT [coagulation HYOSCYAMINE SULFATE ER TB12 0.375 MG factor ix recomb albumin fusion protein [hyoscyamine sulfate] ...... 22 (rix-fp)] ...... 27 HYOSCYAMINE SULFATE SUBL 0.125 MG IDELVION SOLR 2000 UNIT [coagulation [hyoscyamine sulfate] ...... 22 factor ix recomb albumin fusion protein HYOSCYAMINE SULFATE TABS 0.125 MG (rix-fp)] ...... 27 [hyoscyamine sulfate] ...... 22 IDELVION SOLR 250 UNIT [coagulation factor HYOSCYAMINE SULFATE TBDP 0.125 MG ix recomb albumin fusion protein (rix-fp)] 27 [hyoscyamine sulfate] ...... 22 IDELVION SOLR 500 UNIT [coagulation factor HYOSYNE ELIX 0.125 MG/5ML [hyoscyamine ix recomb albumin fusion protein (rix-fp)] 27 sulfate] ...... 22 IFOSFAMIDE SOLR 1 GM [ifosfamide] ...... 17 HYOSYNE SOLN 0.125 MG/ML [hyoscyamine imatinib mesylate tabs 100 mg ...... 17 sulfate] ...... 22 imatinib mesylate tabs 400 mg ...... 17 HYPERLYTE-CR CONC [parenteral IMBRUVICA CAPS 140 MG [ibrutinib] ...... 17 electrolytes] ...... 56 IMBRUVICA CAPS 70 MG [ibrutinib] ...... 17 HYPERRAB S/D SOLN 300 UNIT/2ML [rabies IMBRUVICA TABS 140 MG [ibrutinib]...... 17 immune globulin (human)] ...... 79 IMBRUVICA TABS 280 MG [ibrutinib]...... 17 HYPERRAB SOLN 300 UNIT/ML [rabies IMBRUVICA TABS 420 MG [ibrutinib]...... 17 immune globulin (human)] ...... 79 IMBRUVICA TABS 560 MG [ibrutinib]...... 17 HYPERTET S/D INJ 250 UNIT/ML [tetanus imipramine hcl tabs 10 mg ...... 49 immune globulin (human)] ...... 79 imipramine hcl tabs 25 mg ...... 49 HYQVIA KIT 10 GM/100ML [immune globulin imipramine hcl tabs 50 mg ...... 49 (human)-hyaluronidase (human imiquimod crea 5 % ...... 85 recombinant)] ...... 79 IMOGAM RABIES-HT SOLN 300 UNIT/2ML HYQVIA KIT 2.5 GM/25ML [immune globulin [rabies immune globulin (human)] ...... 79 (human)-hyaluronidase (human IMOVAX RABIES INJ 2.5 UNIT/ML [rabies virus recombinant)] ...... 79 vaccine, hdc] ...... 81 HYQVIA KIT 20 GM/200ML [immune globulin indapamide tabs 1.25 mg ...... 55 (human)-hyaluronidase (human indapamide tabs 2.5 mg ...... 55 recombinant)] ...... 79 indigotindisulfonate sodium soln ...... 52 HYQVIA KIT 30 GM/300ML [immune globulin indomethacin caps 25 mg ...... 38 (human)-hyaluronidase (human indomethacin caps 50 mg ...... 38 recombinant)] ...... 79 indomethacin er cpcr 75 mg...... 38 HYQVIA KIT 5 GM/50ML [immune globulin INDOMETHACIN POWD [indomethacin] ...... 76 (human)-hyaluronidase (human INDOMETHACIN SODIUM SOLR 1 MG recombinant)] ...... 79 [indomethacin sodium] ...... 38 HYSEPT SOLN 0.25 % [sodium hypochlorite] INFANRIX SUSP 25-58-10 [diphtheria, ...... 93 acellular pertussis & tetanus toxoids] ...... 80 IBRANCE CAPS 100 MG [palbociclib] ...... 17 INFED SOLN 50 MG/ML [iron dextran] ...... 25 IBRANCE CAPS 125 MG [palbociclib] ...... 17 INFLECTRA SOLR 100 MG [infliximab-dyyb]73 IBRANCE CAPS 75 MG [palbociclib] ...... 17 INFUMORPH 200 SOLN 200 MG/20ML (10 IBRANCE TABS 100 MG [palbociclib] ...... 17 MG/ML) [morphine sulfate for continuous IBRANCE TABS 125 MG [palbociclib] ...... 17 microinfusion] ...... 38

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INFUMORPH 500 SOLN 500 MG/20ML (25 ISENTRESS CHEW 25 MG [raltegravir MG/ML) [morphine sulfate for continuous potassium] ...... 4 microinfusion] ...... 38 ISENTRESS HD TABS 600 MG [raltegravir INFUVITE ADULT INJ [multiple vitamin] ...... 86 potassium] ...... 4 INFUVITE PEDIATRIC SOLN [pediatric ISENTRESS TABS 400 MG [raltegravir multiple vitamins] ...... 86 potassium] ...... 4 INTEGRILIN SOLN 20 MG/10ML [eptifibatide] ISOMETHEPTENE-DICHLORAL-APAP CAPS ...... 30 65-100-325 MG [isometheptene- INTEGRILIN SOLN 75 MG/100ML [eptifibatide] dichloralphenazone-acetaminophen] ...... 44 ...... 30 isoniazid soln 100 mg/ml ...... 12 INTELENCE TABS 100 MG [etravirine] ...... 4 isoniazid syrp 50 mg/5ml ...... 12 INTELENCE TABS 200 MG [etravirine] ...... 4 isoniazid tabs 100 mg ...... 12 INTELENCE TABS 25 MG [etravirine] ...... 4 isoniazid tabs 300 mg ...... 12 INTRALIPID EMUL 20 % [fat emulsion plant isoproterenol hcl soln 0.2 mg/ml ...... 24 based] ...... 54 isosorbide dinitrate er tbcr 40 mg ...... 36 INTRALIPID EMUL 30 % [fat emulsion plant isosorbide dinitrate tabs 10 mg ...... 36 based] ...... 54 isosorbide dinitrate tabs 20 mg ...... 36 INTRON A SOLN 10000000 UNIT/ML isosorbide dinitrate tabs 30 mg ...... 36 [interferon alfa-2b] ...... 17 isosorbide dinitrate tabs 5 mg ...... 36 INTRON A SOLN 6000000 UNIT/ML [interferon isosorbide mononitrate er tb24 120 mg ...... 36 alfa-2b] ...... 17 isosorbide mononitrate er tb24 30 mg ...... 36 INTRON A SOLR 10000000 UNIT [interferon isosorbide mononitrate er tb24 60 mg ...... 36 alfa-2b] ...... 17 ISOSORBIDE POWD [isosorbide (bulk)] ...... 76 INTRON A SOLR 18000000 UNIT [interferon ISTODAX (OVERFILL) SOLR 10 MG alfa-2b] ...... 17 [romidepsin] ...... 17 INTRON A SOLR 50000000 UNIT [interferon itraconazole caps 100 mg ...... 11 alfa-2b] ...... 17 ivermectin tabs 3 mg ...... 4 INVANZ SOLR 1 GM [ertapenem sodium] ...... 9 IXEMPRA KIT SOLR 15 MG [ixabepilone] ..... 17 INVEGA SUSTENNA SUSY 117 MG/0.75ML IXEMPRA KIT SOLR 45 MG [ixabepilone] ..... 17 [paliperidone palmitate]...... 49 IXIARO SUSP [japanese encephalitis vaccine INVEGA SUSTENNA SUSY 156 MG/ML inactivated adsorbed] ...... 81 [paliperidone palmitate]...... 49 JADENU SPRINKLE PACK 180 MG INVEGA SUSTENNA SUSY 234 MG/1.5ML [deferasirox] ...... 64 [paliperidone palmitate]...... 49 JADENU SPRINKLE PACK 360 MG INVEGA SUSTENNA SUSY 39 MG/0.25ML [deferasirox] ...... 64 [paliperidone palmitate]...... 49 JADENU SPRINKLE PACK 90 MG INVEGA SUSTENNA SUSY 78 MG/0.5ML [deferasirox] ...... 64 [paliperidone palmitate]...... 49 JADENU TABS 180 MG [deferasirox] ...... 64 INVIRASE TABS 500 MG [saquinavir JADENU TABS 360 MG [deferasirox] ...... 64 mesylate] ...... 4 JADENU TABS 90 MG [deferasirox] ...... 64 IOPIDINE SOLN 1 % [apraclonidine hcl] ...... 61 JAKAFI TABS 10 MG [ruxolitinib phosphate]17 IPOL INJ [poliovirus vaccine, ipv] ...... 81 JAKAFI TABS 15 MG [ruxolitinib phosphate]17 ipratropium bromide soln 0.02 % ...... 22 JAKAFI TABS 20 MG [ruxolitinib phosphate]17 ipratropium bromide soln 0.03 % ...... 22 JAKAFI TABS 25 MG [ruxolitinib phosphate]17 ipratropium-albuterol soln 0.5-2.5 (3) mg/3ml JAKAFI TABS 5 MG [ruxolitinib phosphate] . 17 ...... 24 JARDIANCE TABS 10 MG [empagliflozin] ..... 66 IRESSA TABS 250 MG [gefitinib] ...... 17 JARDIANCE TABS 25 MG [empagliflozin] ..... 66 irinotecan hcl soln 500 mg/25ml ...... 17 JETREA SOLN 0.5 MG/0.2ML [ocriplasmin] .. 61 ISAGEL GEL 60 % [antiseptic products, misc.] JEVTANA SOLN 60 MG/1.5ML [cabazitaxel] . 17 ...... 93 JOLIVETTE TABS 0.35 MG [norethindrone ISENTRESS CHEW 100 MG [raltegravir (contraceptive)] ...... 67 potassium] ...... 4 J-TAN PD LIQD 1 MG/ML [brompheniramine

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maleate] ...... 88 KERALYT GEL 6 % [salicylic acid] ...... 84 JULUCA TABS 50-25 MG [dolutegravir KETAMINE HCL POWD [ketamine hcl (bulk)] sodium-rilpivirine hcl] ...... 13 ...... 76 KADCYLA SOLR 100 MG [ado-trastuzumab ketamine hcl soln 10 mg/ml...... 47 emtansine] ...... 17 ketamine hcl soln 100 mg/ml ...... 47 KADCYLA SOLR 160 MG [ado-trastuzumab ketamine hcl soln 50 mg/ml...... 47 emtansine] ...... 18 ketoconazole sham 2 % ...... 82 KALETRA SOLN 400-100 MG/5ML [lopinavir- ketoconazole tabs 200 mg ...... 11 ritonavir] ...... 4 KETO-DIASTIX STRP [urine glucose-ketones KALETRA TABS 100-25 MG [lopinavir- test] ...... 91 ritonavir] ...... 4 KETOPROFEN POWD [ketoprofen (bulk)] ... 76 KALETRA TABS 200-50 MG [lopinavir- ketorolac tromethamine soln 0.4 % ...... 60 ritonavir] ...... 4 ketorolac tromethamine soln 0.5 % ...... 60 KALYDECO PACK 25 MG [ivacaftor]...... 77 ketorolac tromethamine soln 15 mg/ml ...... 38 KALYDECO PACK 50 MG [ivacaftor]...... 73 ketorolac tromethamine soln 30 mg/ml ...... 38 KALYDECO PACK 75 MG [ivacaftor]...... 73 ketorolac tromethamine soln 60 mg/2ml ...... 38 KALYDECO TABS 150 MG [ivacaftor] ...... 73 KETOSTIX STRP [acetone (urine) test] ...... 91 KANJINTI SOLR 420 MG [trastuzumab-anns] KEYTRUDA SOLN 100 MG/4ML ...... 18 [pembrolizumab] ...... 18 KCENTRA KIT 500 UNIT [prothrombin KINERET INJ [anakinra] ...... 70 complex concentrate human] ...... 27 KINRIX SUSP [diph-tetanus tox ad-acell KCL IN DEXTROSE-NACL SOLN 10-5-0.45 pertussis & polio virus, ipv vac]...... 81 MEQ/L-%-% [potassium chloride in KLOR-CON TBCR 8 MEQ [potassium chloride] dextrose & sodium chloride] ...... 57 ...... 57 KCL IN DEXTROSE-NACL SOLN 20-5-0.2 KOATE SOLR 1000 UNIT [antihemophilic MEQ/L-%-% [potassium chloride in factor (human)] ...... 27 dextrose & sodium chloride] ...... 57 KOATE-DVI SOLR 250 UNIT [antihemophilic KCL IN DEXTROSE-NACL SOLN 20-5-0.45 factor (human)] ...... 27 MEQ/L-%-% [potassium chloride in KOATE-DVI SOLR 500 UNIT [antihemophilic dextrose & sodium chloride] ...... 57 factor (human)] ...... 27 KCL IN DEXTROSE-NACL SOLN 20-5-0.9 KOGENATE FS KIT 1000 UNIT [antihemophilic MEQ/L-%-% [potassium chloride in factor (recombinant) (rfviii)] ...... 27 dextrose & sodium chloride] ...... 57 KOGENATE FS KIT 2000 UNIT [antihemophilic KCL IN DEXTROSE-NACL SOLN 30-5-0.45 factor (recombinant) (rfviii)] ...... 27 MEQ/L-%-% [potassium chloride in KOGENATE FS KIT 500 UNIT [antihemophilic dextrose & sodium chloride] ...... 57 factor (recombinant) (rfviii)] ...... 27 KCL IN DEXTROSE-NACL SOLN 40-5-0.45 KOVALTRY SOLR 1000 UNIT [antihemophilic MEQ/L-%-% [potassium chloride in factor (rcmb) plasma/albumin free (rahf- dextrose & sodium chloride] ...... 57 pfm)] ...... 27 KCL IN DEXTROSE-NACL SOLN 40-5-0.9 KOVALTRY SOLR 2000 UNIT [antihemophilic MEQ/L-%-% [potassium chloride in factor (rcmb) plasma/albumin free (rahf- dextrose & sodium chloride] ...... 57 pfm)] ...... 27 KCL-LACTATED RINGERS-D5W SOLN 20 KOVALTRY SOLR 250 UNIT [antihemophilic MEQ/L [potassium chloride in d5w lactated factor (rcmb) plasma/albumin free (rahf- ringers] ...... 57 pfm)] ...... 28 K-EFFERVESCENT TBEF 25 MEQ [potassium KOVALTRY SOLR 3000 UNIT [antihemophilic bicarbonate] ...... 57 factor (rcmb) plasma/albumin free (rahf- KENALOG SUSP 10 MG/ML [triamcinolone pfm)] ...... 28 acetonide] ...... 64 KOVALTRY SOLR 500 UNIT [antihemophilic KENALOG SUSP 40 MG/ML [triamcinolone factor (rcmb) plasma/albumin free (rahf- acetonide] ...... 65 pfm)] ...... 28 KEPIVANCE SOLR 6.25 MG [palifermin] ...... 84 KP BENZOYL PEROXIDE GEL 10 % [benzoyl

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peroxide] ...... 94 MG [lamotrigine] ...... 42 KP BENZOYL PEROXIDE GEL 5 % [benzoyl lamivudine soln 10 mg/ml ...... 4 peroxide] ...... 94 lamivudine tabs 100 mg ...... 13 KP HYDROCORTISONE CREA 1 % lamivudine tabs 150 mg ...... 4 [hydrocortisone (topical)] ...... 93 lamivudine tabs 300 mg ...... 4 KP PRENATAL MULTIVITAMINS TABS 28-0.8 lamivudine-zidovudine tabs 150-300 mg ...... 4 MG [prenatal vit w/ ferrous fumarate-folic lamotrigine chew 25 mg ...... 42 acid] ...... 94 lamotrigine chew 5 mg ...... 42 KP PSEUDOEPHEDRINE HCL TABS 60 MG lamotrigine tabs 100 mg ...... 42 [pseudoephedrine hcl] ...... 88 lamotrigine tabs 150 mg ...... 42 K-PHOS TABS 500 MG [potassium phosphate lamotrigine tabs 200 mg ...... 42 monobasic] ...... 57 lamotrigine tabs 25 mg ...... 42 KRINTAFEL TABS 150 MG [tafenoquine LANOXIN PEDIATRIC SOLN 0.1 MG/ML succinate] ...... 12 [digoxin] ...... 34 K-TAB TBCR 10 MEQ [potassium chloride] . 57 LANTUS SOLN 100 UNIT/ML [insulin glargine] KYNMOBI FILM 10 MG [apomorphine ...... 66 hydrochloride] ...... 45 L-ARGININE POWD [arginine] ...... 92 KYNMOBI FILM 15 MG [apomorphine latanoprost soln 0.005 % ...... 60 hydrochloride] ...... 45 L-CITRULLINE POWD [citrulline (bulk)] ...... 92 KYNMOBI FILM 20 MG [apomorphine leflunomide tabs 10 mg ...... 70 hydrochloride] ...... 45 leflunomide tabs 20 mg ...... 70 KYNMOBI FILM 25 MG [apomorphine LENVIMA (10 MG DAILY DOSE) CPPK 10 MG hydrochloride] ...... 45 [lenvatinib mesylate] ...... 18 KYNMOBI FILM 30 MG [apomorphine LENVIMA (12 MG DAILY DOSE) CPPK 3 x 4 hydrochloride] ...... 45 MG [lenvatinib mesylate] ...... 18 KYNMOBI TITRATION KIT KIT 10/15/20/25/30 LENVIMA (14 MG DAILY DOSE) CPPK 10 & 4 MG [apomorphine hydrochloride] ...... 45 MG [lenvatinib mesylate] ...... 18 KYPROLIS SOLR 10 MG [carfilzomib] ...... 18 LENVIMA (20 MG DAILY DOSE) CPPK 2 x 10 KYPROLIS SOLR 30 MG [carfilzomib] ...... 18 MG [lenvatinib mesylate] ...... 18 KYPROLIS SOLR 60 MG [carfilzomib] ...... 18 LENVIMA (24 MG DAILY DOSE) CPPK 2 x 10 labetalol hcl soln 5 mg/ml ...... 32 MG & 4 MG [lenvatinib mesylate] ...... 18 labetalol hcl tabs 100 mg ...... 32 LETAIRIS TABS 10 MG [ambrisentan] ...... 36 labetalol hcl tabs 200 mg ...... 32 LETAIRIS TABS 5 MG [ambrisentan] ...... 36 labetalol hcl tabs 300 mg ...... 32 letrozole tabs 2.5 mg ...... 18 LACRISERT INST 5 MG [artificial tear insert] leucovorin calcium solr 100 mg ...... 73 ...... 61 leucovorin calcium solr 350 mg ...... 73 LACTATED RINGERS SOLN [lactated ringer's leucovorin calcium solr 50 mg ...... 73 (irrigation)] ...... 56 leucovorin calcium tabs 25 mg ...... 73 LACTATED RINGERS SOLN [lactated leucovorin calcium tabs 5 mg ...... 73 ringer's] ...... 57 LEUKERAN TABS 2 MG [chlorambucil] ...... 18 LACTIC ACID SOLN [lactic acid (bulk)] ...... 92 LEUKINE SOLR 250 MCG [sargramostim] .... 30 LACTOSE MONOHYDRATE POWD [lactose leuprolide acetate kit 1 mg/0.2ml ...... 18 monohydrate] ...... 76 levetiracetam er tb24 500 mg ...... 42 LACTOSE POWD [lactose] ...... 92 levetiracetam er tb24 750 mg ...... 42 lactulose (encephalopathy) soln 10 gm/15ml LEVETIRACETAM IN NACL SOLN 1000 ...... 53 MG/100ML [levetiracetam in sodium lactulose soln 10 gm/15ml ...... 53 chloride] ...... 43 LAMICTAL STARTER KIT 35 x 25 MG LEVETIRACETAM IN NACL SOLN 1500 [lamotrigine] ...... 42 MG/100ML [levetiracetam in sodium LAMICTAL STARTER KIT 42 x 25 MG & 7 X 100 chloride] ...... 43 MG [lamotrigine] ...... 42 LEVETIRACETAM IN NACL SOLN 500 LAMICTAL STARTER KIT 84 x 25 MG & 14X100 MG/100ML [levetiracetam in sodium

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chloride] ...... 43 lidocaine hcl (pf) soln 2 % ...... 71 levetiracetam soln 100 mg/ml ...... 43 lidocaine hcl (pf) soln 4 % ...... 71 levetiracetam soln 500 mg/5ml ...... 43 LIDOCAINE HCL POWD [lidocaine hcl (bulk)] levetiracetam tabs 1000 mg ...... 43 ...... 76 levetiracetam tabs 250 mg ...... 43 lidocaine hcl soln 0.5 % ...... 71 levetiracetam tabs 500 mg ...... 43 lidocaine hcl soln 1 % ...... 71 levetiracetam tabs 750 mg ...... 43 lidocaine hcl soln 2 % ...... 71 levobunolol hcl soln 0.5 % ...... 60 lidocaine hcl soln 4 % ...... 84 levocarnitine inj 200mg/ml ...... 73 lidocaine hcl urethral/mucosal gel 2 % ...... 84 LEVOCARNITINE SOLN 1 GM/10ML lidocaine hcl urethral/mucosal prsy 2 % ...... 84 [levocarnitine (metabolic modifiers)] ...... 73 LIDOCAINE IN D5W SOLN 4-5 MG/ML-% LEVOCARNITINE TABS 330 MG [levocarnitine [lidocaine in d5w] ...... 34 (metabolic modifiers)] ...... 73 LIDOCAINE IN D5W SOLN 8-5 MG/ML-% levofloxacin in d5w soln 250 mg/50ml ...... 9 [lidocaine in d5w] ...... 34 levofloxacin in d5w soln 500 mg/100ml ...... 9 lidocaine oint 5 % ...... 84 levofloxacin in d5w soln 750 mg/150ml ...... 9 lidocaine viscous hcl soln 2 % ...... 61 levofloxacin soln 25 mg/ml ...... 9 lidocaine-epinephrine soln 0.5 %-1 levofloxacin tabs 250 mg ...... 9 200000 ...... 71 levofloxacin tabs 500 mg ...... 9 lidocaine-epinephrine soln 1 %-1 levofloxacin tabs 750 mg ...... 9 100000 ...... 71 LEVOTHYROXINE SODIUM SOLR 200 MCG lidocaine-epinephrine soln 1.5 %-1 [levothyroxine sodium]...... 69 200000 ...... 71 LEVOTHYROXINE SODIUM SOLR 500 MCG lidocaine-epinephrine soln 2 %-1 [levothyroxine sodium]...... 69 100000 ...... 71 levothyroxine sodium tabs 100 mcg ...... 69 200000 ...... 71 levothyroxine sodium tabs 112 mcg ...... 69 lidocaine-prilocaine crea 2.5-2.5 % ...... 84 levothyroxine sodium tabs 125 mcg ...... 69 lidocaine-prilocaine kit 2.5-2.5 % ...... 84 levothyroxine sodium tabs 150 mcg ...... 69 linezolid soln 600 mg/300ml ...... 9 levothyroxine sodium tabs 175 mcg ...... 70 linezolid susr 100 mg/5ml ...... 9 levothyroxine sodium tabs 200 mcg ...... 70 liothyronine sodium tabs 25 mcg ...... 70 levothyroxine sodium tabs 25 mcg ...... 70 liothyronine sodium tabs 5 mcg ...... 70 levothyroxine sodium tabs 300 mcg ...... 70 liothyronine sodium tabs 50 mcg ...... 70 levothyroxine sodium tabs 50 mcg ...... 70 lisinopril tabs 10 mg ...... 35 levothyroxine sodium tabs 75 mcg ...... 70 lisinopril tabs 2.5 mg ...... 35 levothyroxine sodium tabs 88 mcg ...... 70 lisinopril tabs 20 mg ...... 35 LEVOXYL TABS 137 MCG [levothyroxine lisinopril tabs 30 mg ...... 35 sodium] ...... 70 lisinopril tabs 40 mg ...... 35 LEVSIN SOLN 0.5 MG/ML [hyoscyamine lisinopril tabs 5 mg ...... 35 sulfate] ...... 22 lisinopril-hydrochlorothiazide tabs 10-12.5 LEVULAN KERASTICK SOLR 20 % mg ...... 35 [aminolevulinic acid hcl] ...... 85 lisinopril-hydrochlorothiazide tabs 20-12.5 LEXISCAN SOLN 0.4 MG/5ML [regadenoson] mg ...... 35 ...... 52 lisinopril-hydrochlorothiazide tabs 20-25 mg LEXIVA TABS 700 MG [fosamprenavir ...... 35 calcium] ...... 4 L-ISOLEUCINE POWD [isoleucine] ...... 92 LIALDA TBEC 1.2 GM [mesalamine] ...... 62 lithium carbonate caps 150 mg ...... 43 LIDOCAINE HCL (CARDIAC) PF SOLN 100 LITHIUM CARBONATE CAPS 300 MG [lithium MG/5ML [lidocaine hcl (cardiac)] ...... 71 carbonate] ...... 43 lidocaine hcl (cardiac) pf sosy 100 mg/5ml . 34 lithium carbonate caps 600 mg ...... 43 lidocaine hcl (cardiac) sosy 50 mg/5ml ...... 34 lithium carbonate er tbcr 300 mg ...... 43 lidocaine hcl (pf) soln 0.5 % ...... 71 lithium carbonate er tbcr 450 mg ...... 44 lidocaine hcl (pf) soln 1 % ...... 71 LITHIUM CARBONATE TABS 300 MG [lithium

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carbonate] ...... 44 LUCENTIS SOLN 0.5 MG/0.05ML LITHIUM SOLN 8 MEQ/5ML [lithium]...... 44 [ranibizumab] ...... 61 LITHOSTAT TABS 250 MG [acetohydroxamic LUCENTIS SOSY 0.3 MG/0.05ML acid] ...... 53 [ranibizumab] ...... 61 LODOSYN TABS 25 MG [carbidopa] ...... 45 LUCENTIS SOSY 0.5 MG/0.05ML LONSURF TABS 15-6.14 MG [trifluridine- [ranibizumab] ...... 61 tipiracil] ...... 18 LUDENT CHEW 0.55 (0.25 F) MG [sodium LONSURF TABS 20-8.19 MG [trifluridine- fluoride] ...... 74 tipiracil] ...... 18 LUMASON SUSR 60.7-25 MG [sulfur loratadine syrp 5 mg/5ml ...... 88 hexafluoride lipid-type a microspheres] ... 52 loratadine tabs 10 mg ...... 88 LUMIZYME SOLR 50 MG [alglucosidase alfa] lorazepam soln 2 mg/ml ...... 46 ...... 59 lorazepam soln 4 mg/ml ...... 46 LUPRON DEPOT (1-MONTH) KIT 3.75 MG lorazepam tabs 0.5 mg ...... 46 [leuprolide acetate] ...... 18 lorazepam tabs 1 mg ...... 46 LUPRON DEPOT (1-MONTH) KIT 7.5 MG lorazepam tabs 2 mg ...... 46 [leuprolide acetate] ...... 18 LORBRENA TABS 100 MG [lorlatinib] ...... 18 LUPRON DEPOT (3-MONTH) KIT 11.25 MG LORBRENA TABS 25 MG [lorlatinib]...... 18 [leuprolide acetate (3 month)] ...... 18 LORTUSS LQ LIQD 6.25-30 MG/5ML LUPRON DEPOT (3-MONTH) KIT 22.5 MG [doxylamine-pseudoephedrine] ...... 88 [leuprolide acetate (3 month)] ...... 18 losartan potassium tabs 100 mg ...... 35 LUPRON DEPOT (4-MONTH) KIT 30 MG losartan potassium tabs 25 mg ...... 35 [leuprolide acetate (4 month)] ...... 18 losartan potassium tabs 50 mg ...... 35 LUPRON DEPOT (6-MONTH) KIT 45 MG losartan potassium-hctz tabs 100-12.5 mg .. 35 [leuprolide acetate (6 month)] ...... 18 losartan potassium-hctz tabs 100-25 mg ..... 35 LUPRON DEPOT-PED (1-MONTH) KIT 11.25 losartan potassium-hctz tabs 50-12.5 mg .... 35 MG [leuprolide acetate (cpp)] ...... 18 lovastatin tabs 10 mg ...... 31 LUPRON DEPOT-PED (1-MONTH) KIT 15 MG lovastatin tabs 20 mg ...... 31 [leuprolide acetate (cpp)] ...... 18 lovastatin tabs 40 mg ...... 31 LUPRON DEPOT-PED (1-MONTH) KIT 7.5 MG LOVENOX SOLN 100 MG/ML [enoxaparin [leuprolide acetate (cpp)] ...... 18 sodium] ...... 30 LUPRON DEPOT-PED (3-MONTH) KIT 11.25 LOVENOX SOLN 120 MG/0.8ML [enoxaparin MG (PED) [leuprolide acetate (cpp) (3 sodium] ...... 30 month)] ...... 18 LOVENOX SOLN 150 MG/ML [enoxaparin LUPRON DEPOT-PED (3-MONTH) KIT 30 MG sodium] ...... 30 (PED) [leuprolide acetate (cpp) (3 month)] LOVENOX SOLN 30 MG/0.3ML [enoxaparin ...... 18 sodium] ...... 30 L-VALINE POWD [valine] ...... 92 LOVENOX SOLN 300 MG/3ML [enoxaparin LYNPARZA TABS 100 MG [olaparib] ...... 18 sodium] ...... 30 LYNPARZA TABS 150 MG [olaparib] ...... 18 LOVENOX SOLN 40 MG/0.4ML [enoxaparin LYSODREN TABS 500 MG [mitotane] ...... 18 sodium] ...... 30 M.T.E.-5 CONCENTRATE INJ CONC [trace LOVENOX SOLN 60 MG/0.6ML [enoxaparin minerals (cr-cu-mn-se-zn)] ...... 57 sodium] ...... 30 MACRODANTIN CAPS 25 MG [nitrofurantoin LOVENOX SOLN 80 MG/0.8ML [enoxaparin macrocrystal] ...... 14 sodium] ...... 30 MACUGEN SOLN 0.3 MG [pegaptanib sodium] loxapine succinate caps 10 mg ...... 49 ...... 61 loxapine succinate caps 25 mg ...... 49 MAG-AL LIQD 200-200 MG/5ML [aluminum & loxapine succinate caps 5 mg ...... 49 magnesium hydroxide] ...... 91 loxapine succinate caps 50 mg ...... 49 MAGNEBIND 300 TABS 250-300 MG [calcium L-PROLINE POWD [proline] ...... 76 carbonate-magnesium carbonate] ...... 91 LUCENTIS SOLN 0.3 MG/0.05ML MAGNESIUM SULFATE IN D5W SOLN 1-5 [ranibizumab] ...... 61 GM/100ML-% [magnesium sulfate in

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 121 of 144

dextrose] ...... 57 meloxicam tabs 7.5 mg ...... 38 MAGNESIUM SULFATE SOLN 20 GM/500ML melphalan hcl solr 50 mg ...... 19 [magnesium sulfate] ...... 43 memantine hcl tabs 10 mg ...... 47 MAGNESIUM SULFATE SOLN 4 GM/100ML memantine hcl tabs 5 mg ...... 47 [magnesium sulfate] ...... 43 MENOPUR SOLR 75 UNIT [menotropins] ..... 68 MAGNESIUM SULFATE SOLN 4 GM/50ML MENVEO SOLR [meningococcal (a,c,y&w- [magnesium sulfate] ...... 43 135) oligosaccharide conjugate vac] ...... 81 MAGNESIUM SULFATE SOLN 40 GM/1000ML meperidine hcl soln 100 mg/ml ...... 38 [magnesium sulfate] ...... 43 meperidine hcl soln 25 mg/ml ...... 38 magnesium sulfate soln 50 % ...... 43 meperidine hcl soln 50 mg/ml ...... 38 MAGNEVIST SOLN 469.01 MG/ML MEPHYTON TABS 5 MG [phytonadione] ...... 86 [gadopentetate dimeglumine] ...... 53 mercaptopurine tabs 50 mg ...... 19 MAKENA OIL 250 MG/ML meropenem solr 1 gm ...... 9 [hydroxyprogesterone caproate] ...... 69 meropenem solr 500 mg ...... 9 malathion lotn 0.5 % ...... 82 mesalamine enem 4 gm ...... 62 MANGANESE CHLORIDE SOLN 0.1 MG/ML mesalamine supp 1000 mg ...... 62 [manganese chloride] ...... 57 mesalamine tbec 1.2 gm ...... 62 MANNITOL SOLN 25 % [mannitol] ...... 55 MESNA SOLN 100 MG/ML [mesna] ...... 74 maprotiline hcl tabs 25 mg ...... 49 MESNEX TABS 400 MG [mesna] ...... 74 maprotiline hcl tabs 50 mg ...... 49 MESTINON SOLN 60 MG/5ML [pyridostigmine maprotiline hcl tabs 75 mg ...... 49 bromide] ...... 23 MARQIBO SUSP 5 MG/31ML [vincristine MESTINON TBCR 180 MG [pyridostigmine sulfate liposome] ...... 18 bromide] ...... 23 MATULANE CAPS 50 MG [procarbazine hcl] 18 metaproterenol sulfate syrp 10 mg/5ml ...... 24 MD-76 R SOLN 66-10 % [diatrizoate metaproterenol sulfate tabs 10 mg ...... 24 meglumine & sodium] ...... 53 metaproterenol sulfate tabs 20 mg ...... 24 MECLIZINE HCL TABS 12.5 MG [meclizine hcl] metformin hcl er tb24 500 mg ...... 66 ...... 92 metformin hcl er tb24 750 mg ...... 66 meclizine hcl tabs 25 mg ...... 62 metformin hcl tabs 1000 mg ...... 66 MECLIZINE HCL TABS 25 MG [meclizine hcl] metformin hcl tabs 500 mg ...... 66 ...... 92 metformin hcl tabs 850 mg ...... 66 meclofenamate sodium caps 100 mg...... 38 METHADONE HCL POWD [methadone hcl] 76 meclofenamate sodium caps 50 mg ...... 38 methadone hcl soln 10 mg/5ml ...... 38 MEDROL TABS 2 MG [methylprednisolone] 65 METHADONE HCL SOLN 10 MG/ML medroxyprogesterone acetate susp 150 [methadone hcl] ...... 39 mg/ml ...... 69 methadone hcl soln 5 mg/5ml ...... 39 medroxyprogesterone acetate susy 150 METHADONE HCL TABS 10 MG [methadone mg/ml ...... 69 hcl] ...... 39 medroxyprogesterone acetate tabs 10 mg .. 69 METHADONE HCL TABS 5 MG [methadone medroxyprogesterone acetate tabs 2.5 mg . 69 hcl] ...... 39 medroxyprogesterone acetate tabs 5 mg .... 69 methazolamide tabs 25 mg ...... 60 mefenamic acid caps 250 mg ...... 38 methazolamide tabs 50 mg ...... 60 mefloquine hcl tabs 250 mg ...... 12 methenamine hippurate tabs 1 gm ...... 14 megestrol acetate susp 40 mg/ml ...... 18 methimazole tabs 10 mg ...... 70 megestrol acetate susp 400 mg/10ml ...... 18 methimazole tabs 5 mg ...... 70 megestrol acetate tabs 20 mg ...... 19 methocarbamol tabs 500 mg ...... 23 megestrol acetate tabs 40 mg ...... 19 methocarbamol tabs 750 mg ...... 23 MEKINIST TABS 0.5 MG [trametinib dimethyl methotrexate sodium (pf) soln 50 mg/2ml ... 19 sulfoxide] ...... 19 METHOTREXATE SODIUM SOLN 50 MG/2ML MEKINIST TABS 2 MG [trametinib dimethyl [methotrexate sodium] ...... 19 sulfoxide] ...... 19 methotrexate sodium solr 1 gm ...... 19 meloxicam tabs 15 mg ...... 38 methotrexate tabs 2.5 mg ...... 19

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 122 of 144 methoxsalen rapid caps 10 mg ...... 84 metoprolol tartrate soln 5 mg/5ml ...... 32 methyldopa tabs 250 mg ...... 35 metoprolol tartrate tabs 100 mg ...... 32 methyldopa tabs 500 mg ...... 35 metoprolol tartrate tabs 25 mg ...... 32 methyldopate hcl soln 250 mg/5ml ...... 35 metoprolol tartrate tabs 50 mg ...... 32 METHYLENE BLUE SOLN 1 % [methylene metoprolol-hydrochlorothiazide tabs 100-50 blue (antidote)] ...... 74 mg ...... 32 methylergonovine maleate soln 0.2 mg/ml .. 75 metronidazole crea 0.75 % ...... 82 methylergonovine maleate tabs 0.2 mg ...... 75 metronidazole gel 0.75 % ...... 82 methylphenidate hcl er (cd) cpcr 10 mg ...... 41 METRONIDAZOLE IN NACL SOLN 5-0.79 methylphenidate hcl er (cd) cpcr 20 mg ...... 41 MG/ML-% [metronidazole in nacl] ...... 12 methylphenidate hcl er (cd) cpcr 30 mg ...... 41 METRONIDAZOLE IN NACL SOLN 500-0.74 methylphenidate hcl er (cd) cpcr 40 mg ...... 41 MG/100ML-% [metronidazole in nacl] ...... 12 methylphenidate hcl er (cd) cpcr 50 mg ...... 41 metronidazole lotn 0.75 % ...... 82 methylphenidate hcl er (cd) cpcr 60 mg ...... 41 METRONIDAZOLE POWD [metronidazole methylphenidate hcl er tbcr 10 mg ...... 41 (bulk)] ...... 76 methylphenidate hcl er tbcr 18 mg ...... 41 metronidazole tabs 250 mg ...... 12 methylphenidate hcl er tbcr 20 mg ...... 41 metronidazole tabs 500 mg ...... 12 methylphenidate hcl er tbcr 27 mg ...... 41 mexiletine hcl caps 150 mg ...... 34 methylphenidate hcl er tbcr 36 mg ...... 41 mexiletine hcl caps 200 mg ...... 34 methylphenidate hcl er tbcr 54 mg ...... 41 mexiletine hcl caps 250 mg ...... 34 methylphenidate hcl tabs 10 mg ...... 41 MI-ACID MAXIMUM STRENGTH SUSP 400- methylphenidate hcl tabs 20 mg ...... 41 400-40 MG/5ML [alum & mag hydrox- methylphenidate hcl tabs 5 mg ...... 41 simethicone] ...... 92 methylprednisolone acetate susp 40 mg/ml 65 miconazole nitrate vaginal supp 100 mg ...... 93 methylprednisolone acetate susp 80 mg/ml 65 MICRHOGAM ULTRA-FILTERED PLUS SOSY methylprednisolone sodium succ solr 1000 250 UNIT [rho d immune globulin (human)] mg ...... 65 ...... 79 methylprednisolone sodium succ solr 125 mg midazolam hcl (pf) soln 10 mg/2ml ...... 46 ...... 65 midazolam hcl (pf) soln 2 mg/2ml ...... 46 methylprednisolone sodium succ solr 40 mg midazolam hcl (pf) soln 5 mg/ml ...... 46 ...... 65 midazolam hcl soln 10 mg/2ml ...... 46 methylprednisolone tabs 16 mg ...... 65 midazolam hcl soln 2 mg/2ml...... 46 methylprednisolone tabs 32 mg ...... 65 midazolam hcl syrp 2 mg/ml ...... 46 methylprednisolone tabs 4 mg ...... 65 midodrine hcl tabs 10 mg ...... 24 methylprednisolone tabs 8 mg ...... 65 midodrine hcl tabs 2.5 mg ...... 24 methylprednisolone tbpk 4 mg ...... 65 midodrine hcl tabs 5 mg ...... 24 methyltestosterone tabs 10 mg ...... 66 MIFEPREX TABS 200 MG [mifepristone] ...... 75 METOCLOPRAMIDE HCL MONOHYDRATE MIGRANAL SOLN 4 MG/ML POWD [metoclopramide hcl monohydrate] [dihydroergotamine mesylate] ...... 24 ...... 76 milrinone lactate in dextrose soln 20-5 metoclopramide hcl soln 10 mg/10ml ...... 63 mg/100ml-% ...... 34 metoclopramide hcl soln 5 mg/ml ...... 63 milrinone lactate in dextrose soln 40-5 metoclopramide hcl tabs 10 mg ...... 63 mg/200ml-% ...... 34 metoclopramide hcl tabs 5 mg ...... 63 milrinone lactate inj 1mg/ml ...... 34 metolazone tabs 10 mg ...... 55 milrinone lactate soln 10 mg/10ml ...... 34 metolazone tabs 2.5 mg ...... 55 MINOCIN SOLR 100 MG [minocycline hcl] ..... 9 metolazone tabs 5 mg ...... 55 minocycline hcl caps 100 mg ...... 9 METOPIRONE CAPS 250 MG [metyrapone] . 53 minocycline hcl caps 50 mg ...... 9 metoprolol succinate er tb24 100 mg ...... 32 minocycline hcl caps 75 mg ...... 9 metoprolol succinate er tb24 200 mg ...... 32 minoxidil tabs 10 mg ...... 35 metoprolol succinate er tb24 25 mg ...... 32 minoxidil tabs 2.5 mg ...... 35 metoprolol succinate er tb24 50 mg ...... 32 MIOCHOL-E SOLR 20 MG [acetylcholine

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 123 of 144

chloride] ...... 60 [morphine sulfate] ...... 39 MIOSTAT SOLN 0.01 % [carbachol (ophth)] 60 MORPHINE SULFATE SOLN 10 MG/ML MIRENA (52 MG) IUD 20 MCG/24HR [morphine sulfate] ...... 39 [levonorgestrel (iud)] ...... 67 MORPHINE SULFATE SOLN 15 MG/ML mirtazapine tabs 15 mg ...... 49 [morphine sulfate] ...... 39 mirtazapine tabs 30 mg ...... 49 MORPHINE SULFATE SOLN 2 MG/ML mirtazapine tabs 45 mg ...... 49 [morphine sulfate] ...... 39 misoprostol tabs 100 mcg ...... 62 MORPHINE SULFATE SOLN 20 MG/5ML misoprostol tabs 200 mcg ...... 62 [morphine sulfate] ...... 39 mitomycin solr 20 mg ...... 19 MORPHINE SULFATE SOLN 25 MG/ML mitomycin solr 40 mg ...... 19 [morphine sulfate] ...... 39 mitomycin solr 5 mg ...... 19 MORPHINE SULFATE SOLN 4 MG/ML MITOSOL KIT 0.2 MG [mitomycin [morphine sulfate] ...... 39 (ophthalmic)] ...... 59 MORPHINE SULFATE SOLN 5 MG/ML mitoxantrone hcl conc 25 mg/12.5ml ...... 19 [morphine sulfate] ...... 39 M-M-R II SOLR [measles, mumps & rubella MORPHINE SULFATE SOLN 50 MG/ML virus vaccines] ...... 81 [morphine sulfate] ...... 39 modafinil tabs 100 mg ...... 41 MORPHINE SULFATE SOLN 8 MG/ML modafinil tabs 200 mg ...... 41 [morphine sulfate] ...... 39 mometasone furoate crea 0.1 % ...... 83 MORPHINE SULFATE SUPP 10 MG [morphine mometasone furoate oint 0.1 % ...... 83 sulfate] ...... 39 mometasone furoate soln 0.1 % ...... 83 MORPHINE SULFATE SUPP 20 MG [morphine MONOJECT INSULIN SYRINGE MISC 27G X sulfate] ...... 39 1/2 ...... 52 MORPHINE SULFATE SUPP 30 MG [morphine MONOJECT INSULIN SYRINGE MISC 29G X sulfate] ...... 39 1/2 ...... 52 MORPHINE SULFATE SUPP 5 MG [morphine MONONINE SOLR 1000 UNIT [coagulation sulfate] ...... 39 factor ix] ...... 28 MORPHINE SULFATE TABS 15 MG [morphine montelukast sodium chew 4 mg ...... 77 sulfate] ...... 39 montelukast sodium chew 5 mg ...... 77 MORPHINE SULFATE TABS 30 MG [morphine montelukast sodium pack 4 mg ...... 77 sulfate] ...... 39 montelukast sodium tabs 10 mg ...... 77 moxifloxacin hcl soln 0.5 %...... 59 morphine sulfate (concentrate) soln 100 moxifloxacin hcl tabs 400 mg ...... 9 mg/5ml ...... 39 MULTIHANCE SOLN 529 MG/ML [gadobenate morphine sulfate (pf) soln 0.5 mg/ml ...... 39 dimeglumine] ...... 53 morphine sulfate (pf) soln 1 mg/ml ...... 39 MULTITRACE-4 CONCENTRATE SOLN 0.01-1- MORPHINE SULFATE (PF) SOLN 10 MG/ML 0.5-5 MG/ML [trace minerals (cr-cu-mn-zn)] [morphine sulfate] ...... 39 ...... 57 MORPHINE SULFATE (PF) SOLN 2 MG/ML MULTI-VIT/FLUORIDE SOLN 0.5 MG/ML [morphine sulfate] ...... 39 [pediatric multivitamins w/fl] ...... 86 MORPHINE SULFATE (PF) SOLN 4 MG/ML MULTI-VIT/FLUORIDE/IRON SOLN 0.25-10 [morphine sulfate] ...... 39 MG/ML [ped multivitamins w/fl & iron] ...... 86 morphine sulfate er tbcr 100 mg ...... 39 MULTI-VIT/IRON/FLUORIDE SOLN 0.25-10 morphine sulfate er tbcr 15 mg ...... 39 MG/ML [ped multivitamins w/fl & iron] ...... 86 morphine sulfate er tbcr 200 mg ...... 39 MULTIVITAMIN/FLUORIDE CHEW 0.25 MG morphine sulfate er tbcr 30 mg ...... 39 [pediatric multivitamins w/fl] ...... 86 morphine sulfate er tbcr 60 mg ...... 39 MULTIVITAMIN/FLUORIDE CHEW 0.5 MG MORPHINE SULFATE POWD [morphine [pediatric multivitamins w/fl] ...... 86 sulfate] ...... 76 MULTIVITAMIN/FLUORIDE CHEW 1 MG MORPHINE SULFATE SOLN 1 MG/ML [pediatric multivitamins w/fl] ...... 86 [morphine sulfate] ...... 39 MULTIVITAMIN/FLUORIDE SOLN 0.25 MG/ML MORPHINE SULFATE SOLN 10 MG/5ML [pediatric multivitamins w/fl] ...... 86

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 124 of 144 mupirocin oint 2 %...... 82 naproxen susp 125 mg/5ml ...... 40 MUSTARGEN SOLR 10 MG [mechlorethamine naproxen tabs 250 mg ...... 40 hcl] ...... 19 naproxen tabs 375 mg ...... 40 MVASI SOLN 100 MG/4ML [bevacizumab- naproxen tabs 500 mg ...... 40 awwb] ...... 19 naproxen tbec 375 mg ...... 40 MVC-FLUORIDE CHEW 0.25 MG [pediatric naratriptan hcl tabs 1 mg ...... 44 multivitamins w/fl] ...... 86 naratriptan hcl tabs 2.5 mg ...... 44 MVC-FLUORIDE CHEW 0.5 MG [pediatric NARCAN LIQD 4 MG/0.1ML [naloxone hcl] ... 47 multivitamins w/fl] ...... 86 NAROPIN SOLN 10 MG/ML [ropivacaine hcl] MVC-FLUORIDE CHEW 1 MG [pediatric ...... 71 multivitamins w/fl] ...... 86 NAROPIN SOLN 2 MG/ML [ropivacaine hcl] . 72 mycophenolate mofetil caps 250 mg ...... 71 NAROPIN SOLN 5 MG/ML [ropivacaine hcl] . 72 mycophenolate mofetil susr 200 mg/ml ...... 71 NAROPIN SOLN 7.5 MG/ML [ropivacaine hcl] mycophenolate mofetil tabs 500 mg ...... 74 ...... 72 MYLERAN TABS 2 MG [busulfan] ...... 19 NASAL DECONGESTANT PE MAX ST TABS 10 MYOBLOC SOLN 10000 UNIT/2ML MG [phenylephrine hcl (oral)] ...... 91 [rimabotulinumtoxinb] ...... 74 NATACYN SUSP 5 % [natamycin] ...... 59 MYOBLOC SOLN 2500 UNIT/0.5ML NEBUPENT SOLR 300 MG [pentamidine [rimabotulinumtoxinb] ...... 74 isethionate] ...... 12 MYOBLOC SOLN 5000 UNIT/ML nefazodone hcl tabs 100 mg ...... 49 [rimabotulinumtoxinb] ...... 74 nefazodone hcl tabs 150 mg ...... 49 MYRBETRIQ TB24 25 MG [mirabegron] ...... 85 nefazodone hcl tabs 200 mg ...... 49 MYRBETRIQ TB24 50 MG [mirabegron] ...... 85 nefazodone hcl tabs 250 mg ...... 49 NABI-HB SOLN [hepatitis b immune globulin nefazodone hcl tabs 50 mg ...... 49 (human)] ...... 79 NEOMYCIN SULFATE POWD [neomycin nabumetone tabs 500 mg ...... 39 sulfate (topical)] ...... 76 nabumetone tabs 750 mg ...... 39 neomycin sulfate tabs 500 mg ...... 9 nadolol tabs 20 mg ...... 32 neomycin-bacitracin zn-polymyx oint 5-400- nadolol tabs 40 mg ...... 32 10000 ...... 59 nadolol tabs 80 mg ...... 32 neomycin-polymyxin b gu soln 40-200000 ... 82 NAFCILLIN SODIUM IN DEXTROSE SOLN 1 neomycin-polymyxin-dexameth oint 3.5- GM/50ML [nafcillin sodium in dextrose] ..... 9 10000-0.1 ...... 60 NAFCILLIN SODIUM IN DEXTROSE SOLN 2 neomycin-polymyxin-dexameth susp 3.5- GM/100ML [nafcillin sodium in dextrose] ... 9 10000-0.1 ...... 60 nafcillin sodium solr 1 gm ...... 9 neomycin-polymyxin-gramicidin soln 1.75- nafcillin sodium solr 10 gm ...... 9 10000-.025 ...... 59 nafcillin sodium solr 2 gm ...... 9 neomycin-polymyxin-hc soln 1 % ...... 60 NAGLAZYME SOLN 1 MG/ML [galsulfase] ... 59 neomycin-polymyxin-hc susp 3.5-10000-1 ... 60 nalbuphine hcl soln 10 mg/ml ...... 39 NEOPROFEN SOLN 10 MG/ML [ibuprofen nalbuphine hcl soln 20 mg/ml ...... 39 lysine] ...... 40 naloxone hcl soct 0.4 mg/ml ...... 47 NEORAL SOLN 100 MG/ML [cyclosporine naloxone hcl soln 0.4 mg/ml ...... 47 modified (for microemulsion)] ...... 71 naloxone hcl sosy 2 mg/2ml ...... 47 neostigmine methylsulfate soln 0.5 mg/ml .. 23 NALTREXONE HCL POWD [naltrexone hcl NEOSTIGMINE METHYLSULFATE SOLN 10 (bulk)] ...... 47 MG/10ML [neostigmine methylsulfate] ..... 23 naltrexone hcl tabs 50 mg ...... 47 NESACAINE SOLN 1 % [chloroprocaine hcl]72 NAMENDA SOL 10MG/5ML [memantine hcl] 47 NESACAINE SOLN 2 % [chloroprocaine hcl]72 NAMENDA TITRATION PAK TABS 28 x 5 MG & NEUPOGEN SOSY 300 MCG/0.5ML 21 X 10 MG [memantine hcl] ...... 47 [filgrastim] ...... 30 naphazoline hcl soln ...... 61 NEUPOGEN SOSY 480 MCG/0.8ML naproxen sodium tabs 275 mg ...... 39 [filgrastim] ...... 30 naproxen sodium tabs 550 mg ...... 40 NEUT SOLN 4 % [sodium bicarbonate] ...... 53

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 125 of 144 nevirapine er tb24 400 mg ...... 4 [nitroglycerin] ...... 36 nevirapine susp 50 mg/5ml ...... 4 NITROGLYCERIN ER CPCR 6.5 MG nevirapine tabs 200 mg ...... 4 [nitroglycerin] ...... 36 NEXAVAR TABS 200 MG [sorafenib tosylate] NITROGLYCERIN ER CPCR 9 MG ...... 19 [nitroglycerin] ...... 36 NEXPLANON IMPL 68 MG [etonogestrel] ..... 67 NITROGLYCERIN IN D5W SOLN 100-5 NIACIN ER CPCR 250 MG [niacin] ...... 94 MCG/ML-% [nitroglycerin in d5w] ...... 36 NIACIN ER CPCR 500 MG [niacin] ...... 94 NITROGLYCERIN IN D5W SOLN 200-5 NIACIN ER TBCR 250 MG [niacin] ...... 94 MCG/ML-% [nitroglycerin in d5w] ...... 36 NIACIN TABS 100 MG [niacin] ...... 94 NITROGLYCERIN IN D5W SOLN 400-5 NIACIN TABS 250 MG [niacin] ...... 94 MCG/ML-% [nitroglycerin in d5w] ...... 36 NIACIN TABS 50 MG [niacin] ...... 94 nitroglycerin pt24 0.4 mg/hr ...... 36 NIACIN TABS 500 MG [niacin] ...... 94 nitroglycerin soln 5 mg/ml ...... 36 nicardipine hcl soln 2.5 mg/ml ...... 33 nitroprusside sodium soln 25 mg/ml ...... 35 NICORETTE GUM 2 MG [nicotine polacrilex] NITROSTAT SUBL 0.3 MG [nitroglycerin] ..... 36 ...... 88 NITROSTAT SUBL 0.4 MG [nitroglycerin] ..... 37 NICORETTE LOZG 2 MG [nicotine polacrilex] NITROSTAT SUBL 0.6 MG [nitroglycerin] ..... 37 ...... 88 NIVESTYM SOLN 300 MCG/ML [filgrastim- NICORETTE LOZG 4 MG [nicotine polacrilex] aafi] ...... 30 ...... 88 NIVESTYM SOLN 480 MCG/1.6ML [filgrastim- NICORETTE MINI LOZG 2 MG [nicotine aafi] ...... 30 polacrilex] ...... 88 NIVESTYM SOSY 300 MCG/0.5ML [filgrastim- nicotine polacrilex gum 2 mg ...... 88 aafi] ...... 30 nicotine polacrilex gum 4 mg ...... 88 NIVESTYM SOSY 480 MCG/0.8ML [filgrastim- nicotine polacrilex lozg 2 mg ...... 88 aafi] ...... 31 nicotine polacrilex lozg 4 mg ...... 88 NORDITROPIN FLEXPRO SOPN 15 MG/1.5ML nicotine pt24 14 mg/24hr ...... 88 [somatropin] ...... 69 nicotine pt24 21 mg/24hr ...... 88 norepinephrine bitartrate soln 1 mg/ml ...... 24 nicotine pt24 7 mg/24hr ...... 88 norethindrone acetate tabs 5 mg ...... 69 nifedipine caps 10 mg ...... 33 NORMAL SALINE FLUSH SOLN 0.9 % [sodium nifedipine caps 20 mg ...... 33 chloride flush]...... 57 nifedipine er osmotic release tb24 30 mg .... 33 NORPACE CR CP12 100 MG [disopyramide nifedipine er osmotic release tb24 60 mg .... 33 phosphate] ...... 34 nifedipine er osmotic release tb24 90 mg .... 33 NORPACE CR CP12 150 MG [disopyramide nifedipine er tb24 30 mg ...... 33 phosphate] ...... 34 nifedipine er tb24 60 mg ...... 33 nortriptyline hcl caps 10 mg...... 50 nimodipine caps 30 mg ...... 33 nortriptyline hcl caps 25 mg...... 50 NINLARO CAPS 2.3 MG [ixazomib citrate] ... 19 nortriptyline hcl caps 50 mg...... 50 NINLARO CAPS 3 MG [ixazomib citrate] ...... 19 nortriptyline hcl caps 75 mg...... 50 NINLARO CAPS 4 MG [ixazomib citrate] ...... 19 nortriptyline hcl soln 10 mg/5ml ...... 50 NITRO-DUR PT24 0.3 MG/HR [nitroglycerin] 36 NORVIR SOLN 80 MG/ML [ritonavir] ...... 4 NITRO-DUR PT24 0.8 MG/HR [nitroglycerin] 36 NOVAREL SOLR 10000 UNIT [chorionic NITROFURANTOIN MACROCRYSTAL CAPS gonadotropin] ...... 68 100 MG [nitrofurantoin macrocrystal] ...... 14 NOVOSEVEN RT SOLR 1 MG [coagulation NITROFURANTOIN MACROCRYSTAL CAPS factor viia (recombinant)] ...... 28 25 MG [nitrofurantoin macrocrystal] ...... 14 NOVOSEVEN RT SOLR 2 MG [coagulation NITROFURANTOIN MACROCRYSTAL CAPS factor viia (recombinant)] ...... 28 50 MG [nitrofurantoin macrocrystal] ...... 14 NOVOSEVEN RT SOLR 5 MG [coagulation nitrofurantoin monohyd macro caps 100 mg factor viia (recombinant)] ...... 28 ...... 14 NOVOSEVEN RT SOLR 8 MG [coagulation nitrofurantoin susp 25 mg/5ml ...... 14 factor viia (recombinant)] ...... 28 NITROGLYCERIN ER CPCR 2.5 MG nystatin crea 100000 unit/gm ...... 82

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 126 of 144 nystatin susp 100000 unit/ml ...... 11 OMNITROPE SOLR 5.8 MG [somatropin] ..... 69 nystatin tabs 500000 unit ...... 11 ONCASPAR SOLN 750 UNIT/ML nystatin-triamcinolone crea 100000-0.1 [pegaspargase] ...... 19 unit/gm-% ...... 83 ondansetron hcl soln 4 mg/2ml ...... 62 nystatin-triamcinolone oint 100000-0.1 ondansetron hcl soln 4 mg/5ml ...... 62 unit/gm-% ...... 83 ondansetron hcl soln 40 mg/20ml ...... 62 OCTAGAM SOLN 1 GM/20ML [immune ondansetron hcl tabs 4 mg ...... 62 globulin (human) iv] ...... 79 ondansetron hcl tabs 8 mg ...... 62 OCTAGAM SOLN 2.5 GM/50ML [immune ondansetron tbdp 4 mg ...... 62 globulin (human) iv] ...... 80 ondansetron tbdp 8 mg ...... 62 OCTAGAM SOLN 25 GM/500ML [immune ONETOUCH DELICA LANCETS 33G MISC globulin (human) iv] ...... 80 [lancets] ...... 90 octreotide acetate soln 100 mcg/ml ...... 74 ONETOUCH FINEPOINT LANCETS MISC octreotide acetate soln 1000 mcg/ml ...... 74 [lancets] ...... 90 octreotide acetate soln 200 mcg/ml ...... 74 ONETOUCH SURESOFT LANCING DEV MISC octreotide acetate soln 50 mcg/ml ...... 74 [lancets misc.] ...... 90 octreotide acetate soln 500 mcg/ml ...... 74 ONETOUCH ULTRA CONTROL SOLN [blood ODACTRA SUBL 12 SQ-HDM [dust mite mixed glucose calibration] ...... 90 allergen extract] ...... 80 ONETOUCH ULTRA MINI KIT W/DEVICE ODEFSEY TABS 200-25-25 MG [emtricitabine- [blood glucose monitoring supplies] ...... 90 rilpivirine-tenofovir alafenamide fumarate] ONETOUCH ULTRA STRP [glucose blood] . 91 ...... 13 ONETOUCH ULTRASOFT LANCETS MISC ODOMZO CAPS 200 MG [sonidegib [lancets] ...... 90 phosphate] ...... 19 ONETOUCH VERIO SOLN HIGH [blood OFEV CAPS 100 MG [nintedanib esylate] .... 77 glucose calibration] ...... 90 OFEV CAPS 150 MG [nintedanib esylate] .... 77 OPANA SOLN 1 MG/ML [oxymorphone hcl] . 40 OFIRMEV SOLN 10 MG/ML [acetaminophen] OPDIVO SOLN 100 MG/10ML [nivolumab] .... 19 ...... 40 OPDIVO SOLN 40 MG/4ML [nivolumab] ...... 19 ofloxacin soln 0.3 % ...... 59 ORAP TABS 1 MG [pimozide] ...... 50 olanzapine solr 10 mg ...... 50 ORAP TABS 2 MG [pimozide] ...... 50 olanzapine tabs 10 mg ...... 50 ORENCIA CLICKJECT SOAJ 125 MG/ML olanzapine tabs 15 mg ...... 50 [abatacept] ...... 70 olanzapine tabs 2.5 mg ...... 50 ORENCIA SOLR 250 MG [abatacept] ...... 70 olanzapine tabs 20 mg ...... 50 ORENCIA SOSY 125 MG/ML [abatacept] ...... 70 olanzapine tabs 5 mg ...... 50 ORENCIA SOSY 50 MG/0.4ML [abatacept] ... 70 olanzapine tabs 7.5 mg ...... 50 ORENCIA SOSY 87.5 MG/0.7ML [abatacept] 70 olopatadine hcl soln 0.1 % ...... 60 ORKAMBI PACK 100-125 MG [lumacaftor- omeprazole cpdr 10 mg ...... 62 ivacaftor] ...... 77 omeprazole cpdr 20 mg ...... 62 ORKAMBI PACK 150-188 MG [lumacaftor- omeprazole cpdr 40 mg ...... 62 ivacaftor] ...... 77 OMNIPAQUE INJ 300MG/ML [iohexol] ...... 53 ORKAMBI TABS 100-125 MG [lumacaftor- OMNIPAQUE INJ 350MG/ML [iohexol] ...... 53 ivacaftor] ...... 77 OMNIPAQUE SOLN 180 MG/ML [iohexol] ..... 53 ORKAMBI TABS 200-125 MG [lumacaftor- OMNIPAQUE SOLN 240 MG/ML [iohexol] ..... 53 ivacaftor] ...... 78 OMNIPAQUE SOLN 300 MG/ML [iohexol] ..... 53 oseltamivir phosphate caps 30 mg ...... 13 OMNIPAQUE SOLN 350 MG/ML [iohexol] ..... 53 oseltamivir phosphate caps 45 mg ...... 13 OMNITROPE PEN 5 INJ DEVICE MISC oseltamivir phosphate caps 75 mg ...... 13 [injection device] ...... 52 oseltamivir phosphate susr 6 mg/ml ...... 13 OMNITROPE SOCT 10 MG/1.5ML OSMITROL SOLN 20 % [mannitol] ...... 55 [somatropin] ...... 69 OTEZLA TAB 10/20/30 [apremilast] ...... 70 OMNITROPE SOCT 5 MG/1.5ML [somatropin] OTEZLA TABS 30 MG [apremilast] ...... 70 ...... 69 OTEZLA TBPK 10 & 20 & 30 MG [apremilast]70

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 127 of 144

OVIDREL INJ 250 MCG/0.5ML PAPAVERINE HCL POWD [papaverine hcl] . 76 [choriogonadotropin alfa] ...... 68 PAPAVERINE HCL SOLN 30 MG/ML OXACILLIN SODIUM IN DEXTROSE SOLN 1 [papaverine hcl] ...... 37 GM/50ML [oxacillin sodium in dextrose] .... 9 PAREGORIC TINC 2 MG/5ML [paregoric] ..... 62 OXACILLIN SODIUM IN DEXTROSE SOLN 2 paromomycin sulfate caps 250 mg ...... 12 GM/50ML [oxacillin sodium in dextrose] .... 9 paroxetine hcl tabs 10 mg ...... 50 oxacillin sodium solr 1 gm ...... 9 paroxetine hcl tabs 20 mg ...... 50 OXACILLIN SODIUM SOLR 2 GM [oxacillin paroxetine hcl tabs 30 mg ...... 50 sodium] ...... 9 paroxetine hcl tabs 40 mg ...... 50 oxaliplatin soln 100 mg/20ml ...... 19 PEDIARIX SUSP [diph-tetanus tox-acell pert- oxaliplatin soln 50 mg/10ml ...... 19 hepatitis b recomb-polio ipv vac] ...... 81 oxandrolone tabs 10 mg ...... 66 pediatric multivitamins w/fl chew ...... 86 oxandrolone tabs 2.5 mg ...... 66 PEDIATRIC SMALL MASK MISC [masks] ..... 90 oxazepam caps 10 mg ...... 46 peg 3350/electrolytes solr 240 gm ...... 63 oxazepam caps 15 mg ...... 46 peg 3350-kcl-na bicarb-nacl solr 420 gm ..... 63 oxazepam caps 30 mg ...... 46 PEGASYS PROCLICK SOLN 135 MCG/0.5ML oxcarbazepine susp 300 mg/5ml ...... 43 [peginterferon alfa-2a] ...... 11 oxcarbazepine tabs 150 mg ...... 43 PEGASYS PROCLICK SOLN 180 MCG/0.5ML oxcarbazepine tabs 300 mg ...... 43 [peginterferon alfa-2a] ...... 11 oxcarbazepine tabs 600 mg ...... 43 PEGASYS SOLN 180 MCG/0.5ML OXSORALEN ULTRA CAPS 10 MG [peginterferon alfa-2a] ...... 11 [methoxsalen rapid] ...... 84 PEGASYS SOLN 180 MCG/ML [peginterferon oxybutynin chloride er tb24 10 mg ...... 85 alfa-2a]...... 12 oxybutynin chloride er tb24 15 mg ...... 85 PEGINTRON KIT 50 MCG/0.5ML oxybutynin chloride er tb24 5 mg ...... 85 [peginterferon alfa-2b] ...... 12 oxybutynin chloride syrp 5 mg/5ml ...... 85 PEG-INTRON REDIPEN KIT 120 RP oxybutynin chloride tabs 5 mg ...... 85 [peginterferon alfa-2b] ...... 11 oxycodone hcl tabs 5 mg ...... 40 PEG-INTRON REDIPEN KIT 150 RP oxycodone-acetaminophen tabs 10-325 mg 40 [peginterferon alfa-2b] ...... 11 oxycodone-acetaminophen tabs 5-325 mg .. 40 penicillamine caps 250 mg ...... 64 oxycodone-acetaminophen tabs 7.5-325 mg PENICILLIN G POT IN DEXTROSE SOLN ...... 40 20000 UNIT/ML [penicillin g pot in dextrose] OXYTOCIN SOLN 10 UNIT/ML [oxytocin] ..... 75 ...... 9 OZURDEX IMPL 0.7 MG [dexamethasone PENICILLIN G POT IN DEXTROSE SOLN (ophth)] ...... 60 40000 UNIT/ML [penicillin g pot in dextrose] paclitaxel conc 300 mg/50ml ...... 19 ...... 9 PADCEV SOLR 20 MG [enfortumab vedotin- PENICILLIN G POT IN DEXTROSE SOLN ejfv] ...... 19 60000 UNIT/ML [penicillin g pot in dextrose] PADCEV SOLR 30 MG [enfortumab vedotin- ...... 9 ejfv] ...... 19 penicillin g potassium solr 20000000 unit ...... 9 PAIN & FEVER CHILDRENS SOLN 160 penicillin g potassium solr 5000000 unit ...... 9 MG/5ML [acetaminophen] ...... 89 penicillin g procaine susp 600000 unit/ml ...... 9 PAIN RELIEVER TABS 325 MG penicillin g sodium solr 5000000 unit ...... 9 [acetaminophen] ...... 89 penicillin v potassium solr 125 mg/5ml ...... 9 pamidronate disodium soln 30 mg/10ml ...... 74 penicillin v potassium solr 250 mg/5ml ...... 9 pamidronate disodium soln 6 mg/ml...... 74 penicillin v potassium tabs 250 mg ...... 9 pamidronate disodium soln 90 mg/10ml ...... 74 penicillin v potassium tabs 500 mg ...... 10 pamidronate disodium solr 30 mg ...... 74 PENLET II BLOOD SAMPLER KIT [lancets pamidronate disodium solr 90 mg ...... 74 misc.] ...... 90 pancuronium bromide soln 1 mg/ml ...... 23 PENTAM SOLR 300 MG [pentamidine pantoprazole sodium tbec 20 mg ...... 62 isethionate] ...... 12 pantoprazole sodium tbec 40 mg ...... 62 PENTASA CPCR 250 MG [mesalamine] ...... 62

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PENTASA CPCR 500 MG [mesalamine] ...... 62 [phenylephrine hcl (mydriatic)] ...... 61 pentazocine-naloxone hcl tabs 50-0.5 mg ... 40 PHENYLEPHRINE HCL SOLN 2.5 % pentostatin inj 10mg ...... 19 [phenylephrine hcl (mydriatic)] ...... 62 pentoxifylline er tbcr 400 mg ...... 31 phenylephrine-chlorphen-dm liqd ...... 93 PEPTIC RELIEF CHEW 262 MG [bismuth PHENYLHISTINE DH LIQ DH [pseudoeph- subsalicylate] ...... 92 chlorphen w/ cod] ...... 93 PERJETA SOLN 420 MG/14ML [pertuzumab] phenytoin sodium extended caps 100 mg ... 43 ...... 19 phenytoin sodium soln 50 mg/ml ...... 43 permethrin crea 5 % ...... 82 phenytoin susp 125 mg/5ml ...... 43 permethrin lotn 1 % ...... 93 PHLEXY-10 PACK [nutritional supplements] perphenazine tabs 16 mg ...... 50 ...... 91 perphenazine tabs 2 mg ...... 50 PHOSLYRA SOLN 667 MG/5ML [calcium perphenazine tabs 4 mg ...... 50 acetate (phosphate binder)] ...... 57 perphenazine tabs 8 mg ...... 50 PHOSPHOLINE IODIDE SOLR 0.125 % perphenazine-amitriptyline tabs 2-10 mg .... 50 [echothiophate iodide] ...... 60 perphenazine-amitriptyline tabs 2-25 mg .... 50 PHOTREXA-PHOTREXA VISCOUS KIT SOSY perphenazine-amitriptyline tabs 4-10 mg .... 50 0.146 &0.146-20 % [riboflavin5-phos sod & perphenazine-amitriptyline tabs 4-25 mg .... 50 riboflavin 5-phosphate sodium-dextran] .. 61 perphenazine-amitriptyline tabs 4-50 mg .... 50 PHYSOSTIGMINE SALICYLATE SOLN 1 phenelzine sulfate tabs 15 mg ...... 50 MG/ML [physostigmine salicylate] ...... 23 PHENEX-1 POWD [nutritional supplements] phytonadione soln 1 mg/0.5ml ...... 87 ...... 91 pilocarpine hcl soln 1 % ...... 61 PHENOBARBITAL ELIX 20 MG/5ML pilocarpine hcl soln 2 % ...... 61 [phenobarbital] ...... 46 pilocarpine hcl soln 4 % ...... 61 PHENOBARBITAL POWD [phenobarbital] ... 76 pilocarpine hcl tabs 5 mg ...... 23 PHENOBARBITAL SODIUM SOLN 130 MG/ML pimecrolimus crea 1 % ...... 85 [phenobarbital sodium] ...... 46 pimozide tabs 2 mg ...... 50 PHENOBARBITAL SODIUM SOLN 65 MG/ML pioglitazone hcl tabs 15 mg ...... 66 [phenobarbital sodium] ...... 46 pioglitazone hcl tabs 30 mg ...... 66 PHENOBARBITAL TABS 100 MG pioglitazone hcl tabs 45 mg ...... 66 [phenobarbital] ...... 46 piperacillin sod-tazobactam so solr 2.25 (2- PHENOBARBITAL TABS 15 MG 0.25) gm ...... 10 [phenobarbital] ...... 46 piperacillin sod-tazobactam so solr 3.375 (3- PHENOBARBITAL TABS 16.2 MG 0.375) gm ...... 10 [phenobarbital] ...... 46 piperacillin sod-tazobactam so solr 4.5 (4-0.5) PHENOBARBITAL TABS 30 MG gm ...... 10 [phenobarbital] ...... 46 piperacillin sod-tazobactam so solr 40.5 (36- PHENOBARBITAL TABS 32.4 MG 4.5) gm...... 10 [phenobarbital] ...... 46 PLASMA-LYTE A SOLN [electrolyte-a] ...... 57 PHENOBARBITAL TABS 60 MG PLASMANATE SOLN 5 % [plasma protein [phenobarbital] ...... 47 fraction] ...... 25 PHENOBARBITAL TABS 64.8 MG PLURONIC F127 GEL 20 % [pluronic f127 [phenobarbital] ...... 47 base] ...... 76 PHENOBARBITAL TABS 97.2 MG PNEUMOVAX 23 INJ 25 MCG/0.5ML [phenobarbital] ...... 47 [pneumococcal vac polyvalent] ...... 81 PHENOL LIQD [phenol] ...... 93 PODOCON SOLN 25 % [podophyllum resin] 85 PHENOL LIQD 89 % [phenol] ...... 28 podofilox soln 0.5 % ...... 85 phenoxybenzamine hcl caps 10 mg ...... 24 PODOPHYLLUM RESIN POWD [podophyllum PHENTOLAMINE MESYLATE POWD resin] ...... 76 [phentolamine mesylate (bulk)] ...... 76 POLY HIST FORTE TABS 7.5-10 MG phentolamine mesylate solr 5 mg ...... 24 [doxylamine-phenylephrine] ...... 88 PHENYLEPHRINE HCL SOLN 10 % POLYETHYLENE GLYCOL 400 LIQD

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[polyethylene glycol 400] ...... 92 POTASSIUM CITRATE ER TBCR 10 MEQ POLYETHYLENE GLYCOL 8000 POWD (1080 MG) [potassium citrate (alkalinizer)] [polyethylene glycol 8000] ...... 76 ...... 53 polymyxin b-trimethoprim soln 10000-0.1 POTASSIUM CITRATE ER TBCR 5 MEQ (540 unit/ml-% ...... 59 MG) [potassium citrate (alkalinizer)] ...... 53 POLY-VI-SOL SOLN [pediatric multiple POTASSIUM CITRATE-CITRIC ACID SOLN vitamins] ...... 94 1100-334 MG/5ML [potassium citrate-citric POLY-VI-SOL/IRON SOLN 11 MG/ML [pediatric acid] ...... 53 multiple vitamins w/ iron] ...... 94 potassium phosphate inj 3mm/ml ...... 58 POMALYST CAPS 1 MG [pomalidomide] ..... 19 POTASSIUM PHOSPHATES SOLN 45 POMALYST CAPS 2 MG [pomalidomide] ..... 19 MMOLE/15ML [potassium phosphates] .... 58 POMALYST CAPS 3 MG [pomalidomide] ..... 19 PRADAXA CAPS 110 MG [dabigatran etexilate POMALYST CAPS 4 MG [pomalidomide] ..... 19 mesylate] ...... 30 POTABA CAPS 500 MG [potassium PRADAXA CAPS 150 MG [dabigatran etexilate aminobenzoate]...... 86 mesylate] ...... 30 POTASSIUM ACETATE SOLN 2 MEQ/ML PRADAXA CAPS 75 MG [dabigatran etexilate [potassium acetate] ...... 57 mesylate] ...... 30 potassium chloride 0.075%/d5w/nacl 0.225% pramipexole dihydrochloride tabs 0.125 mg 45 inj .075/.2% ...... 57 pramipexole dihydrochloride tabs 0.25 mg . 45 potassium chloride crys er tbcr 10 meq ...... 57 pramipexole dihydrochloride tabs 0.5 mg ... 45 potassium chloride crys er tbcr 20 meq ...... 57 pramipexole dihydrochloride tabs 0.75 mg . 45 potassium chloride er cpcr 10 meq ...... 57 pramipexole dihydrochloride tabs 1 mg ...... 45 potassium chloride er cpcr 8 meq ...... 57 pramipexole dihydrochloride tabs 1.5 mg ... 45 POTASSIUM CHLORIDE IN DEXTROSE SOLN PRAMOSONE OINT 1-1 % [pramoxine-hc] ... 83 20-5 MEQ/L-% [potassium chloride in PRAMOSONE OINT 1-2.5 % [pramoxine-hc] 83 dextrose] ...... 57 pravastatin sodium tabs 10 mg ...... 31 POTASSIUM CHLORIDE IN DEXTROSE SOLN pravastatin sodium tabs 20 mg ...... 31 40-5 MEQ/L-% [potassium chloride in pravastatin sodium tabs 40 mg ...... 31 dextrose] ...... 58 pravastatin sodium tabs 80 mg ...... 31 POTASSIUM CHLORIDE IN NACL SOLN 20- PRAXBIND SOLN 2.5 GM/50ML 0.45 MEQ/L-% [potassium chloride in nacl] [idarucizumab] ...... 28 ...... 58 prazosin hcl caps 1 mg ...... 31 POTASSIUM CHLORIDE IN NACL SOLN 20-0.9 prazosin hcl caps 2 mg ...... 31 MEQ/L-% [potassium chloride in nacl] ..... 58 prazosin hcl caps 5 mg ...... 31 POTASSIUM CHLORIDE IN NACL SOLN 40-0.9 PRECEDEX SOLN 200 MCG/2ML MEQ/L-% [potassium chloride in nacl] ..... 58 [dexmedetomidine hcl] ...... 47 POTASSIUM CHLORIDE PACK 20 MEQ PRED MILD SUSP 0.12 % [prednisolone [potassium chloride] ...... 58 acetate (ophth)] ...... 60 potassium chloride sol 10% sf ...... 58 prednisolone acetate susp 1 % ...... 60 POTASSIUM CHLORIDE SOLN 10 MEQ/100ML prednisolone sodium phosphate soln 1 % .. 60 [potassium chloride] ...... 58 prednisolone sodium phosphate soln 15 POTASSIUM CHLORIDE SOLN 10 MEQ/50ML mg/5ml...... 65 [potassium chloride] ...... 58 prednisolone sodium phosphate soln 6.7 (5 potassium chloride soln 2 meq/ml ...... 58 base) mg/5ml ...... 65 POTASSIUM CHLORIDE SOLN 20 MEQ/100ML prednisolone soln 15 mg/5ml ...... 65 [potassium chloride] ...... 58 prednisone soln 5 mg/5ml ...... 65 POTASSIUM CHLORIDE SOLN 20 MEQ/50ML prednisone tabs 1 mg ...... 65 [potassium chloride] ...... 58 prednisone tabs 10 mg ...... 65 POTASSIUM CHLORIDE SOLN 40 MEQ/100ML prednisone tabs 2.5 mg ...... 65 [potassium chloride] ...... 58 prednisone tabs 20 mg ...... 65 POTASSIUM CHLORIDE SOLN 40 MEQ/15ML prednisone tabs 5 mg ...... 65 (20%) [potassium chloride] ...... 58 prednisone tabs 50 mg ...... 65

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 130 of 144 prednisone tbpk 10 mg (21) ...... 65 PRIVIGEN SOLN 5 GM/50ML [immune prednisone tbpk 5 mg (21) ...... 65 globulin (human) iv] ...... 80 pregabalin caps 100 mg ...... 43 probenecid tabs 500 mg ...... 58 pregabalin caps 150 mg ...... 43 procainamide hcl soln 100 mg/ml ...... 34 pregabalin caps 200 mg ...... 43 procainamide hcl soln 500 mg/ml ...... 34 pregabalin caps 225 mg ...... 43 PROCALAMINE SOLN 3 % [amino acid pregabalin caps 25 mg ...... 43 electrolyte infusion] ...... 55 pregabalin caps 300 mg ...... 43 prochlorperazine edisylate soln 10 mg/2ml . 50 pregabalin caps 50 mg ...... 43 prochlorperazine maleate tabs 10 mg ...... 50 pregabalin caps 75 mg ...... 43 prochlorperazine maleate tabs 5 mg ...... 50 pregabalin soln 20 mg/ml ...... 43 PROCRIT SOLN 10000 UNIT/ML [epoetin alfa] PREMARIN SOLR 25 MG [estrogens, ...... 31 conjugated] ...... 68 PROCRIT SOLN 2000 UNIT/ML [epoetin alfa] PREPIDIL GEL 0.5 MG/3GM [dinoprostone] . 75 ...... 31 PRETOMANID TABS 200 MG [pretomanid] .. 12 PROCRIT SOLN 20000 UNIT/ML [epoetin alfa] PREVIDENT 5000 PLUS CREA 1.1 % [sodium ...... 31 fluoride (dental)] ...... 74 PROCRIT SOLN 3000 UNIT/ML [epoetin alfa] PREVIDENT GEL 1.1 % [sodium fluoride ...... 31 (dental)] ...... 74 PROCRIT SOLN 4000 UNIT/ML [epoetin alfa] PREVIDENT SOLN 0.2 % [sodium fluoride ...... 31 (dental)] ...... 74 PROCRIT SOLN 40000 UNIT/ML [epoetin alfa] PREVNAR 13 SUSP [pneumococcal 13-valent ...... 31 conjugate vaccine] ...... 81 PRODIGY CONTROL SOLUTION SOLN LOW PREVYMIS SOLN 240 MG/12ML [letermovir] 13 [blood glucose calibration] ...... 90 PREVYMIS SOLN 480 MG/24ML [letermovir] 14 PROFERRIN ES TABS 12 MG [iron heme PREVYMIS TABS 240 MG [letermovir] ...... 14 polypeptide] ...... 88 PREVYMIS TABS 480 MG [letermovir] ...... 14 PROFERRIN-FORTE TABS 12-1 MG [iron PREZCOBIX TABS 800-150 MG [darunavir- heme polypeptide-folic acid] ...... 25 cobicistat] ...... 14 PROFILNINE SOLR 1000 UNIT [factor ix PREZISTA TABS 150 MG [darunavir complex] ...... 28 ethanolate] ...... 4 PROFILNINE SOLR 1500 UNIT [factor ix PREZISTA TABS 600 MG [darunavir complex] ...... 28 ethanolate] ...... 4 PROFILNINE SOLR 500 UNIT [factor ix PREZISTA TABS 75 MG [darunavir complex] ...... 28 ethanolate] ...... 4 progesterone caps 100 mg ...... 69 PREZISTA TABS 800 MG [darunavir progesterone caps 200 mg ...... 69 ethanolate] ...... 4 PROGESTERONE MICRONIZED POWD PRIFTIN TABS 150 MG [rifapentine] ...... 12 [progesterone micronized (bulk)] ...... 76 PRIMAQUINE PHOSPHATE TABS 26.3 (15 PROGESTERONE OIL 50 MG/ML Base) MG [primaquine phosphate] ...... 12 [progesterone] ...... 69 PRIMAXIN IV SOLR 250-250 MG [imipenem- PROGESTERONE WETTABLE POWD cilastatin] ...... 10 [progesterone (bulk)] ...... 76 PRIMAXIN IV SOLR 500-500 MG [imipenem- PROGLYCEM SUSP 50 MG/ML [diazoxide] .. 35 cilastatin] ...... 10 PROGRAF SOLN 5 MG/ML [tacrolimus] ...... 71 primidone tab 50mg...... 43 PROLEUKIN SOLR 22000000 UNIT primidone tabs 250 mg ...... 43 [aldesleukin] ...... 19 PRIMSOL SOLN 50 MG/5ML [trimethoprim PROMACTA PACK 25 MG [eltrombopag hcl] ...... 10 olamine] ...... 31 PRIVIGEN SOLN 10 GM/100ML [immune PROMACTA TABS 12.5 MG [eltrombopag globulin (human) iv] ...... 80 olamine] ...... 31 PRIVIGEN SOLN 20 GM/200ML [immune PROMACTA TABS 25 MG [eltrombopag globulin (human) iv] ...... 80 olamine] ...... 31

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PROMACTA TABS 50 MG [eltrombopag hcl] ...... 94 olamine] ...... 31 QUELICIN SOLN 20 MG/ML [succinylcholine PROMACTA TABS 75 MG [eltrombopag chloride] ...... 23 olamine] ...... 31 quetiapine fumarate tabs 100 mg ...... 50 promethazine hcl soln 25 mg/ml ...... 14 quetiapine fumarate tabs 200 mg ...... 50 promethazine hcl tabs 12.5 mg ...... 14 quetiapine fumarate tabs 25 mg ...... 50 promethazine hcl tabs 25 mg...... 15 quetiapine fumarate tabs 300 mg ...... 50 promethazine-codeine soln 6.25-10 mg/5ml 77 quetiapine fumarate tabs 400 mg ...... 50 promethazine-dm soln 6.25-15 mg/5ml ...... 77 quetiapine fumarate tabs 50 mg ...... 50 promethazine-dm syrp 6.25-15 mg/5ml ...... 77 QUINACRINE HCL POWD [quinacrine hcl] .. 76 propafenone hcl tabs 150 mg ...... 34 quinidine gluconate er tbcr 324 mg ...... 34 propafenone hcl tabs 225 mg ...... 34 QUINIDINE GLUCONATE SOLN 80 MG/ML propafenone hcl tabs 300 mg ...... 34 [quinidine gluconate] ...... 34 propantheline bromide tabs 15 mg ...... 22 quinidine sulfate tabs 200 mg ...... 34 proparacaine hcl soln 0.5 %...... 61 quinidine sulfate tabs 300 mg ...... 34 propofol emul 1000 mg/100ml ...... 47 RABAVERT SUSR [rabies vaccine, pcec] .... 81 propofol emul 200 mg/20ml ...... 47 raloxifene hcl tabs 60 mg ...... 68 propranolol hcl er cp24 120 mg ...... 32 ramipril caps 10 mg ...... 35 propranolol hcl er cp24 160 mg ...... 32 ramipril caps 2.5 mg ...... 35 propranolol hcl er cp24 60 mg ...... 32 ramipril caps 5 mg ...... 35 propranolol hcl er cp24 80 mg ...... 32 RAPAMUNE SOLN 1 MG/ML [sirolimus] ...... 71 propranolol hcl soln 1 mg/ml ...... 32 rasagiline mesylate tabs 0.5 mg ...... 45 propranolol hcl soln 20 mg/5ml ...... 32 rasagiline mesylate tabs 1 mg ...... 45 propranolol hcl tabs 10 mg ...... 32 RASUVO SOAJ 10 MG/0.2ML [methotrexate propranolol hcl tabs 20 mg ...... 32 (antirheumatic)] ...... 70 propranolol hcl tabs 40 mg ...... 32 RASUVO SOAJ 12.5 MG/0.25ML [methotrexate propranolol hcl tabs 60 mg ...... 32 (antirheumatic)] ...... 70 propranolol hcl tabs 80 mg ...... 32 RASUVO SOAJ 15 MG/0.3ML [methotrexate PROPYLENE GLYCOL LIQD [propylene (antirheumatic)] ...... 70 glycol (bulk)] ...... 92 RASUVO SOAJ 17.5 MG/0.35ML [methotrexate propylthiouracil tabs 50 mg ...... 70 (antirheumatic)] ...... 70 PROQUAD SUSR [measles-mumps-rubella- RASUVO SOAJ 20 MG/0.4ML [methotrexate varicella virus vaccines] ...... 81 (antirheumatic)] ...... 70 PROSOL SOLN 20 % [amino acid infusion] . 55 RASUVO SOAJ 22.5 MG/0.45ML [methotrexate PROSTIN E2 SUPP 20 MG [dinoprostone] ... 75 (antirheumatic)] ...... 70 protamine sulfate soln 10 mg/ml ...... 28 RASUVO SOAJ 25 MG/0.5ML [methotrexate PROTONIX SOLR 40 MG [pantoprazole (antirheumatic)] ...... 70 sodium] ...... 62 RASUVO SOAJ 27.5 MG/0.55ML [methotrexate protriptyline hcl tabs 10 mg ...... 50 (antirheumatic)] ...... 74 protriptyline hcl tabs 5 mg ...... 50 RASUVO SOAJ 30 MG/0.6ML [methotrexate PSEUDOEPHEDRINE HCL TABS 30 MG (antirheumatic)] ...... 70 [pseudoephedrine hcl] ...... 88 RASUVO SOAJ 7.5 MG/0.15ML [methotrexate PULMICORT FLEXHALER AEPB 180 MCG/ACT (antirheumatic)] ...... 71 [budesonide (inhalation)] ...... 65 READI-CAT 2 SUSP 2 % [barium sulfate] ..... 53 PULMOZYME SOLN 1 MG/ML [dornase alfa] 59 READI-CAT 2 SUSP 2.1 % [barium sulfate] .. 53 PURIXAN SUSP 2000 MG/100ML RECOMBINATE SOLR 1241-1800 UNIT [mercaptopurine] ...... 19 [antihemophilic factor (recombinant) (rfviii)] pyrazinamide tabs 500 mg ...... 12 ...... 28 pyridostigmine bromide er tbcr 180 mg ...... 23 RECOMBINATE SOLR 1801-2400 UNIT pyridostigmine bromide tabs 60 mg ...... 23 [antihemophilic factor (recombinant) (rfviii)] pyridoxine hcl soln 100 mg/ml ...... 86 ...... 28 PYRIDOXINE HCL TABS 25 MG [pyridoxine RECOMBINATE SOLR 220-400 UNIT

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[antihemophilic factor (recombinant) (rfviii)] RETIN-A MICRO GEL 0.1 % [tretinoin ...... 28 microsphere] ...... 84 RECOMBINATE SOLR 401-800 UNIT RETISERT IMPL 0.59 MG [fluocinolone [antihemophilic factor (recombinant) (rfviii)] acetonide (ophth)] ...... 60 ...... 28 RETROVIR SOLN 10 MG/ML [zidovudine] .... 14 RECOMBINATE SOLR 801-1240 UNIT REVLIMID CAPS 10 MG [lenalidomide] ...... 19 [antihemophilic factor (recombinant) (rfviii)] REVLIMID CAPS 15 MG [lenalidomide] ...... 19 ...... 28 REVLIMID CAPS 2.5 MG [lenalidomide] ...... 19 RECOMBIVAX HB SUSP 10 MCG/ML [hepatitis REVLIMID CAPS 20 MG [lenalidomide] ...... 19 b vaccine (recomb)] ...... 81 REVLIMID CAPS 25 MG [lenalidomide] ...... 19 RECOMBIVAX HB SUSP 40 MCG/ML [hepatitis REVLIMID CAPS 5 MG [lenalidomide] ...... 19 b vaccine (recomb)] ...... 81 RHOGAM ULTRA-FILTERED PLUS SOSY 1500 RECOMBIVAX HB SUSP 5 MCG/0.5ML UNIT [rho d immune globulin (human)] .... 80 [hepatitis b vaccine (recomb)] ...... 81 RHOPHYLAC SOSY 1500 UNIT/2ML [rho d RECOTHROM SOLR 20000 UNIT [thrombin immune globulin (human)] ...... 80 (recombinant)] ...... 28 ribavirin caps 200 mg ...... 12 RECOTHROM SOLR 5000 UNIT [thrombin RIDAURA CAPS 3 MG [auranofin] ...... 63 (recombinant)] ...... 28 rifabutin caps 150 mg ...... 12 REESES PINWORM MEDICINE SUSP 144 (50 rifampin caps 150 mg ...... 12 Base) MG/ML [pyrantel pamoate] ...... 88 rifampin caps 300 mg ...... 12 REGONOL SOLN 10 MG/2ML [pyridostigmine rifampin solr 600 mg ...... 12 bromide] ...... 23 riluzole tabs 50 mg ...... 47 RELENZA DISKHALER AEPB 5 MG/BLISTER rimantadine hcl tabs 100 mg ...... 14 [zanamivir] ...... 14 RIMSO-50 SOLN 50 % [dimethyl sulfoxide] .. 74 REMICADE SOLR 100 MG [infliximab] ...... 71 RINGERS IRRIGATION SOLN [ringer's REMODULIN SOLN 100 MG/20ML [treprostinil] irrigation] ...... 56 ...... 37 RINGERS SOLN [ringer's] ...... 58 REMODULIN SOLN 20 MG/20ML [treprostinil] RISPERDAL CONSTA SRER 12.5 MG ...... 37 [risperidone microspheres] ...... 50 REMODULIN SOLN 200 MG/20ML [treprostinil] RISPERDAL CONSTA SRER 25 MG ...... 37 [risperidone microspheres] ...... 50 REMODULIN SOLN 50 MG/20ML [treprostinil] RISPERDAL CONSTA SRER 37.5 MG ...... 37 [risperidone microspheres] ...... 50 RENAL CAPS 1 MG [b-complex w/ c & folic RISPERDAL CONSTA SRER 50 MG acid] ...... 86 [risperidone microspheres] ...... 50 RENVELA PACK 2.4 GM [sevelamer RISPERIDONE SOLN 1 MG/ML [risperidone]50 carbonate] ...... 55 RISPERIDONE TABS 0.25 MG [risperidone] . 50 RENVELA TABS 800 MG [sevelamer RISPERIDONE TABS 0.5 MG [risperidone] ... 50 carbonate] ...... 55 risperidone tabs 1 mg ...... 50 RESCRIPTOR TABS 100 MG [delavirdine RISPERIDONE TABS 2 MG [risperidone] ...... 51 mesylate] ...... 4 RISPERIDONE TABS 3 MG [risperidone] ...... 51 RESCRIPTOR TABS 200 MG [delavirdine RISPERIDONE TABS 4 MG [risperidone] ...... 51 mesylate] ...... 5 ritonavir tabs 100 mg ...... 14 reserpine tab 0.1mg ...... 35 RITUXAN SOLN 100 MG/10ML [rituximab] .... 19 reserpine tab 0.25mg ...... 35 RITUXAN SOLN 500 MG/50ML [rituximab] .... 19 RETIN-A CREA 0.025 % [tretinoin] ...... 84 rizatriptan benzoate tabs 10 mg ...... 44 RETIN-A CREA 0.05 % [tretinoin] ...... 84 rizatriptan benzoate tabs 5 mg ...... 44 RETIN-A CREA 0.1 % [tretinoin] ...... 84 rizatriptan benzoate tbdp 10 mg ...... 44 RETIN-A GEL 0.01 % [tretinoin] ...... 84 rizatriptan benzoate tbdp 5 mg ...... 44 RETIN-A GEL 0.025 % [tretinoin] ...... 84 rocuronium bromide soln 100 mg/10ml ...... 23 RETIN-A MICRO GEL 0.04 % [tretinoin rocuronium bromide soln 50 mg/5ml ...... 23 microsphere] ...... 84 romidepsin solr 10 mg ...... 20

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 133 of 144 ropinirole hcl er tb24 12 mg ...... 45 scopolamine pt72 1 mg/3days ...... 62 ropinirole hcl er tb24 2 mg ...... 45 selegiline hcl caps 5 mg ...... 47 ropinirole hcl er tb24 4 mg ...... 45 selegiline hcl tabs 5 mg ...... 45 ropinirole hcl er tb24 6 mg ...... 45 SELENIUM SOLN 40 MCG/ML [selenious acid] ropinirole hcl er tb24 8 mg ...... 45 ...... 58 ropinirole hcl tabs 0.25 mg ...... 45 selenium sulfide lotn 2.5 % ...... 82 ropinirole hcl tabs 0.5 mg ...... 45 SELZENTRY TABS 150 MG [maraviroc] ...... 5 ropinirole hcl tabs 1 mg ...... 45 SELZENTRY TABS 25 MG [maraviroc] ...... 5 ropinirole hcl tabs 2 mg ...... 45 SELZENTRY TABS 300 MG [maraviroc] ...... 5 ropinirole hcl tabs 3 mg ...... 45 SELZENTRY TABS 75 MG [maraviroc] ...... 5 ropinirole hcl tabs 4 mg ...... 45 SENSORCAINE-MPF/EPINEPHRINE SOLN ropinirole hcl tabs 5 mg ...... 45 0.75-1 rosuvastatin calcium tabs 10 mg ...... 31 200000 % [bupivacaine w/ epinephrine] ... 72 rosuvastatin calcium tabs 20 mg ...... 31 SEREVENT DISKUS AEPB 50 MCG/DOSE rosuvastatin calcium tabs 40 mg ...... 31 [salmeterol xinafoate] ...... 25 rosuvastatin calcium tabs 5 mg ...... 32 SEROSTIM SOLR 4 MG [somatropin (non- ROTARIX SUSR [rotavirus vaccine, live oral] refrigerated)] ...... 69 ...... 81 SEROSTIM SOLR 5 MG [somatropin (non- ROTATEQ SOLN [rotavirus vaccine, live oral refrigerated)] ...... 69 pentavalent] ...... 81 SEROSTIM SOLR 6 MG [somatropin (non- ROZLYTREK CAPS 100 MG [entrectinib] ..... 20 refrigerated)] ...... 69 ROZLYTREK CAPS 200 MG [entrectinib] ..... 20 sertraline hcl tabs 100 mg ...... 51 RYANODEX SUSR 250 MG [dantrolene sertraline hcl tabs 25 mg ...... 51 sodium] ...... 23 sertraline hcl tabs 50 mg ...... 51 RYDAPT CAPS 25 MG [midostaurin] ...... 20 sevelamer carbonate pack 2.4 gm ...... 55 S2 (RACEPINEPHRINE) NEBU 2.25 % sevelamer carbonate tabs 800 mg ...... 55 [racepinephrine hcl] ...... 88 SF 5000 PLUS CREA 1.1 % [sodium fluoride SABRIL PACK 500 MG [vigabatrin] ...... 43 (dental)] ...... 74 SALICYLIC ACID POWD [salicylic acid (bulk)] SHINGRIX SUSR 50 MCG/0.5ML [zoster ...... 76 vaccine recombinant adjuvanted] ...... 81 SALSALATE TABS 500 MG [salsalate] ...... 40 sildenafil citrate tabs 100 mg ...... 37 SALSALATE TABS 750 MG [salsalate] ...... 40 sildenafil citrate tabs 20 mg ...... 37 SANDIMMUNE CAPS 100 MG [cyclosporine] SILENOR TABS 3 MG [doxepin hcl (sleep)] .. 47 ...... 71 SILENOR TABS 6 MG [doxepin hcl (sleep)] .. 47 SANDIMMUNE CAPS 25 MG [cyclosporine] 71 SILVER SULFADIAZINE CREA 1 % [silver SANDIMMUNE SOLN 100 MG/ML sulfadiazine] ...... 82 [cyclosporine] ...... 71 simvastatin tabs 10 mg ...... 32 SANDIMMUNE SOLN 50 MG/ML simvastatin tabs 20 mg ...... 32 [cyclosporine] ...... 71 simvastatin tabs 40 mg ...... 32 SANDOSTATIN LAR DEPOT KIT 10 MG simvastatin tabs 5 mg ...... 32 [octreotide acetate] ...... 74 simvastatin tabs 80 mg ...... 32 SANDOSTATIN LAR DEPOT KIT 20 MG sirolimus soln 1 mg/ml ...... 74 [octreotide acetate] ...... 74 sirolimus tabs 0.5 mg ...... 71 SANDOSTATIN LAR DEPOT KIT 30 MG sirolimus tabs 1 mg ...... 71 [octreotide acetate] ...... 74 sirolimus tabs 2 mg ...... 71 SANTYL OINT 250 UNIT/GM [collagenase] .. 85 SKYRIZI (150 MG DOSE) PSKT 75 MG/0.83ML SARCLISA SOLN 100 MG/5ML [isatuximab- [risankizumab-rzaa] ...... 85 irfc] ...... 20 SLO-NIACIN TBCR 500 MG [niacin] ...... 94 SARCLISA SOLN 500 MG/25ML [isatuximab- SLO-NIACIN TBCR 750 MG [niacin] ...... 94 irfc] ...... 20 SM FOAMING ANTACID CHEW 80-20 MG SARNA LOTN 0.5-0.5 % [camphor & menthol] [aluminum hydroxide-mag trisil] ...... 92 ...... 93 SM STOMACH RELIEF TABS 262 MG [bismuth

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subsalicylate] ...... 92 sodium polystyrene sulfonate susp 30 SOD CITRATE-CITRIC ACID SOLN 500-334 gm/120ml ...... 55 MG/5ML [sodium citrate & citric acid] ...... 53 solifenacin succinate tabs 10 mg ...... 85 SODIUM ACETATE SOLN 2 MEQ/ML [sodium solifenacin succinate tabs 5 mg ...... 85 acetate] ...... 53 SOLIRIS SOLN 300 MG/30ML [eculizumab] .. 74 SODIUM BENZOATE POWD [sodium SOLU-CORTEF SOLR 100 MG benzoate] ...... 76 [hydrocortisone sod succinate] ...... 65 SODIUM BICARBONATE SOLN 4.2 % [sodium SOLU-CORTEF SOLR 1000 MG bicarbonate] ...... 53 [hydrocortisone sod succinate] ...... 65 SODIUM BICARBONATE SOLN 7.5 % [sodium SOLU-CORTEF SOLR 250 MG bicarbonate] ...... 53 [hydrocortisone sod succinate] ...... 65 SODIUM BICARBONATE SOLN 8.4 % [sodium SOLU-CORTEF SOLR 500 MG bicarbonate] ...... 53 [hydrocortisone sod succinate] ...... 65 SODIUM CHLORIDE (PF) SOLN 0.9 % [sodium SOLU-MEDROL SOLR 125 MG chloride] ...... 58 [methylprednisolone sod succ]...... 65 SODIUM CHLORIDE BACTERIOSTATIC SOLN SOLU-MEDROL SOLR 500 MG 0.9 % [bacteriostatic sodium chloride] ..... 58 [methylprednisolone sod succ]...... 65 SODIUM CHLORIDE NEBU 0.9 % [sodium SORBITOL SOLN 70 % [sorbitol (laxative)] .. 92 chloride (inhalant)] ...... 77 SORBITOL SOLN 70 % [sorbitol] ...... 76 SODIUM CHLORIDE NEBU 10 % [sodium sotalol hcl (af) tabs 120 mg ...... 32 chloride (inhalant)] ...... 77 sotalol hcl (af) tabs 160 mg ...... 32 SODIUM CHLORIDE NEBU 3 % [sodium sotalol hcl (af) tabs 80 mg ...... 33 chloride (inhalant)] ...... 77 sotalol hcl tabs 120 mg ...... 33 SODIUM CHLORIDE NEBU 7 % [sodium sotalol hcl tabs 160 mg ...... 33 chloride (inhalant)] ...... 77 sotalol hcl tabs 240 mg ...... 33 SODIUM CHLORIDE SOLN 0.45 % [sodium sotalol hcl tabs 80 mg ...... 33 chloride] ...... 58 SOVALDI PACK 150 MG [sofosbuvir]...... 12 SODIUM CHLORIDE SOLN 0.9 % [sodium SOVALDI PACK 200 MG [sofosbuvir]...... 12 chloride (gu irrigant)] ...... 56 SOVALDI TABS 200 MG [sofosbuvir] ...... 12 SODIUM CHLORIDE SOLN 0.9 % [sodium SOVALDI TABS 400 MG [sofosbuvir] ...... 12 chloride] ...... 58 SPIRIVA RESPIMAT AERS 2.5 MCG/ACT SODIUM CHLORIDE SOLN 3 % [sodium [tiotropium bromide monohydrate] ...... 22 chloride] ...... 58 spironolactone tabs 100 mg ...... 35 SODIUM CHLORIDE SOLN 4 MEQ/ML [sodium spironolactone tabs 25 mg ...... 35 chloride] ...... 58 spironolactone tabs 50 mg ...... 35 SODIUM CHLORIDE SOLN 5 % [sodium spironolactone-hctz tabs 25-25 mg ...... 35 chloride] ...... 58 SPORANOX SOLN 10 MG/ML [itraconazole] 11 SODIUM CHLORIDE TABS 1 GM [sodium SPRYCEL TABS 100 MG [dasatinib] ...... 20 chloride] ...... 94 SPRYCEL TABS 140 MG [dasatinib] ...... 20 SODIUM EDECRIN SOLR 50 MG [ethacrynate SPRYCEL TABS 20 MG [dasatinib] ...... 20 sodium] ...... 55 SPRYCEL TABS 50 MG [dasatinib] ...... 20 SODIUM FLUORIDE CHEW 1.1 (0.5 F) MG SPRYCEL TABS 70 MG [dasatinib] ...... 20 [sodium fluoride] ...... 74 SPRYCEL TABS 80 MG [dasatinib] ...... 20 SODIUM FLUORIDE SOLN 1.1 (0.5 F) MG/ML SQUARIC ACID DIBUTYLESTER POW [sodium fluoride] ...... 74 DIBUTYLS [squaric acid dibutylester] ...... 76 sodium phenylbutyrate powd 3 gm/tsp ...... 54 SSKI SOLN 1 GM/ML [potassium iodide SODIUM PHOSPHATES SOLN 45 (expectorant)] ...... 70 MMOLE/15ML [sodium phosphates (sodium stavudine caps 15 mg ...... 5 phosphate dibasic & monobasic)] ...... 58 stavudine caps 20 mg ...... 5 sodium polystyrene sulfonate powd ...... 55 stavudine caps 30 mg ...... 5 sodium polystyrene sulfonate susp 15 stavudine caps 40 mg ...... 5 gm/60ml ...... 55 STELARA SOLN 45 MG/0.5ML [ustekinumab]

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...... 85 SULFUR PRECIPITATED POWD [sulfur STELARA SOSY 45 MG/0.5ML [ustekinumab] (bulk)] ...... 92 ...... 85 sulindac tabs 150 mg ...... 40 STELARA SOSY 90 MG/ML [ustekinumab] .. 85 sulindac tabs 200 mg ...... 40 sterile water for injection soln ...... 74 sumatriptan soln 20 mg/act ...... 44 STERILE WATER FOR INJECTION SOLN sumatriptan succinate refill soct 6 mg/0.5ml [water for injection, sterile] ...... 76 ...... 44 STERILE WATER FOR IRRIGATION SOLN sumatriptan succinate soaj 6 mg/0.5ml ...... 44 [water for irrigation, sterile] ...... 56 sumatriptan succinate soln 6 mg/0.5ml ...... 44 STIMATE SOLN 1.5 MG/ML [desmopressin sumatriptan succinate sosy 6 mg/0.5ml ...... 44 acetate] ...... 69 sumatriptan succinate tabs 100 mg ...... 44 STIOLTO RESPIMAT AERS 2.5-2.5 MCG/ACT sumatriptan succinate tabs 25 mg ...... 44 [tiotropium bromide-olodaterol hcl] ...... 22 sumatriptan succinate tabs 50 mg ...... 44 STIVARGA TABS 40 MG [regorafenib] ...... 20 SURE COMFORT INSULIN SYRINGE MISC STRENSIQ SOLN 18 MG/0.45ML [asfotase 28G X 1/2 ...... 90 alfa] ...... 59 SURE COMFORT INSULIN SYRINGE MISC STRENSIQ SOLN 28 MG/0.7ML [asfotase alfa] 29G X 1/2 ...... 90 ...... 59 SURE COMFORT INSULIN SYRINGE MISC STRENSIQ SOLN 40 MG/ML [asfotase alfa] . 59 30G X 1/2 ...... 90 STRENSIQ SOLN 80 MG/0.8ML [asfotase alfa] SURE COMFORT INSULIN SYRINGE MISC ...... 59 30G X 5/16 ...... 91 streptomycin sulfate solr 1 gm ...... 10 SURE COMFORT INSULIN SYRINGE MISC STRIBILD TABS 150-150-200-300 MG 31G X 5/16 ...... 91 [elvitegravir-cobicistat-emtricitabine- SURVANTA SUSP 25-0.9 MG/ML-% [beractant tenofovir df] ...... 5 in nacl] ...... 77 STRIVERDI RESPIMAT AERS 2.5 MCG/ACT SUTENT CAPS 12.5 MG [sunitinib malate] ... 20 [olodaterol hcl] ...... 25 SUTENT CAPS 25 MG [sunitinib malate] ...... 20 sucralfate tabs 1 gm ...... 62 SUTENT CAPS 37.5 MG [sunitinib malate] ... 20 sufentanil citrate soln 50 mcg/ml ...... 40 SUTENT CAPS 50 MG [sunitinib malate] ...... 20 sulfacetamide sodium soln 10 % ...... 59 SYLVANT SOLR 100 MG [siltuximab] ...... 20 SULFACETAMIDE SODIUM-SULFUR EMUL 10- SYLVANT SOLR 400 MG [siltuximab] ...... 20 5 % [sulfacetamide sodium w/ sulfur] ...... 84 SYMBICORT AERO 160-4.5 MCG/ACT SULFACETAMIDE SODIUM-SULFUR LOTN 10- [budesonide-formoterol fumarate 5 % [sulfacetamide sodium w/ sulfur] ...... 84 dihydrate] ...... 65 SULFACETAMIDE SODIUM-SULFUR SUSP 10- SYMBICORT AERO 80-4.5 MCG/ACT 5 % [sulfacetamide sodium w/ sulfur] ...... 84 [budesonide-formoterol fumarate SULFACETAMIDE SODIUM-SULFUR SUSP 8-4 dihydrate] ...... 65 % [sulfacetamide sodium w/ sulfur] ...... 84 SYMDEKO TBPK 100-150 & 150 MG sulfacetamide-prednisolone soln 10-0.23 % 60 [tezacaftor-ivacaftor] ...... 78 sulfadiazine tabs 500 mg ...... 10 SYMDEKO TBPK 50-75 & 75 MG [tezacaftor- sulfamethoxazole-trimethoprim soln 400-80 ivacaftor] ...... 78 mg/5ml ...... 10 SYMFI LO TABS 400-300-300 MG [efavirenz- sulfamethoxazole-trimethoprim susp 200-40 lamivudine-tenofovir disoproxil fumarate] . 5 mg/5ml ...... 10 SYMFI TABS 600-300-300 MG [efavirenz- sulfamethoxazole-trimethoprim tabs 400-80 lamivudine-tenofovir disoproxil fumarate] . 5 mg ...... 10 SYMLINPEN 120 SOPN 2700 MCG/2.7ML sulfamethoxazole-trimethoprim tabs 800-160 [pramlintide acetate] ...... 66 mg ...... 10 SYMTUZA TABS 800-150-200-10 MG SULFAMYLON CREA 85 MG/GM [mafenide [darunavir-cobicistat-emtricitabine- acetate] ...... 82 tenofovir alafenamide] ...... 5 sulfasalazine tabs 500 mg ...... 10 SYNAGIS SOLN 100 MG/ML [palivizumab] ... 14 sulfasalazine tbec 500 mg ...... 10 SYNAGIS SOLN 50 MG/0.5ML [palivizumab] 14

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SYNAREL SOLN 2 MG/ML [nafarelin acetate] temazepam caps 30 mg ...... 47 ...... 69 temozolomide caps 100 mg ...... 20 SYNERCID SOLR 150-350 MG [quinupristin- temozolomide caps 140 mg ...... 20 dalfopristin] ...... 10 temozolomide caps 180 mg ...... 20 TABLOID TABS 40 MG [thioguanine] ...... 20 temozolomide caps 20 mg ...... 20 tacrolimus caps 0.5 mg ...... 71 temozolomide caps 250 mg ...... 20 tacrolimus caps 1 mg ...... 71 temozolomide caps 5 mg ...... 20 tacrolimus caps 5 mg ...... 71 TENIPOSIDE SOLN 10 MG/ML [teniposide] .. 20 TACROLIMUS OINT 0.03 % [tacrolimus tenofovir disoproxil fumarate tabs 300 mg .. 14 (topical)] ...... 85 terazosin hcl caps 1 mg ...... 31 TACROLIMUS OINT 0.1 % [tacrolimus terazosin hcl caps 10 mg ...... 31 (topical)] ...... 85 terazosin hcl caps 2 mg ...... 31 tadalafil (pah) tabs 20 mg ...... 37 terazosin hcl caps 5 mg ...... 31 tadalafil tabs 10 mg ...... 37 terbinafine hcl tabs 250 mg ...... 11 tadalafil tabs 2.5 mg ...... 37 terbutaline sulfate inj 1mg/ml...... 25 tadalafil tabs 20 mg ...... 37 terbutaline sulfate soln 1 mg/ml ...... 25 tadalafil tabs 5 mg ...... 37 terbutaline sulfate tabs 2.5 mg ...... 25 TAFINLAR CAPS 50 MG [dabrafenib mesylate] terbutaline sulfate tabs 5 mg...... 25 ...... 20 testosterone cypionate soln 200 mg/ml ...... 66 TAFINLAR CAPS 75 MG [dabrafenib mesylate] testosterone enanthate soln 200 mg/ml ...... 66 ...... 20 testosterone gel 12.5 mg/act (1%) ...... 66 TAGRISSO TABS 40 MG [osimertinib testosterone gel 20.25 mg/act (1.62%)...... 66 mesylate] ...... 20 testosterone gel 25 mg/2.5gm (1%) ...... 66 TAGRISSO TABS 80 MG [osimertinib testosterone gel 50 mg/5gm (1%) ...... 66 mesylate] ...... 20 TESTOSTERONE PROPIONATE POWD TAKHZYRO SOLN 300 MG/2ML [lanadelumab- [testosterone propionate (bulk)] ...... 76 flyo] ...... 74 TETRACAINE HCL SOLN 0.5 % [tetracaine hcl TAMIFLU CAPS 30 MG [oseltamivir (ophth)] ...... 61 phosphate] ...... 14 TETRACAINE HCL SOLN 1 % [tetracaine hcl] TAMIFLU CAPS 45 MG [oseltamivir ...... 72 phosphate] ...... 14 TETRACYCLINE HCL CAPS 250 MG TAMIFLU CAPS 75 MG [oseltamivir [tetracycline hcl] ...... 10 phosphate] ...... 14 TETRACYCLINE HCL CAPS 500 MG TAMIFLU SUSR 6 MG/ML [oseltamivir [tetracycline hcl] ...... 10 phosphate] ...... 14 TETRAVISC SOLN 0.5 % [tetracaine hcl tamoxifen citrate tabs 10 mg ...... 20 (ophth)] ...... 61 tamoxifen citrate tabs 20 mg ...... 20 THALOMID CAPS 100 MG [thalidomide] ...... 74 tamsulosin hcl caps 0.4 mg ...... 31 THALOMID CAPS 150 MG [thalidomide] ...... 74 TARGRETIN CAPS 75 MG [bexarotene] ...... 20 THALOMID CAPS 200 MG [thalidomide] ...... 74 TARGRETIN GEL 1 % [bexarotene (topical)] 85 THALOMID CAPS 50 MG [thalidomide] ...... 74 TASIGNA CAPS 150 MG [nilotinib hcl] ...... 20 THAM SOLN 30 MEQ/100ML [tromethamine]53 TASIGNA CAPS 200 MG [nilotinib hcl] ...... 20 theophylline er tb12 100 mg ...... 85 TAXOTERE INJ 80MG/2ML [docetaxel] ...... 20 theophylline er tb12 200 mg ...... 85 tazarotene crea 0.1 % ...... 85 theophylline er tb12 300 mg ...... 86 TAZORAC CREA 0.05 % [tazarotene] ...... 85 theophylline er tb12 450 mg ...... 86 TAZORAC GEL 0.05 % [tazarotene] ...... 85 theophylline er tb24 400 mg ...... 86 TAZORAC GEL 0.1 % [tazarotene] ...... 85 THEOPHYLLINE IN D5W SOLN 0.8-5 MG/ML-% TDVAX SUSP 2-2 LF/0.5ML [tetanus- [theophylline in dextrose] ...... 86 diphtheria toxoids (td)] ...... 80 thiamine hcl soln 100 mg/ml ...... 86 TECENTRIQ SOLN 1200 MG/20ML THIOLA TABS 100 MG [tiopronin] ...... 74 [atezolizumab] ...... 20 thioridazine hcl tabs 10 mg ...... 51 temazepam caps 15 mg ...... 47 thioridazine hcl tabs 100 mg ...... 51

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 137 of 144 thioridazine hcl tabs 25 mg ...... 51 torsemide tabs 20 mg ...... 55 thioridazine hcl tabs 50 mg ...... 51 torsemide tabs 5 mg ...... 55 thiotepa solr 15 mg ...... 20 TRACE ELEMENTS 4/PEDIATRIC SOLN 1-100- thiothixene caps 1 mg ...... 51 30-500 MCG/ML [trace minerals (cr-cu-mn- thiothixene caps 10 mg ...... 51 zn)] ...... 58 thiothixene caps 2 mg ...... 51 TRACLEER TABS 125 MG [bosentan] ...... 37 thiothixene caps 5 mg ...... 51 TRACLEER TABS 62.5 MG [bosentan] ...... 37 THROMBATE III SOLR 500 UNIT [antithrombin TRACLEER TBSO 32 MG [bosentan] ...... 78 iii (human)] ...... 30 TRADJENTA TABS 5 MG [linagliptin] ...... 66 THROMBIN-JMI KIT 20000 UNIT [thrombin] . 28 tramadol hcl tabs 50 mg ...... 40 THROMBIN-JMI SOLR 20000 UNIT [thrombin] tramadol-acetaminophen tabs 37.5-325 mg . 40 ...... 28 TRANEXAMIC ACID POWD [tranexamic acid THROMBIN-JMI SOLR 5000 UNIT [thrombin]28 (bulk)] ...... 76 THYMOL CRYS [thymol] ...... 92 tranexamic acid soln 1000 mg/10ml ...... 28 THYROGEN SOLR 1.1 MG [thyrotropin alfa] 53 tranexamic acid tabs 650 mg ...... 28 TICE BCG SUSR 50 MG [bcg live intravesical] TRANSDERM-SCOP (1.5 MG) PT72 1 ...... 81 MG/3DAYS [scopolamine] ...... 62 timolol maleate soln 0.25 % ...... 61 tranylcypromine sulfate tabs 10 mg ...... 51 timolol maleate soln 0.5 % ...... 61 TRAVASOL SOLN 10 % [amino acid infusion] TISSUEBLUE SOSY 0.025 % [brilliant blue g] ...... 55 ...... 53 TRAVEL SICKNESS CHEW 25 MG [meclizine TIVICAY PD TBSO 5 MG [dolutegravir hcl] ...... 92 sodium] ...... 14 trazodone hcl tabs 100 mg ...... 51 TIVICAY TABS 10 MG [dolutegravir sodium] 14 trazodone hcl tabs 150 mg ...... 51 TIVICAY TABS 25 MG [dolutegravir sodium] 14 trazodone hcl tabs 50 mg ...... 51 TIVICAY TABS 50 MG [dolutegravir sodium] . 5 TREANDA SOLR 100 MG [bendamustine hcl] tizanidine hcl tabs 2 mg ...... 23 ...... 20 tizanidine hcl tabs 4 mg ...... 23 TRECATOR TABS 250 MG [ethionamide] ..... 12 TNKASE KIT 50 MG [tenecteplase] ...... 30 TREMFYA SOPN 100 MG/ML [guselkumab] . 85 TOBI PODHALER CAPS 28 MG [tobramycin] TREMFYA SOSY 100 MG/ML [guselkumab] . 85 ...... 10 treprostinil soln 100 mg/20ml...... 37 TOBRADEX OINT 0.3-0.1 % [tobramycin- treprostinil soln 20 mg/20ml...... 37 dexamethasone] ...... 60 treprostinil soln 200 mg/20ml...... 37 tobramycin nebu 300 mg/5ml ...... 10 treprostinil soln 50 mg/20ml...... 37 tobramycin soln 0.3 % ...... 59 tretinoin caps 10 mg ...... 20 tobramycin sulfate soln 10 mg/ml ...... 10 triamcinolone acetonide crea 0.025 %...... 83 tobramycin sulfate soln 80 mg/2ml ...... 10 triamcinolone acetonide crea 0.1 % ...... 83 tobramycin sulfate solr 1.2 gm ...... 10 triamcinolone acetonide crea 0.5 % ...... 83 TOBREX OINT 0.3 % [tobramycin (ophth)] .. 59 triamcinolone acetonide lotn 0.1 % ...... 83 tolbutamide tabs 500 mg ...... 66 triamcinolone acetonide oint 0.025 % ...... 83 TOLNAFTATE CREA 1 % [tolnaftate] ...... 93 triamcinolone acetonide oint 0.1 % ...... 83 TOLNAFTATE SOLN 1 % [tolnaftate] ...... 93 triamcinolone acetonide oint 0.5 % ...... 83 topiramate cpsp 15 mg ...... 43 TRIAMCINOLONE ACETONIDE POWD topiramate cpsp 25 mg ...... 43 [triamcinolone acetonide (topical)] ...... 76 topiramate tabs 100 mg ...... 43 triamcinolone acetonide pste 0.1 % ...... 83 topiramate tabs 200 mg ...... 43 triamterene-hctz caps 37.5-25 mg ...... 55 topiramate tabs 25 mg ...... 43 TRIAMTERENE-HCTZ TABS 37.5-25 MG topiramate tabs 50 mg ...... 43 [triamterene & hydrochlorothiazide] ...... 55 topotecan hcl solr 4 mg ...... 20 TRIAMTERENE-HCTZ TABS 75-50 MG TORISEL SOLN 25 MG/ML [temsirolimus] ... 20 [triamterene & hydrochlorothiazide] ...... 55 torsemide tabs 10 mg ...... 55 TRI-BUFFERED ASPIRIN TABS 325 MG torsemide tabs 100 mg ...... 55 [aspirin buffered (cal carb-mag carb-mag

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oxide)] ...... 89 TYSABRI CONC 300 MG/15ML [natalizumab] TRI-CHLOR LIQD 80 % [trichloroacetic acid] ...... 74 ...... 74 TYVASO SOLN 0.6 MG/ML [treprostinil] ...... 37 TRICITRATES SOLN 550-500-334 MG/5ML [pot ULTIVA SOLR 1 MG [remifentanil hcl] ...... 40 & sod citrates w/citric ac] ...... 53 ULTIVA SOLR 2 MG [remifentanil hcl] ...... 40 trifluoperazine hcl tabs 1 mg ...... 51 ULTIVA SOLR 5 MG [remifentanil hcl] ...... 40 trifluoperazine hcl tabs 10 mg ...... 51 ULTOMIRIS SOLN 1100 MG/11ML trifluoperazine hcl tabs 2 mg ...... 51 [ravulizumab-cwvz] ...... 75 trifluoperazine hcl tabs 5 mg ...... 51 ULTOMIRIS SOLN 300 MG/30ML trifluridine soln 1 % ...... 59 [ravulizumab-cwvz] ...... 75 trihexyphenidyl hcl soln 0.4 mg/ml ...... 45 ULTOMIRIS SOLN 300 MG/3ML [ravulizumab- trihexyphenidyl hcl tabs 2 mg ...... 45 cwvz] ...... 75 trihexyphenidyl hcl tabs 5 mg ...... 45 ULTRA THIN LANCETS 30G MISC [lancets] 91 TRIKAFTA TBPK 100-50-75 & 150 MG ULTRABAG/DIANEAL/1.5% DEXTROSE SOLN [elexacaftor-tezacaftor-ivacaftor]...... 78 344 MOSM/L [peritoneal dialysis solutions] TRIKAFTA TBPK 50-25-37.5 & 75 MG ...... 56 [elexacaftor-tezacaftor-ivacaftor]...... 78 ULTRABAG/DIANEAL/2.5% DEXTROSE SOLN trimethoprim tabs 100 mg ...... 14 395 MOSM/L [peritoneal dialysis solutions] trimipramine maleate caps 100 mg ...... 51 ...... 56 trimipramine maleate caps 25 mg ...... 51 ULTRA-COMFORT INSULIN SYRINGE MISC trimipramine maleate caps 50 mg ...... 51 31G X 5/16 ...... 91 TRISENOX SOLN 12 MG/6ML [arsenic UNITUXIN SOLN 17.5 MG/5ML [dinutuximab] trioxide] ...... 20 ...... 20 TRIUMEQ TABS 600-50-300 MG [abacavir- UREA POWD [urea (bulk)] ...... 92 dolutegravir-lamivudine] ...... 5 URSO FORTE TABS 500 MG [ursodiol] ...... 63 TRI-VI-SOL A/C/D SOLN 250-50-10 [pediatric ursodiol tabs 250 mg ...... 63 vitamins adc] ...... 94 VAGIFEM TABS 10 MCG [estradiol vaginal] . 68 TRI-VIT/FLUORIDE SOLN 0.5 MG/ML valacyclovir hcl tabs 1 gm ...... 14 [pediatric vitamins acd w/ fluoride] ...... 86 valacyclovir hcl tabs 500 mg ...... 14 TRIZIVIR TABS 300-150-300 MG [abacavir VALCYTE SOLR 50 MG/ML [valganciclovir sulfate-lamivudine-zidovudine]...... 14 hcl] ...... 14 TROPHAMINE SOLN 10 % [amino acid valganciclovir hcl tabs 450 mg ...... 14 infusion] ...... 55 valproate sodium soln 500 mg/5ml ...... 43 TROPHAMINE SOLN 6 % [amino acid valproic acid caps 250 mg ...... 43 infusion] ...... 55 valproic acid soln 250 mg/5ml ...... 43 tropicamide soln 0.5 % ...... 61 valsartan tabs 160 mg ...... 35 tropicamide soln 1 % ...... 61 valsartan tabs 320 mg ...... 35 trospium chloride er cp24 60 mg ...... 85 valsartan tabs 40 mg ...... 35 trospium chloride tabs 20 mg ...... 85 valsartan tabs 80 mg ...... 35 TRUZONE PEAK FLOW METER DEVI [peak valsartan-hydrochlorothiazide tabs 160-12.5 flow meter] ...... 52 mg ...... 35 TUBERSOL SOLN 5 UNIT/0.1ML [tuberculin valsartan-hydrochlorothiazide tabs 160-25 mg ppd] ...... 53 ...... 35 TUKYSA TABS 150 MG [tucatinib] ...... 20 valsartan-hydrochlorothiazide tabs 320-12.5 TUKYSA TABS 50 MG [tucatinib] ...... 20 mg ...... 35 TWINRIX SUSY 720-20 ELU-MCG/ML valsartan-hydrochlorothiazide tabs 320-25 mg [hepatitis a (inactivated)-hepatitis b ...... 35 (recombinant) vaccines] ...... 81 valsartan-hydrochlorothiazide tabs 80-12.5 TYKERB TABS 250 MG [lapatinib ditosylate] mg ...... 35 ...... 20 vancomycin hcl caps 125 mg ...... 10 TYPHIM VI SOLN 25 MCG/0.5ML [typhoid vi vancomycin hcl caps 250 mg ...... 10 polysaccharide vaccine]...... 81 VANCOMYCIN HCL IN DEXTROSE SOLN 1-5

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GM/200ML-% [vancomycin hcl-dextrose] . 10 VICTOZA SOPN 18 MG/3ML [liraglutide] ...... 66 VANCOMYCIN HCL IN DEXTROSE SOLN 500- VIDEX SOLR 2 GM [didanosine] ...... 5 5 MG/100ML-% [vancomycin hcl-dextrose] VIDEX SOLR 4 GM [didanosine] ...... 5 ...... 10 VIMIZIM SOLN 5 MG/5ML [elosulfase alfa] ... 59 vancomycin hcl solr 1 gm ...... 10 vinblastine sulfate soln 1 mg/ml ...... 21 vancomycin hcl solr 10 gm ...... 10 vincristine sulfate soln 1 mg/ml ...... 21 vancomycin hcl solr 5 gm ...... 10 vinorelbine tartrate soln 10 mg/ml ...... 21 vancomycin hcl solr 500 mg ...... 10 vinorelbine tartrate soln 50 mg/5ml ...... 21 VAQTA SUSP 25 UNIT/0.5ML [hepatitis a VIRACEPT TABS 250 MG [nelfinavir mesylate] vaccine] ...... 81 ...... 5 VAQTA SUSP 50 UNIT/ML [hepatitis a VIRACEPT TABS 625 MG [nelfinavir mesylate] vaccine] ...... 81 ...... 5 VARITHENA FOAM 180 MG/18ML [polidocanol VIRAMUNE SUSP 50 MG/5ML [nevirapine] ..... 5 (laureth-9)] ...... 36 VIRAZOLE SOLR 6 GM [ribavirin] ...... 14 VARIVAX INJ 1350 PFU/0.5ML [varicella virus VIRTUSSIN DAC SOLN 30-10-100 MG/5ML vaccine live] ...... 81 [pseudoephedrine w/ codeine-gg] ...... 93 VAXCHORA SUSR [cholera vaccine live VISUDYNE SOLR 15 MG [verteporfin] ...... 61 attenuated] ...... 81 VITAMIN B-6 TABS 100 MG [pyridoxine hcl] 94 VECTICAL OINT 3 MCG/GM [calcitriol VITAMIN B-6 TABS 50 MG [pyridoxine hcl] .. 94 (topical)] ...... 85 vitamin d (ergocalciferol) caps 1.25 mg vecuronium bromide solr 10 mg ...... 23 (50000 ut) ...... 86 vecuronium bromide solr 20 mg ...... 23 vitamin k1 soln 1 mg/0.5ml ...... 87 VEKLURY SOLN 100 MG/20ML [remdesivir] 14 vitamin k1 soln 10 mg/ml ...... 87 VEKLURY SOLR 100 MG [remdesivir] ...... 14 VITAMINS ACD-FLUORIDE SOLN 0.25 MG/ML VELCADE SOLR 3.5 MG [bortezomib] ...... 20 [pediatric vitamins acd w/ fluoride] ...... 86 VENCLEXTA STARTING PACK TBPK 10 & 50 VIVOTIF CPDR [typhoid vaccine] ...... 81 & 100 MG [venetoclax] ...... 21 VOLUMEN SUSP 0.1 % [barium sulfate] ...... 53 VENCLEXTA TABS 10 MG [venetoclax] ...... 21 VORAXAZE SOLR 1000 UNIT [glucarpidase]59 VENCLEXTA TABS 100 MG [venetoclax] ...... 21 voriconazole solr 200 mg ...... 14 VENCLEXTA TABS 50 MG [venetoclax] ...... 21 voriconazole tabs 200 mg ...... 11 venlafaxine hcl er cp24 150 mg ...... 51 voriconazole tabs 50 mg ...... 11 venlafaxine hcl er cp24 37.5 mg ...... 51 VOSEVI TABS 400-100-100 MG [sofosbuvir- venlafaxine hcl er cp24 75 mg ...... 51 velpatasvir-voxilaprevir] ...... 14 venlafaxine hcl tabs 100 mg ...... 51 VOTRIENT TABS 200 MG [pazopanib hcl] .... 21 venlafaxine hcl tabs 25 mg ...... 51 VPRIV SOLR 400 UNIT [velaglucerase alfa] . 59 venlafaxine hcl tabs 37.5 mg ...... 51 VYVANSE CAPS 10 MG [lisdexamfetamine venlafaxine hcl tabs 50 mg ...... 51 dimesylate] ...... 41 venlafaxine hcl tabs 75 mg ...... 51 VYVANSE CAPS 20 MG [lisdexamfetamine VENOFER SOLN 20 MG/ML [iron sucrose] .. 25 dimesylate] ...... 41 VENTAVIS SOLN 10 MCG/ML [iloprost] ...... 37 VYVANSE CAPS 30 MG [lisdexamfetamine VENTAVIS SOLN 20 MCG/ML [iloprost] ...... 37 dimesylate] ...... 41 VENTOLIN HFA AERS 108 (90 Base) MCG/ACT VYVANSE CAPS 40 MG [lisdexamfetamine [albuterol sulfate] ...... 25 dimesylate] ...... 41 verapamil hcl er tbcr 120 mg ...... 33 VYVANSE CAPS 50 MG [lisdexamfetamine verapamil hcl er tbcr 180 mg ...... 33 dimesylate] ...... 41 verapamil hcl er tbcr 240 mg ...... 33 VYVANSE CAPS 60 MG [lisdexamfetamine VERAPAMIL HCL POWD [verapamil hcl] ..... 77 dimesylate] ...... 41 verapamil hcl soln 2.5 mg/ml ...... 33 VYVANSE CAPS 70 MG [lisdexamfetamine verapamil hcl tabs 120 mg ...... 33 dimesylate] ...... 41 verapamil hcl tabs 40 mg ...... 33 VYXEOS SUSR 44-100 MG [daunorubicin- verapamil hcl tabs 80 mg ...... 33 cytarabine liposome] ...... 21 VFEND IV SOLR 200 MG [voriconazole] ...... 11 warfarin sodium tabs 1 mg ...... 30

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 140 of 144 warfarin sodium tabs 10 mg ...... 30 XYNTHA KIT 250 UNIT [antihemophilic factor warfarin sodium tabs 2 mg ...... 30 (rcmb) moroctocog alfa(bdd-rfviii,mor)] ... 28 warfarin sodium tabs 2.5 mg ...... 30 XYNTHA KIT 500 UNIT [antihemophilic factor warfarin sodium tabs 3 mg ...... 30 (rcmb) moroctocog alfa(bdd-rfviii,mor)] ... 29 warfarin sodium tabs 4 mg ...... 30 XYNTHA SOLOFUSE KIT 3000 UNIT warfarin sodium tabs 5 mg ...... 30 [antihemophilic factor (rcmb) moroctocog warfarin sodium tabs 6 mg ...... 30 alfa(bdd-rfviii,mor)] ...... 29 warfarin sodium tabs 7.5 mg ...... 30 YERVOY SOLN 200 MG/40ML [ipilimumab] .. 21 WIDE-SEAL DIAPHRAGM 60 DPRH 2 % YERVOY SOLN 50 MG/10ML [ipilimumab] .... 21 [diaphragm wide seal] ...... 51 YF-VAX INJ [yellow fever vaccine] ...... 81 WIDE-SEAL DIAPHRAGM 65 DPRH 2 % YONDELIS SOLR 1 MG [trabectedin] ...... 21 [diaphragm wide seal] ...... 51 ZANOSAR SOLR 1 GM [streptozocin] ...... 21 WIDE-SEAL DIAPHRAGM 70 DPRH 2 % ZARXIO SOSY 300 MCG/0.5ML [filgrastim- [diaphragm wide seal] ...... 51 sndz] ...... 31 WIDE-SEAL DIAPHRAGM 75 DPRH 2 % ZARXIO SOSY 480 MCG/0.8ML [filgrastim- [diaphragm wide seal] ...... 51 sndz] ...... 31 WIDE-SEAL DIAPHRAGM 80 DPRH 2 % ZEJULA CAPS 100 MG [niraparib tosylate] .. 21 [diaphragm wide seal] ...... 51 ZELBORAF TABS 240 MG [vemurafenib] ...... 21 WIDE-SEAL DIAPHRAGM 85 DPRH 2 % ZENPEP CPEP 10000-32000 UNIT [diaphragm wide seal] ...... 51 [pancrelipase (lipase-protease-amylase)] 63 WIDE-SEAL DIAPHRAGM 90 DPRH 2 % ZENPEP CPEP 15000-47000 UNIT [diaphragm wide seal] ...... 51 [pancrelipase (lipase-protease-amylase)] 63 WIDE-SEAL DIAPHRAGM 95 DPRH 2 % ZENPEP CPEP 20000-63000 UNIT [diaphragm wide seal] ...... 51 [pancrelipase (lipase-protease-amylase)] 63 WILATE KIT 1000-1000 UNIT [antihemophilic ZENPEP CPEP 25000-79000 UNIT factor/von willebrand factor complex [pancrelipase (lipase-protease-amylase)] 63 (human)] ...... 28 ZENPEP CPEP 3000-10000 UNIT WILATE KIT 500-500 UNIT [antihemophilic [pancrelipase (lipase-protease-amylase)] 63 factor/von willebrand factor complex ZENPEP CPEP 40000-126000 UNIT (human)] ...... 28 [pancrelipase (lipase-protease-amylase)] 63 XALKORI CAPS 200 MG [crizotinib] ...... 21 ZENPEP CPEP 5000-24000 UNIT XALKORI CAPS 250 MG [crizotinib] ...... 21 [pancrelipase (lipase-protease-amylase)] 63 XELJANZ TABS 10 MG [tofacitinib citrate] ... 75 ZIAGEN SOLN 20 MG/ML [abacavir sulfate] ... 5 XELJANZ TABS 5 MG [tofacitinib citrate] ..... 75 zidovudine caps 100 mg ...... 5 XELJANZ XR TB24 11 MG [tofacitinib citrate] zidovudine syrp 50 mg/5ml ...... 5 ...... 75 zidovudine tabs 300 mg ...... 5 XERAC AC SOLN 6.25 % [aluminum chloride ZINC CHLORIDE SOLN 1 MG/ML [zinc in alcohol] ...... 93 chloride] ...... 58 XGEVA SOLN 120 MG/1.7ML [denosumab] .. 21 ZINC SULFATE GRAN [zinc sulfate]...... 77 XIFAXAN TABS 550 MG [rifaximin] ...... 10 ZINC SULFATE HEPTAHYDRATE POWD [zinc XOLAIR SOLR 150 MG [omalizumab] ...... 78 sulfate] ...... 92 XOLAIR SOSY 150 MG/ML [omalizumab] ..... 78 ZINC SULFATE MONOHYDRATE POWD [zinc XOLAIR SOSY 75 MG/0.5ML [omalizumab] .. 78 sulfate] ...... 93 XTANDI CAPS 40 MG [enzalutamide] ...... 21 ZINC SULFATE SOLN 1 MG/ML [zinc sulfate] XTANDI TABS 40 MG [enzalutamide]...... 21 ...... 58 XTANDI TABS 80 MG [enzalutamide]...... 21 ZINECARD SOLR 250 MG [dexrazoxane hcl]75 XYLOCAINE-MPF/EPINEPHRINE SOLN 1 %-1 ZINECARD SOLR 500 MG [dexrazoxane hcl]75 200000 [lidocaine w/ epinephrine] ...... 72 ziprasidone hcl caps 20 mg ...... 51 XYNTHA KIT 1000 UNIT [antihemophilic factor ziprasidone hcl caps 40 mg ...... 51 (rcmb) moroctocog alfa(bdd-rfviii,mor)] .. 28 ziprasidone hcl caps 60 mg ...... 51 XYNTHA KIT 2000 UNIT [antihemophilic factor ziprasidone hcl caps 80 mg ...... 51 (rcmb) moroctocog alfa(bdd-rfviii,mor)] .. 28 ZITHROMAX PACK 1 GM [azithromycin] ...... 10

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會員服務聯絡中心每週七天每天24小時提供語言協助服務（節假日除外）。本機構在全部營業時間內 免費為您提供口譯，包括手語服務，以及殘障人士輔助器材和服務。我們還可為您和您的親友提供使 用本機構設施與服務所需要的任何特別協助。您還可免費索取翻譯成您的語言的資料，以及符合您需 求的大號字體或其他格式的版本。若需更多資訊，請致電 1-800-757-7585（TTY專線使用者請撥 711）。

申訴指任何您或您的授權代表透過申訴程序來表達不滿的做法。例如，如果您認為自己受到歧視，即可提出申 訴。若需瞭解適用於自己的爭議解決選項，請參閱《承保範圍說明書》(Evidence of Coverage) 或《保險證明 書》(Certificate of Insurance)，或咨詢會員服務代表。如果您是 Medicare、Medi-Cal、高風險醫療保險計劃 (Major Risk Medical Insurance Program, MRMIP)、Medi-Cal Access、聯邦僱員健康保險計劃 (Federal Employees Health Benefits Program, FEHBP) 或 CalPERS 會員，採取上述行動尤其重要，因為您可能有不同 的爭議解決選項。

您可透過以下方式提出申訴： • 在健康保險計劃服務設施的會員服務處填寫《投訴或福利索賠/申請表》（地址見《健康服務指南》 (Your Guidebook) 或我們網站kp.org上的服務設施名錄） • 將書面申訴信郵寄到健康保險計劃服務設施的會員服務處（地址見《健康服務指南》或我們網站 kp.org上的服務設施名錄） • 致電我們的會員服務聯絡中心，免費電話號碼是1-800-757-7585（TTY專線請撥711） • 在我們的網站上填寫申訴表，網址是kp.org

如果您在提交申訴時需要協助，請致電我們的會員服務聯絡中心。

涉及人種、膚色、原國籍、性別、年齡或殘障歧視的一切申訴都將通知Kaiser Permanente的民權事務協 調員。您也可與Kaiser Permanente的民權事務協調員直接聯絡，地址： One Kaiser Plaza, 12th Floor, Suite 1223, Oakland, CA 94612。

您還可以電子方式透過民權辦公室的投訴入口網站向美國健康與公共服務部民權辦公室提出民權投 訴，網址是 ocrportal.hhs.gov/ocr/portal/lobby.jsf 或者按照如下資訊採用郵寄或電話方式聯絡：U.S. Department of Health and Human Services, 200 Independence Avenue SW, Room 509F, HHH Building, Washington, D.C. 20201, 1-800-368-1019, 1-800-537-7697（TDD）。投訴表可 從網站 hhs.gov/ocr/office/file/index.html 下載。

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 143 of 144

California Member Services 24 hours a day, seven days a week (closed holidays) 1-800-464-4000 English 1- 800-788-0616 Spanish 1-800-757-7585 Chinese dialects 711 TTY for the hearing/speech impaired

Please recycle. MOM 60379021 09/2015

Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 144 of 144