Plan FIDA VillageCareMAX Full Advantage (Plan Medicare-Medicaid)

Transcription

1 H9345_MBR17_03h Approved Plan FIDA VillageCareMAX Full Advantage (Plan Medicare-Medicaid) Lis Medikaman Ki Kouvri 2017 (Fòmilè)

2 Plan FIDA VillageCareMAX Full Advantage Lismedikamanki kouvri (Fòmilè) 2017 Lis sa a se yon lis medikaman ke pàtisipan yo ka jwenn nan Plan FIDA VillageCareMAX Full Advantage. Plan FIDA VillageCareMAX Full Advantage se yon plan jesyon swen ki te pase kontra avèk konpayi Medicare ak New York State Department of Health (Medicaid)pou l bay patisipan yo benefistoude pwogram sa yoatravè demonstrasyonfully Integrated Duals Advantage (FIDA).Pwogram sa a se pou moun ki gen toude Medicare ak Medicaid e ki ranpli lòt kondisyon kalifikasyon pou demonstrasyon FIDA Lis Medikaman ki Kouvri yo ak/oswa famasi ak rezo founisè yo ka chanje tanzantan pandan ane a. Nap voye yon avi avan nou fè yon chanjman ka p afekte w. Benefis yo kapab chanje nandat 1e Janviye chak ane. Ou ka toujou verifye lis medikamanki ajou ki kouvri yo nan planvillagecaremax Full Advantage FIDA sou entènèt nanwww.villagecaremax.org osinon rele sèvis pàtisipan pou plan FIDA VillageCareMAX Full Advantage nan Yo gen dwa aplike limitasyon ak restrikyon.pou plis enfòmasyon, rele sèvis pàtisipan pou plan FIDA VillageCareMAX Full Advantage oswa limanyèl pàtisipan pou plan FIDA VillageCareMAX Full Advantage la. Pa gen okenn ko-peman pou tout medikaman ki kouvri yo. Ou ka jwenn enfòmasyon sa a gratis nan lòt fòma, tankou gwo karaktè, Bray oswa odyo. Rele nan pandan lè 8:00am jiska 8:00pm. Itilizatè TTY yo dwe rele nimweo 711.Apèl sa a gratis. Diskriminasyon se kont lalwa. ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call (TTY: 711). ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: 711). 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 (TTY: 711) 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (TTY: 711) 번으로전화해주십시오. Si ou gen kesyon, tanpri rele Plan FIDAVillageCareMAXFullAdvantagenan ,8:00nan20:00,7jou pà semèn.apèl sa a se gratis.itilizatè ATS ta dwe rele 711. Pou plis ii? enfòmasyon,vizite

3 ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (телетайп: 711). ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero (TTY: 711) ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele (TTY: 711). Lè ou enskri, nou pral mande ou nan k ilang ou pito resevwa kominikasyon ak enfòmasyon yo voye pa lapòs. Nou pral kenbe preferans ou nan yon dosye epi ou mèt chanje lang ou prefere a lè ou kontakte Sèvis Patisipan nou nan nimewo pandan èdtan 8è di maten ak 8è di swa, 7 jou pa semèn. Itilizatè TTY yo dwe rele 711. Koutfil la gratis. Eta Nouyòk kreye yon pwogramenvestigasyon poupatisipan ki rele (Rezo Pwomosyon Konsomatè Endepandan)Independent Consumer Advocacy Network(ICAN) pou bay pàtisipan yo asistans konfidansyèl gratis sou nenpòt sèvis Plan FIDAVillageCareMAX Full Advantage ofri.ou kapab kontakte ICAN nan nimewo sa a gratis oubyen sou entènèt nan (Itilizatè TTY yo dwe rele 711, epi lè sa a swiv èd memwa yo pou pase ) Si ou gen kesyon, tanpri rele Plan FIDAVillageCareMAXFullAdvantagenan ,8:00nan20:00,7jou pà semèn.apèl sa a se gratis.itilizatè ATS ta dwe rele 711. Pou plis iii? enfòmasyon,vizite

4 Kesyon yo poze souvan (FAQ) Wa p Jwenn isit la repons pou kesyon ou genyen yo konsènan lismedikaman ki kouvri yo. Ou kapab li tout FAQ (kesyon yo poze souvan yo) pou w jwenn plis enfòmasyon oswa gade yon kesyon ak repons li. 1. Ki medikaman sou preskripsyon ki sou lis medikaman yo kouvri yo? (Nou rele Lis Medikaman ki Kouvri a Lis Medikaman pou pi kout.) Medikaman ki sou Lis Medikaman ki kouvri ki nan 1e paj la se mekikaman Plan FIDAVillageCareMAX Full Advantage kouvri. Medikaman sa yo disponib nan famasi ki nan rezo nou an. Yon famasi ap nan rezo nou si nou gen akò avèk li poultravay avèk nou ak pou ba w sèvis.nou rele famasi sa yo famasi rezo. Plan FIDA VillageCareMAX Full Advantage ap kouvri tout medikaman ki sou lis medikaman an si: Doktè w oswa lòt moun ki preskri w di ke ou bezwen yo pou w geri oswa pou w rete an sante Medikaman an nesesè pou kondisyon w, epi Ou rampli preskripsyon wnan yon fàmasi rezo ki fè pati Plan FIDA VillageCareMAX Full Advantage. Plan FIDAVillageCareMAX Full Advantage ka gen etap siplemantè pou w jwenn aksè nan sèten medikaman(gade nan #5 anba a).nan sèten ka, ou ka bezwen fè yon bagay avan pou w jwenn yon medikaman, tankou eseye lòt medikaman avan. Ou kapab wè tou yon lis medikaman ki ajou nou kouvri sou sit entènet nou nanwww.villagecaremax.org ou rele sèvis patisipan nan (TTY: 711). 2. Eske lismedikaman an ka chanje pafwa? Wi. Plan FIDA VillageCareMAX Full Advantage ka ajoute oubyen retire medikaman nan lis medikaman an pandan ane a. Jeneralman, lis medikaman an pral chanje sèlman si: Si gen yon nouvo medikaman ki travay menm jan avèk youn ki nan lis medikaman an,oswa Nou aprann ke yon medikaman danjere. Nouka chanje règ nou yo sou medikaman. Pa egzanp, nou ka: Si ou gen kesyon, tanpri rele Plan FIDAVillageCareMAXFullAdvantagenan ,8:00nan20:00,7jou pà semèn.apèl sa a se gratis.itilizatè ATS ta dwe rele 711. Pou plis iv? enfòmasyon,vizite

5 Deside pou n mande oswa pa mande apwobasyon davans pou yon medikaman. (Apwobasyon davans se yon pèmisyon nan men Plan FIDA VillageCareMAX Full Advantage oswa (Ekip Entèdisiplinè w) Interdisiplinary Team (IDT) avan ou ka jwenn yon medikaman.) Ajoute oswa chanje kantite medikaman ou ka genyen (ki rele limit kantite ). Ajoute ou chanje restriksyon etap terapi nan yon medikaman. (Etap terapi vle di ou dwe eseye yon medikaman avan pou nou kouvri yon lòt medikaman.) (Pou plis enfòmasyon sou règ medikaman sa yo, gade nan pajvi.) Nou pra di w lè yon medikaman wa p pran soti nan lis medikaman an. Nou pral di w tou lè nou chanje règ kouvèti sou yonmedikaman. Kesyon 3, 4 ak 7 anba a gen plis enfòmasyon sou sak pase lè lis medikaman la chanje. Ou ka toujou tcheke lis medikaman ki ajou Plan FIDA VillageCareMAX Full Advantage lasou entènet nan Ou ka rele sèvis patisipan tou pou w verifye lis medikaman aktyèl la nan Itilizatè ATS yo dwe rele Sak pase lè yon medikaman ki pi bon mache travaymenm jan ak yon medikaman ki deja sou lismedikaman an? Si yon medikaman ki pi bon mache vin disponib e ki travay menm jan ak yon medikaman kideja sou lis medikaman an: Famasyen w kapab ba w medikaman sa apwochen fwa wa p rampli preskripsyon w. Si ou menm ak fournisè w deside ke medikaman ki pi bon mache a pa pi bon pou ou, founisè w ka di famasyen w pou l kontinye ba w medikaman wa p pran kounye a. Plan FIDA VillageCareMAX Full Advantage ka deside pou l retire medikaman ki pi chèa sou lis medikaman an. Si wa p pran yon medikaman nou retire sou lis medikaman an paske yon medikaman ki pi bon mache parèt e ki travay menm jan, na p fè w konnen omwen 60 jou avan nou retire l sou lis medikaman anoubyen lèwa p renouvle preskripsyon w.lè sa a ou ka jwenn yon rezèv 60 jou pou medikaman sa a avannou fè chanjman an nan lis medikaman.plan FIDA VillageCareMAX Full Advantage ap voye yon lèt ba ou lè wa p pran yon medikaman ki soti nan lis medikaman an. Sit entènet nou an gen enfòmasyon pi ajou apwopo lismedikaman nou an.ou ka toujou tchekewww.villagecaremax.org oubyen rele sèvis patisipan an si ou gen kesyon.nimewo telefon nou se Itilizatè ATS dwe rele 711. Nou ouvri 7 jou pà semenn sòti nan 8:00am pou rive 8:00pm. Si ou gen kesyon, tanpri rele Plan FIDAVillageCareMAXFullAdvantagenan ,8:00nan20:00,7jou pà semèn.apèl sa a se gratis.itilizatè ATS ta dwe rele 711. Pou plis v? enfòmasyon,vizite

6 4. Sak pase lè nou dekouvri ke yon medikaman danjere? Si (Administrasyon Medikaman ak Manje) Food and Drug Administration (FDA)a di ke yon medikaman wa p pran danjere, nou pral retire l nan lis medikaman an touswit. Nou pral voye yon lèt ba ou epi rele w nan telefòn pou di w ke medikaman danjere a soti nan lis la. Tanpri pale ak doktè w si wa p pran yon medikaman FDAdetèmine ki danjere.dokte w ka preskri yon medikaman lòt pou ranplace medikaman ki pa disponib la. 5. Eske gen restriksyon oubyen limit nan kouvèti medikaman? Osinon èske gen aksyon obligatwa ki dwè fèt pou w jwenn sèten medikaman? Wi, sèten medikaman gen règ sou kouvèti oswa gen limit sou kantite ou ka jwenn. Nan sèten ka, ou menm oswa doktè w oswa lòt moun ki preskri w dwe fè yon bagay avan pou w jwenn medikaman sa a.pà egzanp: Apwobasyon davans(oubyen otorizasyon davans):pou sèten medikaman, ou menm, doktè w oswa lòt moun ki preskri w dwe gen apwobasyon Plan FIDA VillageCareMAX Full Advantage oubyen (Ekip Entèdisiplinè) Interdisciplinary Team (IDT)w avan ou ka rampli preskripsyon w. Si ou pa jwenn apwobasyon, Plan FIDA VillageCareMAX Full Advantage gen dwa pa kouvrimedikamansa a. Limit kantite:pafwa Plan FIDA VillageCareMAX Full Advantage limite kantite medikaman ou ka jwenn. Etap terapi:pafwaplan FIDA VillageCareMAX Full Advantage mande pou w fè terapi etap. Sa vle di ou pral gen pou w esaye medikaman nan sètenlòd pou kondisyon medikal ou.ou ka gen pou w esaye yon medikaman avan pou nou kouvri yon lòt. Si doktè w panse ke premye medikaman pa mache pou ou, alò nou pral kouvri dezyèm lan. Ou ka dekouvi si medikaman w gen egzijans siplemantè oswa limit si ou gade nan endèks nan paj1. Ou ka jwenn plis enfòmasyon tou si ou vizite sit entènet nou nannou afiche sou entènet la dokiman ki eksplike otorizasyon davans nou ak restriksyon etap terapi.ou ka mande tou pou nou voye yon kopi ba ou. Ou ka mande yon egzanpsyon pou limit sa yo.tanpri gade kesyon 11 pou plis enfòmasyon sou egzanpsyon. Si ou nan yon mezon retret oubyen nan yon etablisman swen alontèm epi ou bezwen yon medikaman ki pa sou lis medikamanan, oswa si ou pa ka jwennmedikaman ou bezwen fasil, nou ka ede w.nou pral kouvwi yon stok medikaman ijans ou bezwen an pou 31 jou (eksepte si ou gen preskripsyon pou mwens jou), menm si ou se yon nouvo patisipan ou non nan plan FIDA VillageCareMAX Full Advantage.Sa pral ba w tan pou w pale ak doktè w oswa lòt Si ou gen kesyon, tanpri rele Plan FIDAVillageCareMAXFullAdvantagenan ,8:00nan20:00,7jou pà semèn.apèl sa a se gratis.itilizatè ATS ta dwe rele 711. Pou plis vi? enfòmasyon,vizite

7 moun ki preskri w. Li ka ede w deside si gen yon medikaman similè sou lis medikamanan ou ka pran pito oubyen si li nesesè pou w mande yon ekzanpsyon. Tanpri gade nan kesyon 11 la pou plis enfòmasyon sou ekzanpsyon. 6. Kijan wa p konnen si medikaman ou bezwwn an gen limitasyon oubyen si gen aksyon obligatwa pou w pran pou w jwenn medikaman an? Lis Medikamanki Kouvri nan paj 1 an gen yon ribrik ki make Aksyon obligatwa, restriksyon oswa limit sou itilizasyon. 7. Saka p rive si nou chanje règ nou yo sou fason nou kouvri medikaman yo? Pà egzanp, si nou ajoute apwobasyon davans(apwouve), limit kantite ak/oswarestriksyon etap terapi sou yon medikaman. Nou pral di w si nou ajoute apwobasyon davans, limit kantite ak/oswa restriksyon etap terapi sou yon medikaman. Na p fè w konnen omwen 60 jou avan nou ajoute restriksyon sa yo oswa lè ou pra l renouvle preskripsyon w.kidonk, ou ka jwenn yon rezèv medikamanpou 60 jou avan nou fè chanjman an nan lismedikaman an.saap ba w tan pou w pale avèk doktè w oswa lot moun ki preskri w konsènan kisa pou w fè nan lavni. 8. Kouman ou ka jwenn yon medikamannan lis medikamanan? Gen de fason pou w jwenn yon medikaman: Ou ka chèche pà lòd alfabetik (si ou kon òtografmedikaman sa a), osinon Ou ka chèche pa kondisyon medikal. Pou w chèche alfabetikman, ale nan pati lis alfabetik nan paj I-1.Epi chèche non medikamanan nan lis sa a. Pou w chèche pakondisyon medikal, chache seksyon ki make lis medikaman pa kondisyon medikal nan paj 1.Medikaman yo nan seksyon sa a gwoupe pa kategori depann de kondisyon medikal yo trete a. Pà egzanp, si ou gen yon kondisyon kadyak, oudwe chèche nan kategori, ajan kadyovaskilè a. Se kote sa a ou pral jwenn medikaman ki trete kondisyon kadyak. 9. Sa ka p pase si medikaman ou vle pran an pa sou lis medikamanan? Si ou pa wè medikaman w sou lis medikamanan, rele sèvis patisitan nan epi mande pou li. Itilizatè ATS dwe rele 711.Si ou aprann ke Plan FIDA VillageCareMAX Full Advantage pa kouvri medikaman sa a, ou ka fè youn nan bagay sa yo: Si ou gen kesyon, tanpri rele Plan FIDAVillageCareMAXFullAdvantagenan ,8:00nan20:00,7jou pà semèn.apèl sa a se gratis.itilizatè ATS ta dwe rele 711. Pou plis vii? enfòmasyon,vizite

8 Mande sèvis patisipan pou yon lismedikamantankou sa ou vle pran an. Epi montre doktè w ak lòt moun ki preskri w lis la. Li ka preskri w yon medikamannan lis medikamanan ki menm jan avèkmedikaman ou vle pran an. Oswa Ou ka mande plan (Ekip Entèdisiplinè)Interdisiplinary Team (IDT) pou fè yon egzanpsyon pou kouvri medikaman w. Tanpri gade nan kesyon 11 pou plis enfomasyon sou egzanpsyon. 10. E si ou se yon nouvo patisipan nan plan FIDA VillageCareMAX Full Advantage epi ou pa ka jwenn medikaman w sou lis medikaman an oubyen ou gen pwoblèm pou w jwennmedikaman w? Nou kapab ede. Nou dwè kouvri yon apwovizyònman medikaman tamporè pou jiska 90 jou, si li nesesè, pandan 90 jou ou patisipan nan Plan FIDAVillageCareMAX Full Advantage la.sa pral ba w tan pou wpale ak doktè w oswa lòt moun ki preskri w. Li ka ede w deside si gen yon medikamanki menm jan nan lis medikaman an ou ka pran olye pou w mande yon egzanpsyon. Na p kouvri yon apwovizyònman medikaman tamporè w jiska 90 jou pou si: Wa p pran yon medikaman ki pa sou lis medikaman nou an, oswa Règ plan sante w pa kite jwenn kantite medikaman yo preskri w, oswa Medikaman an bezwen yon apwobasyon davansnan plan FIDA VillageCareMAX Full Advantage oswa (Ekip Entèdisiplinè) Interdisiplinary Team (IDT)w, oswa Wa p pran yon medikaman ki fè pati de yon restriksyon etap terapi. Si ou rete nan yon mezon retrèt oswa nan yon lòt etablisman alontèm, ou ka rampli preskripsyon w pou jiska 98 jou. Ou ka renouvlemedikamananplizyè fwa pandan premye 90 jou ou nan plan an. Sa baymoun ki preskri w yo tan pou chanje medikaman w pou medikamanki sou lis medikaman an oswa pou w mande yon egzanpsyon. Plan FIDA VillageCareMAX Full Advantage gen yon pwosesis tranzisyon epili asire kouvètimedikamanpou nouvo manm ak manm ki nan seksyon D aktyèl yo.pafwa ou ka gen yon chanjman nan nivo swen w, tankouyon konje oswa admisyon nan yon mezon swen alontèm oswa nan yon lopital. Nan ka sa yo, Plan FIDAVillageCareMAX Full Advantage pral ba w yon sèl apwovizyònman medikaman ijans ki pa nan fòmilè a. Medikamanki panan fòmilè a gen ladann toude medikaman seksyon D ki pa nan plan fòmilè aak Medikaman nan Seksyon D ki nan fòmilè a men ki bezwen apwobasyon davans oubyen etap terapi daprè règ jesyon plan itilizasyon.tanpri rele sèvis patisipan si ou gen kesyon. Ou ka rele a 8:00am jiska 8:00pm, 7 jou pà semèn. Itilizatè ATS yo dwe rele 711. Si ou gen kesyon, tanpri rele Plan FIDAVillageCareMAXFullAdvantagenan ,8:00nan20:00,7jou pà semèn.apèl sa a se gratis.itilizatè ATS ta dwe rele 711. Pou plis viii? enfòmasyon,vizite

9 11. Eske ou ka mande yon egzanpsyon pou w kouvri medikaman w? Wi. Ou ka mande Plan FIDA VillageCareMAX Full Advantage oswa (Ekip Entèdisiplinè) Interdisiplinary Team (IDT) w pou l fè yon egzanpsyon pou kouvri yon medikaman ki pa sou lis medikamanan. Ou ka tou mande Plan FIDA VillageCareMAX Full Advantage oswa IDT w pou chanje règ medikaman w. Pa egzanp, Plan FIDA VillageCareMAX Full Advantage ka limite kantite yon medikaman nou ka kouvri. Si medikaman w gen yon limit, ou ka mande nou oswaidt w pou chanje limit la epi kouvri plis. Lòt egzanp: Ou ka mande nou oswa IDT w pou retire restriksyon etap terapi oswa bezwen apwobasyon davans yo. 12. Konbyen tan sa pran pou w jwenn yon apwobasyon? Premyèman, Plan FIDA VillageCareMAX Full Advantage oubyen (Ekip Entèdisiplinè) Interdisiplinary Team (IDT) w dwe resevwa yon deklarasyon ki soti nan men moun ki preskri w ki sipòte demann pou w gen yon egzanpsyon.apre nou fin resevwa deklarasyon sa a, wa p resevwa yon desizyon sou demann egzanpsyon an nan espas 72 èdtan. Si ou menm oswa preskriptè w panse ke sante w ka petèt nan danje si ou rete tann pou 72 èdtan pou yon desizyon, ou ka mande pou yon egzanpsyon akselere. Sa se yon desizyon ki pi rapid. Si moun ki preskri w la sipòte demann ou, ou pral resevwa yon desizyon nan 24 èdtan apre nou resevwa deklarasyon sipòki soti nan men moun ki preskri w la. 13. Kouman ou ka mande yon egzanpsyon? Pou w mande pou yon egzanpsyon, rele Manadjè Swen w. Manadjè Swen w pra l travay avèk ou ansanm avèk founisè w pou l ede w mande yon egzanpsyon. 14. Kisa medikaman jenerik ye? Medikaman Jjenerik fèt ak menm engredyan ak medikaman mak yo. Yo dabitid koute mwen chè pasemedikaman mak yo epi yo pa gen non ki rekoni. Medikaman jenerik aprouve pa Food and Drug Administration (FDA). Plan FIDA VillageCareMAX Full Advantage kouvri medikaman makakmedikaman jenerik. Si ou gen kesyon, tanpri rele Plan FIDAVillageCareMAXFullAdvantagenan ,8:00nan20:00,7jou pà semèn.apèl sa a se gratis.itilizatè ATS ta dwe rele 711. Pou plis ix? enfòmasyon,vizite

10 15. Kisa Medikaman OTC ye? OTCvle di Over the Counter - Medikaman ki Vann San Preskripsyon. Plan FIDA VillageCareMAX Full Advantage kouvri kèk medikamanotc lè founisè w preskri yo. Ou ka li nan Lis medikaman nan plan FIDA VillageCareMAX Full Advantage pou wè w ki medikaman OTC ki kouvri. MedikamanOTCyo nan ranje Eske Plan FIDA VillageCareMAX Full Advantage kouvri pwodwi OTC ki pamedikaman? Plan FIDA VillageCareMAX Full Advantage kouvri kèk pwodwi OTC ki pa medikaman lè yo ekri tankou yon preskripsyon pa founisè w. Egzanp yo enkli: Ekipman OTC pou dyabèt tankou twal gaz, twal abaz alkol, sereng pou ensilin epi zegwi. Ou ka gade nan lis medikamannan Plan FIDAVillageCareMAX Full Advantage pou w wè ki medikaman ki kouvri. Ou ka li lis medikaman nan Plan FIDAVillageCareMAX Full Advantage pou w wè ki pwodwi OTC ki pa medikaman ki kouvri. 17. Kisa kopeman an ye? Nou pa pmande w yon kopeman pou medikamanki sou lis medikamanan. 18. Kisa nivo medikaman an ye? Nan fòmilè pou Plan FIDA VillageCareMAX Full Advantage,wa p wè 4 nivo medikamanki enkli nan lis fòmilè a. Medikaman nan nivo 1 se medikaman jenerik Medicare kouvri Medikaman nan nivo 2 se medikaman mak epi medikamanespesyal Medicare kouvri Medikaman nan nivo 3 se medikamanjenerik ki pa nan seskyon D epi medikaman mak Medicaid kouvri Medikaman nivo 4 se medikaman nan vant lib (OCT) Medicaid kouvri Kòm yon manm nan plan nou, w ap paye $0 kopeman pou medikaman nan nenpòt nan 4 nivo sa yo. Si ou gen kesyon, tanpri rele Plan FIDAVillageCareMAXFullAdvantagenan ,8:00nan20:00,7jou pà semèn.apèl sa a se gratis.itilizatè ATS ta dwe rele 711. Pou plis x? enfòmasyon,vizite

11 Lis medikaman ki kouvri yo Lis medikaman ki kouvri anba a ki kòmanse nan paj 1 bay w enfòmasyon sou medikaman ki kouvri nan Plan FIDA VillageCareMAX Full Advantage.Si ou gen pwoblèm pou w jwenn medikaman w nan lis la, tounen nan endeks ki komanseanba a nan paji-1. Premye ribrik tablo a afiche non medikaman an.medikaman mak yo ekri an majiskil (pa egzanp, LIPITOR epi medikaman jenerik yo ekri an italik ak lèt miniskil (egzanp, ibuprofen). Enfòmasyon nan ribrik aksyon nesesè, restriksyon oswa limit izajyo di w si Plan FIDAVillageCareMAX Full Advantage gen règ pou kouvri medikaman w. PA Si ou gen kesyon, tanpri rele Plan FIDAVillageCareMAXFullAdvantagenan ,8:00nan20:00,7jou pà semèn.apèl sa a se gratis.itilizatè ATS ta dwe rele 711. Pou plis xi? enfòmasyon,vizite PA- HRM ABREVYASYON DESKRIPSYON EKSPLIKASYON Restriksyon OtorizasyonDavans Restriksyon Apwobasyon Davans pou detèminasyon Seksyon B kont Seksyon D Restriksyon OtorizasyonDavans pou medikaman ki gen Gwo Risk Restriksyon Jesyon Itilizasyon Ou menm (oubyen doktè w) oblije gen otorizasyon davansnan Plan FIDA VillageCareMAX Full Advantage avan ou rampli preskripsyon pou medikaman sa a. San apwobasyon davans, Plan FIDAVillageCareMAX Full Advantage gen dwa pa kouvri medikaman sa a. Medikaman sa a petèt ka kalifye pou peman anba Medicare Seksyon B ou D. Ou menm (oswa doktè w) dwe gen otorizasyon davansnan Plan FIDA VillageCareMAX Full Advantage pou detèmine si medikaman sa a kouvri anba Medicare Seksyon D ou B avan ou esaye rampli preskipsyon w pou medikaman sa a. San otorizasyon davans, Plan FIDA VillageCareMAX Full Advantage gen dwapa kouvri medikaman sa a. CMS jije ke medikaman sa a ka danjere e poutèt sa li se yon medikaman ki gen Gwo Risk pou benefisyè Medicaire ki gen 65 ane oswa pi gran yo. Patisipan ki gen 65 ane oswa ki pi gran yo dwe jwenn otorizasyon davans nan Plan FIDA VillageCareMAX Full Advantage avan pou yo rampli preskipsyon pou medikamansa a. San otorizasyon sa a, Plan FIDA VillageCareMAX Full Advantage gen dwa pa kouvri medikaman sa a. PA NSO Restriksyon Otorizasyon Davans pou Nouvo Patisipan Sèlman Si ou se yon nouvo patisipan oswa si ou poko pran medikaman sa a, ou menm (oswa doktè w) oblije gen otorizasyon davans nan VillageCareMAX Full Advantage FIDA Plan Avan ou ranpli preskripsyon pou medikaman sa a. San apwobasyon davans, Plan VillageCareMAX Full Advantage FIDA gen dwa pa kouvri medikaman sa a.

12 QL ST Restriksyon Limit Kantite Restriksyon Etap Terapi Plan FIDA VillageCareMAX Full Advantage limite kantite nan medikaman sa a ki kouvri pa preskripsyon, oswa nan yon peryòd tan espesifik. Avan Plan FIDA VillageCareMAX Full Advantage ka founi kouvèti pou medikaman sa a, ou dwè esaye lòt medikamanpou trrete kondisyon medikal ou avan. Medikamansa a ka kouvri sèlman si lot medikaman an pa mache pou ou. Lòt Kondisyon Espesyal pou Kouvèti * LA NM Medikaman ki gen Aksè Limite Medikaman sa a ka petèt disponib sèlman nan sèten famasi. Pou plis enfòmasyon, konsilte anèks famasi w oswa rele Sèvis Patisipan nan , 8:00 am to 8:00 pm, 7 jou pa semèm. Itilizatè ATS yo dwe rele 711. Medikaman ki pa nan Lòd Lapòs Sa a se pa yon medikaman ki nan seksyon D Ou kaanmezi pou w resevwa plis pase 1 mwa rezèv nan pi fò nan medikaman ki nan fòmilè w la pa lapòs pou yon pri redwi pataje. Medikaman ki pa disponib pa lapòs yonote nan NM nan kolòn Limit/Kondisyon nan fòmilè w la Sa a se pa yon medikaman kinan seksyon D, oswayon medikaman oswa yon pwodwi OTC. Remak: * bò kote yon medikaman vle di ke medikaman an pa yon medikaman ki nan "Seksyon D" e li enkli nan ranje 3 ak 4. Medikaman sa yo gen diferan règ pou fè apèl. Yon apèl se yon fason fòmèl pou mande yon revizyon oswa yon chanjman konsènan desizyon kouvèti si ou panse ke te gen yon erè. Pa egzanp, Plan FIDA VillageCareMAX Full Advantage ak (Ekip Entèdisiplinè)Interdisiplinary Team (IDT) w ka deside ke yon medikaman ou bezwen pa kouvri epi Medicare ak Medicaid pa kouvri medikaman sa a ankò. Si ou menm oswa doktè oswa lòt moun ki preskri w pa dakò avèk desizyon sa a, ou gen dwa fè apèl. Pou w mande enstriksyon sou kijan pou w fè apèl, rele sèvis patisipan an nan oswa (Rezo Defans Dwa Konsomatè Endepandan) Independent Consumer Advocacy Network (ICAN) nan (Itilizatè TTY yo Si ou gen kesyon, tanpri rele Plan FIDAVillageCareMAXFullAdvantagenan ,8:00nan20:00,7jou pà semèn.apèl sa a se gratis.itilizatè ATS ta dwe rele 711. Pou plis xii? enfòmasyon,vizite

13 dwe rele 711, epi lè sa a swic èd memwa yo pou pase ) Ou kapab li manyèl patisipan an tou pou w konnen kijan pou w fè apèl kont yon desizyon. Lis Medikaman pa Kondisyon Medikal Medikaman ki nan seksyon sa a gwoupe pa kategori depann de kalite kondisyon medikal yo trete. Pa egzanp, si ou gen yon maladi kè, ou dwe gade nan kategori ajan kadyovaskilè. Se la wa p jwenn medikaman ka p trete maladi kè. Si ou gen kesyon, tanpri rele Plan FIDAVillageCareMAXFullAdvantagenan ,8:00nan20:00,7jou pà semèn.apèl sa a se gratis.itilizatè ATS ta dwe rele 711. Pou plis xiii? enfòmasyon,vizite

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15 Table of Contents Analgesics... 3 Anesthetics Anti-Addiction/Substance Abuse Treatment Agents Antianxiety Agents Antibacterials Anticancer Agents Anticholinergic Agents Anticonvulsants Antidementia Agents Antidepressants Antidiabetic Agents Antifungals Antigout Agents Antihistamines Anti-Infectives (Skin And Mucous Membrane) Antimigraine Agents Antimycobacterials Antinausea Agents Antiparasite Agents Antiparkinsonian Agents Antipsychotic Agents Antivirals (Systemic) Blood Products/Modifiers/Volume Expanders

16 Caloric Agents Cardiovascular Agents Central Nervous System Agents Contraceptives Cough And Cold Products Dental And Oral Agents Dermatological Agents Devices Disinfectants (For Non-Dermatologic Use) Enzyme Replacement/Modifiers Eye, Ear, Nose, Throat Agents Gastrointestinal Agents Genitourinary Agents Heavy Metal Antagonists Hormonal Agents, Stimulant/Replacement/Modifying Immunological Agents Inflammatory Bowel Disease Agents Irrigating Solutions Metabolic Bone Disease Agents Miscellaneous Therapeutic Agents Ophthalmic Agents Replacement Preparations Respiratory Tract Agents Skeletal Muscle Relaxants Sleep Disorder Agents Vasodilating Agents Vitamins And Minerals

17 Analgesics Analgesics, Miscellaneous acephen 120 mg suppository outer 120 mg * acephen 325 mg suppository outer 325 mg * acephen 650 mg suppository outer 650 mg * acetaminophen 120 mg suppos outer 120 mg * acetaminophen 160 mg/5 ml elx 160 mg/5 ml * acetaminophen 325 mg liqui-gel 325 mg * acetaminophen 500 mg softgel 500 mg * acetaminophen 650 mg suppos 650 mg * acetaminophen 80 mg rapid tab children's 80 mg * acetaminophen-codeine oral solution mg/5 ml acetaminophen-codeine oral tablet mg acetaminophen-codeine oral tablet mg acetaminophen-codeine oral tablet mg ALLZITAL ORAL TABLET MG ascomp with codeine oral capsule mg (Children's Fever Reducing) (Non-Aspirin) (Pain Relief) (Tylophen) (Feverall) (Children's Acetaminophen) (Tylenol-Codeine #3) (Tylenol-Codeine #4) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (240 per 30 days) QL (360 per 30 days) QL (240 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (2700 per 30 days) QL (360 per 30 days) QL (360 per 30 days) QL (180 per 30 days) PA-HRM; QL (360 per 30 days); AGE (Max 64 Years) PA-HRM; QL (180 per 30 days); AGE (Max 64 Years) 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 3

18 BELBUCA BUCCAL FILM 150 MCG, 300 MCG, 450 MCG, 600 MCG, 75 MCG, 750 MCG, 900 MCG buprenorphine hcl injection solution 0.3 mg/ml buprenorphine hcl injection syringe 0.3 mg/ml buprenorphine transdermal patch weekly 10 mcg/hour, 15 mcg/hour, 20 mcg/hour, 5 mcg/hour, 7.5 mcg/hour butalbital compound w/codeine oral capsule mg butalbital-acetaminop-caf-cod oral capsule mg, mg butalbital-acetaminophen oral tablet mg butalbital-acetaminophen-caff oral capsule mg butalbital-acetaminophen-caff oral tablet mg butalbital-aspirin-caffeine oral capsule mg BUTRANS TRANSDERMAL PATCH WEEKLY 10 MCG/HOUR, 15 MCG/HOUR, 20 MCG/HOUR, 5 MCG/HOUR, 7.5 MCG/HOUR (Buprenex) (Butrans) (Marten-Tab) (Esgic) (Esgic) (Fiorinal) QL (60 per 30 days) QL (4 per 28 days) PA-HRM; QL (180 per 30 days); AGE (Max 64 Years) PA-HRM; QL (180 per 30 days); AGE (Max 64 Years) PA-HRM; QL (180 per 30 days); AGE (Max 64 Years) PA-HRM; QL (180 per 30 days); AGE (Max 64 Years) PA-HRM; QL (180 per 30 days); AGE (Max 64 Years) PA-HRM; QL (180 per 30 days); AGE (Max 64 Years) QL (4 per 28 days) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 4

19 capacet oral capsule mg PA-HRM; QL (180 per 30 days); AGE (Max 64 Years) child non-aspirin 160 mg/5 ml QL (240 per 30 days) children's 160 mg/5 ml * child pain-fever 160 mg/5 ml a/f, QL (240 per 30 days) asa/f, ibu/f 160 mg/5 ml * child tactinal 80 mg tab chw 80 mg QL (30 per 30 days) * children's mapap 80 mg rapid 80 QL (30 per 30 days) mg * codeine sulfate oral tablet 15 mg, 30 QL (180 per 30 days) mg, 60 mg cvs acetaminophen 8-hr 650 mg (Mapap Arthritis QL (180 per 30 days) caplet 650 mg * Pain) cvs child non-asa 80 mg tb chw 80 QL (30 per 30 days) mg * cvs non-aspirin jr tab chew 160 mg QL (30 per 30 days) * cvs pain relief 325 mg liq gel 325 QL (360 per 30 days) mg * cvs pain relief adult liquid 500 QL (120 per 30 days) mg/15 ml * endocet oral tablet mg QL (240 per 30 days) endocet oral tablet mg, 5- QL (360 per 30 days) 325 mg endocet oral tablet mg QL (300 per 30 days) endodan oral tablet mg QL (360 per 30 days) fentanyl citrate buccal lozenge on a handle 1,200 mcg, 1,600 mcg, 200 (Actiq) PA; QL (120 per 30 days) mcg, 400 mcg, 600 mcg, 800 mcg fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr (Duragesic) QL (10 per 30 days) 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 5

20 fentanyl transdermal patch 72 hour QL (10 per 30 days) 37.5 mcg/hour, 62.5 mcg/hour, 87.5 mcg/hour feverall 120 mg suppository QL (30 per 30 days) children's, outer 120 mg * feverall 325 mg suppository junior QL (30 per 30 days) str, outer 325 mg * feverall 650 mg suppository adult, QL (30 per 30 days) inner 650 mg * hydrocodone-acetaminophen oral QL (2700 per 30 days) solution mg/5 ml, mg/7.5ml(7.5ml) hydrocodone-acetaminophen oral QL (2700 per 30 days) (Hycet) solution mg/15 ml hydrocodone-acetaminophen oral QL (390 per 30 days) (Xodol 10/300) tablet mg hydrocodone-acetaminophen oral QL (360 per 30 days) tablet mg, mg, (Norco) mg hydrocodone-acetaminophen oral QL (360 per 30 days) (Verdrocet) tablet mg hydrocodone-acetaminophen oral QL (390 per 30 days) (Xodol 5/300) tablet mg hydrocodone-acetaminophen oral QL (390 per 30 days) (Xodol 7.5/300) tablet mg hydrocodone-ibuprofen oral tablet QL (150 per 30 days) (Ibudone) mg, mg hydrocodone-ibuprofen oral tablet QL (150 per 30 days) mg hydromorphone (pf) injection solution 10 (mg/ml) (5 ml) hydromorphone (pf) injection solution 10 mg/ml hydromorphone 10 mg/ml vial p/f,sdv,latex-f 10 mg/ml hydromorphone injection solution 2 mg/ml, 4 mg/ml You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 6

21 hydromorphone injection syringe 2 mg/ml, 4 mg/ml (Dilaudid) hydromorphone oral liquid 1 mg/ml (Dilaudid) QL (1200 per 30 days) hydromorphone oral tablet 2 mg, 4 QL (180 per 30 days) (Dilaudid) mg, 8 mg HYSINGLA ER ORAL QL (30 per 30 days) TABLET,ORAL ONLY,EXT.REL.24 HR 100 MG, 120 MG, 20 MG, 30 MG, 40 MG, 60 MG, 80 MG infant pain relv 80 mg/0.8 ml a/f, QL (30 per 30 days) gluten-free 80 mg/0.8 ml * jr pain-fever 160 mg rapid tab QL (30 per 30 days) junior,bubblegum 160 mg * junior mapap 160 mg rapid tab 160 QL (30 per 30 days) mg * LAZANDA NASAL SPRAY,NON- AEROSOL 100 MCG/SPRAY, 300 MCG/SPRAY, 400 MCG/SPRAY PA; QL (30 per 30 days) lorcet (hydrocodone) oral tablet 5- QL (360 per 30 days) 325 mg lorcet hd oral tablet mg QL (360 per 30 days) lorcet plus oral tablet mg QL (360 per 30 days) mapap 160 mg/5 ml liquid 160 mg/5 QL (240 per 30 days) ml * mapap 160 mg/5 ml suspension 160 QL (240 per 30 days) mg/5 ml * mapap 325 mg tablet 325 mg * QL (360 per 30 days) mapap 500 mg capsule 500 mg * QL (240 per 30 days) mapap 500 mg tablet 500 mg * QL (240 per 30 days) mapap 500 mg/15 ml liquid 500 QL (120 per 30 days) mg/15 ml * mapap 80 mg tablet chew 80 mg * QL (30 per 30 days) mapap arthritis er 650 mg cplt 650 QL (180 per 30 days) mg * 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 7

22 margesic oral capsule mg PA-HRM; QL (180 per 30 days); AGE (Max 64 Years) methadone injection solution 10 mg/ml methadone oral solution 10 mg/5 QL (1800 per 30 days) ml, 5 mg/5 ml methadone oral tablet 10 mg (Dolophine) QL (360 per 30 days) methadone oral tablet 5 mg (Dolophine) QL (180 per 30 days) methadose oral tablet,soluble 40 mg QL (90 per 30 days) morphine 10 mg/ml carpuject outer, p/f, l/f, suv 10 mg/ml morphine 2 mg/ml carpuject outer, l/f, p/f, sdv 2 mg/ml morphine 4 mg/ml syringe p/f, latexfree,suv 4 mg/ml morphine 8 mg/ml syringe 8 mg/ml morphine concentrate oral solution QL (180 per 30 days) 100 mg/5 ml (20 mg/ml) morphine intramuscular pen injector 10 mg/0.7 ml morphine intravenous cartridge 15 mg/ml morphine intravenous syringe 10 mg/ml, 2 mg/ml, 4 mg/ml, 8 mg/ml morphine oral solution 10 mg/5 ml QL (700 per 30 days) morphine oral solution 20 mg/5 ml QL (300 per 30 days) (4 mg/ml) MORPHINE ORAL TABLET 15 QL (180 per 30 days) MG MORPHINE ORAL TABLET 30 QL (120 per 30 days) MG morphine oral tablet extended QL (60 per 30 days) (MS Contin) release 100 mg, 200 mg, 60 mg morphine oral tablet extended QL (180 per 30 days) (MS Contin) release 15 mg You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 8

23 morphine oral tablet extended QL (120 per 30 days) (MS Contin) release 30 mg non-aspirin x-str 167 mg/5 ml 500 QL (120 per 30 days) mg/15 ml * nortemp 80 mg/0.8 ml drop 80 QL (30 per 30 days) mg/0.8 ml * NUCYNTA ER ORAL TABLET QL (60 per 30 days) EXTENDED RELEASE 12 HR 100 MG, 150 MG, 200 MG, 250 MG, 50 MG NUCYNTA ORAL TABLET 100 QL (181 per 30 days) MG, 50 MG, 75 MG oxycodone oral concentrate 20 QL (120 per 30 days) mg/ml oxycodone oral solution 5 mg/5 ml QL (1300 per 30 days) oxycodone oral tablet 10 mg QL (180 per 30 days) oxycodone oral tablet 15 mg, 30 mg (Roxicodone) QL (120 per 30 days) oxycodone oral tablet 20 mg QL (120 per 30 days) oxycodone oral tablet 5 mg (Roxicodone) QL (180 per 30 days) oxycodone oral tablet,oral only,ext.rel.12 hr 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 60 mg (OxyContin) QL (60 per 30 days) oxycodone oral tablet,oral QL (120 per 30 days) (OxyContin) only,ext.rel.12 hr 80 mg oxycodone-acetaminophen oral QL (1800 per 30 days) solution mg/5 ml oxycodone-acetaminophen oral QL (240 per 30 days) (Percocet) tablet mg oxycodone-acetaminophen oral QL (360 per 30 days) (Percocet) tablet mg, mg oxycodone-acetaminophen oral QL (300 per 30 days) (Endocet) tablet mg oxycodone-aspirin oral tablet QL (360 per 30 days) mg 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 9

24 OXYCONTIN ORAL QL (60 per 30 days) TABLET,ORAL ONLY,EXT.REL.12 HR 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 60 MG OXYCONTIN ORAL QL (120 per 30 days) TABLET,ORAL ONLY,EXT.REL.12 HR 80 MG oxymorphone oral tablet 10 mg (Opana) QL (120 per 30 days) oxymorphone oral tablet 5 mg (Opana) QL (180 per 30 days) oxymorphone oral tablet extended QL (60 per 30 days) release 12 hr 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 5 mg, 7.5 mg pain relief 500 mg capsule 500 mg * QL (240 per 30 days) pharbetol 325 mg tablet regular QL (360 per 30 days) strength 325 mg * pharbetol 500 mg caplet extra-str, QL (240 per 30 days) caplet 500 mg * pv non-aspirin 500 mg softgel exstr,liq filled 500 mg * QL (240 per 30 days) q-pap 160 mg/5 ml solution a/f, QL (240 per 30 days) cherry 160 mg/5 ml * q-pap 325 mg tablet 325 mg * QL (360 per 30 days) q-pap 80 mg/0.8 ml drops 80 mg/0.8 QL (30 per 30 days) ml * q-pap ex-str 500 mg tablet aspirin QL (240 per 30 days) free 500 mg * reprexain oral tablet mg, QL (150 per 30 days) mg, mg sm pain rel jr str tab chew 160 mg * QL (30 per 30 days) sm pain reliever 80 mg tab QL (30 per 30 days) children's 80 mg * tactinal 325 mg tablet 325 mg * QL (360 per 30 days) tactinal 500 mg tablet extra-strength QL (240 per 30 days) 500 mg * You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 10

25 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Non Dwòg tencon oral tablet mg PA-HRM; QL (180 per 30 days); AGE (Max 64 Years) tramadol oral tablet 50 mg (Ultram) QL (240 per 30 days) tramadol-acetaminophen oral tablet QL (240 per 30 days) (Ultracet) mg vicodin es oral tablet mg QL (390 per 30 days) vicodin hp oral tablet mg QL (390 per 30 days) vicodin oral tablet mg QL (390 per 30 days) XTAMPZA ER ORAL QL (60 per 30 days) CAPSULE,SPRINKLE,ER 12HR TMPRR 13.5 MG, 18 MG, 9 MG XTAMPZA ER ORAL QL (120 per 30 days) CAPSULE,SPRINKLE,ER 12HR TMPRR 27 MG XTAMPZA ER ORAL CAPSULE,SPRINKLE,ER 12HR TMPRR 36 MG QL (240 per 30 days) xylon 10 oral tablet mg QL (150 per 30 days) zebutal oral capsule mg PA-HRM; QL (180 per 30 days); AGE (Max 64 Years) Nonsteroidal Anti-Inflammatory Agents ADVIL 100 MG TABLET JR STRENGTH,COATED 100 MG * ADVIL 200 MG TABLET 200 MG * ADVIL JR STR 100 MG TAB CHEW TB CHEW,8 HOUR,GRAPE 100 MG * aspirin 300 mg suppository 300 mg * aspirin 325 mg tablet 325 mg * (Bayer Aspirin) aspirin 600 mg suppository 600 mg * Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 11

26 aspirin 81 mg chewable tablet 81 mg * (Aspirin Childrens) aspirin buffered 325 mg tab 325 mg * (Buffered Aspirin) aspirin ec 325 mg tablet 325 mg * (E.C. Prin) aspirin ec 500 mg tablet 500 mg * aspirin ec 81 mg tablet low dose 81 (Aspirin Low mg * Dose) aspir-low ec 81 mg tablet 81 mg * bufferin 325 mg tablet coated 325 mg * CALDOLOR INTRAVENOUS RECON SOLN 400 MG/4 ML (100 MG/ML) celecoxib oral capsule 100 mg, 200 mg, 400 mg, 50 mg (Celebrex) CHILDREN'S ADVIL 100 MG/5 ML (OTC) 100 MG/5 ML * cvs ibuprofen 200 mg softgel liquid filled,softge 200 mg * (Advil Liqui-Gel) diclofenac potassium oral tablet 50 mg diclofenac sodium oral tablet extended release 24 hr 100 mg (Voltaren-XR) diclofenac sodium oral tablet,delayed release (dr/ec) 25 mg, 50 mg, 75 mg diclofenac-misoprostol oral tablet,ir,delayed rel,biphasic (Arthrotec 50) mg-mcg diclofenac-misoprostol oral tablet,ir,delayed rel,biphasic (Arthrotec 75) mg-mcg diflunisal oral tablet 500 mg ecotrin ec 325 mg tablet saftey coated 325 mg * QL (60 per 30 days) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 12

27 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Non Dwòg ecpirin ec 325 mg tablet 325 mg * etodolac oral capsule 200 mg, 300 mg etodolac oral tablet 400 mg (Lodine) etodolac oral tablet 500 mg etodolac oral tablet extended release 24 hr 400 mg, 500 mg, 600 mg fenoprofen oral tablet 600 mg FLECTOR TRANSDERMAL PA PATCH 12 HOUR 1.3 % flurbiprofen oral tablet 100 mg, 50 mg gnp ibuprofen jr str 100 mg tb 100 mg * ibuprofen 100 mg/5 ml susp children's (otc) 100 mg/5 ml * (Children's Advil) ibuprofen 200 mg tablet 200 mg * (Advil) ibuprofen oral suspension 100 mg/5 ml (Children's Advil) ibuprofen oral tablet 400 mg, 600 mg, 800 mg indomethacin oral capsule 25 mg QL (240 per 30 days) indomethacin oral capsule 50 mg QL (120 per 30 days) indomethacin oral capsule, extended QL (60 per 30 days) release 75 mg indomethacin sodium intravenous recon soln 1 mg infant ibuprofen 50 mg/1.25 ml d/f,a/f,non-staining 50 mg/1.25 ml * infants' advil 50 mg/1.25 ml 50 mg/1.25 ml * ketoprofen oral capsule 50 mg, 75 mg ketoprofen oral capsule,ext rel. pellets 24 hr 200 mg Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 13

28 ketorolac oral tablet 10 mg QL (20 per 30 days) mefenamic acid oral capsule 250 mg (Ponstel) meloxicam oral suspension 7.5 mg/5 ml meloxicam oral tablet 15 mg, 7.5 mg (Mobic) nabumetone oral tablet 500 mg, 750 mg naproxen oral suspension 125 mg/5 ml (Naprosyn) naproxen oral tablet 250 mg, 375 mg naproxen oral tablet 500 mg (Naprosyn) naproxen oral tablet,delayed release (EC-Naprosyn) (dr/ec) 375 mg, 500 mg naproxen sodium oral tablet 275 mg naproxen sodium oral tablet 550 mg (Anaprox DS) piroxicam oral capsule 10 mg, 20 mg (Feldene) sm ibuprofen ib 100 mg tablet junior (Advil) strength 100 mg * st. joseph aspirin 81 mg chew orange 81 mg * st. joseph aspirin ec 81 mg tb enteric coated 81 mg * sulindac oral tablet 150 mg, 200 mg tolmetin oral capsule 400 mg tolmetin oral tablet 200 mg, 600 mg tri buffered asa 325 mg tab 325 mg * VOLTAREN TOPICAL GEL 1 % wal-profen 200 mg softgel softgel 200 mg * Anesthetics Local Anesthetics glydo mucous membrane jelly in applicator 2 % You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 14

29 lidocaine (pf) injection solution 15 mg/ml (1.5 %), 20 mg/ml (2 %), 5 (Xylocaine-MPF) mg/ml (0.5 %) lidocaine (pf) injection solution 40 mg/ml (4 %) lidocaine hcl injection solution 10 mg/ml (1 %), 20 mg/ml (2 %), 5 (Xylocaine) mg/ml (0.5 %) lidocaine hcl mucous membrane jelly 2 % lidocaine hcl mucous membrane solution 4 % (40 mg/ml) lidocaine topical adhesive patch,medicated 5 % (Lidoderm) lidocaine topical ointment 5 % lidocaine viscous mucous membrane solution 2 % lidocaine-prilocaine topical cream % Anti-Addiction/Substance Abuse Treatment Agents Anti-Addiction/Substance Abuse Treatment Agents acamprosate oral tablet,delayed release (dr/ec) 333 mg BUNAVAIL BUCCAL FILM MG BUNAVAIL BUCCAL FILM MG, MG buprenorphine hcl sublingual tablet 2 mg, 8 mg buprenorphine-naloxone sublingual tablet mg, 8-2 mg buproban oral tablet extended release 12 hr 150 mg PA QL (30 per 30 days) QL (60 per 30 days) QL (90 per 30 days) QL (90 per 30 days) 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 15

30 bupropion hcl (smoking deter) oral tablet extended release 12 hr 150 (Zyban) mg CHANTIX CONTINUING MONTH BOX ORAL TABLET 1 MG CHANTIX ORAL TABLET 0.5 MG, 1 MG CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK 0.5 MG (11)- 1 MG (42) disulfiram oral tablet 250 mg, 500 mg (Antabuse) naloxone injection solution 0.4 mg/ml naloxone injection syringe 0.4 mg/ml, 1 mg/ml naltrexone oral tablet 50 mg (Revia) NARCAN NASAL SPRAY,NON- AEROSOL 2 MG/ACTUATION, 4 MG/ACTUATION nicorelief 2 mg gum 2 mg * nicorelief 4 mg gum 4 mg * NICORETTE 2 MG CHEWING GUM WHITE ICE MINT 2 MG * nicotine 14 mg/24hr patch step 2 (otc) 14 mg/24 hr * (Nicoderm CQ) nicotine 2 mg chewing gum sugar free 2 mg * (Nicorelief) nicotine 2 mg lozenge mint, 3 (Stop Smoking quittube 2 mg * Aid) nicotine 21 mg/24hr patch outer, clear, step 1 (otc) 21 mg/24 hr * (NTS Step 1) nicotine 22 mg/24hr patch 1 week starter kit 22 mg/24 hr * nicotine 4 mg chewing gum 4 mg * (Nicorelief) QL (168 per 84 days) QL (168 per 84 days) QL (53 per 28 days) QL (4 per 30 days) QL (180 per 365 days) QL (168 per 365 days) QL (168 per 365 days) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 16

31 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Non Dwòg nicotine 4 mg lozenge mint, 3 (Stop Smoking quittube 4 mg * Aid) nicotine 7 mg/24hr patch step 3 QL (180 per 365 days) (Nicoderm CQ) (otc) 7 mg/24 hr * NICOTROL INHALATION QL (1008 per 90 days) CARTRIDGE 10 MG SUBOXONE SUBLINGUAL FILM QL (60 per 30 days) 12-3 MG, 8-2 MG SUBOXONE SUBLINGUAL FILM QL (30 per 30 days) MG, 4-1 MG ZUBSOLV SUBLINGUAL QL (30 per 30 days) TABLET MG, MG, MG, MG, MG ZUBSOLV SUBLINGUAL QL (60 per 30 days) TABLET MG Antianxiety Agents Benzodiazepines alprazolam oral tablet 0.25 mg, 0.5 QL (120 per 30 days) (Xanax) mg, 1 mg alprazolam oral tablet 2 mg (Xanax) QL (150 per 30 days) chlordiazepoxide hcl oral capsule QL (120 per 30 days) 10 mg, 25 mg, 5 mg clonazepam oral tablet 0.5 mg, 1 mg (Klonopin) QL (90 per 30 days) clonazepam oral tablet 2 mg (Klonopin) QL (300 per 30 days) clonazepam oral tablet,disintegrating mg, 0.25 mg, 0.5 mg, 1 mg QL (90 per 30 days) clonazepam oral QL (300 per 30 days) tablet,disintegrating 2 mg clorazepate dipotassium oral tablet QL (180 per 30 days) 15 mg, 3.75 mg clorazepate dipotassium oral tablet QL (180 per 30 days) (Tranxene T-Tab) 7.5 mg diazepam injection solution 5 mg/ml QL (10 per 28 days) Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 17

32 diazepam intensol oral concentrate QL (1200 per 30 days) 5 mg/ml diazepam oral solution 5 mg/5 ml (1 QL (1200 per 30 days) mg/ml) diazepam oral tablet 10 mg, 2 mg, 5 QL (120 per 30 days) (Valium) mg diazepam rectal kit mg, mg (Diastat AcuDial) diazepam rectal kit 2.5 mg (Diastat) lorazepam injection solution 2 QL (2 per 30 days) (Ativan) mg/ml lorazepam oral tablet 0.5 mg, 1 mg (Ativan) QL (90 per 30 days) lorazepam oral tablet 2 mg (Ativan) QL (150 per 30 days) ONFI ORAL SUSPENSION 2.5 PA NSO; QL (480 per MG/ML 30 days) ONFI ORAL TABLET 10 MG, 20 PA NSO; QL (60 per MG 30 days) Antibacterials Aminoglycosides BETHKIS INHALATION SOLUTION FOR NEBULIZATION 300 MG/4 ML gentamicin in nacl (iso-osm) intravenous piggyback 100 mg/100 ml, 100 mg/50 ml, 60 mg/50 ml, 70 mg/50 ml, 80 mg/100 ml, 80 mg/50 ml, 90 mg/100 ml gentamicin injection solution 40 mg/ml gentamicin ped 20 mg/2 ml vial latex-free, sdv 20 mg/2 ml gentamicin sulfate (pf) intravenous solution 100 mg/10 ml neomycin oral tablet 500 mg streptomycin intramuscular recon soln 1 gram You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 18

33 TOBI PODHALER INHALATION CAPSULE, W/INHALATION DEVICE 28 MG tobramycin in % nacl inhalation solution for nebulization 300 mg/5 ml tobramycin in 0.9 % nacl intravenous piggyback 60 mg/50 ml tobramycin sulfate injection solution 10 mg/ml, 40 mg/ml Antibacterials, Miscellaneous bacitracin intramuscular recon soln 50,000 unit chloramphenicol sod succinate intravenous recon soln 1 gram clindamycin 75 mg/5 ml soln 75 mg/5 ml clindamycin hcl oral capsule 150 mg, 300 mg, 75 mg clindamycin in 5 % dextrose intravenous piggyback 300 mg/50 ml, 600 mg/50 ml, 900 mg/50 ml clindamycin pediatric oral recon soln 75 mg/5 ml clindamycin phosphate injection solution 150 (mg/ml) (6 ml) clindamycin phosphate injection solution 150 mg/ml clindamycin phosphate intravenous solution 600 mg/4 ml colistin (colistimethate na) injection recon soln 150 mg daptomycin intravenous recon soln 500 mg linezolid intravenous parenteral solution 600 mg/300 ml (Tobi) (BACiiM) (Cleocin Pediatric) (Cleocin HCl) (Cleocin in 5 % dextrose) (Cleocin) (Cleocin) (Coly-Mycin M Parenteral) (Cubicin) (Zyvox) QL (224 per 28 days) 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 19

34 linezolid oral suspension for reconstitution 100 mg/5 ml (Zyvox) linezolid oral tablet 600 mg (Zyvox) methenamine hippurate oral tablet 1 gram (Hiprex) metronidazole in nacl (iso-os) intravenous piggyback 500 mg/100 (Metro I.V.) ml metronidazole oral capsule 375 mg (Flagyl) metronidazole oral tablet 250 mg, 500 mg (Flagyl) nitrofurantoin macrocrystal oral capsule 100 mg, 25 mg, 50 mg nitrofurantoin monohyd/m-cryst oral capsule 100 mg (Macrodantin) (Macrobid) polymyxin b sulfate injection recon soln 500,000 unit SYNERCID INTRAVENOUS RECON SOLN 500 MG trimethoprim oral tablet 100 mg vancomycin hcl 1g/200 ml bag 1 gram/200 ml PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (120 per 30 days); AGE (Max 64 Years) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (60 per 30 days); AGE (Max 64 Years) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 20

35 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Non Dwòg vancomycin intravenous recon soln 1,000 mg, 10 gram, 750 mg vancomycin intravenous recon soln 500 mg vancomycin oral capsule 125 mg, 250 mg (Vancocin) XIFAXAN ORAL TABLET 200 MG XIFAXAN ORAL TABLET 550 MG Cephalosporins cefaclor oral capsule 250 mg, 500 mg cefaclor oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml cefadroxil oral capsule 500 mg cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml cefadroxil oral tablet 1 gram cefazolin in dextrose (iso-os) intravenous piggyback 1 gram/50 ml, 2 gram/50 ml cefazolin injection recon soln 1 gram, 10 gram, 500 mg cefdinir oral capsule 300 mg cefdinir oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml cefditoren pivoxil oral tablet 200 mg cefditoren pivoxil oral tablet 400 mg (Spectracef) CEFEPIME 1 GM INJECTION 1 GRAM/50 ML cefepime hcl 1 gm vial 10's, sdv 1 gram (Maxipime) PA; QL (9 per 30 days) Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite PA 21

36 cefepime hcl 2 gram vial latex/f, sdv, (Maxipime) outer 2 gram CEFEPIME INJECTION RECON SOLN 1 GRAM, 2 GRAM (Maxipime) CEFEPIME-DEXTROSE 2 GM/50 ML 2 GRAM/50 ML cefotaxime injection recon soln 1 gram, 10 gram, 2 gram (Claforan) cefotaxime injection recon soln 500 mg cefoxitin 2 gm piggyback bag 2 gram/50 ml cefoxitin 2 gm vial l/f, outer, sdv 2 gram cefoxitin intravenous recon soln 1 gram, 10 gram cefoxitin intravenous recon soln 2 gram cefpodoxime oral suspension for reconstitution 100 mg/5 ml, 50 mg/5 ml cefpodoxime oral tablet 100 mg, 200 mg cefprozil oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml cefprozil oral tablet 250 mg, 500 mg ceftazidime injection recon soln 2 gram (Fortaz) ceftazidime injection recon soln 6 gram (TAZICEF) ceftibuten oral capsule 400 mg (Cedax) ceftibuten oral suspension for reconstitution 180 mg/5 ml (Cedax) ceftriaxone 1 gm piggyback l/g, single use 1 gram/50 ml You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 22

37 ceftriaxone 2 gm piggyback l/f, single use 2 gram/50 ml ceftriaxone injection recon soln 1 gram, 10 gram, 250 mg, 500 mg ceftriaxone intravenous recon soln 1 gram, 2 gram cefuroxime axetil oral tablet 250 mg, 500 mg cefuroxime sodium injection recon soln 750 mg (Zinacef) cefuroxime sodium intravenous recon soln 1.5 gram, 7.5 gram (Zinacef) cephalexin oral capsule 250 mg, 500 mg, 750 mg (Keflex) cephalexin oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml cephalexin oral tablet 250 mg, 500 mg MEFOXIN IN DEXTROSE (ISO- OSM) INTRAVENOUS PIGGYBACK 1 GRAM/50 ML, 2 GRAM/50 ML SUPRAX ORAL CAPSULE 400 MG SUPRAX ORAL TABLET,CHEWABLE 100 MG, 200 MG tazicef injection recon soln 2 gram, 6 gram TEFLARO INTRAVENOUS RECON SOLN 400 MG, 600 MG Macrolides azithromycin intravenous recon soln 500 mg (Zithromax) azithromycin oral packet 1 gram (Zithromax) 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 23

38 azithromycin oral suspension for reconstitution 100 mg/5 ml, 200 (Zithromax) mg/5 ml azithromycin oral tablet 250 mg (6 pack), 500 mg (3 pack) azithromycin oral tablet 250 mg, 500 mg, 600 mg (Zithromax) clarithromycin oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml clarithromycin oral tablet 250 mg clarithromycin oral tablet 500 mg (Biaxin) clarithromycin oral tablet extended release 24 hr 500 mg DIFICID ORAL TABLET 200 MG QL (20 per 10 days) e.e.s. 400 oral tablet 400 mg e.e.s. granules oral suspension for reconstitution 200 mg/5 ml ery-tab oral tablet,delayed release (dr/ec) 250 mg, 500 mg ERY-TAB ORAL TABLET,DELAYED RELEASE (DR/EC) 333 MG erythrocin (as stearate) oral tablet 250 mg ERYTHROCIN INTRAVENOUS RECON SOLN 1,000 MG, 500 MG erythromycin ethylsuccinate oral suspension for reconstitution 200 (E.E.S. Granules) mg/5 ml erythromycin ethylsuccinate oral tablet 400 mg (E.E.S. 400) erythromycin oral capsule,delayed release(dr/ec) 250 mg erythromycin oral tablet 250 mg, 500 mg You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 24

39 Miscellaneous B-Lactam Antibiotics aztreonam injection recon soln 1 gram, 2 gram CAYSTON INHALATION SOLUTION FOR NEBULIZATION 75 MG/ML imipenem-cilastatin intravenous recon soln 250 mg, 500 mg INVANZ INJECTION RECON SOLN 1 GRAM meropenem intravenous recon soln 1 gram, 500 mg Penicillins amoxicillin oral capsule 250 mg, 500 mg amoxicillin oral suspension for reconstitution 125 mg/5 ml, 200 mg/5 ml, 250 mg/5 ml, 400 mg/5 ml amoxicillin oral tablet 500 mg, 875 mg amoxicillin oral tablet,chewable 125 mg, 250 mg amoxicillin-pot clavulanate oral suspension for reconstitution mg/5 ml, mg/5 ml amoxicillin-pot clavulanate oral suspension for reconstitution mg/5 ml amoxicillin-pot clavulanate oral suspension for reconstitution mg/5 ml amoxicillin-pot clavulanate oral tablet mg amoxicillin-pot clavulanate oral tablet mg, mg (Azactam) (Primaxin IV) (Merrem) (Augmentin) (Augmentin ES- 600) (Augmentin) LA 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 25

40 amoxicillin-pot clavulanate oral tablet extended release 12 hr 1, mg amoxicillin-pot clavulanate oral tablet,chewable mg, mg ampicillin oral capsule 250 mg, 500 mg ampicillin oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml ampicillin sodium injection recon soln 1 gram, 10 gram, 125 mg, 2 gram, 250 mg, 500 mg ampicillin sodium intravenous recon soln 2 gram ampicillin-sulbactam injection recon soln 1.5 gram, 15 gram, 3 gram BICILLIN C-R INTRAMUSCULAR SYRINGE 1,200,000 UNIT/ 2 ML(600K/600K), 1,200,000 UNIT/ 2 ML(900K/300K) BICILLIN L-A INTRAMUSCULAR SYRINGE 1,200,000 UNIT/2 ML, 2,400,000 UNIT/4 ML, 600,000 UNIT/ML dicloxacillin oral capsule 250 mg, 500 mg nafcillin 2 gm vial 10's, latex-free 2 gram nafcillin injection recon soln 1 gram, 10 gram nafcillin intravenous recon soln 2 gram (Augmentin XR) (Unasyn) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 26

41 oxacillin in dextrose(iso-osm) intravenous piggyback 1 gram/50 ml, 2 gram/50 ml oxacillin injection recon soln 10 gram, 2 gram oxacillin intravenous recon soln 1 gram penicillin g pot in dextrose intravenous piggyback 1 million unit/50 ml, 2 million unit/50 ml, 3 million unit/50 ml penicillin g potassium injection recon soln 5 million unit penicillin g procaine intramuscular syringe 1.2 million unit/2 ml, 600,000 unit/ml penicillin gk 20 million unit 20 million unit penicillin v potassium oral recon soln 125 mg/5 ml, 250 mg/5 ml penicillin v potassium oral tablet 250 mg, 500 mg pfizerpen-g injection recon soln 20 million unit piperacillin-tazobactam intravenous recon soln 2.25 gram, gram, 4.5 gram, 40.5 gram Quinolones ciprofloxacin hcl oral tablet 100 mg, 750 mg ciprofloxacin hcl oral tablet 250 mg, 500 mg ciprofloxacin in 5 % dextrose intravenous piggyback 200 mg/100 ml (Pfizerpen-G) (Pfizerpen-G) (Zosyn) (Cipro) 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 27

42 ciprofloxacin in 5 % dextrose intravenous piggyback 400 mg/200 (Cipro in D5W) ml ciprofloxacin lactate intravenous solution 200 mg/20 ml, 400 mg/40 ml ciprofloxacin oral suspension,microcapsule recon 250 (Cipro) mg/5 ml, 500 mg/5 ml levofloxacin in d5w intravenous piggyback 250 mg/50 ml, 500 mg/100 ml, 750 mg/150 ml levofloxacin intravenous solution 25 mg/ml levofloxacin oral solution 250 mg/10 ml levofloxacin oral tablet 250 mg, 500 mg, 750 mg (Levaquin) moxifloxacin oral tablet 400 mg (Avelox) ofloxacin oral tablet 300 mg, 400 mg Sulfonamides sulfadiazine oral tablet 500 mg sulfamethoxazole-trimethoprim intravenous solution mg/5 ml sulfamethoxazole-trimethoprim oral suspension mg/5 ml (Sulfatrim) sulfamethoxazole-trimethoprim oral tablet mg (Bactrim) sulfamethoxazole-trimethoprim oral tablet mg (Bactrim DS) sulfasalazine oral tablet 500 mg (Sulfazine) sulfasalazine oral tablet,delayed (Azulfidine ENtabs) release (dr/ec) 500 mg You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 28

43 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Non Dwòg sulfatrim oral suspension mg/5 ml Tetracyclines doxy-100 intravenous recon soln 100 mg doxycycline hyclate intravenous recon soln 100 mg doxycycline hyclate oral capsule 100 mg, 50 mg doxycycline hyclate oral tablet 100 mg, 20 mg doxycycline monohydrate oral capsule 100 mg, 75 mg doxycycline monohydrate oral capsule 150 mg doxycycline monohydrate oral capsule 50 mg doxycycline monohydrate oral suspension for reconstitution 25 mg/5 ml doxycycline monohydrate oral tablet 100 mg doxycycline monohydrate oral tablet 150 mg, 50 mg, 75 mg minocycline oral capsule 100 mg, 50 mg, 75 mg minocycline oral tablet 100 mg, 50 mg, 75 mg tetracycline oral capsule 250 mg, 500 mg tigecycline intravenous recon soln 50 mg TYGACIL INTRAVENOUS RECON SOLN 50 MG Anticancer Agents Anticancer Agents (Doxy-100) (Morgidox) (Mondoxyne NL) (Monodox) (Vibramycin) (Avidoxy) (Minocin) (Tygacil) Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 29

44 ABRAXANE INTRAVENOUS SUSPENSION FOR RECONSTITUTION 100 MG ADCETRIS INTRAVENOUS RECON SOLN 50 MG adriamycin intravenous solution 2 mg/ml, 20 mg/10 ml adrucil 2,500 mg/50 ml vial outer, latex-free 2.5 gram/50 ml adrucil intravenous solution 500 mg/10 ml AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION 2 MG, 3 MG, 5 MG AFINITOR ORAL TABLET 10 MG AFINITOR ORAL TABLET 2.5 MG, 5 MG, 7.5 MG ALECENSA ORAL CAPSULE 150 MG ALIMTA INTRAVENOUS RECON SOLN 100 MG, 500 MG ALUNBRIG ORAL TABLET 30 MG anastrozole oral tablet 1 mg (Arimidex) AVASTIN INTRAVENOUS SOLUTION 25 MG/ML, 25 MG/ML (16 ML) azacitidine injection recon soln 100 mg (Vidaza) BAVENCIO INTRAVENOUS SOLUTION 20 MG/ML BELEODAQ INTRAVENOUS RECON SOLN 500 MG BENDEKA INTRAVENOUS SOLUTION 25 MG/ML PA NSO; QL (4 per 21 days) PA NSO; QL (112 per 28 days) PA NSO; QL (56 per 28 days) PA NSO; QL (28 per 28 days) PA NSO; QL (240 per 30 days) PA NSO; QL (180 per 30 days) PA NSO PA NSO PA NSO PA NSO You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 30

45 bexarotene oral capsule 75 mg (Targretin) bicalutamide oral tablet 50 mg (Casodex) bleomycin injection recon soln 15 unit (Bleo 15K) bleomycin injection recon soln 30 unit BLINCYTO INTRAVENOUS KIT 35 MCG BOSULIF ORAL TABLET 100 MG BOSULIF ORAL TABLET 500 MG CABOMETYX ORAL TABLET 20 MG, 60 MG CABOMETYX ORAL TABLET 40 MG CAPRELSA ORAL TABLET 100 MG CAPRELSA ORAL TABLET 300 MG clofarabine intravenous solution 20 mg/20 ml (Clolar) COMETRIQ ORAL CAPSULE 100 MG/DAY(80 MG X1-20 MG X1), 140 MG/DAY(80 MG X1-20 MG X3), 60 MG/DAY (20 MG X 3/DAY) COTELLIC ORAL TABLET 20 MG cyclophosphamide intravenous recon soln 1 gram, 2 gram, 500 mg CYCLOPHOSPHAMIDE ORAL CAPSULE 25 MG, 50 MG PA NSO; QL (420 per 30 days) PA NSO; QL (140 per 365 days) PA NSO; QL (120 per 30 days) PA NSO; QL (30 per 30 days) PA NSO; QL (30 per 30 days) PA NSO; QL (60 per 30 days) PA NSO; QL (60 per 30 days) PA NSO; QL (30 per 30 days) PA NSO; QL (112 per 28 days) PA NSO; LA; QL (63 per 28 days) ; ST 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 31

46 CYRAMZA INTRAVENOUS SOLUTION 10 MG/ML, 10 MG/ML (50 ML) DARZALEX INTRAVENOUS SOLUTION 20 MG/ML decitabine intravenous recon soln 50 mg doxorubicin 200 mg/100 ml vial latex-free 2 mg/ml doxorubicin intravenous solution 50 mg/25 ml doxorubicin, peg-liposomal intravenous suspension 2 mg/ml DROXIA ORAL CAPSULE 200 MG, 300 MG, 400 MG ELIGARD (3 MONTH) SUBCUTANEOUS SYRINGE 22.5 MG ELIGARD (4 MONTH) SUBCUTANEOUS SYRINGE 30 MG ELIGARD (6 MONTH) SUBCUTANEOUS SYRINGE 45 MG ELIGARD SUBCUTANEOUS SYRINGE 7.5 MG (1 MONTH) EMCYT ORAL CAPSULE 140 MG EMPLICITI INTRAVENOUS RECON SOLN 300 MG, 400 MG ERIVEDGE ORAL CAPSULE 150 MG ETOPOPHOS INTRAVENOUS RECON SOLN 100 MG etoposide intravenous solution 20 mg/ml (Toposar) exemestane oral tablet 25 mg (Aromasin) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. (Dacogen) (Adriamycin) (Adriamycin) (Doxil) PA NSO PA NSO; LA QL (1 per 84 days) QL (1 per 112 days) QL (1 per 168 days) PA NSO PA NSO; QL (30 per 30 days) If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 32

47 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Non Dwòg FARESTON ORAL TABLET 60 MG FARYDAK ORAL CAPSULE 10 MG, 15 MG, 20 MG FASLODEX INTRAMUSCULAR SYRINGE 250 MG/5 ML floxuridine injection recon soln 0.5 gram fluorouracil 5,000 mg/100 ml latexfree 5 gram/100 ml (Adrucil) fluorouracil intravenous solution 1 gram/20 ml fluorouracil intravenous solution 2.5 gram/50 ml, 500 mg/10 ml (Adrucil) flutamide oral capsule 125 mg GAZYVA INTRAVENOUS SOLUTION 1,000 MG/40 ML GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG, 5 MG HERCEPTIN INTRAVENOUS RECON SOLN 150 MG, 440 MG HEXALEN ORAL CAPSULE 50 MG hydroxyurea oral capsule 500 mg (Hydrea) IBRANCE ORAL CAPSULE 100 MG, 125 MG, 75 MG ICLUSIG ORAL TABLET 15 MG ICLUSIG ORAL TABLET 45 MG ifosfamide 1 gm/20 ml vial sdv,p/f,latex-free 1 gram/20 ml ifosfamide intravenous recon soln 1 gram (Ifex) PA NSO PA NSO PA NSO; QL (30 per 30 days) PA NSO PA NSO; QL (21 per 28 days) PA NSO; QL (60 per 30 days) PA NSO; QL (30 per 30 days) Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 33

48 ifosfamide-mesna intravenous kit 1-1 gram, 3,000-1,000 mg imatinib oral tablet 100 mg (Gleevec) imatinib oral tablet 400 mg (Gleevec) IMBRUVICA ORAL CAPSULE 140 MG IMFINZI INTRAVENOUS SOLUTION 50 MG/ML, 50 MG/ML (10 ML) IMLYGIC INJECTION SUSPENSION 10EXP6 (1 MILLION) PFU/ML IMLYGIC INJECTION SUSPENSION 10EXP8 (100 MILLION) PFU/ML INLYTA ORAL TABLET 1 MG INLYTA ORAL TABLET 5 MG IRESSA ORAL TABLET 250 MG IXEMPRA INTRAVENOUS RECON SOLN 15 MG, 45 MG JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 25 MG, 5 MG KEYTRUDA INTRAVENOUS RECON SOLN 50 MG KEYTRUDA INTRAVENOUS SOLUTION 100 MG/4 ML (25 MG/ML) KISQALI FEMARA CO-PACK ORAL TABLET 200 MG/DAY(200 MG X 1)-2.5 MG PA NSO; QL (90 per 30 days) PA NSO; QL (60 per 30 days) PA NSO PA NSO PA NSO; QL (4 per 365 days) PA NSO; QL (8 per 28 days) PA NSO; QL (180 per 30 days) PA NSO; QL (60 per 30 days) PA NSO; QL (60 per 30 days) PA NSO; QL (60 per 30 days) PA NSO PA NSO PA NSO; QL (49 per 28 days) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 34

49 KISQALI FEMARA CO-PACK ORAL TABLET 400 MG/DAY(200 MG X 2)-2.5 MG KISQALI FEMARA CO-PACK ORAL TABLET 600 MG/DAY(200 MG X 3)-2.5 MG KISQALI ORAL TABLET 200 MG/DAY (200 MG X 1), 400 MG/DAY (200 MG X 2), 600 MG/DAY (200 MG X 3) KYPROLIS INTRAVENOUS RECON SOLN 30 MG KYPROLIS INTRAVENOUS RECON SOLN 60 MG LARTRUVO INTRAVENOUS SOLUTION 10 MG/ML LENVIMA ORAL CAPSULE 10 MG/DAY (10 MG X 1/DAY), 14 MG/DAY(10 MG X 1-4 MG X 1), 18 MG/DAY (10 MG X 1-4 MG X2), 20 MG/DAY (10 MG X 2), 24 MG/DAY(10 MG X 2-4 MG X 1), 8 MG/DAY (4 MG X 2) letrozole oral tablet 2.5 mg (Femara) LEUKERAN ORAL TABLET 2 MG leuprolide subcutaneous kit 1 mg/0.2 ml LONSURF ORAL TABLET MG LONSURF ORAL TABLET MG LUPRON DEPOT (3 MONTH) INTRAMUSCULAR SYRINGE KIT MG, 22.5 MG PA NSO; QL (70 per 28 days) PA NSO; QL (91 per 28 days) PA NSO; QL (63 per 28 days) PA NSO; QL (12 per 28 days) PA NSO; QL (6 per 28 days) PA NSO; LA PA NSO PA NSO; QL (100 per 28 days) PA NSO; QL (80 per 28 days) QL (1 per 84 days) 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 35

50 LUPRON DEPOT (4 MONTH) INTRAMUSCULAR SYRINGE KIT 30 MG LUPRON DEPOT (6 MONTH) INTRAMUSCULAR SYRINGE KIT 45 MG LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 3.75 MG, 7.5 MG LYNPARZA ORAL CAPSULE 50 MG LYSODREN ORAL TABLET 500 MG MATULANE ORAL CAPSULE 50 MG megestrol oral tablet 20 mg, 40 mg MEKINIST ORAL TABLET 0.5 MG MEKINIST ORAL TABLET 2 MG mercaptopurine oral tablet 50 mg methotrexate sodium (pf) injection recon soln 1 gram methotrexate sodium (pf) injection solution 25 mg/ml methotrexate sodium injection solution 25 mg/ml methotrexate sodium oral tablet 2.5 mg mitoxantrone intravenous concentrate 2 mg/ml NEXAVAR ORAL TABLET 200 MG nilutamide oral tablet 150 mg (Nilandron) NINLARO ORAL CAPSULE 2.3 MG, 3 MG, 4 MG QL (1 per 84 days) QL (1 per 168 days) PA NSO; QL (480 per 30 days) PA NSO; QL (90 per 30 days) PA NSO; QL (30 per 30 days) ; ST PA NSO; QL (120 per 30 days) PA NSO; QL (3 per 28 days) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 36

51 ODOMZO ORAL CAPSULE 200 MG ONCASPAR INJECTION SOLUTION 750 UNIT/ML ONIVYDE INTRAVENOUS DISPERSION 4.3 MG/ML OPDIVO INTRAVENOUS SOLUTION 100 MG/10 ML, 40 MG/4 ML POMALYST ORAL CAPSULE 1 MG, 2 MG, 3 MG, 4 MG PORTRAZZA INTRAVENOUS SOLUTION 800 MG/50 ML (16 MG/ML) PROLEUKIN INTRAVENOUS RECON SOLN 22 MILLION UNIT PURIXAN ORAL SUSPENSION 20 MG/ML REVLIMID ORAL CAPSULE 10 MG, 15 MG, 2.5 MG, 20 MG, 25 MG, 5 MG RITUXAN INTRAVENOUS CONCENTRATE 10 MG/ML RUBRACA ORAL TABLET 200 MG, 250 MG, 300 MG RYDAPT ORAL CAPSULE 25 MG SOLTAMOX ORAL SOLUTION 10 MG/5 ML SPRYCEL ORAL TABLET 100 MG, 140 MG, 50 MG, 70 MG, 80 MG SPRYCEL ORAL TABLET 20 MG STIVARGA ORAL TABLET 40 MG PA NSO; LA PA NSO PA NSO PA NSO; QL (21 per 28 days) PA NSO; QL (100 per 21 days) PA NSO; LA PA NSO PA NSO; QL (120 per 30 days) PA NSO; QL (224 per 28 days) PA NSO; QL (30 per 30 days) PA NSO; QL (60 per 30 days) PA NSO; QL (84 per 28 days) 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 37

52 SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 37.5 MG, 50 MG SYLVANT INTRAVENOUS RECON SOLN 100 MG, 400 MG SYNRIBO SUBCUTANEOUS RECON SOLN 3.5 MG TABLOID ORAL TABLET 40 MG TAFINLAR ORAL CAPSULE 50 MG, 75 MG TAGRISSO ORAL TABLET 40 MG, 80 MG tamoxifen oral tablet 10 mg, 20 mg TARCEVA ORAL TABLET 100 MG, 25 MG TARCEVA ORAL TABLET 150 MG TARGRETIN ORAL CAPSULE 75 MG TARGRETIN TOPICAL GEL 1 % TASIGNA ORAL CAPSULE 150 MG, 200 MG TECENTRIQ INTRAVENOUS SOLUTION 1,200 MG/20 ML (60 MG/ML) TEMODAR INTRAVENOUS RECON SOLN 100 MG thiotepa injection recon soln 15 mg (Tepadina) toposar intravenous solution 20 mg/ml TREANDA INTRAVENOUS RECON SOLN 100 MG TRELSTAR MG VIAL INNER, SDV MG TRELSTAR 3.75 MG VIAL INNER, SDV 3.75 MG PA NSO; QL (30 per 30 days) PA NSO PA NSO; QL (28 per 28 days) PA NSO; QL (120 per 30 days) PA NSO; LA; QL (30 per 30 days) PA NSO; QL (60 per 30 days) PA NSO; QL (90 per 30 days) PA NSO; QL (420 per 30 days) PA NSO; QL (60 per 28 days) PA NSO; QL (112 per 28 days) PA NSO; QL (20 per 21 days) PA NSO QL (1 per 84 days) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 38

53 TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 22.5 MG TRELSTAR INTRAMUSCULAR SYRINGE MG/2 ML TRELSTAR INTRAMUSCULAR SYRINGE 3.75 MG/2 ML tretinoin (chemotherapy) oral capsule 10 mg TREXALL ORAL TABLET 10 MG, 15 MG, 5 MG, 7.5 MG TYKERB ORAL TABLET 250 MG UNITUXIN INTRAVENOUS SOLUTION 3.5 MG/ML VALSTAR INTRAVESICAL SOLUTION 40 MG/ML VELCADE INJECTION RECON SOLN 3.5 MG VENCLEXTA ORAL TABLET 10 MG VENCLEXTA ORAL TABLET 100 MG VENCLEXTA ORAL TABLET 50 MG VENCLEXTA STARTING PACK ORAL TABLETS,DOSE PACK 10 MG-50 MG- 100 MG vinorelbine intravenous solution 10 mg/ml, 50 mg/5 ml (Navelbine) VOTRIENT ORAL TABLET 200 MG XALKORI ORAL CAPSULE 200 MG, 250 MG XATMEP ORAL SOLUTION 2.5 MG/ML QL (1 per 168 days) QL (1 per 84 days) ; ST PA NSO PA NSO PA NSO; LA; QL (60 per 30 days) PA NSO; LA; QL (120 per 30 days) PA NSO; LA; QL (30 per 30 days) PA NSO; LA; QL (42 per 28 days) PA NSO; QL (120 per 30 days) PA NSO; QL (60 per 30 days) ; ST 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 39

54 XTANDI ORAL CAPSULE 40 MG YERVOY INTRAVENOUS SOLUTION 200 MG/40 ML (5 MG/ML), 50 MG/10 ML (5 MG/ML) YONDELIS INTRAVENOUS RECON SOLN 1 MG ZEJULA ORAL CAPSULE 100 MG ZELBORAF ORAL TABLET 240 MG ZOLADEX SUBCUTANEOUS IMPLANT 10.8 MG ZOLADEX SUBCUTANEOUS IMPLANT 3.6 MG ZOLINZA ORAL CAPSULE 100 MG ZYDELIG ORAL TABLET 100 MG, 150 MG ZYKADIA ORAL CAPSULE 150 MG ZYTIGA ORAL TABLET 250 MG, 500 MG Anticholinergic Agents Antimuscarinics/Antispasmodics atropine injection syringe 0.05 mg/ml, 0.1 mg/ml propantheline oral tablet 15 mg Anticonvulsants Anticonvulsants APTIOM ORAL TABLET 200 MG, 400 MG, 600 MG, 800 MG BANZEL ORAL SUSPENSION 40 MG/ML PA NSO; QL (120 per 30 days) PA NSO PA NSO PA NSO; QL (90 per 30 days) PA NSO; QL (240 per 30 days) QL (1 per 84 days) QL (1 per 28 days) PA NSO; QL (60 per 30 days) PA NSO; QL (140 per 28 days) PA NSO; QL (120 per 30 days) ST ST You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 40

55 BANZEL ORAL TABLET 200 MG, 400 MG BRIVIACT INTRAVENOUS SOLUTION 50 MG/5 ML BRIVIACT ORAL SOLUTION 10 MG/ML BRIVIACT ORAL TABLET 10 MG, 100 MG, 25 MG, 50 MG, 75 MG carbamazepine oral capsule, er multiphase 12 hr 100 mg, 200 mg, (Carbatrol) 300 mg carbamazepine oral suspension 100 mg/5 ml (Tegretol) carbamazepine oral tablet 200 mg (Epitol) carbamazepine oral tablet extended release 12 hr 100 mg, 200 mg, 400 (Tegretol XR) mg carbamazepine oral tablet,chewable 100 mg CELONTIN ORAL CAPSULE 300 MG DILANTIN ORAL CAPSULE 30 MG divalproex oral capsule, delayed rel (Depakote sprinkle 125 mg Sprinkles) divalproex oral tablet extended release 24 hr 250 mg, 500 mg (Depakote ER) divalproex oral tablet,delayed release (dr/ec) 125 mg, 250 mg, 500 (Depakote) mg epitol oral tablet 200 mg ethosuximide oral capsule 250 mg (Zarontin) ethosuximide oral solution 250 mg/5 ml (Zarontin) ST QL (80 per 30 days) QL (600 per 30 days) QL (60 per 30 days) 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 41

56 felbamate oral suspension 600 mg/5 ml (Felbatol) felbamate oral tablet 400 mg, 600 mg (Felbatol) fosphenytoin injection solution 100 mg pe/2 ml, 500 mg pe/10 ml (Cerebyx) FYCOMPA ORAL SUSPENSION 0.5 MG/ML FYCOMPA ORAL TABLET 10 MG, 12 MG, 2 MG, 4 MG, 6 MG, 8 MG gabapentin oral capsule 100 mg, 300 mg, 400 mg (Neurontin) gabapentin oral solution 250 mg/5 ml (Neurontin) gabapentin oral tablet 600 mg, 800 mg (Neurontin) GABITRIL ORAL TABLET 12 MG, 16 MG lamotrigine oral tablet 100 mg, 150 mg, 200 mg, 25 mg (Lamictal) lamotrigine oral tablet extended release 24hr 100 mg, 200 mg, 25 (Lamictal XR) mg, 250 mg, 300 mg, 50 mg lamotrigine oral tablet, chewable dispersible 25 mg, 5 mg (Lamictal) lamotrigine oral tablets,dose pack (Lamictal Starter 25 mg (35) (Blue) Kit) levetiracetam intravenous solution 500 mg/5 ml (Keppra) levetiracetam oral solution 100 mg/ml (Keppra) levetiracetam oral tablet 1,000 mg, 250 mg, 500 mg (Keppra) levetiracetam oral tablet 750 mg (Roweepra) ST ST ST You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 42

57 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Non Dwòg levetiracetam oral tablet extended release 24 hr 500 mg, 750 mg (Keppra XR) LYRICA ORAL CAPSULE 100 QL (90 per 30 days) MG, 150 MG, 200 MG, 225 MG, 25 MG, 300 MG, 50 MG, 75 MG LYRICA ORAL SOLUTION 20 QL (900 per 30 days) MG/ML oxcarbazepine oral suspension 300 mg/5 ml (60 mg/ml) (Trileptal) oxcarbazepine oral tablet 150 mg, 300 mg, 600 mg (Trileptal) OXTELLAR XR ORAL TABLET ST EXTENDED RELEASE 24 HR 150 MG, 300 MG, 600 MG PEGANONE ORAL TABLET 250 MG phenobarbital oral elixir 20 mg/5 ml QL (1500 per 30 days) (4 mg/ml) phenobarbital oral tablet 100 mg, QL (90 per 30 days) 15 mg, 16.2 mg, 32.4 mg, 60 mg, 64.8 mg, 97.2 mg phenobarbital oral tablet 30 mg QL (200 per 30 days) phenytoin oral suspension 125 mg/5 ml (Dilantin-125) phenytoin oral tablet,chewable 50 mg (Dilantin Infatabs) phenytoin sodium extended oral (Dilantin capsule 100 mg Extended) phenytoin sodium extended oral capsule 200 mg, 300 mg (Phenytek) phenytoin sodium intravenous solution 50 mg/ml phenytoin sodium intravenous syringe 50 mg/ml POTIGA ORAL TABLET 200 MG, ST; QL (90 per MG, 400 MG days) Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 43

58 POTIGA ORAL TABLET 50 MG primidone oral tablet 250 mg, 50 mg (Mysoline) ROWEEPRA ORAL TABLET 1,000 MG, 500 MG, 750 MG SABRIL ORAL POWDER IN PACKET 500 MG SABRIL ORAL TABLET 500 MG SPRITAM ORAL TABLET FOR SUSPENSION 1,000 MG SPRITAM ORAL TABLET FOR SUSPENSION 250 MG, 500 MG, 750 MG tiagabine oral tablet 2 mg, 4 mg (Gabitril) topiramate oral capsule, sprinkle 15 mg, 25 mg (Topamax) topiramate oral capsule,sprinkle,er 24hr 100 mg, 150 mg, 200 mg, 25 (Qudexy XR) mg, 50 mg topiramate oral tablet 100 mg, 200 mg, 25 mg, 50 mg (Topamax) TROKENDI XR ORAL CAPSULE,EXTENDED RELEASE 24HR 100 MG, 200 MG, 25 MG, 50 MG valproate sodium intravenous solution 500 mg/5 ml (100 mg/ml) (Depacon) valproic acid (as sodium salt) oral solution 250 mg/5 ml (Depakene) valproic acid oral capsule 250 mg (Depakene) VIMPAT INTRAVENOUS SOLUTION 200 MG/20 ML VIMPAT ORAL SOLUTION 10 MG/ML VIMPAT ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG ST; QL (270 per 30 days) ST; QL (60 per 30 days) ST; QL (120 per 30 days) ST ST; QL (200 per 5 days) ST; QL (1200 per 30 days) ST; QL (60 per 30 days) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 44

59 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Non Dwòg zonisamide oral capsule 100 mg, 25 mg (Zonegran) zonisamide oral capsule 50 mg Antidementia Agents Antidementia Agents donepezil oral tablet 10 mg, 23 mg, QL (30 per 30 days) (Aricept) 5 mg donepezil oral tablet,disintegrating QL (30 per 30 days) 10 mg, 5 mg galantamine oral capsule,ext rel. QL (30 per 30 days) (Razadyne ER) pellets 24 hr 16 mg, 24 mg, 8 mg galantamine oral solution 4 mg/ml QL (200 per 30 days) galantamine oral tablet 12 mg, 4 QL (60 per 30 days) (Razadyne) mg, 8 mg memantine oral solution 2 mg/ml QL (360 per 30 days) memantine oral tablet 10 mg, 5 mg (Namenda) QL (60 per 30 days) memantine oral tablets,dose pack 5- (Namenda Titration QL (49 per 28 days) 10 mg Pak) NAMENDA XR ORAL QL (28 per 28 days) CAP,SPRINKLE,ER 24HR DOSE PACK MG NAMENDA XR ORAL QL (30 per 30 days) CAPSULE,SPRINKLE,ER 24HR 14 MG, 21 MG, 28 MG, 7 MG NAMZARIC ORAL QL (56 per 365 days) CAP,SPRINKLE,ER 24HR DOSE PACK 7/14/21/28 MG-10 MG NAMZARIC ORAL QL (30 per 30 days) CAPSULE,SPRINKLE,ER 24HR MG, MG, MG, 7-10 MG rivastigmine tartrate oral capsule QL (60 per 30 days) 1.5 mg, 3 mg, 4.5 mg, 6 mg rivastigmine transdermal patch 24 QL (30 per 30 days) hour 13.3 mg/24 hour, 4.6 mg/24 hr, (Exelon) 9.5 mg/24 hr Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 45

60 Antidepressants Antidepressants amitriptyline oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg amoxapine oral tablet 100 mg, 150 mg, 25 mg, 50 mg BRINTELLIX ORAL TABLET 10 ST MG, 20 MG, 5 MG bupropion hcl oral tablet 100 mg, 75 mg bupropion hcl oral tablet extended release 12 hr 100 mg, 150 mg, 200 (Wellbutrin SR) mg bupropion hcl oral tablet extended release 24 hr 150 mg, 300 mg (Wellbutrin XL) citalopram oral solution 10 mg/5 ml QL (600 per 30 days) citalopram oral tablet 10 mg, 20 QL (30 per 30 days) (Celexa) mg, 40 mg clomipramine oral capsule 25 mg, 50 mg, 75 mg (Anafranil) desipramine oral tablet 10 mg, 25 mg (Norpramin) desipramine oral tablet 100 mg, 150 mg, 50 mg, 75 mg desvenlafaxine succinate oral tablet extended release 24 hr 100 mg, 25 mg, 50 mg (Pristiq) doxepin oral capsule 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg doxepin oral concentrate 10 mg/ml duloxetine oral capsule,delayed release(dr/ec) 20 mg, 60 mg (Cymbalta) duloxetine oral capsule,delayed release(dr/ec) 30 mg (Cymbalta) duloxetine oral capsule,delayed release(dr/ec) 40 mg (Irenka) ST; QL (30 per 30 days) (Cymbalta); QL (60 per 30 days) (Cymbalta); QL (30 per 30 days) (Irenka); QL (30 per 30 days) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 46

61 EMSAM TRANSDERMAL PATCH 24 HOUR 12 MG/24 HR, 6 MG/24 HR, 9 MG/24 HR escitalopram oxalate oral solution 5 mg/5 ml escitalopram oxalate oral tablet 10 mg, 20 mg, 5 mg (Lexapro) FETZIMA ORAL CAPSULE,EXT REL 24HR DOSE PACK 20 MG (2)- 40 MG (26) FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR 120 MG, 20 MG, 40 MG, 80 MG fluoxetine oral capsule 10 mg, 20 mg, 40 mg (Prozac) fluoxetine oral capsule,delayed release(dr/ec) 90 mg (Prozac Weekly) fluoxetine oral solution 20 mg/5 ml (4 mg/ml) fluoxetine oral tablet 10 mg, 20 mg (Sarafem) fluvoxamine oral capsule,extended release 24hr 100 mg, 150 mg fluvoxamine oral tablet 100 mg, 25 mg, 50 mg imipramine hcl oral tablet 10 mg, 25 (Tofranil) mg, 50 mg imipramine pamoate oral capsule 100 mg, 125 mg, 150 mg, 75 mg maprotiline oral tablet 25 mg, 50 mg, 75 mg MARPLAN ORAL TABLET 10 MG mirtazapine oral tablet 15 mg, 30 mg, 45 mg (Remeron) mirtazapine oral tablet 7.5 mg QL (30 per 30 days) ST ST 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 47

62 mirtazapine oral tablet,disintegrating 15 mg, 30 mg, (Remeron SolTab) 45 mg nefazodone oral tablet 100 mg, 150 mg, 200 mg, 250 mg, 50 mg nortriptyline oral capsule 10 mg, 25 mg, 50 mg, 75 mg (Pamelor) nortriptyline oral solution 10 mg/5 ml olanzapine-fluoxetine oral capsule mg, mg, 3-25 mg, 6-25 (Symbyax) mg, 6-50 mg paroxetine hcl oral tablet 10 mg, 20 mg, 30 mg, 40 mg (Paxil) paroxetine hcl oral tablet extended release 24 hr 12.5 mg, 25 mg, 37.5 (Paxil CR) mg PAXIL ORAL SUSPENSION 10 MG/5 ML perphenazine-amitriptyline oral tablet 2-10 mg, 2-25 mg, 4-10 mg, 4-25 mg, 4-50 mg phenelzine oral tablet 15 mg (Nardil) PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 100 MG, 25 MG, 50 MG protriptyline oral tablet 10 mg, 5 mg sertraline oral concentrate 20 mg/ml (Zoloft) sertraline oral tablet 100 mg, 25 mg, 50 mg (Zoloft) SURMONTIL ORAL CAPSULE 100 MG, 25 MG, 50 MG tranylcypromine oral tablet 10 mg (Parnate) trazodone oral tablet 100 mg, 150 mg, 300 mg, 50 mg ST; QL (30 per 30 days) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 48

63 trimipramine oral capsule 100 mg, 25 mg, 50 mg TRINTELLIX ORAL TABLET 10 MG, 20 MG, 5 MG venlafaxine oral capsule,extended release 24hr 150 mg, 37.5 mg, 75 mg venlafaxine oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 75 mg venlafaxine oral tablet extended release 24hr 150 mg, 37.5 mg, 75 mg VIIBRYD ORAL TABLET 10 MG, 20 MG, 40 MG VIIBRYD ORAL TABLETS,DOSE PACK 10 MG (7)- 20 MG (23) Antidiabetic Agents Antidiabetic Agents, Miscellaneous acarbose oral tablet 100 mg, 25 mg, 50 mg CYCLOSET ORAL TABLET 0.8 MG GLYXAMBI ORAL TABLET 10-5 MG, 25-5 MG INVOKAMET ORAL TABLET 150-1,000 MG, MG, 50-1,000 MG INVOKAMET ORAL TABLET MG INVOKAMET XR ORAL TABLET, IR - ER, BIPHASIC 24HR 150-1,000 MG, MG, 50-1,000 MG, MG INVOKANA ORAL TABLET 100 MG (Surmontil) (Effexor XR) (Precose) ST QL (90 per 30 days) QL (180 per 30 days) ST; QL (30 per 30 days) ST; QL (60 per 30 days) ST; QL (120 per 30 days) ST; QL (60 per 30 days) ST; QL (60 per 30 days) 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 49

64 INVOKANA ORAL TABLET 300 ST; QL (30 per 30 MG days) JANUMET ORAL TABLET 50-1,000 MG, MG JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 100-1,000 MG, 50-1,000 MG, MG JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG JARDIANCE ORAL TABLET 10 ST; QL (30 per 30 MG, 25 MG days) JENTADUETO ORAL TABLET 2.5-1,000 MG, MG, MG JENTADUETO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 2.5-1,000 MG, 5-1,000 MG KORLYM ORAL TABLET 300 PA; QL (112 per 28 MG days) metformin oral tablet 1,000 mg (Glucophage) QL (75 per 30 days) metformin oral tablet 500 mg (Glucophage) QL (150 per 30 days) metformin oral tablet 850 mg (Glucophage) QL (90 per 30 days) metformin oral tablet extended QL (120 per 30 days) (Glucophage XR) release 24 hr 500 mg metformin oral tablet extended QL (90 per 30 days) (Glucophage XR) release 24 hr 750 mg metformin oral tablet extended ST; QL (60 per 30 (Fortamet) release 24hr 1,000 mg days) metformin oral tablet extended ST; QL (120 per 30 (Fortamet) release 24hr 500 mg days) miglitol oral tablet 100 mg, 25 mg, QL (90 per 30 days) (Glyset) 50 mg nateglinide oral tablet 120 mg, 60 QL (90 per 30 days) (Starlix) mg You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 50

65 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Non Dwòg pioglitazone oral tablet 15 mg, 30 QL (30 per 30 days) (Actos) mg, 45 mg pioglitazone-glimepiride oral tablet QL (30 per 30 days) (DUETACT) 30-2 mg, 30-4 mg pioglitazone-metformin oral tablet QL (90 per 30 days) (Actoplus MET) mg, mg repaglinide oral tablet 0.5 mg QL (240 per 30 days) repaglinide oral tablet 1 mg, 2 mg (Prandin) QL (240 per 30 days) repaglinide-metformin oral tablet 1- QL (150 per 30 days) 500 mg, mg SYMLINPEN 120 SUBCUTANEOUS PEN PA; QL (10.8 per 28 days) INJECTOR 2,700 MCG/2.7 ML SYMLINPEN 60 SUBCUTANEOUS PEN INJECTOR 1,500 MCG/1.5 ML PA; QL (6 per 28 days) SYNJARDY ORAL TABLET ,000 MG, MG, 5-1,000 MG, MG SYNJARDY XR ORAL TABLET, IR - ER, BIPHASIC 24HR 10-1,000 MG, 25-1,000 MG SYNJARDY XR ORAL TABLET, IR - ER, BIPHASIC 24HR ,000 MG, 5-1,000 MG TRADJENTA ORAL TABLET 5 MG TRULICITY SUBCUTANEOUS PEN INJECTOR 0.75 MG/0.5 ML, 1.5 MG/0.5 ML VICTOZA Insulins HUMULIN R U-500 (CONC) KWIKPEN SUBCUTANEOUS INSULIN PEN 500 UNIT/ML (3 ML) ST; QL (60 per 30 days) ST; QL (30 per 30 days) ST; QL (60 per 30 days) QL (24 per 28 days) Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 51

66 HUMULIN R U-500 QL (40 per 28 days) (CONCENTRATED) SUBCUTANEOUS SOLUTION 500 UNIT/ML LANTUS SOLOSTAR QL (30 per 28 days) SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML) LANTUS SUBCUTANEOUS QL (40 per 28 days) SOLUTION 100 UNIT/ML NOVOLIN 70/30 QL (40 per 28 days) SUBCUTANEOUS SUSPENSION 100 UNIT/ML (70-30) NOVOLIN N SUBCUTANEOUS QL (40 per 28 days) SUSPENSION 100 UNIT/ML NOVOLIN R INJECTION QL (40 per 28 days) SOLUTION 100 UNIT/ML NOVOLOG FLEXPEN QL (30 per 28 days) SUBCUTANEOUS INSULIN PEN 100 UNIT/ML NOVOLOG MIX FLEXPEN QL (30 per 28 days) SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (70-30) NOVOLOG MIX QL (40 per 28 days) SUBCUTANEOUS SOLUTION 100 UNIT/ML (70-30) NOVOLOG PENFILL QL (30 per 28 days) SUBCUTANEOUS CARTRIDGE 100 UNIT/ML NOVOLOG SUBCUTANEOUS QL (40 per 28 days) SOLUTION 100 UNIT/ML TOUJEO SOLOSTAR SUBCUTANEOUS INSULIN PEN 300 UNIT/ML (1.5 ML) Sulfonylureas glimepiride oral tablet 1 mg, 2 mg (Amaryl) QL (30 per 30 days) glimepiride oral tablet 4 mg (Amaryl) QL (60 per 30 days) glipizide oral tablet 10 mg (Glucotrol) QL (120 per 30 days) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 52

67 glipizide oral tablet 5 mg (Glucotrol) QL (60 per 30 days) glipizide oral tablet extended QL (60 per 30 days) (Glucotrol XL) release 24hr 10 mg glipizide oral tablet extended QL (30 per 30 days) (Glucotrol XL) release 24hr 2.5 mg, 5 mg glipizide-metformin oral tablet 2.5- QL (240 per 30 days) 250 mg glipizide-metformin oral tablet 2.5- QL (120 per 30 days) 500 mg, mg glyburide micronized oral tablet 1.5 PA-HRM; AGE (Max (Glynase) mg, 3 mg, 6 mg 64 Years) glyburide oral tablet 1.25 mg, 2.5 PA-HRM; AGE (Max mg, 5 mg 64 Years) glyburide-metformin oral tablet PA-HRM; AGE (Max mg 64 Years) glyburide-metformin oral tablet 2.5- PA-HRM; AGE (Max (Glucovance) 500 mg, mg 64 Years) tolazamide oral tablet 250 mg QL (120 per 30 days) tolazamide oral tablet 500 mg QL (60 per 30 days) tolbutamide oral tablet 500 mg QL (180 per 30 days) Antifungals Antifungals 3-day vaginal cream 2 % * ABELCET INTRAVENOUS SUSPENSION 5 MG/ML aloe vesta 2% antifungal oint 12's 2 % * AMBISOME INTRAVENOUS SUSPENSION FOR RECONSTITUTION 50 MG amphotericin b injection recon soln 50 mg anti-fungal 1% powder 1 % * antifungal 2% cream 2 % * 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 53

68 baza antifungal 2% cream 12's 2 % * blis-to-sol 1% liquid 1 % * CANCIDAS INTRAVENOUS RECON SOLN 50 MG, 70 MG (Loprox (as ciclopirox topical cream 0.77 % olamine)) ciclopirox topical gel 0.77 % ciclopirox topical shampoo 1 % (Loprox) ciclopirox topical solution 8 % (Penlac) ciclopirox topical suspension 0.77 (Loprox (as % olamine)) clotrim 1% vaginal cream 1 % * (Clotrimazole-7) (Athletic Foot clotrimazole 1% cream (otc) 1 % * Cream) clotrimazole 1% solution (otc) 1 % * clotrimazole insert 100 mg * clotrimazole mucous membrane troche 10 mg (Athletic Foot clotrimazole topical cream 1 % Cream) clotrimazole topical solution 1 % clotrimazole-7 cream 1 % * clotrimazole-betamethasone topical (Lotrisone) cream % clotrimazole-betamethasone topical lotion % critic-aid clear af 2% oint 12's, w/ antifungal 2 % * cvs miconazole 3 combo pack 3pref applic w/cream 4 % (200 mg)- 2 % (Monistat 3) (9 gram) * dermafungal 2% ointment 2 % * econazole topical cream 1 % You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 54

69 fluconazole in nacl (iso-osm) intravenous piggyback 100 mg/50 ml, 200 mg/100 ml, 400 mg/200 ml fluconazole oral suspension for reconstitution 10 mg/ml, 40 mg/ml (Diflucan) fluconazole oral tablet 100 mg, 150 mg, 200 mg, 50 mg (Diflucan) flucytosine oral capsule 250 mg, 500 mg (Ancobon) fungi cure intensive 1% spray 1 % * fungoid-d 1% cream 1 % * griseofulvin microsize oral tablet 500 mg inzo antifungal 2% cream 2 % * itraconazole oral capsule 100 mg (Sporanox) ketoconazole oral tablet 200 mg ketoconazole topical cream 2 % ketoconazole topical shampoo 2 % (Nizoral) lamisil af defens 1% spray pwd 1 % * lamisil af defense 1% powder 1 % * LAMISIL ANTIFUNGAL 1% SPRAY FOR ATHLETES FOOT 1 % * LAMISIL AT 1% GEL 1 % * micatin 2% antifungal cream 2 % * miconazole 3 combo pack 3 sup,9gm crm w/app 200 mg- 2 % (9 gram) * miconazole mg vag supp 100 mg * miconazole nitrate 2% cream 2 % * (Monistat 7) miconazole-3 vaginal suppository 200 mg MONISTAT 3 COMBO PACK 4 % (200 MG)- 2 % (9 GRAM) * 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 55

70 monistat 7 cream 7 applicators 2 % * NOXAFIL ORAL SUSPENSION 200 MG/5 ML (40 MG/ML) NOXAFIL ORAL TABLET,DELAYED RELEASE (DR/EC) 100 MG nyamyc topical powder 100,000 unit/gram nyata topical powder 100,000 unit/gram nystatin oral suspension 100,000 unit/ml nystatin oral tablet 500,000 unit nystatin topical cream 100,000 unit/gram nystatin topical ointment 100,000 unit/gram nystatin topical powder 100,000 unit/gram (Nyata) nystatin-triamcinolone topical cream 100, unit/g-% nystatin-triamcinolone topical ointment 100, unit/gram-% nystop topical powder 100,000 unit/gram pv foot odor control 1% powder 1 % * qc 3 day vaginal 4% cream 200 mg/5 gram (4 %) * ra antifungal 1% liquid spray liquid spray 1 % * remedy phytplx antifungal oint 2 % * terbinafine 1% cream 1 % * (Lamisil AT) terbinafine hcl oral tablet 250 mg (Lamisil) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 56

71 tolnaftate 1% cream 1 % * (Tinactin) tolnaftate 1% solution 1 % * (Blis-To-Sol (tolnaftate)) tolnaftate 1% spray powder 1 % * (Athlete's Foot (tolnaftate)) triple paste af 2% ointment 2 % * vagistat-3 combo pack 200 mg- 2 % (9 gram) * voriconazole intravenous solution 200 mg (Vfend IV) voriconazole oral suspension for reconstitution 200 mg/5 ml (40 (Vfend) mg/ml) voriconazole oral tablet 200 mg, 50 mg (Vfend) Antigout Agents Antigout Agents, Other allopurinol oral tablet 100 mg, 300 mg (Zyloprim) COLCRYS ORAL TABLET 0.6 MG probenecid oral tablet 500 mg probenecid-colchicine oral tablet mg ULORIC ORAL TABLET 40 MG, 80 MG ZURAMPIC ORAL TABLET 200 MG Antihistamines Antihistamines alavert 10 mg odt non-drowsy, mint 10 mg * alavert d-12 allergy-sinus tab mg * QL (30 per 30 days) ST; QL (30 per 30 days) 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 57

72 aller-chlor 2 mg/5 ml syrup 2 mg/5 ml * aller-chlor 4 mg tablet 4 mg * allerclear d-12hr tablet mg * allerclear d-24hr er tablet nondrowsy mg * allergy 4 mg tablet 4 mg * allerhist mg tablet 1.34 mg * aller-tec d mg tablet mg * ambi 60pse-4cpm tablet 4-60 mg * aprodine tablet mg * banophen 25 mg capsule 25 mg * banophen 25 mg tablet 25 mg * banophen allergy 12.5 mg/5 ml a/f 12.5 mg/5 ml * benadryl allergy 25 mg ultratb ultratab 25 mg * cetirizine hcl 1 mg/ml soln children, (Children's s/f, grape (otc) 1 mg/ml * Allergy(cetirizine)) cetirizine hcl 10 mg chew tab (All Day Allergy children's,outer,u-d 10 mg * (cetirizine)) cetirizine hcl 10 mg tablet 10 mg * (Wal-Zyr (cetirizine)) cetirizine hcl 5 mg chew tab (Children's children's,outer,u-d 5 mg * Cetirizine) cetirizine-pse er mg tab (Allergy-Congest mg * Relief-D (cet)) child allegra allergy 30 mg/5 ml suspension 30 mg/5 ml * child loratadine 5 mg/5 ml syr grape, s/f 5 mg/5 ml * (Claritin) child triaminic cold & allergy mg/5 ml * child wal-tap cold-allergy elx mg/5 ml * You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 58

73 child wal-zyr 1 mg/ml solution cherry 1 mg/ml * children's wal-fex 30 mg/5 ml 30 mg/5 ml * CHILDREN'S ZYRTEC 10 MG ODT 10 MG * child's aller-tec 1 mg/ml soln 1 mg/ml * CHILD'S CLARITIN 5 MG TAB CHEW 5 MG * child's wal-zyr 10 mg chew tab 10 mg * CLARITIN 10 MG LIQUI-GEL CAP 10 MG * CLARITIN 5 MG REDITABS 5 MG * cold-allergy-sinus oral tablet mg * compoz 25 mg gelcap 25 mg * cvs allergy relief 10 mg sftgl 10 mg * cvs cold & cough nighttime liq mg/5 ml * cvs loratadine-d 24hr tablet nondrowsy mg * cyproheptadine oral syrup 2 mg/5 ml cyproheptadine oral tablet 4 mg dailyhist mg tablet 1.34 mg * dayhist allergy 1.34 mg tablet 12 hr relief 1.34 mg * dimaphen elixir a/f, grape, gluten-f mg/5 ml * dimetapp cold & congest liquid mg/5 ml * 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 59

74 diphenhist 12.5 mg/5 ml soln 12.5 mg/5 ml * diphenhist 25 mg capsule 25 mg * diphenhist 25 mg captab captab 25 mg * diphenhydramine 25 mg capsule (Complete Allergy (otc) 25 mg * Medicine) diphenhydramine 50 mg capsule (otc) 50 mg * (Sleepgels) diphenhydramine hcl injection solution 50 mg/ml ed chlorped jr syrup 2 mg/5 ml * ed-a-hist 4 mg-10 mg tablet 4-10 mg * eq allergy relief 25 mg tablet 25 mg * fexofenadine hcl 180 mg tablet 24 hour, non-drowsy (otc) 180 mg * (Allegra Allergy) fexofenadine hcl 30 mg/5 ml 30 mg/5 ml * (Aller-ease) fexofenadine hcl 60 mg tablet indoor/outdoor (otc) 60 mg * (Wal-Fex Allergy) hm z-sleep 25 mg softgel 25 mg * hydroxyzine hcl intramuscular solution 25 mg/ml, 50 mg/ml hydroxyzine hcl oral solution 10 mg/5 ml hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg levocetirizine oral solution 2.5 mg/5 ml (Xyzal) levocetirizine oral tablet 5 mg (Xyzal) loratadine 10 mg softgel 10 mg * (Claritin Liqui-Gel) loratadine 10 mg tablet 10 mg * (Wal-itin) loratadine-d 12 hour tablet nondrowsy mg * You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 60

75 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Non Dwòg night sleep aid 50 mg/30 ml lq 50 mg/30 ml * promethazine oral syrup 6.25 mg/5 ml pv nyt-time sleep 25 mg caplet 25 mg * q-dryl 12.5 mg/5 ml liquid a/f,unboxed 12.5 mg/5 ml * siladryl 12.5 mg/5 ml liquid 12.5 mg/5 ml * simply sleep 25 mg caplet caplet 25 mg * sleep aid 25 mg tablet 25 mg * sm allergy relief 1.34 mg tab 1.34 mg * sm sinus and allergy tablet maximum strength 4-60 mg * sm z-sleep 50 mg/30 ml liquid berry,gluten-free 50 mg/30 ml * sudogest sinus & allergy tab 4-60 mg * unisom 50 mg sleepgels softgel 50 mg * unisom 50 mg/30 ml liquid 50 mg/30 ml * unisom sleep aid 25 mg tablet 25 mg * vicks qlearquil night 25 mg 25 mg * wal-act d cold & allergy tab mg * wal-dryl allergy 12.5 mg/5 ml children,a/f,s/f,d/f 12.5 mg/5 ml * wal-dryl allergy 25 mg capsule 25 mg * wal-dryl allergy 25 mg minitab minitab, coated 25 mg * PA-HRM; AGE (Max 64 Years) Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 61

76 wal-fex allergy 180 mg tablet 180 mg * wal-fex allergy 60 mg tablet 60 mg * wal-finate 4 mg tablet 4 mg * wal-finate-d tablet 4-60 mg * wal-itin 10 mg odt non-drowsy 10 mg * wal-itin 10 mg tablet non-drowsy,24 hr rlf 10 mg * wal-itin 5 mg/5 ml syrup children's, grape 5 mg/5 ml * wal-itin d 12 hour tablet mg * wal-itin d 24 hour tablet mg * wal-phed pe sinus-allergy tab 4-10 mg * wal-phed sinus and allergy tab 4-60 mg * wal-sleep z 25 mg odt 25 mg * wal-sleep z 25 mg softgel 25 mg * wal-sleep z 50 mg/30 ml liquid berry, a/f, d/f, s/f 50 mg/30 ml * wal-som 25 mg odt 25 mg * wal-som 25 mg tablet 25 mg * wal-som 50 mg softgel softgel 50 mg * wal-tap elixir mg/5 ml * wal-zyr 10 mg tablet 10 mg * wal-zyr d tablet 12 hr relief mg * ZYRTEC 10 MG ODT 10 MG * Anti-Infectives (Skin And Mucous Membrane) Anti-Infectives (Skin And Mucous Membrane) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 62

77 ? Non Dwòg ABREVA 10% CREAM 10 % * AVC VAGINAL VAGINAL CREAM 15 % clindamycin phosphate vaginal cream 2 % (Cleocin) metronidazole vaginal gel 0.75 % (Metrogel Vaginal) terconazole vaginal cream 0.4 % (Terazol 7) terconazole vaginal cream 0.8 % terconazole vaginal suppository 80 mg Antimigraine Agents Antimigraine Agents dihydroergotamine injection QL (30 per 28 days) (D.H.E.45) solution 1 mg/ml dihydroergotamine nasal spray,nonaerosol 0.5 mg/pump act. (4 mg/ml) QL (8 per 28 days) (Migranal) ERGOMAR SUBLINGUAL QL (40 per 28 days) TABLET 2 MG naratriptan oral tablet 1 mg, 2.5 mg (Amerge) QL (18 per 28 days) rizatriptan oral tablet 10 mg, 5 mg (Maxalt) QL (18 per 28 days) rizatriptan oral tablet,disintegrating QL (18 per 28 days) (Maxalt-MLT) 10 mg, 5 mg sumatriptan nasal spray,nonaerosol QL (12 per 28 days) 20 mg/actuation, 5 (Imitrex) mg/actuation sumatriptan succinate oral tablet QL (18 per 28 days) (Imitrex) 100 mg, 25 mg, 50 mg sumatriptan succinate subcutaneous (Imitrex STATdose QL (4 per 28 days) cartridge 4 mg/0.5 ml, 6 mg/0.5 ml Kit Refill) sumatriptan succinate subcutaneous QL (4 per 28 days) (Imitrex STATdose pen injector 4 mg/0.5 ml, 6 mg/0.5 Pen) ml sumatriptan succinate subcutaneous QL (4 per 28 days) (Imitrex) solution 6 mg/0.5 ml sumatriptan succinate subcutaneous QL (4 per 28 days) syringe 6 mg/0.5 ml 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a. Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 63

78 zolmitriptan oral tablet 2.5 mg, 5 mg (Zomig) zolmitriptan oral tablet,disintegrating 2.5 mg, 5 mg (Zomig ZMT) Antimycobacterials Antimycobacterials CAPASTAT INJECTION RECON SOLN 1 GRAM dapsone oral tablet 100 mg, 25 mg ethambutol oral tablet 100 mg ethambutol oral tablet 400 mg (Myambutol) isoniazid oral solution 50 mg/5 ml isoniazid oral tablet 100 mg, 300 mg PASER ORAL GRANULES DR FOR SUSP IN PACKET 4 GRAM PRIFTIN ORAL TABLET 150 MG pyrazinamide oral tablet 500 mg rifabutin oral capsule 150 mg (Mycobutin) rifampin intravenous recon soln 600 mg (Rifadin) rifampin oral capsule 150 mg, 300 mg (Rifadin) RIFATER ORAL TABLET MG SIRTURO ORAL TABLET 100 MG TRECATOR ORAL TABLET 250 MG Antinausea Agents Antinausea Agents AKYNZEO ORAL CAPSULE MG aprepitant oral capsule 125 mg, 40 mg, 80 mg (Emend) QL (12 per 28 days) QL (12 per 28 days) PA; QL (188 per 168 days) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 64

79 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Non Dwòg aprepitant oral capsule,dose pack (Emend) 125 mg (1)- 80 mg (2) compro rectal suppository 25 mg cvs motion sickness 50 mg tab 50 mg * cvs motion sickness relief tab chewable tablet 25 mg * dimenhydrinate injection solution 50 mg/ml dramamine 50 mg tablet 50 mg * dramamine less drowsy 25 mg tb 25 mg * driminate 50 mg tablet 50 mg * dronabinol oral capsule 10 mg, 2.5 PA (Marinol) mg, 5 mg EMEND INTRAVENOUS RECON QL (2 per 28 days) SOLN 150 MG EMEND ORAL CAPSULE 125 MG, 40 MG EMEND ORAL SUSPENSION FOR RECONSTITUTION 125 MG (25 MG/ ML FINAL CONC.) granisetron (pf) intravenous solution 100 mcg/ml granisetron hcl intravenous solution 1 mg/ml, 1 mg/ml (1 ml) granisetron hcl oral tablet 1 mg meclizine 12.5 mg caplet caplet (otc) 12.5 mg * meclizine 25 mg tablet (otc) 25 mg * (VertiCalm) meclizine oral tablet 12.5 mg meclizine oral tablet 25 mg (VertiCalm) medi-meclizine 25 mg tablet outer, f/c 25 mg * ondansetron hcl (pf) injection solution 4 mg/2 ml Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 65

80 ondansetron hcl (pf) injection syringe 4 mg/2 ml ondansetron hcl oral solution 4 (Zofran (as mg/5 ml hydrochloride)) ondansetron hcl oral tablet 24 mg ondansetron hcl oral tablet 4 mg, 8 (Zofran (as mg hydrochloride)) ondansetron oral (Zofran ODT) tablet,disintegrating 4 mg, 8 mg phenadoz rectal suppository 12.5 PA-HRM; AGE (Max mg, 25 mg 64 Years) prochlorperazine edisylate injection solution 10 mg/2 ml (5 mg/ml) prochlorperazine maleate oral tablet 10 mg, 5 mg (Compazine) prochlorperazine rectal suppository 25 mg (Compazine) promethazine oral tablet 12.5 mg, PA-HRM; AGE (Max 25 mg, 50 mg 64 Years) promethazine rectal suppository PA-HRM; AGE (Max (Phenadoz) 12.5 mg, 25 mg 64 Years) promethazine rectal suppository 50 PA-HRM; AGE (Max (Phenergan) mg 64 Years) promethegan rectal suppository PA-HRM; AGE (Max 12.5 mg, 25 mg, 50 mg 64 Years) ra motion sickness rlf tb chew raspberry flavor 25 mg * TRANSDERM-SCOP QL (10 per 30 days) TRANSDERMAL PATCH 3 DAY 1.5 MG (1 MG OVER 3 DAYS) travel sickness 25 mg tab chew 25 mg * wal-dram 50 mg tablet 50 mg * Antiparasite Agents Antiparasite Agents You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 66

81 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Non Dwòg ALBENZA ORAL TABLET 200 MG ALINIA ORAL SUSPENSION FOR RECONSTITUTION 100 MG/5 ML ALINIA ORAL TABLET 500 MG atovaquone oral suspension 750 mg/5 ml (Mepron) atovaquone-proguanil oral tablet mg (Malarone) atovaquone-proguanil oral tablet (Malarone mg Pediatric) chloroquine phosphate oral tablet 250 mg, 500 mg COARTEM ORAL TABLET MG DARAPRIM ORAL TABLET 25 PA MG hydroxychloroquine oral tablet 200 mg (Plaquenil) ivermectin oral tablet 3 mg (Stromectol) mefloquine oral tablet 250 mg NEBUPENT INHALATION RECON SOLN 300 MG paromomycin oral capsule 250 mg PENTAM INJECTION RECON SOLN 300 MG PRIMAQUINE ORAL TABLET QL (90 per 30 days) 26.3 MG quinine sulfate oral capsule 324 mg (Qualaquin) PA; QL (42 per 7 days) Antiparkinsonian Agents Antiparkinsonian Agents amantadine hcl oral capsule 100 mg amantadine hcl oral solution 50 mg/5 ml Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 67

82 amantadine hcl oral tablet 100 mg APOKYN SUBCUTANEOUS CARTRIDGE 10 MG/ML benztropine oral tablet 0.5 mg, 1 mg, 2 mg bromocriptine oral capsule 5 mg (Parlodel) bromocriptine oral tablet 2.5 mg (Parlodel) cabergoline oral tablet 0.5 mg carbidopa oral tablet 25 mg (Lodosyn) carbidopa-levodopa oral tablet mg, mg, mg (Sinemet) carbidopa-levodopa oral tablet extended release mg, (Sinemet CR) mg carbidopa-levodopa-entacapone oral tablet mg (Stalevo 50) carbidopa-levodopa-entacapone oral tablet mg (Stalevo 75) carbidopa-levodopa-entacapone oral tablet mg (Stalevo 100) carbidopa-levodopa-entacapone oral tablet mg (Stalevo 125) carbidopa-levodopa-entacapone oral tablet mg (Stalevo 150) carbidopa-levodopa-entacapone oral tablet mg (Stalevo 200) entacapone oral tablet 200 mg (Comtan) NEUPRO TRANSDERMAL PATCH 24 HOUR 1 MG/24 HOUR, 2 MG/24 HOUR, 3 MG/24 HOUR, 4 MG/24 HOUR, 6 MG/24 HOUR, 8 MG/24 HOUR pramipexole oral tablet mg, 0.25 mg, 0.5 mg, 0.75 mg, 1 mg, 1.5 (Mirapex) mg rasagiline oral tablet 0.5 mg, 1 mg (Azilect) QL (60 per 30 days) PA-HRM; AGE (Max 64 Years) QL (30 per 30 days) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 68

83 ropinirole oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg, 5 mg (Requip) ropinirole oral tablet extended release 24 hr 12 mg, 2 mg, 4 mg, 6 (Requip XL) mg, 8 mg selegiline hcl oral capsule 5 mg (Eldepryl) selegiline hcl oral tablet 5 mg trihexyphenidyl oral elixir 0.4 mg/ml PA-HRM; AGE (Max 64 Years) trihexyphenidyl oral tablet 2 mg, 5 PA-HRM; AGE (Max mg 64 Years) XADAGO ORAL TABLET 100 PA; QL (30 per 30 MG, 50 MG days) Antipsychotic Agents Antipsychotic Agents ABILIFY MAINTENA QL (1 per 28 days) INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 300 MG, 400 MG ABILIFY MAINTENA QL (1 per 28 days) INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 300 MG, 400 MG aripiprazole oral solution 1 mg/ml QL (900 per 30 days) aripiprazole oral tablet 10 mg, 15 QL (30 per 30 days) (Abilify) mg, 20 mg, 30 mg, 5 mg aripiprazole oral tablet 2 mg (Abilify) QL (60 per 30 days) aripiprazole oral QL (90 per 30 days) tablet,disintegrating 10 mg aripiprazole oral QL (60 per 30 days) tablet,disintegrating 15 mg ARISTADA INTRAMUSCULAR QL (3.9 per 56 days) SUSPENSION,EXTENDED REL SYRING 1,064 MG/3.9 ML 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 69

84 ARISTADA INTRAMUSCULAR QL (1.6 per 28 days) SUSPENSION,EXTENDED REL SYRING 441 MG/1.6 ML ARISTADA INTRAMUSCULAR QL (2.4 per 28 days) SUSPENSION,EXTENDED REL SYRING 662 MG/2.4 ML ARISTADA INTRAMUSCULAR QL (3.2 per 28 days) SUSPENSION,EXTENDED REL SYRING 882 MG/3.2 ML chlorpromazine injection solution 25 mg/ml chlorpromazine oral tablet 10 mg, 100 mg, 200 mg, 25 mg, 50 mg clozapine oral tablet 100 mg (Clozaril) QL (270 per 30 days) clozapine oral tablet 200 mg QL (135 per 30 days) clozapine oral tablet 25 mg (Clozaril) QL (90 per 30 days) clozapine oral tablet 50 mg QL (90 per 30 days) clozapine oral tablet,disintegrating 100 mg, 12.5 mg, 150 mg, 200 mg, (FazaClo) ST 25 mg FANAPT ORAL TABLET 1 MG, 10 MG, 12 MG, 2 MG, 4 MG, 6 MG, 8 MG FANAPT ORAL TABLETS,DOSE PACK 1MG(2)-2MG(2)- 4MG(2)- 6MG(2) fluphenazine decanoate injection solution 25 mg/ml fluphenazine hcl injection solution 2.5 mg/ml fluphenazine hcl oral concentrate 5 mg/ml fluphenazine hcl oral elixir 2.5 mg/5 ml fluphenazine hcl oral tablet 1 mg, 10 mg, 2.5 mg, 5 mg ST; QL (60 per 30 days) ST; QL (8 per 28 days) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 70

85 GEODON INTRAMUSCULAR RECON SOLN 20 MG/ML (FINAL CONC.) haloperidol dec 50 mg/ml vial 50 mg/ml haloperidol decanoate intramuscular solution 100 mg/ml haloperidol decanoate intramuscular solution 50 mg/ml haloperidol lactate injection solution 5 mg/ml haloperidol lactate oral concentrate 2 mg/ml haloperidol oral tablet 0.5 mg, 1 mg, 10 mg, 2 mg, 20 mg, 5 mg INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 117 MG/0.75 ML INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 156 MG/ML INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 234 MG/1.5 ML INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 39 MG/0.25 ML INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 78 MG/0.5 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 273 MG/0.875 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 410 MG/1.315 ML (Haldol Decanoate) (Haldol Decanoate) (Haldol Decanoate) (Haldol) QL (6 per 28 days) QL (0.75 per 28 days) QL (1 per 28 days) QL (1.5 per 28 days) QL (0.25 per 28 days) QL (0.5 per 28 days) QL (0.875 per 84 days) QL (1.315 per 84 days) 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 71

86 INVEGA TRINZA QL (1.75 per 84 days) INTRAMUSCULAR SYRINGE 546 MG/1.75 ML INVEGA TRINZA QL (2.625 per 84 days) INTRAMUSCULAR SYRINGE 819 MG/2.625 ML LATUDA ORAL TABLET 120 QL (30 per 30 days) MG, 20 MG, 40 MG, 60 MG, 80 MG loxapine succinate oral capsule 10 mg, 25 mg, 5 mg, 50 mg molindone oral tablet 10 mg QL (240 per 30 days) molindone oral tablet 25 mg QL (270 per 30 days) molindone oral tablet 5 mg QL (120 per 30 days) NUPLAZID ORAL TABLET 17 PA NSO; QL (60 per MG 30 days) olanzapine intramuscular recon soln QL (30 per 30 days) (Zyprexa) 10 mg olanzapine oral tablet 10 mg, 15 QL (30 per 30 days) (Zyprexa) mg, 2.5 mg, 20 mg, 5 mg, 7.5 mg olanzapine oral tablet,disintegrating QL (30 per 30 days) (Zyprexa Zydis) 10 mg, 15 mg, 20 mg, 5 mg paliperidone oral tablet extended QL (30 per 30 days) (Invega) release 24hr 1.5 mg, 3 mg, 9 mg paliperidone oral tablet extended QL (60 per 30 days) (Invega) release 24hr 6 mg perphenazine oral tablet 16 mg, 2 mg, 4 mg, 8 mg pimozide oral tablet 1 mg, 2 mg (Orap) quetiapine oral tablet 100 mg, 200 (Seroquel) QL (90 per 30 days) mg, 25 mg, 300 mg, 400 mg, 50 mg quetiapine oral tablet extended release 24 hr 150 mg, 300 mg, 400 mg, 50 mg quetiapine oral tablet extended release 24 hr 200 mg (Seroquel XR) (Seroquel XR) ST; QL (60 per 30 days) ST; QL (30 per 30 days) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 72

87 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Non Dwòg REXULTI ORAL TABLET 0.25 ST; QL (120 per 30 MG days) REXULTI ORAL TABLET 0.5 MG ST; QL (60 per 30 days) REXULTI ORAL TABLET 1 MG, ST; QL (30 per 30 2 MG, 3 MG, 4 MG days) RISPERDAL CONSTA QL (4 per 28 days) INTRAMUSCULAR SYRINGE 12.5 MG/2 ML, 25 MG/2 ML, 37.5 MG/2 ML, 50 MG/2 ML risperidone oral solution 1 mg/ml (Risperdal) QL (480 per 30 days) risperidone oral tablet 0.25 mg, 0.5 QL (60 per 30 days) (Risperdal) mg, 1 mg, 2 mg, 3 mg, 4 mg risperidone oral QL (60 per 30 days) tablet,disintegrating 0.25 mg risperidone oral QL (60 per 30 days) (Risperdal M- tablet,disintegrating 0.5 mg, 1 mg, 2 TAB) mg risperidone oral (Risperdal M- QL (120 per 30 days) tablet,disintegrating 3 mg, 4 mg TAB) SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 10 MG, 2.5 MG, 5 MG ST; QL (60 per 30 days) thioridazine oral tablet 10 mg, 100 PA NSO-HRM; AGE mg, 25 mg, 50 mg (Max 64 Years) thiothixene oral capsule 1 mg, 10 mg, 2 mg, 5 mg trifluoperazine oral tablet 1 mg, 10 mg, 2 mg, 5 mg VERSACLOZ ORAL ST; QL (540 per 30 SUSPENSION 50 MG/ML days) VRAYLAR ORAL CAPSULE 1.5 ST; QL (30 per 30 MG, 3 MG, 4.5 MG, 6 MG VRAYLAR ORAL CAPSULE,DOSE PACK 1.5 MG (1)- 3 MG (6) days) ST; QL (7 per 30 days) Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 73

88 ziprasidone hcl oral capsule 20 mg, 40 mg, 60 mg, 80 mg (Geodon) ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 210 MG, 300 MG ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 405 MG Antivirals (Systemic) Antiretrovirals abacavir oral tablet 300 mg (Ziagen) abacavir-lamivudine oral tablet mg (Epzicom) abacavir-lamivudine-zidovudine oral tablet mg (Trizivir) APTIVUS ORAL CAPSULE 250 MG APTIVUS ORAL SOLUTION 100 MG/ML ATRIPLA ORAL TABLET MG COMPLERA ORAL TABLET MG CRIXIVAN ORAL CAPSULE 200 MG, 400 MG DESCOVY ORAL TABLET MG didanosine oral capsule,delayed release(dr/ec) 125 mg, 200 mg, 250 (Videx EC) mg, 400 mg EDURANT ORAL TABLET 25 MG QL (60 per 30 days) QL (2 per 28 days) QL (1 per 28 days) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 74

89 EMTRIVA ORAL CAPSULE 200 MG EMTRIVA ORAL SOLUTION 10 MG/ML EPIVIR HBV ORAL SOLUTION 25 MG/5 ML (5 MG/ML) EVOTAZ ORAL TABLET MG FUZEON SUBCUTANEOUS RECON SOLN 90 MG GENVOYA ORAL TABLET MG INTELENCE ORAL TABLET 100 MG, 200 MG, 25 MG INVIRASE ORAL CAPSULE 200 MG INVIRASE ORAL TABLET 500 MG ISENTRESS HD ORAL TABLET 600 MG ISENTRESS ORAL POWDER IN PACKET 100 MG ISENTRESS ORAL TABLET 400 MG ISENTRESS ORAL TABLET,CHEWABLE 100 MG, 25 MG KALETRA ORAL TABLET MG, MG lamivudine oral solution 10 mg/ml (Epivir) lamivudine oral tablet 100 mg (Epivir HBV) lamivudine oral tablet 150 mg, 300 mg (Epivir) lamivudine-zidovudine oral tablet mg (Combivir) 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 75

90 LEXIVA ORAL SUSPENSION 50 MG/ML LEXIVA ORAL TABLET 700 MG lopinavir-ritonavir oral solution mg/5 ml (Kaletra) nevirapine oral suspension 50 mg/5 ml (Viramune) nevirapine oral tablet 200 mg (Viramune) nevirapine oral tablet extended release 24 hr 100 mg, 400 mg (Viramune XR) NORVIR ORAL CAPSULE 100 MG NORVIR ORAL SOLUTION 80 MG/ML NORVIR ORAL TABLET 100 MG ODEFSEY ORAL TABLET MG PREZCOBIX ORAL TABLET MG-MG PREZISTA ORAL SUSPENSION 100 MG/ML PREZISTA ORAL TABLET 150 MG, 400 MG, 600 MG, 75 MG, 800 MG RESCRIPTOR ORAL TABLET 200 MG RESCRIPTOR ORAL TABLET, DISPERSIBLE 100 MG RETROVIR INTRAVENOUS SOLUTION 10 MG/ML REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG REYATAZ ORAL POWDER IN PACKET 50 MG SELZENTRY ORAL SOLUTION 20 MG/ML You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 76

91 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Non Dwòg SELZENTRY ORAL TABLET 150 MG, 25 MG, 300 MG, 75 MG stavudine oral capsule 15 mg, 20 mg, 30 mg, 40 mg (Zerit) stavudine oral recon soln 1 mg/ml (Zerit) STRIBILD ORAL TABLET MG SUSTIVA ORAL CAPSULE 200 MG, 50 MG SUSTIVA ORAL TABLET 600 MG TIVICAY ORAL TABLET 10 MG, 25 MG, 50 MG TRIUMEQ ORAL TABLET MG TRUVADA ORAL TABLET MG, MG, MG, MG VIDEX 2 GRAM PEDIATRIC ORAL RECON SOLN 10 MG/ML (FINAL) VIRACEPT ORAL TABLET 250 MG, 625 MG VIREAD ORAL POWDER 40 MG/SCOOP (40 MG/GRAM) VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG, 300 MG VITEKTA ORAL TABLET 150 MG, 85 MG ZERIT ORAL RECON SOLN 1 MG/ML ZIAGEN ORAL SOLUTION 20 MG/ML zidovudine oral capsule 100 mg (Retrovir) zidovudine oral syrup 10 mg/ml (Retrovir) zidovudine oral tablet 300 mg Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 77

92 Antivirals, Miscellaneous foscarnet intravenous solution 24 mg/ml (Foscavir) oseltamivir oral capsule 30 mg (Tamiflu) QL (84 per 180 days) oseltamivir oral capsule 45 mg (Tamiflu) QL (48 per 180 days) oseltamivir oral capsule 75 mg (Tamiflu) QL (42 per 180 days) RELENZA DISKHALER INHALATION BLISTER WITH DEVICE 5 MG/ACTUATION rimantadine oral tablet 100 mg (Flumadine) SYNAGIS INTRAMUSCULAR SOLUTION 100 MG/ML, 50 MG/0.5 ML TAMIFLU ORAL SUSPENSION FOR RECONSTITUTION 6 MG/ML Hcv Antivirals DAKLINZA ORAL TABLET 30 MG, 60 MG, 90 MG EPCLUSA ORAL TABLET MG HARVONI ORAL TABLET MG OLYSIO ORAL CAPSULE 150 MG SOVALDI ORAL TABLET 400 MG TECHNIVIE ORAL TABLET MG VIEKIRA PAK ORAL TABLETS,DOSE PACK 12.5 MG- 75 MG -50 MG/250 MG VIEKIRA XR ORAL TABLET, IR - ER, BIPHASIC 24HR 8.33 MG- 50 MG MG-200 MG PA QL (540 per 180 days) PA; QL (28 per 28 days) PA; QL (28 per 28 days) PA; QL (30 per 30 days) PA; QL (28 per 28 days) PA; QL (28 per 28 days) PA; QL (56 per 28 days) PA; QL (112 per 28 days) PA; QL (84 per 28 days) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 78

93 ZEPATIER ORAL TABLET MG Interferons INTRON A INJECTION RECON SOLN 10 MILLION UNIT (1 ML), 18 MILLION UNIT (1 ML), 50 MILLION UNIT (1 ML) INTRON A INJECTION SOLUTION 10 MILLION UNIT/ML, 6 MILLION UNIT/ML PEGASYS PROCLICK SUBCUTANEOUS PEN INJECTOR 135 MCG/0.5 ML, 180 MCG/0.5 ML PEGASYS SUBCUTANEOUS SOLUTION 180 MCG/ML PEGASYS SUBCUTANEOUS SYRINGE 180 MCG/0.5 ML PEGINTRON SUBCUTANEOUS KIT 120 MCG/0.5 ML, 150 MCG/0.5 ML, 50 MCG/0.5 ML, 80 MCG/0.5 ML SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 MCG, 600 MCG Nucleosides And Nucleotides acyclovir 1,000 mg/20 ml vial latexfree,sdv 50 mg/ml acyclovir oral capsule 200 mg (Zovirax) acyclovir oral suspension 200 mg/5 ml (Zovirax) acyclovir oral tablet 400 mg, 800 mg (Zovirax) acyclovir sodium intravenous recon soln 500 mg PA; QL (30 per 30 days) PA NSO PA NSO PA NSO; QL (4 per 28 days) 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 79

94 acyclovir sodium intravenous solution 50 mg/ml adefovir oral tablet 10 mg (Hepsera) entecavir oral tablet 0.5 mg, 1 mg (Baraclude) famciclovir oral tablet 125 mg, 250 mg, 500 mg ganciclovir sodium intravenous recon soln 500 mg (Cytovene) ribasphere oral capsule 200 mg ribasphere oral tablet 200 mg, 400 mg, 600 mg ribavirin inhalation recon soln 6 gram (Virazole) TYZEKA ORAL TABLET 600 MG valacyclovir oral tablet 1 gram, 500 mg (Valtrex) valganciclovir oral tablet 450 mg (Valcyte) VEMLIDY ORAL TABLET 25 MG VIRAZOLE INHALATION RECON SOLN 6 GRAM Blood Products/Modifiers/Volume Expanders Anticoagulants CEPROTIN (BLUE BAR) INTRAVENOUS RECON SOLN 500 UNIT ELIQUIS ORAL TABLET 2.5 MG, 5 MG enoxaparin subcutaneous solution 300 mg/3 ml (Lovenox) enoxaparin subcutaneous syringe 100 mg/ml, 120 mg/0.8 ml, 150 mg/ml, 30 mg/0.3 ml, 40 mg/0.4 ml, (Lovenox) 60 mg/0.6 ml, 80 mg/0.8 ml QL (30 per 30 days) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 80

95 fondaparinux subcutaneous syringe 10 mg/0.8 ml fondaparinux subcutaneous syringe 2.5 mg/0.5 ml fondaparinux subcutaneous syringe 5 mg/0.4 ml fondaparinux subcutaneous syringe 7.5 mg/0.6 ml heparin (porcine) in 5 % dex intravenous parenteral solution 20,000 unit/500 ml (40 unit/ml) heparin (porcine) in 5 % dex intravenous parenteral solution 25,000 unit/250 ml(100 unit/ml) heparin (porcine) injection solution 1,000 unit/ml, 10,000 unit/ml, 20,000 unit/ml, 5,000 unit/ml heparin 25,000 unit/250 ml (100 unit/ml)-0.45% nacl bag l/f,inner,single-use 25,000 unit/250 ml heparin, porcine (pf) injection solution 5,000 unit/0.5 ml heparin, porcine (pf) injection syringe 5,000 unit/0.5 ml IPRIVASK SUBCUTANEOUS RECON SOLN 15 MG jantoven oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg PRADAXA ORAL CAPSULE 110 MG, 150 MG, 75 MG warfarin oral tablet 1 mg, 10 mg, 3 mg warfarin oral tablet 2 mg, 2.5 mg, 4 mg, 5 mg, 6 mg, 7.5 mg (Arixtra) (Arixtra) (Arixtra) (Arixtra) (Coumadin) (Jantoven) QL (24 per 30 days) QL (15 per 30 days) QL (12 per 30 days) QL (18 per 30 days) PA; QL (24 per 28 days) ST; QL (60 per 30 days) 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 81

96 XARELTO ORAL TABLET 10 MG, 15 MG, 20 MG XARELTO ORAL TABLETS,DOSE PACK 15 MG (42)- 20 MG (9) Blood Formation Modifiers CINRYZE INTRAVENOUS RECON SOLN 500 UNIT (5 ML) EPOGEN 10,000 UNITS/ML VIAL SDV, P/F, OUTER 10,000 UNIT/ML EPOGEN INJECTION SOLUTION 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML GRANIX SUBCUTANEOUS SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML LEUKINE INJECTION RECON SOLN 250 MCG MIRCERA INJECTION SYRINGE 100 MCG/0.3 ML, 150 MCG/0.3 ML, 200 MCG/0.3 ML, 30 MCG/0.3 ML, 50 MCG/0.3 ML, 75 MCG/0.3 ML MOZOBIL SUBCUTANEOUS SOLUTION 24 MG/1.2 ML (20 MG/ML) NEULASTA SUBCUTANEOUS SYRINGE 6 MG/0.6ML NEULASTA SUBCUTANEOUS SYRINGE, W/ WEARABLE INJECTOR 6 MG/0.6 ML NEUPOGEN INJECTION SOLUTION 300 MCG/ML, 480 MCG/1.6 ML PA PA; QL (12 per 28 days) PA; QL (12 per 28 days) PA; QL (0.6 per 28 days) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 82

97 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Non Dwòg NEUPOGEN INJECTION SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML PROCRIT INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML PROCRIT INJECTION SOLUTION 40,000 UNIT/ML PROMACTA ORAL TABLET 12.5 MG, 25 MG, 50 MG, 75 MG ZARXIO INJECTION SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML Hematologic Agents, Miscellaneous anagrelide oral capsule 0.5 mg (Agrylin) anagrelide oral capsule 1 mg protamine intravenous solution 10 mg/ml tranexamic acid intravenous solution 1,000 mg/10 ml (100 (Cyklokapron) PA; QL (12 per 28 days) PA; QL (6 per 28 days) PA; QL (30 per 30 days) ST mg/ml) tranexamic acid oral tablet 650 mg (Lysteda) QL (30 per 30 days) Platelet-Aggregation Inhibitors aspirin-dipyridamole oral capsule, er multiphase 12 hr mg (Aggrenox) BRILINTA ORAL TABLET 60 MG, 90 MG cilostazol oral tablet 100 mg, 50 mg clopidogrel oral tablet 300 mg, 75 mg (Plavix) dipyridamole oral tablet 25 mg, 50 mg, 75 mg EFFIENT ORAL TABLET 10 MG, 5 MG QL (30 per 30 days) Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 83

98 pentoxifylline oral tablet extended release 400 mg Caloric Agents Caloric Agents AMINO ACIDS 15 % INTRAVENOUS PARENTERAL SOLUTION 15 % AMINOSYN 10 % INTRAVENOUS PARENTERAL SOLUTION 10 % AMINOSYN 7 % WITH ELECTROLYTES INTRAVENOUS PARENTERAL SOLUTION 7 % AMINOSYN 8.5 % INTRAVENOUS PARENTERAL SOLUTION 8.5 % AMINOSYN 8.5 %- ELECTROLYTES INTRAVENOUS PARENTERAL SOLUTION 8.5 % AMINOSYN II 10 % INTRAVENOUS PARENTERAL SOLUTION 10 % AMINOSYN II 15 % INTRAVENOUS PARENTERAL SOLUTION 15 % AMINOSYN II 7 % INTRAVENOUS PARENTERAL SOLUTION 7 % AMINOSYN II 8.5 % INTRAVENOUS PARENTERAL SOLUTION 8.5 % AMINOSYN II 8.5 %- ELECTROLYTES INTRAVENOUS PARENTERAL SOLUTION 8.5 % You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 84

99 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Non Dwòg AMINOSYN M 3.5 % INTRAVENOUS PARENTERAL SOLUTION 3.5 % AMINOSYN-HBC 7% INTRAVENOUS PARENTERAL SOLUTION 7 % AMINOSYN-PF 10 % INTRAVENOUS PARENTERAL SOLUTION 10 % AMINOSYN-PF 7 % (SULFITE- FREE) INTRAVENOUS PARENTERAL SOLUTION 7 % AMINOSYN-RF 5.2 % INTRAVENOUS PARENTERAL SOLUTION 5.2 % CLINIMIX 5%/D15W SULFITE FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX 5%/D25W SULFITE- FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX 2.75%/D5W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 2.75 % CLINIMIX 4.25%/D10W SULF FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX 4.25%/D5W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX 4.25%-D20W SULF- FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 85

100 CLINIMIX 4.25%-D25W SULF- FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX 5%-D20W(SULFITE- FREE) INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX E 2.75%/D10W SUL FREE INTRAVENOUS PARENTERAL SOLUTION 2.75 % CLINIMIX E 2.75%/D5W SULF FREE INTRAVENOUS PARENTERAL SOLUTION 2.75 % CLINIMIX E 4.25%/D10W SUL FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX E 4.25%/D25W SUL FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX E 4.25%/D5W SULF FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX E 5%/D15W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX E 5%/D20W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX E 5%/D25W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 5 % You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 86

101 CLINISOL SF 15 % INTRAVENOUS PARENTERAL SOLUTION 15 % dex4 glucose 4 gm tablet chew watermelon flavor 4 gram * dex4 glucose 40% gel 40 % * dextrose 10 % in water (d10w) intravenous parenteral solution 10 % dextrose 20 % in water (d20w) intravenous parenteral solution 20 % dextrose 25 % in water (d25w) intravenous syringe dextrose 40 % in water (d40w) intravenous parenteral solution 40 % dextrose 5 % in ringer's intravenous parenteral solution 5 % dextrose 5 % in water (d5w) intravenous parenteral solution dextrose 50 % in water (d50w) intravenous parenteral solution dextrose 50 % in water (d50w) intravenous syringe dextrose 70 % in water (d70w) intravenous parenteral solution FREAMINE HBC 6.9 % INTRAVENOUS PARENTERAL SOLUTION 6.9 % FREAMINE III 10 % INTRAVENOUS PARENTERAL SOLUTION 10 % gluco burst 40% gel 40 % * glucose 4 gram tablet chew na/f, (TRUEplus caffeine free 4 gram * Glucose) 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 87

102 glucose 40% gel tropical fruit 40 % * glutose 15 gel 3 pak, outer, u-d 40 % * HEPATAMINE 8% INTRAVENOUS PARENTERAL SOLUTION 8 % insta-glucose gel 24 gram/31 gram * INTRALIPID INTRAVENOUS EMULSION 20 %, 30 % KABIVEN INTRAVENOUS EMULSION % NEPHRAMINE 5.4 % INTRAVENOUS PARENTERAL SOLUTION 5.4 % NUTRILIPID INTRAVENOUS EMULSION 20 % PERIKABIVEN INTRAVENOUS EMULSION % PREMASOL 10 % INTRAVENOUS PARENTERAL SOLUTION 10 % PREMASOL 6 % INTRAVENOUS PARENTERAL SOLUTION 6 % PROCALAMINE 3% INTRAVENOUS PARENTERAL SOLUTION 3 % PROSOL 20 % INTRAVENOUS PARENTERAL SOLUTION smoflipid intravenous emulsion 20 % TRAVASOL 10 % INTRAVENOUS PARENTERAL SOLUTION 10 % You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 88

103 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Non Dwòg TROPHAMINE 10 % INTRAVENOUS PARENTERAL SOLUTION 10 % TROPHAMINE 6% INTRAVENOUS PARENTERAL SOLUTION 6 % trueplus glucose 15 gram gel fruit punch gram-unit/42 ml * Cardiovascular Agents Alpha-Adrenergic Agents clonidine hcl oral tablet 0.1 mg, 0.2 mg, 0.3 mg clonidine transdermal patch weekly 0.1 mg/24 hr clonidine transdermal patch weekly 0.2 mg/24 hr clonidine transdermal patch weekly 0.3 mg/24 hr clorpres oral tablet mg, mg, mg doxazosin oral tablet 1 mg, 2 mg, 4 mg, 8 mg (Catapres) (Catapres-TTS-1) (Catapres-TTS-2) (Catapres-TTS-3) (Cardura) guanfacine oral tablet 1 mg, 2 mg midodrine oral tablet 10 mg, 2.5 mg, 5 mg NORTHERA ORAL CAPSULE 100 MG, 200 MG, 300 MG phenylephrine hcl injection solution 10 mg/ml (Vazculep) prazosin oral capsule 1 mg, 2 mg, 5 mg (Minipress) Angiotensin Ii Receptor Antagonists candesartan oral tablet 16 mg, 32 mg, 4 mg, 8 mg (Atacand) QL (4 per 28 days) QL (4 per 28 days) QL (8 per 28 days) PA-HRM; AGE (Max 64 Years) PA; QL (180 per 30 days) Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 89

104 candesartan-hydrochlorothiazid oral tablet mg, mg, (Atacand HCT) mg ENTRESTO ORAL TABLET MG, MG, MG irbesartan oral tablet 150 mg, 300 mg, 75 mg (Avapro) irbesartan-hydrochlorothiazide oral tablet mg, mg (Avalide) losartan oral tablet 100 mg, 25 mg, 50 mg (Cozaar) losartan-hydrochlorothiazide oral tablet mg, mg, 50- (Hyzaar) 12.5 mg olmesartan oral tablet 20 mg, 40 mg, 5 mg (Benicar) olmesartan-amlodipin-hcthiazid oral tablet mg, (Tribenzor) mg, mg, mg, mg olmesartan-hydrochlorothiazide oral tablet mg, mg, (Benicar HCT) mg telmisartan oral tablet 20 mg, 40 mg, 80 mg (Micardis) telmisartan-hydrochlorothiazid oral tablet mg, mg, 80- (Micardis HCT) 25 mg valsartan oral tablet 160 mg, 320 mg, 40 mg, 80 mg (Diovan) valsartan-hydrochlorothiazide oral tablet mg, mg, 320- (Diovan HCT) 12.5 mg, mg, mg Angiotensin-Converting Enzyme Inhibitors benazepril oral tablet 10 mg, 5 mg benazepril oral tablet 20 mg, 40 mg (Lotensin) QL (60 per 30 days) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 90

105 benazepril-hydrochlorothiazide oral tablet mg, mg, 20- (Lotensin HCT) 25 mg benazepril-hydrochlorothiazide oral tablet mg captopril oral tablet 100 mg, 12.5 mg, 25 mg, 50 mg captopril-hydrochlorothiazide oral tablet mg, mg, mg, mg enalapril maleate oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg (Vasotec) enalaprilat intravenous solution 1.25 mg/ml enalapril-hydrochlorothiazide oral tablet mg (Vaseretic) enalapril-hydrochlorothiazide oral tablet mg fosinopril oral tablet 10 mg, 20 mg, 40 mg fosinopril-hydrochlorothiazide oral tablet mg, mg lisinopril oral tablet 10 mg (Prinivil) lisinopril oral tablet 2.5 mg, 20 mg, 30 mg, 40 mg, 5 mg (Zestril) lisinopril-hydrochlorothiazide oral tablet mg, mg, 20- (Zestoretic) 25 mg moexipril oral tablet 15 mg, 7.5 mg moexipril-hydrochlorothiazide oral tablet mg, mg, mg perindopril erbumine oral tablet 2 mg, 4 mg, 8 mg QBRELIS ORAL SOLUTION 1 MG/ML ST 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 91

106 quinapril oral tablet 10 mg, 20 mg, 40 mg, 5 mg (Accupril) quinapril-hydrochlorothiazide oral tablet mg, mg, 20- (Accuretic) 25 mg ramipril oral capsule 1.25 mg, 10 mg, 2.5 mg, 5 mg (Altace) trandolapril oral tablet 1 mg, 4 mg trandolapril oral tablet 2 mg (Mavik) Antiarrhythmic Agents amiodarone oral tablet 100 mg, 200 mg, 400 mg (Pacerone) disopyramide phosphate oral capsule 100 mg, 150 mg (Norpace) dofetilide oral capsule 125 mcg, 250 mcg, 500 mcg (Tikosyn) flecainide oral tablet 100 mg, 150 mg, 50 mg lidocaine (pf) intravenous syringe 50 mg/5 ml (1 %) lidocaine in 5 % dextrose (pf) intravenous parenteral solution 8 mg/ml (0.8 %) mexiletine oral capsule 150 mg, 200 mg, 250 mg MULTAQ ORAL TABLET 400 MG pacerone oral tablet 100 mg, 200 mg, 400 mg procainamide injection solution 100 mg/ml, 500 mg/ml propafenone oral capsule,extended release 12 hr 225 mg, 325 mg, 425 (Rythmol SR) mg propafenone oral tablet 150 mg, 225 mg, 300 mg You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 92

107 quinidine gluconate oral tablet extended release 324 mg quinidine sulfate oral tablet 200 mg, 300 mg quinidine sulfate oral tablet extended release 300 mg Beta-Adrenergic Blocking Agents acebutolol oral capsule 200 mg, 400 mg atenolol oral tablet 100 mg, 25 mg, 50 mg (Tenormin) atenolol-chlorthalidone oral tablet mg (Tenoretic 100) atenolol-chlorthalidone oral tablet mg (Tenoretic 50) betaxolol oral tablet 10 mg, 20 mg bisoprolol fumarate oral tablet 10 mg, 5 mg bisoprolol-hydrochlorothiazide oral tablet mg, mg, 5- (Ziac) 6.25 mg BYSTOLIC ORAL TABLET 10 MG, 2.5 MG, 20 MG, 5 MG BYVALSON ORAL TABLET 5-80 MG carvedilol oral tablet 12.5 mg, 25 mg, mg, 6.25 mg (Coreg) esmolol intravenous solution 100 mg/10 ml (10 mg/ml) (Brevibloc) labetalol intravenous solution 5 mg/ml labetalol oral tablet 100 mg, 200 mg, 300 mg metoprolol succinate oral tablet extended release 24 hr 100 mg, 200 (Toprol XL) mg, 25 mg, 50 mg 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 93

108 metoprolol ta-hydrochlorothiaz oral tablet mg, mg metoprolol ta-hydrochlorothiaz oral tablet mg (Lopressor HCT) metoprolol tartrate intravenous solution 5 mg/5 ml (Lopressor) metoprolol tartrate intravenous syringe 5 mg/5 ml metoprolol tartrate oral tablet 100 mg, 50 mg (Lopressor) metoprolol tartrate oral tablet 25 mg, 37.5 mg, 75 mg nadolol oral tablet 20 mg, 40 mg, 80 (Corgard) mg pindolol oral tablet 10 mg, 5 mg propranolol intravenous solution 1 mg/ml propranolol oral capsule,extended release 24 hr 120 mg, 160 mg, 60 (Inderal LA) mg, 80 mg propranolol oral solution 20 mg/5 ml (4 mg/ml), 40 mg/5 ml (8 mg/ml) propranolol oral tablet 10 mg, 20 mg, 40 mg, 60 mg, 80 mg propranolol-hydrochlorothiazid oral tablet mg, mg sorine oral tablet 120 mg, 160 mg, 240 mg, 80 mg sotalol 120 mg tablet 120 mg (Sorine) sotalol af oral tablet 120 mg sotalol oral tablet 160 mg (Sorine) sotalol oral tablet 240 mg (Betapace) sotalol oral tablet 80 mg (Sotalol AF) timolol maleate oral tablet 10 mg, 20 mg, 5 mg Calcium-Channel Blocking Agents You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 94

109 cartia xt oral capsule,extended release 24hr 120 mg, 180 mg, 240 mg, 300 mg diltiazem 24hr er 180 mg cap 180 mg (Cardizem CD) diltiazem 24hr er 360 mg cap 360 mg (Cardizem CD) diltiazem hcl intravenous recon soln 100 mg diltiazem hcl intravenous solution 5 mg/ml diltiazem hcl oral capsule, extended release 180 mg, 360 mg (Taztia XT) diltiazem hcl oral capsule, extended release 420 mg (Tiazac) diltiazem hcl oral capsule,extended release 12 hr 120 mg, 60 mg, 90 mg diltiazem hcl oral capsule,extended release 24hr 120 mg, 240 mg, 300 (Cartia XT) mg diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg (Cardizem) diltiazem hcl oral tablet 90 mg diltiazem hcl oral tablet extended release 24 hr 180 mg, 240 mg, 300 (Matzim LA) mg, 360 mg, 420 mg dilt-xr oral capsule,ext release degradable 120 mg, 180 mg, 240 mg matzim la oral tablet extended release 24 hr 180 mg, 240 mg, 300 mg, 360 mg, 420 mg taztia xt oral capsule, extended release 120 mg, 180 mg, 240 mg, 300 mg, 360 mg verapamil intravenous syringe 2.5 mg/ml 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 95

110 verapamil oral capsule, 24 hr er pellet ct 100 mg, 200 mg, 300 mg (Verelan PM) verapamil oral capsule,ext rel. pellets 24 hr 120 mg, 180 mg, 240 mg, 360 mg (Verelan) verapamil oral tablet 120 mg, 80 mg (Calan) verapamil oral tablet 40 mg verapamil oral tablet extended release 120 mg, 180 mg, 240 mg (Calan SR) Cardiovascular Agents, Miscellaneous CORLANOR ORAL TABLET 5 MG, 7.5 MG DEMSER ORAL CAPSULE 250 MG digitek oral tablet 125 mcg digitek oral tablet 250 mcg digoxin 0.25 mg/ml syringe 250 mcg/ml PA-HRM; PA REQUIRED: High Risk Med for Ages 65 and Older and Dose is Greater than 125mcg per Day; QL (30 per 30 days); AGE (Max 64 Years) PA-HRM; PA REQUIRED: High Risk Med for Ages 65 and Older; QL (30 per 30 days); AGE (Max 64 Years) PA-HRM; PA REQUIRED: High Risk Med for Ages 65 and Older; AGE (Max 64 Years) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 96

111 digoxin injection solution 250 mcg/ml DIGOXIN ORAL SOLUTION 50 MCG/ML (Lanoxin) digoxin oral tablet 125 mcg (Lanoxin) digoxin oral tablet 250 mcg (Digox) dobutamine in d5w intravenous parenteral solution 1,000 mg/250 ml (4,000 mcg/ml), 250 mg/250 ml (1 mg/ml), 500 mg/250 ml (2,000 mcg/ml) dobutamine intravenous solution 250 mg/20 ml (12.5 mg/ml), 500 mg/40 ml (12.5 mg/ml) PA-HRM; PA REQUIRED: High Risk Med for Ages 65 and Older; AGE (Max 64 Years) PA-HRM; PA REQUIRED: High Risk Med for Ages 65 and Older and Dose is Greater than 125mcg per Day; AGE (Max 64 Years) PA-HRM; PA REQUIRED: High Risk Med for Ages 65 and Older and Dose is Greater than 125mcg per Day; QL (30 per 30 days); AGE (Max 64 Years) PA-HRM; PA REQUIRED: High Risk Med for Ages 65 and Older; QL (30 per 30 days); AGE (Max 64 Years) 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 97

112 dopamine in 5 % dextrose intravenous solution 200 mg/250 ml (800 mcg/ml), 400 mg/250 ml (1,600 mcg/ml), 800 mg/250 ml (3,200 mcg/ml) dopamine intravenous solution 200 mg/5 ml (40 mg/ml), 400 mg/5 ml (80 mg/ml), 800 mg/10 ml (80 mg/ml), 800 mg/5 ml (160 mg/ml) epinephrine hcl (pf) injection solution 1 mg/ml (1 ml) epinephrine injection auto-injector 0.15 mg/0.15 ml epinephrine injection auto-injector 0.15 mg/0.3 ml epinephrine injection auto-injector 0.3 % epinephrine injection auto-injector 0.3 mg/0.3 ml epinephrine injection syringe 0.1 mg/ml FIRAZYR SUBCUTANEOUS SYRINGE 30 MG/3 ML hydralazine injection solution 20 mg/ml hydralazine oral tablet 10 mg, 100 mg, 25 mg, 50 mg LANOXIN ORAL TABLET MCG (Auvi-Q) (EpiPen Jr 2-Pak) (Auvi-Q) GENERIC FOR ADRENACLICK GENERIC FOR EPIPEN PA-HRM; PA REQUIRED: High Risk Med for Ages 65 and Older; QL (30 per 30 days); AGE (Max 64 Years) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 98

113 LANOXIN ORAL TABLET 62.5 MCG milrinone in 5 % dextrose intravenous piggyback 20 mg/100 ml (200 mcg/ml), 40 mg/200 ml (200 mcg/ml) milrinone intravenous solution 1 mg/ml norepinephrine bitartrate intravenous solution 1 mg/ml RANEXA ORAL TABLET EXTENDED RELEASE 12 HR 1,000 MG, 500 MG Dihydropyridines afeditab cr oral tablet extended release 30 mg, 60 mg amlodipine oral tablet 10 mg, 2.5 mg, 5 mg amlodipine-benazepril oral capsule mg, mg, 5-10 mg, 5-20 mg, 5-40 mg amlodipine-benazepril oral capsule mg amlodipine-olmesartan oral tablet mg, mg, 5-20 mg, 5-40 mg amlodipine-valsartan oral tablet mg, mg, mg, mg (Levophed (bitartrate)) (Norvasc) (Lotrel) (Azor) (Exforge) PA-HRM; PA REQUIRED: High Risk Med for Ages 65 and Older and Dose is Greater than 125mcg per Day; QL (60 per 30 days); AGE (Max 64 Years) 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 99

114 amlodipine-valsartan-hcthiazid oral tablet mg, mg, mg, mg, (Exforge HCT) mg CLEVIPREX INTRAVENOUS EMULSION 50 MG/100 ML felodipine oral tablet extended release 24 hr 10 mg, 2.5 mg, 5 mg isradipine oral capsule 2.5 mg, 5 mg nicardipine oral capsule 20 mg, 30 mg nifedical xl oral tablet extended release 24hr 30 mg, 60 mg nifedipine oral tablet extended release 24hr 30 mg, 60 mg, 90 mg (Procardia XL) nifedipine oral tablet extended release 30 mg, 90 mg (Adalat CC) nifedipine oral tablet extended release 60 mg (Afeditab CR) Diuretics amiloride oral tablet 5 mg amiloride-hydrochlorothiazide oral tablet 5-50 mg bumetanide injection solution 0.25 mg/ml bumetanide oral tablet 0.5 mg, 1 mg, 2 mg chlorothiazide oral tablet 250 mg, 500 mg chlorothiazide sodium intravenous recon soln 500 mg (Diuril IV) chlorthalidone oral tablet 25 mg, 50 mg DYRENIUM ORAL CAPSULE 100 MG, 50 MG You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 100

115 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Non Dwòg furosemide injection solution 10 mg/ml furosemide injection syringe 10 mg/ml furosemide oral solution 10 mg/ml, 40 mg/5 ml (8 mg/ml) furosemide oral tablet 20 mg, 40 mg, 80 mg (Lasix) hydrochlorothiazide oral capsule 12.5 mg (Microzide) hydrochlorothiazide oral tablet 12.5 mg, 25 mg, 50 mg indapamide oral tablet 1.25 mg, 2.5 mg methyclothiazide oral tablet 5 mg metolazone oral tablet 10 mg, 2.5 mg, 5 mg spironolactone oral tablet 100 mg, 25 mg, 50 mg (Aldactone) spironolacton-hydrochlorothiaz oral (Aldactazide) tablet mg torsemide oral tablet 10 mg, 20 mg (Demadex) torsemide oral tablet 100 mg, 5 mg triamterene-hydrochlorothiazid oral capsule mg (Dyazide) triamterene-hydrochlorothiazid oral capsule mg triamterene-hydrochlorothiazid oral tablet mg (Maxzide-25mg) triamterene-hydrochlorothiazid oral tablet mg (Maxzide) Dyslipidemics amlodipine-atorvastatin oral tablet mg, mg, mg, mg, 5-10 mg, 5-20 mg, 5-40 mg, 5-80 mg (Caduet) Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 101

116 amlodipine-atorvastatin oral tablet mg, mg, mg atorvastatin oral tablet 10 mg, 20 mg, 40 mg, 80 mg (Lipitor) cholestyramine light oral powder 4 gram cholestyramine light oral powder in packet 4 gram cholestyramine packet outer 4 gram (Questran) colestipol hcl granules packet 5 gram (Colestid) colestipol oral granules 5 gram (Colestid) colestipol oral tablet 1 gram (Colestid) endur-acin sr 500 mg tablet 500 mg * ezetimibe oral tablet 10 mg (Zetia) fenofibrate micronized oral capsule 130 mg, 134 mg, 200 mg, 43 mg, 67 mg fenofibrate nanocrystallized oral tablet 145 mg, 48 mg (Tricor) fenofibrate oral tablet 120 mg, 40 mg (Fenoglide) fenofibrate oral tablet 160 mg, 54 mg fenofibric acid (choline) oral capsule,delayed release(dr/ec) 135 (Trilipix) mg, 45 mg fenofibric acid oral tablet 105 mg, 35 mg (Fibricor) gemfibrozil oral tablet 600 mg (Lopid) JUXTAPID ORAL CAPSULE 10 MG, 30 MG, 40 MG, 60 MG JUXTAPID ORAL CAPSULE 20 MG PA; QL (30 per 30 days) PA; QL (90 per 30 days) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 102

117 JUXTAPID ORAL CAPSULE 5 MG KYNAMRO SUBCUTANEOUS SYRINGE 200 MG/ML LIVALO ORAL TABLET 1 MG, 2 MG, 4 MG lovastatin oral tablet 10 mg, 20 mg, 40 mg niacin 50 mg tablet 50 mg * niacin 500 mg capsule sa 500 mg * niacin 500 mg tablet 500 mg * (Niacor) niacin oral tablet extended release (Niaspan 24 hr 1,000 mg, 500 mg, 750 mg Extended-Release) niacin tr 500 mg caplet caplet 500 mg * (Endur-Acin) niacinamide 500 mg tablet 500 mg * (Niacin (niacinamide)) niacor oral tablet 500 mg omega-3 acid ethyl esters oral capsule 1 gram (Lovaza) PRALUENT PEN SUBCUTANEOUS PEN INJECTOR 150 MG/ML, 75 MG/ML PRALUENT SYRINGE SUBCUTANEOUS SYRINGE 150 MG/ML, 75 MG/ML pravastatin oral tablet 10 mg pravastatin oral tablet 20 mg, 40 mg, 80 mg (Pravachol) prevalite oral powder 4 gram prevalite packet outer 4 gram REPATHA PUSHTRONEX SUBCUTANEOUS WEARABLE INJECTOR 420 MG/3.5 ML PA; QL (45 per 30 days) PA; QL (4 per 28 days) QL (30 per 30 days) QL (120 per 30 days) PA; QL (2 per 28 days) PA; QL (2 per 28 days) PA; QL (3.5 per 28 days) 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 103

118 REPATHA SURECLICK PA; QL (3 per 28 days) SUBCUTANEOUS PEN INJECTOR 140 MG/ML REPATHA SYRINGE PA; QL (3 per 28 days) SUBCUTANEOUS SYRINGE 140 MG/ML rosuvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg (Crestor) simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg (Zocor) simvastatin oral tablet 80 mg (Zocor) QL (30 per 30 days) VASCEPA ORAL CAPSULE 0.5 QL (240 per 30 days) GRAM VASCEPA ORAL CAPSULE 1 QL (120 per 30 days) GRAM WELCHOL ORAL POWDER IN PACKET 3.75 GRAM WELCHOL ORAL TABLET 625 MG Renin-Angiotensin-Aldosterone System Inhibitors eplerenone oral tablet 25 mg, 50 mg (Inspra) TEKAMLO ORAL TABLET MG, MG, MG, MG TEKTURNA HCT ORAL TABLET MG, MG, MG, MG TEKTURNA ORAL TABLET 150 MG, 300 MG Vasodilators BIDIL ORAL TABLET MG isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 mg isosorbide dinitrate oral tablet 5 mg (Isordil Titradose) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit ST ST ST 104

119 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Non Dwòg isosorbide dinitrate oral tablet extended release 40 mg (ISOCHRON) isosorbide mononitrate oral tablet 10 mg, 20 mg isosorbide mononitrate oral tablet extended release 24 hr 120 mg, 30 mg, 60 mg minitran transdermal patch 24 hour 0.1 mg/hr, 0.2 mg/hr, 0.6 mg/hr minitran transdermal patch 24 hour 0.4 mg/hr minoxidil oral tablet 10 mg, 2.5 mg NITRO-BID TRANSDERMAL OINTMENT 2 % nitroglycerin in 5 % dextrose intravenous solution 100 mg/250 ml (400 mcg/ml), 25 mg/250 ml (100 mcg/ml), 50 mg/250 ml (200 mcg/ml) nitroglycerin intravenous solution 50 mg/10 ml (5 mg/ml) nitroglycerin sublingual tablet 0.3 mg, 0.4 mg, 0.6 mg (Nitrostat) nitroglycerin transdermal patch 24 hour 0.1 mg/hr, 0.2 mg/hr, 0.6 (Nitro-Dur) mg/hr nitroglycerin transdermal patch 24 hour 0.4 mg/hr (Nitro-Dur) PROGLYCEM ORAL SUSPENSION 50 MG/ML Central Nervous System Agents Central Nervous System Agents AMPYRA ORAL TABLET EXTENDED RELEASE 12 HR 10 MG QL (30 per 30 days) QL (60 per 30 days) QL (30 per 30 days) QL (60 per 30 days) PA; QL (60 per 30 days) Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 105

120 atomoxetine oral capsule 10 mg, 100 mg, 18 mg, 25 mg, 40 mg, 60 mg, 80 mg AUBAGIO ORAL TABLET 14 MG, 7 MG AUSTEDO ORAL TABLET 12 MG, 9 MG (Strattera) AUSTEDO ORAL TABLET 6 MG AVONEX (WITH ALBUMIN) INTRAMUSCULAR KIT 30 MCG AVONEX INTRAMUSCULAR PEN INJECTOR KIT 30 MCG/0.5 ML AVONEX INTRAMUSCULAR SYRINGE KIT 30 MCG/0.5 ML BETASERON SUBCUTANEOUS KIT 0.3 MG caffeine citrate intravenous solution 60 mg/3 ml (20 mg/ml) caffeine citrate oral solution 60 mg/3 ml (20 mg/ml) clonidine hcl oral tablet extended release 12 hr 0.1 mg COPAXONE SUBCUTANEOUS SYRINGE 20 MG/ML, 40 MG/ML dexmethylphenidate oral tablet 10 mg, 2.5 mg, 5 mg dextroamphetamine oral capsule, extended release 10 mg, 15 mg, 5 mg dextroamphetamine oral tablet 10 mg, 5 mg dextroamphetamine-amphetamine oral capsule,extended release 24hr 10 mg, 15 mg, 5 mg (Cafcit) (Kapvay) (Focalin) (Dexedrine Spansule) (Zenzedi) (Adderall XR) PA; QL (28 per 28 days) PA; QL (120 per 30 days) PA; QL (60 per 30 days) PA PA PA PA PA QL (60 per 30 days) QL (120 per 30 days) QL (180 per 30 days) QL (30 per 30 days) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 106

121 dextroamphetamine-amphetamine oral capsule,extended release 24hr 20 mg, 25 mg, 30 mg dextroamphetamine-amphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 30 mg, 5 mg, 7.5 mg EXTAVIA SUBCUTANEOUS KIT 0.3 MG flumazenil intravenous solution 0.1 mg/ml GILENYA ORAL CAPSULE 0.5 MG guanfacine oral tablet extended release 24 hr 1 mg, 2 mg, 3 mg, 4 mg INGREZZA ORAL CAPSULE 40 MG LEMTRADA INTRAVENOUS SOLUTION 12 MG/1.2 ML lithium carbonate oral capsule 150 mg, 300 mg, 600 mg lithium carbonate oral tablet 300 mg lithium carbonate oral tablet extended release 300 mg lithium carbonate oral tablet extended release 450 mg lithium citrate oral solution 8 meq/5 ml methylphenidate oral capsule, er biphasic mg, 20 mg, 40 mg, 50 mg, 60 mg methylphenidate oral capsule, er biphasic mg methylphenidate oral capsule,er biphasic mg, 40 mg (Adderall XR) (Adderall) (Intuniv ER) (Lithobid) (Metadate CD) (Metadate CD) (Ritalin LA) QL (60 per 30 days) QL (60 per 30 days) PA PA; QL (28 per 28 days) PA; QL (60 per 30 days) PA QL (30 per 30 days) QL (60 per 30 days) QL (30 per 30 days) 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 107

122 methylphenidate oral capsule,er biphasic mg methylphenidate oral solution 10 mg/5 ml, 5 mg/5 ml methylphenidate oral tablet 10 mg, 20 mg, 5 mg methylphenidate oral tablet extended release 10 mg methylphenidate oral tablet extended release 20 mg methylphenidate oral tablet extended release 24hr 18 mg, 27 mg, 54 mg methylphenidate oral tablet extended release 24hr 36 mg NUEDEXTA ORAL CAPSULE MG OCREVUS INTRAVENOUS SOLUTION 30 MG/ML PLEGRIDY SUBCUTANEOUS PEN INJECTOR 125 MCG/0.5 ML, 63 MCG/0.5 ML- 94 MCG/0.5 ML PLEGRIDY SUBCUTANEOUS SYRINGE 125 MCG/0.5 ML, 63 MCG/0.5 ML- 94 MCG/0.5 ML RADICAVA INTRAVENOUS PIGGYBACK 30 MG/100 ML REBIF (WITH ALBUMIN) SUBCUTANEOUS SYRINGE 22 MCG/0.5 ML, 44 MCG/0.5 ML REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 22 MCG/0.5 ML, 44 MCG/0.5 ML, 8.8MCG/0.2ML-22 MCG/0.5ML (6) (Methylin) (Ritalin) (Metadate ER) (Concerta) (Concerta) QL (30 per 30 days) QL (900 per 30 days) QL (90 per 30 days) QL (90 per 30 days) QL (90 per 30 days) QL (30 per 30 days) QL (60 per 30 days) QL (60 per 30 days) PA; QL (20 per 180 days) PA PA PA; QL (2800 per 28 days) PA PA You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 108

123 REBIF TITRATION PACK SUBCUTANEOUS SYRINGE 8.8MCG/0.2ML-22 MCG/0.5ML (6) riluzole oral tablet 50 mg (Rilutek) SAVELLA ORAL TABLET 100 MG, 12.5 MG, 25 MG, 50 MG SAVELLA ORAL TABLETS,DOSE PACK 12.5 MG (5)-25 MG(8)-50 MG(42) STRATTERA ORAL CAPSULE 10 MG, 100 MG, 18 MG, 25 MG, 40 MG, 60 MG, 80 MG TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 120 MG TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 120 MG (14)- 240 MG (46), 240 MG tetrabenazine oral tablet 12.5 mg, 25 mg (Xenazine) ZINBRYTA SUBCUTANEOUS SYRINGE 150 MG/ML Contraceptives Contraceptives altavera (28) oral tablet mg alyacen 1/35 (28) oral tablet 1-35 mg-mcg alyacen 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 mcg amethia lo oral tablets,dose pack,3 month 0.10 mg-20 mcg (84)/10 mcg (7) PA QL (60 per 30 days) QL (60 per 30 days) PA; QL (14 per 30 days) PA; QL (60 per 30 days) PA; QL (112 per 28 days) PA; QL (1 per 28 days) QL (91 per 84 days) 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 109

124 amethia oral tablets,dose pack,3 month 0.15 mg-30 mcg (84)/10 mcg (7) apri oral tablet mg aranelle (28) oral tablet 0.5/1/ mg-mcg ashlyna oral tablets,dose pack,3 month 0.15 mg-30 mcg (84)/10 mcg (7) aubra oral tablet mg-mcg aviane oral tablet mg-mcg azurette (28) oral tablet mgx21 /0.01 mg x 5 balziva (28) oral tablet mgmcg bekyree (28) oral tablet mgx21 /0.01 mg x 5 blisovi 24 fe oral tablet 1 mg-20 mcg (24)/75 mg (4) blisovi fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg (21)/75 mg (7) blisovi fe 1/20 (28) oral tablet 1 mg- 20 mcg (21)/75 mg (7) briellyn oral tablet mg-mcg camila oral tablet 0.35 mg camrese lo oral tablets,dose pack,3 month 0.10 mg-20 mcg (84)/10 mcg (7) camrese oral tablets,dose pack,3 month 0.15 mg-30 mcg (84)/10 mcg (7) caziant (28) oral tablet 0.1/.125/ mg-mcg cryselle (28) oral tablet mgmcg QL (91 per 84 days) QL (91 per 84 days) QL (91 per 84 days) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 110

125 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Non Dwòg cyclafem 1/35 (28) oral tablet 1-35 mg-mcg cyclafem 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 mcg cyred oral tablet mg dasetta 1/35 (28) oral tablet 1-35 mg-mcg dasetta 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 mcg daysee oral tablets,dose pack,3 QL (91 per 84 days) month 0.15 mg-30 mcg (84)/10 mcg (7) deblitane oral tablet 0.35 mg delyla (28) oral tablet mgmcg desog-e.estradiol/e.estradiol oral tablet mgx21 /0.01 mg x 5 (Viorele (28)) desogestrel-ethinyl estradiol oral tablet mg (Desogen) drospirenone-ethinyl estradiol oral tablet mg (YAZ (28)) drospirenone-ethinyl estradiol oral tablet mg (Zarah) econtra ez 1.5 mg tablet inner 1.5 QL (6 per 365 days) mg * elinest oral tablet mg-mcg ELLA ORAL TABLET 30 MG QL (6 per 365 days) emoquette oral tablet mg enpresse oral tablet (6)/75-40 (5)/125-30(10) enskyce oral tablet mg errin oral tablet 0.35 mg estarylla oral tablet mg-mcg ethynodiol diac-eth estradiol oral tablet 1-50 mg-mcg (Zovia 1/50E (28)) Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 111

126 fallback solo 1.5 mg tablet outer 1.5 mg * falmina (28) oral tablet mgmcg femynor oral tablet mg-mcg gianvi (28) oral tablet mg gildagia oral tablet mg-mcg gildess 1.5/30 (21) oral tablet mg-mcg gildess 1/20 (21) oral tablet 1-20 mg-mcg gildess 24 fe oral tablet 1 mg-20 mcg (24)/75 mg (4) gildess fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg (21)/75 mg (7) gildess fe 1/20 (28) oral tablet 1 mg- 20 mcg (21)/75 mg (7) heather oral tablet 0.35 mg introvale oral tablets,dose pack,3 month 0.15 mg-30 mcg jencycla oral tablet 0.35 mg jolessa oral tablets,dose pack,3 month 0.15 mg-30 mcg jolivette oral tablet 0.35 mg juleber oral tablet mg junel 1.5/30 (21) oral tablet mg-mcg junel 1/20 (21) oral tablet 1-20 mgmcg junel fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg (21)/75 mg (7) junel fe 1/20 (28) oral tablet 1 mg- 20 mcg (21)/75 mg (7) junel fe 24 oral tablet 1 mg-20 mcg (24)/75 mg (4) QL (6 per 365 days) QL (91 per 84 days) QL (91 per 84 days) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 112

127 kariva (28) oral tablet mgx21 /0.01 mg x 5 kelnor 1/35 (28) oral tablet 1-35 mg-mcg kimidess (28) oral tablet mgx21 /0.01 mg x 5 kurvelo oral tablet mg l norgest/e.estradiol-e.estrad oral tablets,dose pack,3 month 0.10 mg- 20 mcg (84)/10 mcg (7) (Camrese Lo) l norgest/e.estradiol-e.estrad oral tablets,dose pack,3 month 0.15 mg- (Seasonique) 30 mcg (84)/10 mcg (7) larin 1.5/30 (21) oral tablet mg-mcg larin 1/20 (21) oral tablet 1-20 mgmcg larin 24 fe oral tablet 1 mg-20 mcg (24)/75 mg (4) larin fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg (21)/75 mg (7) larin fe 1/20 (28) oral tablet 1 mg- 20 mcg (21)/75 mg (7) larissia oral tablet mg-mcg leena 28 oral tablet 0.5/1/ mg-mcg lessina oral tablet mg-mcg levonest (28) oral tablet (6)/75-40 (5)/125-30(10) levonor-eth estrad outer (Levora 0.15/ mg (28)) levonorgestrel 1.5 mg tablet (otc) 1.5 mg * (Fallback Solo) levonorgestrel-ethinyl estrad oral tablet mg-mcg (Orsythia) QL (91 per 84 days) QL (91 per 84 days) QL (91 per 84 days) QL (6 per 365 days) 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 113

128 levonorgestrel-ethinyl estrad oral QL (91 per 84 days) tablets,dose pack,3 month 0.15 mg- 30 mcg (Jolessa) levonorg-eth estrad triphasic oral QL (91 per 84 days) tablet (6)/75-40 (5)/125-30(10) (Myzilra) levora-28 oral tablet mg lomedia 24 fe oral tablet 1 mg-20 mcg (24)/75 mg (4) loryna (28) oral tablet mg low-ogestrel (28) oral tablet mg-mcg lutera (28) oral tablet mgmcg lyza oral tablet 0.35 mg marlissa oral tablet mg microgestin 1.5/30 (21) oral tablet mg-mcg microgestin 1/20 (21) oral tablet 1-20 mg-mcg microgestin fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg (21)/75 mg (7) microgestin fe 1/20 (28) oral tablet 1 mg-20 mcg (21)/75 mg (7) mono-linyah oral tablet mgmcg mononessa (28) oral tablet mg-mcg my way 1.5 mg tablet (otc) 1.5 mg * QL (6 per 365 days) myzilra oral tablet (6)/75-40 (5)/125-30(10) necon 0.5/35 (28) oral tablet mg-mcg necon 1/35 (28) oral tablet 1-35 mgmcg You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 114

129 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Non Dwòg necon 1/50 (28) oral tablet 1-50 mgmcg necon 10/11 (28) oral tablet /1-35 mg-mcg/mg-mcg necon 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 mcg next choice one dose 1.5 mg tb (otc) 1.5 mg * nikki (28) oral tablet mg nora-be oral tablet 0.35 mg norethindrone (contraceptive) oral tablet 0.35 mg (Norlyroc) norethindrone ac-eth estradiol oral tablet 1-20 mg-mcg (Larin 1/20 (21)) norethindrone-e.estradiol-iron oral tablet 1 mg-20 mcg (24)/75 mg (4) (Blisovi 24 Fe) norgestimate-ethinyl estradiol oral tablet 0.18/0.215/0.25 mg-25 mcg (Tri-Lo-Marzia) norgestimate-ethinyl estradiol oral tablet 0.18/0.215/0.25 mg-35 mcg (Tri-Linyah) (28) norgestimate-ethinyl estradiol oral tablet mg-mcg (Mono-Linyah) norlyda oral tablet 0.35 mg norlyroc oral tablet 0.35 mg nortrel 0.5/35 (28) oral tablet mg-mcg nortrel 1/35 (21) oral tablet 1-35 mg-mcg nortrel 1/35 (28) oral tablet 1-35 mg-mcg nortrel 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 mcg NUVARING VAGINAL RING MG/24 HR ocella oral tablet mg QL (6 per 365 days) ST; QL (1 per 28 days) Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 115

130 ogestrel (28) oral tablet mgmcg opcicon one-step 1.5 mg tablet 1.5 QL (6 per 365 days) mg * option mg tablet 1.5 mg * QL (6 per 365 days) orsythia oral tablet mg-mcg philith oral tablet mg-mcg pimtrea (28) oral tablet mgx21 /0.01 mg x 5 pirmella oral tablet 0.5/0.75/1 mg- 35 mcg, 1-35 mg-mcg portia oral tablet mg previfem oral tablet mg-mcg quasense oral tablets,dose pack,3 QL (91 per 84 days) month 0.15 mg-30 mcg react 1.5 mg tablet 1.5 mg * QL (6 per 365 days) reclipsen (28) oral tablet mg setlakin oral tablets,dose pack,3 QL (91 per 84 days) month 0.15 mg-30 mcg sharobel oral tablet 0.35 mg sprintec (28) oral tablet mgmcg sronyx oral tablet mg-mcg syeda oral tablet mg tarina fe 1/20 (28) oral tablet 1 mg- 20 mcg (21)/75 mg (7) tilia fe oral tablet 1-20(5)/1-30(7) /1mg-35mcg (9) tri femynor oral tablet 0.18/0.215/0.25 mg-35 mcg (28) tri-estarylla oral tablet 0.18/0.215/0.25 mg-35 mcg (28) tri-legest fe oral tablet 1-20(5)/1-30(7) /1mg-35mcg (9) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 116

131 tri-linyah oral tablet 0.18/0.215/0.25 mg-35 mcg (28) tri-lo-estarylla oral tablet 0.18/0.215/0.25 mg-25 mcg tri-lo-marzia oral tablet 0.18/0.215/0.25 mg-25 mcg tri-lo-sprintec oral tablet 0.18/0.215/0.25 mg-25 mcg trinessa (28) oral tablet 0.18/0.215/0.25 mg-35 mcg (28) tri-previfem (28) oral tablet 0.18/0.215/0.25 mg-35 mcg (28) tri-sprintec (28) oral tablet 0.18/0.215/0.25 mg-35 mcg (28) trivora (28) oral tablet (6)/75-40 (5)/125-30(10) velivet triphasic regimen (28) oral tablet 0.1/.125/ mg-mcg vestura (28) oral tablet mg vienva oral tablet mg-mcg viorele (28) oral tablet mgx21 /0.01 mg x 5 vyfemla (28) oral tablet mgmcg wera (28) oral tablet mg-mcg xulane transdermal patch weekly QL (3 per 28 days) mcg/24 hr zarah oral tablet mg zenchent (28) oral tablet mgmcg zovia 1/35e (28) oral tablet 1-35 mg-mcg zovia 1/50e (28) oral tablet 1-50 mg-mcg Cough And Cold Products Cough And Cold Products 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Non Dwòg Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 117

132 25cpd-200gfn liquid mg/5 ml * 2cpm-15dm-5peh liquid s/f,a/f,gluten-free mg/5 ml * 3brm-15dm-30pse liquid mg/5 ml * actinel pediatric liquid mg/5 ml * adt robitussin peak cld dm max mg/5 ml * adult robitussin peak cold dm nondrowsy mg/5 ml * adult wal-tussin dm max liq a/f,cherry menthol mg/5 ml * adult wal-tussin dm syrup a/f,s/f,chry-menthol mg/5 ml * adult wal-tussin liquid 100 mg/5 ml * alka-seltzer plus mucus-conges mg * ambi 10peh-4cpm-20dm tablet mg * ambi 20dm-4cpm tablet 4-20 mg * ambi 40pse-400gfn-20dm tablet mg * ambi 60pse-4cpm-20dm tablet mg * benzonatate 100 mg capsule 100 mg * (Tessalon Perles) 3 $0 benzonatate 150 mg capsule 150 mg * (Zonatuss) 3 $0 benzonatate 200 mg capsule 200 mg * 3 $0 bio-dtuss dmx liquid mg/5 ml * You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 118

133 bionel pediatric liquid mg/5 ml * biospec dmx liquid mg/5 ml * bp 8 cough oral suspension a/f, grape (otc) mg/5 ml * bromfed dm cough syrup mg/5 ml * 3 $0 bromphenir-pseudoephed-dm syr (rx) mg/5 ml * (Bromfed DM) 3 $0 brotapp dm liquid mg/5 ml * centergy dm pediatric drops mg/ml * 3 $0 cheratussin ac syrup (otc) mg/5 ml * cheratussin dac syrup mg/5 ml * child plus cough-runny nose cherry flavor mg/5 ml * child robitussin er 30 mg/5 ml 30 mg/5 ml * child sudafed pe cough-cold lq mg/5 ml * child triaminic cgh-congst syr mg/5 ml * child wal-tussin 7.5 mg odt 7.5 mg * children's mucinex cough liq a/f mg/5 ml * children's silfedrine liq 15 mg/5 ml * childs sudafed 15 mg/5 ml liq nondrowsy,a/f,s/f 15 mg/5 ml * chl mucinex chest congest liq a/f 100 mg/5 ml * codituss dm syrup mg/5 ml * 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 119

134 cold multi-symptom day-night pseudoephedrine-free mg * cold multi-symptom night liq a/f, honey lemon mg/15 ml * cold relief multi-symp caplet cplt,12 day,12 night mg * cold-flu relief d/n softgel mg(d)/ mg * cold-flu relief liquid ,000 mg/30 ml * congestac tablet mg * congest-eze mg caplet mg * coricidin hbp cold-multi sympt mg/15 ml * coricidin hbp softgel mg * cough & cold tablet 4-30 mg * cough relief liquid 15 mg/5 ml * cough syrup 200 mg/10 ml 100 mg/5 ml * cvs chest cong relief pe tab mg * cvs chest congest + cough liq mg/5 ml * cvs chest congest relief dm tb mg * cvs child cold-cough day liq mg/5 ml * cvs child cough & runny nose mg/5 ml * cvs child cough dm er 30 mg/5 30 mg/5 ml * cvs child's chest congest liq 100 mg/5 ml * You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 120

135 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Non Dwòg cvs cough & sore throat susp mg/5 ml * cvs mucus er 600 mg tablet 12 hour 600 mg * cvs nighttime cough liquid cherry flavor mg/15 ml * cvs tussin cf liquid a/f, non drowsy mg/5 ml * cvs tussin cgh 15 mg liq gels nondrowsy, liq gels 15 mg * cvs tussin dm cough-chest liq mg/5 ml * daytime cold & cough liquid 1, mg/30 ml * daytime cough liquid a/f, gluten-free 5 mg/5 ml * daytime-nighttime cold-flu liq multisymptom mg/15 ml * daytime-nighttime cough liquid 15mg/15ml(d)/ mg/30ml * delsym cough+chest cngst dm lq mg/5 ml * despec-dm tablet mg * dextromethorphan er 30 mg/5 ml 30 (Children's Cough mg/5 ml * DM ER) diabetic tussin dm liquid mg/5 ml * diabetic tussin dm max-str liq mg/5 ml * diabetic tussin ex liquid a/f,d/f,na/f,s/f 100 mg/5 ml * DIMETAPP LONG-ACTING COUGH LIQ MG/5 ML * ed bron gp liquid mg/5 ml * entre-cough liquid mg/5 ml * Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 121

136 expectorant 100 mg/5 ml syrup 100 mg/5 ml * expectorant dm cough liquid mg/5 ml * expectorant max cough-cold mg/5 ml * extra action cough syrup mg/5 ml * flu hbp tablet mg * geri-tussin dm syrup mg/5 ml * guaifenesin 200 mg tablet (otc) 200 mg * (Expectorant) guaifenesin er 1,200 mg tablet 1,200 (Mucinex) mg * head congestion day-night pack mg * hydrocodone-chlorphen er susp 10- (Tussionex 8 mg/5 ml * Pennkinetic ER) 3 $0 hydrocodone-homatropine mg tablet mg * (Tussigon) 3 $0 hydrocodone-homatropine syrup mg/5 ml * (Hydromet) 3 $0 hydromet syrup mg/5 ml * 3 $0 kidkare cough & cold liquid mg/5 ml * liquibid d-r tablet mg * lohist-dm syrup mg/5 ml * lortuss ex liquid mg/5 ml * mar-cof bp liquid mg/5 ml * mar-cof cg liquid mg/5 ml * MUCINEX FAST-MAX COLD- FLU-THRT MG * You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 122

137 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Non Dwòg mucinex fast-max dm max liquid maximum strength mg/5 ml * mucus dm mg tablet mg * mucus dm max 1, mg tab 60-1,200 mg * mucus relief 400 mg tablet d/f 400 mg * nasal-sinus decongest tab 30 mg * NEO DM SYRUP MG/5 ML * neo-tuss liquid mg/5 ml * night time cold med liquid mg/15 ml * night time cough & sore throat ,000 mg/30 ml * nohist-dm liquid mg/5 ml * pecgen dmx mg/5 ml liq mg/5 ml * pediacare multi-symt cold liq non drowsy, grape mg/5 ml * phenylhistine dh liquid (otc) mg/5 ml * promethazine vc-codeine syrup mg/5 ml * 3 $0 promethazine-codeine syrup mg/5 ml * 3 $0 promethazine-dm syrup mg/5 ml * 3 $0 (Nasal pseudoephed 30 mg/5 ml soln 30 Decongestant mg/5 ml * (pseudoeph)) pseudoephedrine 30 mg tablet 30 mg * (Sudafed) pseudoephedrine 60 mg tablet exstr, non drowsy (otc) 60 mg * (Sudogest) Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 123

138 pv flu relief therapy liquid daytime mg/15 ml * pv night-time softgel multisympt.,softgel mg * pv tussin pe liquid mg/5 ml * ra anti-tussive dm syrup mg/5 ml * ra day cold-flu relief softgel a/f, multi-symptom mg * ra daytime-nighttime softgel cold-flu relief mg(d)/ mg * ra flu formula gelcap mg * ra mucus relief 400 mg tablet 400 mg * ra multi-symptom cold caplet nighttime,cplt mg * refenesen 400 mg tablet 400 mg * refenesen pe caplet mg * relcof c liquid mg/5 ml * REZIRA SOLUTION 60-5 MG/5 ML * 3 $0 robafen 100 mg/5 ml syrup 100 mg/5 ml * robafen cough 15 mg liquidgel nondrowsy,liquidgel 15 mg * robafen-dm syrup mg/5 ml * robitussin cough-chest dm liq mg/5 ml * robitussin cough-chest-cong dm mg * ROBITUSSIN LONG-ACTING LIQ MG/5 ML * robitussin pediatric cough syp a/f,long-acting 7.5 mg/5 ml * You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 124

139 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Non Dwòg rydex liquid mg/5 ml * rynex dm liquid a/f, prof use only mg/5 ml * safetussin dm liquid mg/5 ml * sb cough control dm liquid mg/5 ml * scot-tussin 100 mg/5 ml liq 100 mg/5 ml * scot-tussin dm s-f liquid 2-15 mg/5 ml * siltussin sa 100 mg/5 ml syr 100 mg/5 ml * sm adult nasal decongestant lq 15 mg/5 ml * sm cold & cough liquid children's, day time mg/5 ml * sm cough & runny nose liquid 1-5 mg/5 ml * sm cough-head congestion lq mg/5 ml * sm flu severe cold-congestion maximum strength ,000 mg * sm nite time cold-flu liquid ,000 mg/30 ml * sm nite time cold-flu rel sfgl softgel mg * sm pain reliever cold caplet mg * sm pedia relief liquid mg/5 ml * sm severe cold m-s caplet mg * sm tussin cf syrup mg/5 ml * Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 125

140 sudafed 30 mg tablet nondrowsy,max-str 30 mg * sudogest 30 mg tablet boxed 30 mg * sudogest 60 mg tablet 60 mg * suphedrin liquid 15 mg/5 ml * suphedrine pe combo pack cplt mg * triaminic daytime cold-cough children's, cherry mg/5 ml * tusnel diabetic liquid (otc) mg/5 ml * TUSNEL LIQUID A/F,A/F,D/F MG/5 ML * TUSSI PRES-B LIQUID MG/5 ML * tussin cold-congestion gelcap liquid gelcap mg * tussin dm syrup mg/5 ml * vicks dayquil cough liquid a/f,8 hr rlf 5 mg/5 ml * vicks dayquil liquid cold/flu relief, a/f mg/15 ml * vicks nature fusion cough liq 5 mg/5 ml * vicks nyquil liquicaps cold & flu mg * virtussin ac liquid mg/5 ml * virtussin dac liquid mg/5 ml * v-r infant non-asa cold drp mg/1.6 ml * v-r non-aspirin flu gelcap gelatin caplet mg * v-r pedia relief inf drops decongestant mg/0.8 ml * You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 126

141 vr triacting cold-cough liq mg/5 ml * v-r tussin cf syrup mg/5 ml * wal-flu severe cold-cough pckt mg * wal-phed 30 mg tablet non-drowsy 30 mg * wal-phed pe day-night combo pk caplet mg * wal-tussin cough 15 mg softgel 15 mg * wal-tussin max str cough syrup maximum strength 15 mg/5 ml * zephrex-d 30 mg tablet 30 mg * zyncof mg/5 ml liquid mg/5 ml * Dental And Oral Agents Dental And Oral Agents cevimeline oral capsule 30 mg (Evoxac) chlorhexidine gluconate mucous (Paroex Oral membrane mouthwash 0.12 % Rinse) oralone dental paste 0.1 % periogard mucous membrane mouthwash 0.12 % pilocarpine hcl oral tablet 5 mg, 7.5 (Salagen mg (pilocarpine)) triamcinolone acetonide dental paste 0.1 % (Oralone) Dermatological Agents Dermatological Agents, Other 8-MOP ORAL CAPSULE 10 MG acitretin oral capsule 10 mg, 17.5 mg, 25 mg (Soriatane) acne medication 10% gel 10 % * 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 127

142 acne medication 10% lotion 10 % * acne medication 5% gel 5 % * ACNE MEDICATION 5% LOTION 5 % * acyclovir topical ointment 5 % (Zovirax) QL (15 per 12 days) ALCOHOL PADS TOPICAL PADS, MEDICATED ALCOHOL PREP PADS amlactin 12% lotion 12 % * ammonium lactate 12% cream fragrance free (otc) 12 % * (Geri-Hydrolac) ammonium lactate 12% lotion fragrance free (otc) 12 % * (AmLactin) ammonium lactate topical cream 12 % (Geri-Hydrolac) ammonium lactate topical lotion 12 % (AmLactin) ANACAINE TOPICAL OINTMENT 10 % benzoyl peroxide 10% gel aqueous (Acne Treatment (otc) 10 % * (benzoyl perox)) benzoyl peroxide 5% gel aqueous (otc) 5 % * (BP) BETADINE 5% SPRAY 5 % * calcipotriene scalp solution % calcipotriene topical cream % (Dovonex) calcipotriene topical ointment % (Calcitrene) calcitrene topical ointment % calcitriol topical ointment 3 mcg/gram (Vectical) CASTELLANI PAINT 1.5% COLORLESS 1.5 % * CONDYLOX TOPICAL GEL 0.5 % You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 128

143 COSENTYX (150 MG/ML) 300 PA MG DOSE-2 PENS 150 MG/ML COSENTYX (150 MG/ML) 300 PA MG DOSE-2 SYRINGES 150 MG/ML COSENTYX PEN PA SUBCUTANEOUS PEN INJECTOR 150 MG/ML COSENTYX SUBCUTANEOUS PA SYRINGE 150 MG/ML cutter backwoods 25% spray 25 % * QL (340 per 180 days) cutter skinsations 7% spray 7 % * QL (354 per 180 days) cvs skin treatment body lotion 12 % * diclofenac sodium topical gel 3 % (Solaraze) DUPIXENT SUBCUTANEOUS PA SYRINGE 300 MG/2 ML fluorouracil topical cream 0.5 % (Carac) fluorouracil topical cream 5 % (Efudex) fluorouracil topical solution 2 %, 5 % geri-hydrolac 12% lotion 12 % * geri-hydrolac 5% lotion 5 % * imiquimod topical cream in packet 5 PA NSO; QL (24 per (Aldara) % 30 days) INSECT REPELLENT 20% QL (236 per 180 days) SPRAY 20 % * LACTINOL HX CREAM * lobana bath oil * methoxsalen oral capsule,liqdfilled,rapid rel 10 mg (Oxsoralen Ultra) NATRAPEL 20% SPRAY 20 % * QL (354 per 180 days) off active 15% spray 15 % * QL (340 per 180 days) off deep woods 25% spray 25 % * QL (340 per 180 days) 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 129

144 off deep woods dry 25% spray 25 % QL (226 per 180 days) * off familycare 15% rplnt i spr 15 % QL (142 per 180 days) * PANRETIN TOPICAL GEL 0.1 % persa-gel 10% 12's,max-strength 10 % * PICATO TOPICAL GEL % QL (3 per 56 days) PICATO TOPICAL GEL 0.05 % QL (2 per 56 days) podofilox topical solution 0.5 % potassium hydroxide topical solution 5 % pv acne pimple 10% gel 10 % * repel sportsmen 25% spray 25 % * QL (368 per 180 days) repel sportsmen max 40% spray 40 QL (368 per 180 days) % * SANTYL TOPICAL OINTMENT 250 UNIT/GRAM SILIQ SUBCUTANEOUS PA SYRINGE 210 MG/1.5 ML TALTZ 80 MG/ML PA AUTOINJECTOR P/F,L/F,SDV,OUTER 80 MG/ML TALTZ AUTOINJECTOR (3 PA PACK) SUBCUTANEOUS AUTO- INJECTOR 80 MG/ML TALTZ SYRINGE PA SUBCUTANEOUS SYRINGE 80 MG/ML TOLAK TOPICAL CREAM 4 % VALCHLOR TOPICAL GEL % zenatane oral capsule 10 mg, 20 mg, 30 mg, 40 mg zinc oxide 20% ointment 20 % * Dermatological Antibacterials You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 130

145 bacitracin 500 unit/gm ointmnt 500 unit/gram * (Bacitraycin Plus) bacitraycin plus 500 unit/gm 500 unit/gram * clindamycin phosphate topical gel 1 % (Clindagel) clindamycin phosphate topical lotion 1 % (Cleocin T) clindamycin phosphate topical solution 1 % (Cleocin T) clindamycin phosphate topical swab 1 % (Clindacin P) cvs triple antibiotic ointment 3.5mg- 400 unit- 5,000 unit/gram * ery pads topical swab 2 % erythromycin with ethanol topical gel 2 % (Erygel) erythromycin with ethanol topical solution 2 % erythromycin with ethanol topical swab 2 % (Ery Pads) gentamicin topical cream 0.1 % gentamicin topical ointment 0.1 % metronidazole topical cream 0.75 % (MetroCream) metronidazole topical gel 0.75 % (Rosadan) metronidazole topical gel 1 % (Metrogel) metronidazole topical lotion 0.75 % (MetroLotion) mupirocin calcium topical cream 2 % (Bactroban) mupirocin topical ointment 2 % (Centany) neomycin-polymyxin b gu irrigation (Neosporin GU solution 40 mg-200,000 unit/ml Irrigant) neosporin ointment 3.5mg-400 unit- 5,000 unit/gram * rosadan topical cream 0.75 % 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 131

146 selenium sulfide topical lotion 2.5 % silver nitrate topical ointment 10 % silver nitrate topical solution 10 %, 25 %, 50 % silver sulfadiazine topical cream 1 % (Silvadene) ssd topical cream 1 % sulfacetamide sodium (acne) topical suspension 10 % (Klaron) triple antibiotic ointment 3.5mg-400 unit- 5,000 unit/gram * Dermatological Anti-Inflammatory Agents ala-cort topical cream 1 %, 2.5 % ala-scalp topical lotion 2 % alclometasone topical cream 0.05 % alclometasone topical ointment 0.05 % anti-itch 1% lotion 1 % * aquanil hc 1% lotion 1 % * beta hc 1% lotion 1 % * betamethasone dipropionate topical cream 0.05 % betamethasone dipropionate topical lotion 0.05 % betamethasone dipropionate topical ointment 0.05 % betamethasone valerate topical cream 0.1 % betamethasone valerate topical foam 0.12 % (Luxiq) betamethasone valerate topical lotion 0.1 % betamethasone valerate topical ointment 0.1 % You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 132

147 betamethasone, augmented topical cream 0.05 % (Diprolene AF) betamethasone, augmented topical gel 0.05 % betamethasone, augmented topical lotion 0.05 % betamethasone, augmented topical ointment 0.05 % (Diprolene) clobetasol 0.05% cream 0.05 % (Temovate) clobetasol scalp solution 0.05 % (Cormax) clobetasol topical foam 0.05 % (Olux) clobetasol topical gel 0.05 % clobetasol topical lotion 0.05 % (Clobex) clobetasol topical ointment 0.05 % (Temovate) clobetasol topical shampoo 0.05 % (Clobex) clobetasol-emollient topical cream 0.05 % clocortolone pivalate topical cream 0.1 % (Cloderm) cormax scalp solution 0.05 % cortaid 1% cream 12 hr, anti-itch 1 % * cortizone-10 1% creme 1 % * cortizone-10 1% creme maximum strength 1 % * cortizone-10 1% ointment 1 % * dermarest eczema 1% lotion 1 % * desonide topical cream 0.05 % (Tridesilon) desonide topical ointment 0.05 % desoximetasone topical cream 0.05 %, 0.25 % (Topicort) desoximetasone topical gel 0.05 % (Topicort) desoximetasone topical ointment 0.05 %, 0.25 % (Topicort) ELIDEL TOPICAL CREAM 1 % 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 133

148 EUCRISA TOPICAL OINTMENT 2 % fluocinonide topical cream 0.05 % fluocinonide topical gel 0.05 % fluocinonide topical ointment 0.05 % fluocinonide topical solution 0.05 % fluocinonide-e topical cream 0.05 % fluticasone topical cream 0.05 % (Cutivate) fluticasone topical ointment % halobetasol propionate topical (Ultravate) cream 0.05 % halobetasol propionate topical (Ultravate) ointment 0.05 % hydro skin 1% lotion 1 % * hydrocortisone 0.5% cream (otc) 0.5 % * hydrocortisone 0.5% ointment 0.5 % * hydrocortisone 1% cream maximum (Hydrocream) strength (otc) 1 % * hydrocortisone 1% cream maximum strength 1 % * hydrocortisone 1% lotion (otc) 1 % (Cortisone * (hydrocortisone)) hydrocortisone 1% ointment carton (Anti-Itch (HC)) (otc) 1 % * hydrocortisone buty 0.1% cream 0.1 (Locoid) % hydrocortisone butyrate topical (Locoid) ointment 0.1 % hydrocortisone butyrate topical (Locoid) solution 0.1 % hydrocortisone topical cream 1 % (Hydrocream) hydrocortisone butyr-emollient (Locoid topical cream 0.1 % Lipocream) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 134

149 hydrocortisone topical cream 2.5 % (Ala-Cort) hydrocortisone topical lotion 2.5 % hydrocortisone topical ointment 1 % (Anti-Itch (HC)) hydrocortisone topical ointment 2.5 % hydrocortisone valerate topical cream 0.2 % hydrocortisone valerate topical ointment 0.2 % mometasone topical cream 0.1 % (Elocon) mometasone topical ointment 0.1 % (Elocon) mometasone topical solution 0.1 % neosporin 1% anti-itch cream 1 % * prednicarbate topical cream 0.1 % (Dermatop) prednicarbate topical ointment 0.1 % (Dermatop) preparation h hc 1% cream 1 % * procto-med hc topical cream with perineal applicator 2.5 % procto-pak topical cream with perineal applicator 1 % proctosol hc topical cream with perineal applicator 2.5 % proctozone-hc topical cream with perineal applicator 2.5 % recort plus 1% cream 1 % * tacrolimus topical ointment 0.03 %, 0.1 % (Protopic) triamcinolone acetonide topical cream %, 0.5 % triamcinolone acetonide topical cream 0.1 % (Triderm) triamcinolone acetonide topical lotion %, 0.1 % 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 135

150 triamcinolone acetonide topical ointment %, 0.1 %, 0.5 % trianex topical ointment 0.05 % tridesilon topical cream 0.05 % u-cort topical cream 1-10 % Dermatological Retinoids adapalene topical cream 0.1 % (Differin) adapalene topical gel 0.1 % (Differin) tazarotene topical cream 0.1 % (Tazorac) TAZORAC TOPICAL CREAM 0.05 %, 0.1 % tretinoin gel micro 0.04% tube 0.04 PA (Retin-A Micro) % tretinoin gel micro 0.1% tube 0.1 % (Retin-A Micro) PA tretinoin microspheres topical gel (Retin-A Micro PA with pump 0.04 %, 0.1 % Pump) tretinoin topical cream %, PA (Retin-A) 0.05 %, 0.1 % tretinoin topical gel 0.01 %, PA (Retin-A) % tretinoin topical gel 0.05 % (Atralin) PA Scabicides And Pediculicides cvs lice killing shampoo maximum strength % * cvs permethrin 1% lotion 1 % * (Nix Creme Rinse) malathion topical lotion 0.5 % (Ovide) NIX 1% CREME RINSE LIQUID W/ NIT COMB 1 % * permethrin topical cream 5 % (Elimite) ra lice treatment 1% crm rinse 2x59ml, 2 combs 1 % * sm lice treatment 1% crm rinse 1 % * v-r lice cream rinse 1 % * Devices Devices You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 136

151 ASSURE ID INSULIN SAFETY SYRINGE 1 ML 29 GAUGE X 1/2" BD INSULIN SYR 0.3 ML 6MMX31G 0.3 ML 31 GAUGE X 15/64" BD INSULIN SYR 0.5 ML 6MMX31G 1/2 ML 31 GAUGE X 15/64" BD INSULIN SYR 1 ML 6MMX31G 1 ML 31 GAUGE X 15/64" BD ULTRA-FINE PEN NDL 8MMX31G SHORT 31 GAUGE X 5/16" BLADDER CONTROL PAD X- LONG 9'S,X-LONG * GAUZE PAD TOPICAL BANDAGE 2 X 2 " GAUZE PADS, STERILE 2"X2" 2 X 2 " INSULIN SYRINGE-NEEDLE U- (Ultilet Insulin 100 SYRINGE 0.3 ML 29 GAUGE Syringe) INSULIN SYRINGE-NEEDLE U- 100 SYRINGE 1 ML 29 GAUGE X (BD Insulin Syringe Safety- 1/2" Lok) INSULIN SYRINGE-NEEDLE U- 100 SYRINGE 1/2 ML 28 GAUGE (Monoject Syringe) PEN NEEDLE, DIABETIC (Comfort EZ Pen NEEDLE 29 GAUGE X 1/2" Needles) VGO 40 DISPOSABLE DEVICE Disinfectants (For Non- Dermatologic Use) Disinfectants (For Non- Dermatologic Use) sm iodine tincture * 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 137

152 Enzyme Replacement/Modifiers Enzyme Replacement/Modifiers ADAGEN INTRAMUSCULAR SOLUTION 250 UNIT/ML ALDURAZYME INTRAVENOUS SOLUTION 2.9 MG/5 ML CEREZYME INTRAVENOUS RECON SOLN 400 UNIT CREON ORAL CAPSULE,DELAYED RELEASE(DR/EC) 12,000-38,000-60,000 UNIT, 24,000-76, ,000 UNIT, 3,000-9,500-15,000 UNIT, 36, , ,000 UNIT, 6,000-19,000-30,000 UNIT ELAPRASE INTRAVENOUS SOLUTION 6 MG/3 ML ELITEK INTRAVENOUS RECON SOLN 1.5 MG, 7.5 MG FABRAZYME INTRAVENOUS RECON SOLN 35 MG KANUMA INTRAVENOUS SOLUTION 2 MG/ML KRYSTEXXA INTRAVENOUS SOLUTION 8 MG/ML KUVAN ORAL TABLET,SOLUBLE 100 MG MYOZYME INTRAVENOUS RECON SOLN 50 MG NAGLAZYME INTRAVENOUS SOLUTION 5 MG/5 ML ORFADIN ORAL CAPSULE 10 MG, 2 MG, 20 MG, 5 MG ORFADIN ORAL SUSPENSION 4 MG/ML PA You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 138

153 PULMOZYME INHALATION SOLUTION 1 MG/ML STRENSIQ SUBCUTANEOUS SOLUTION 100 MG/ML, 40 MG/ML VIMIZIM INTRAVENOUS SOLUTION 5 MG/5 ML (1 MG/ML) VPRIV INTRAVENOUS RECON SOLN 400 UNIT ZAVESCA ORAL CAPSULE 100 MG ZENPEP ORAL CAPSULE,DELAYED RELEASE(DR/EC) 10,000-34,000-55,000 UNIT, 15,000-51,000-82,000 UNIT, 20,000-68, ,000 UNIT, 25,000-85, ,000 UNIT, 3,000-10,000-16,000 UNIT, 40, , ,000 UNIT, 5,000-17,000-27,000 UNIT Eye, Ear, Nose, Throat Agents Eye, Ear, Nose, Throat Agents, Miscellaneous AKTEN (PF) OPHTHALMIC GEL 3.5 % alcaine ophthalmic drops 0.5 % altacaine ophthalmic drops 0.5 % altamist 0.65% nose spray 0.65 % * apraclonidine ophthalmic drops 0.5 % (Iopidine) artificial tears * artificial tears 1.4 % drops 1.4 % * artificial tears drops p/f, sterile % * PA; LA PA QL (90 per 30 days) 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 139

154 artificial tears eye drops strl % * ARTIFICIAL TEARS EYE OINTMENT % * atropine ophthalmic drops 1 % ayr saline 0.65% nose drops 0.65 % * ayr saline 0.65% nose spray 0.65 % * azelastine nasal aerosol,spray 137 mcg (0.1 %) azelastine ophthalmic drops 0.05 % bion tears eye drops % * carteolol ophthalmic drops 1 % cromolyn ophthalmic drops 4 % cvs artificial tears drops sterile % * cvs lubricant 0.6% eye drops 0.6 % * cvs lubricant dry eye rlf 1% 1 % * cvs lubricant eye ointment p/f % * cvs lubricant gel eye drops % * cvs lubricating eye drops dry eye soln % * cvs nasal spray 0.05% 0.05 % * cvs saline 0.65% nose spray 0.65 % * cyclopentolate ophthalmic drops 0.5 %, 1 %, 2 % (Cyclogyl) CYSTARAN OPHTHALMIC DROPS 0.44 % deep sea 0.65% nose spray 0.65 % * dristan long lasting mist 0.05 % * epinastine ophthalmic drops 0.05 % (Elestat) QL (30 per 25 days) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 140

155 eq gentle 0.3% eye drops 0.3 % * eq revive plus 0.5% eye drops 0.5 % * flucaine ophthalmic drops % GENTEAL GEL DROPS % * GENTEAL MILD 0.2% EYE DROPS 0.2 % * GENTEAL SEVERE 0.3% EYE GEL P/F, STRL, INNER 0.3 % * GENTEAL TEARS 0.1%-0.2%- 0.3% % * genteal tears 0.1%-0.3% drop % * homatropaire ophthalmic drops 5 % homatropine hbr ophthalmic drops 5 % (Homatropaire) ipratropium bromide nasal spray,non-aerosol 0.03 % ipratropium bromide nasal spray,non-aerosol 0.06 % isopto tears 0.5% eye drops 0.5 % * LACRISERT OPHTHALMIC INSERT 5 MG little remedies stuffy nose kt w/ nasal aspirator 0.65 % * lubricant % eye drops % * lubricant % eye drops % * lubricating plus 0.5% eye drps p/f, 30x0.4ml 0.5 % * lubrifresh pm eye ointment % * QL (30 per 28 days) QL (15 per 10 days) 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 141

156 mucinex sinus-max nasal spray full force 0.05 % * muro-128 2% eye drops 2 % * muro-128 5% eye drops 5 % * muro-128 5% eye ointment 5 % * naphazoline ophthalmic drops 0.1 % natural balance tears drops 0.4 % * natural balance tears eye drop % * nature's tears drops 0.4 % * neo-synephrine 12 hour spray 0.05 % * ocean 0.65% nasal spray 0.65 % * olopatadine ophthalmic drops 0.1 % (Patanol) OTOVEL OTIC SOLUTION % (0.25 ML) PATADAY OPHTHALMIC DROPS 0.2 % phenylephrine hcl ophthalmic drops 10 %, 2.5 % proparacaine ophthalmic drops 0.5 % pure & gentle eye drops lubricant 0.3 % * pv artificial tears 0.4 % * pv lubricant 1.4 % eye drops 1.4 % * pv pure-gentle eye drops sterile 0.3 % * REFRESH CELLUVISC 1% EYE DROPS 1 % * REFRESH CLASSIC EYE DROPS U-D,P/F,30X.4ML % * REFRESH LACRI-LUBE OINTMENT % * retaine cmc 0.5% eye drops 0.5 % * You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 142

157 retaine hpmc 0.3% eye drops 0.3 % * retaine pm eye ointment % * sea soft 0.65% nasal mist 0.65 % * sm lubricant eye drops strl % * sochlor 5% eye drops 5 % * sodium chloride 5% eye drop 5 % * (Muro 128) sodium chloride 5% eye oint 5 % * (Muro 128) soothe night time lub eye oint % * SYSTANE 0.3% EYE GEL 0.3 % * SYSTANE GEL EYE DROPS % * tears again 1.4 % drops 1.4 % * tears again eye ointment % * tears naturale free drops u- d,36x.9ml,p/f % * ultra fresh pm ointment * vicks qlearquil 0.05% mist 0.05 % * vicks sinex 12 hour spray 0.05 % * Eye, Ear, Nose, Throat Anti- Infectives Agents acetic acid otic solution 2 % bacitracin ophthalmic ointment 500 unit/gram bacitracin-polymyxin b ophthalmic ointment ,000 unit/gram (Polycin) bleph-10 ophthalmic drops 10 % CIPRODEX OTIC DROPS,SUSPENSION % ciprofloxacin hcl ophthalmic drops 0.3 % (Ciloxan) ciprofloxacin hcl otic dropperette 0.2 % (Cetraxal) 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 143

158 COLY-MYCIN S OTIC DROPS,SUSPENSION MG/ML erythromycin ophthalmic ointment 5 mg/gram (0.5 %) gatifloxacin ophthalmic drops 0.5 % (Zymaxid) gentak ophthalmic ointment 0.3 % (3 mg/gram) gentamicin ophthalmic drops 0.3 % gentamicin ophthalmic ointment 0.3 % (3 mg/gram) (Gentak) levofloxacin ophthalmic drops 0.5 % MOXEZA OPHTHALMIC DROPS, VISCOUS 0.5 % NATACYN OPHTHALMIC DROPS,SUSPENSION 5 % neomycin-bacitracin-poly-hc ophthalmic ointment ,000 (Neo-Polycin HC) mg-unit/g-1% neomycin-bacitracin-polymyxin ophthalmic ointment ,000 (Neo-Polycin) mg-unit-unit/g neomycin-polymyxin b-dexameth ophthalmic drops,suspension (Maxitrol) 3.5mg/ml-10,000 unit/ml-0.1 % neomycin-polymyxin b-dexameth ophthalmic ointment 3.5 mg/g- (Maxitrol) 10,000 unit/g-0.1 % neomycin-polymyxin-gramicidin ophthalmic drops 1.75 mg-10,000 unit-0.025mg/ml neomycin-polymyxin-hc ophthalmic drops,suspension , mgunit-mg/ml neomycin-polymyxin-hc otic drops,suspension ,000-1 mg/ml-unit/ml-% You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 144

159 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Non Dwòg neomycin-polymyxin-hc otic solution ,000-1 mg/mlunit/ml-% neo-polycin hc ophthalmic ointment ,000 mg-unit/g-1% neo-polycin ophthalmic ointment ,000 mg-unit-unit/g ofloxacin ophthalmic drops 0.3 % (Ocuflox) ofloxacin otic drops 0.3 % (Floxin) polymyxin b sulf-trimethoprim ophthalmic drops 10,000 unit- 1 mg/ml REFRESH OPTIVE ADVANCED DROPS % * REFRESH OPTIVE MEGA-3 DROPS % * sulfacetamide sodium ophthalmic drops 10 % sulfacetamide sodium ophthalmic ointment 10 % sulfacetamide-prednisolone ophthalmic drops 10 %-0.23 % (0.25 %) (Polytrim) (Bleph-10) TOBRADEX OPHTHALMIC OINTMENT % TOBRADEX ST OPHTHALMIC DROPS,SUSPENSION % tobramycin ophthalmic drops 0.3 % (Tobrex) tobramycin-dexamethasone ophthalmic drops,suspension (TobraDex) % trifluridine ophthalmic drops 1 % (Viroptic) VIGAMOX OPHTHALMIC DROPS 0.5 % ZIRGAN OPHTHALMIC GEL 0.15 % Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 145

160 ZYLET OPHTHALMIC DROPS,SUSPENSION % Eye, Ear, Nose, Throat Anti- Inflammatory Agents ALREX OPHTHALMIC DROPS,SUSPENSION 0.2 % bromfenac ophthalmic drops 0.09 % dexamethasone sodium phosphate ophthalmic drops 0.1 % diclofenac sodium ophthalmic drops 0.1 % DUREZOL OPHTHALMIC DROPS 0.05 % flunisolide nasal spray,non-aerosol 25 mcg (0.025 %) fluorometholone ophthalmic drops,suspension 0.1 % (FML Liquifilm) flurbiprofen sodium ophthalmic drops 0.03 % (Ocufen) fluticasone nasal spray,suspension 50 mcg/actuation (ClariSpray) ILEVRO OPHTHALMIC DROPS,SUSPENSION 0.3 % ketorolac ophthalmic drops 0.4 % (Acular LS) ketorolac ophthalmic drops 0.5 % (Acular) LOTEMAX OPHTHALMIC DROPS,GEL 0.5 % LOTEMAX OPHTHALMIC DROPS,SUSPENSION 0.5 % LOTEMAX OPHTHALMIC OINTMENT 0.5 % NEVANAC OPHTHALMIC DROPS,SUSPENSION 0.1 % prednisolone acetate ophthalmic drops,suspension 1 % (Pred Forte) ST QL (50 per 25 days) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 146

161 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Non Dwòg prednisolone sodium phosphate ophthalmic drops 1 % PROLENSA OPHTHALMIC DROPS 0.07 % RESTASIS MULTIDOSE OPHTHALMIC DROPS 0.05 % RESTASIS OPHTHALMIC DROPPERETTE 0.05 % Gastrointestinal Agents Antiflatulents bicarsim forte 125 mg tablet 125 mg * cvs gas relief 125 mg chew tab extra strength 125 mg * cvs gas relief 125 mg softgel softgel 125 mg * cvs gas relief 80 mg tab chew 80 mg * gas relief 125 mg chew tablet max str,lactose-free 125 mg * gas relief 20 mg/0.3 ml drops dyefree 40 mg/0.6 ml * gas relief 80 tablet chew 80 mg * gas-x ultra strength softgel 180 mg * mi-acid gas 80 mg tab chew 80 mg * mytab gas 80 mg tablet chew 80 mg * mytab gas max str 125 mg tab 125 mg * simethicone 180 mg softgel 180 mg (Gas Relief Ultra * Strength) v-r anti-gas 166 mg softgel 166 mg * Antiulcer Agents And Acid Suppressants QL (5.5 per 30 days) QL (60 per 30 days) Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 147

162 acid reducer 20 mg tablet maximum strength 20 mg * amoxicil-clarithromy-lansopraz oral combo pack mg CARAFATE ORAL SUSPENSION 100 MG/ML cimetidine hcl oral solution 300 mg/5 ml cimetidine oral tablet 200 mg (Prevpac) (Acid Reducer (cimetidine)) cimetidine oral tablet 300 mg, 400 mg, 800 mg cvs acid reducer 150 mg tablet maximum strength 150 mg * cvs cimetidine 200 mg tablet (otc) (Acid Reducer 200 mg * (cimetidine)) esomeprazole sodium intravenous recon soln 20 mg esomeprazole sodium intravenous recon soln 40 mg (Nexium IV) famotidine (pf) intravenous solution 20 mg/2 ml famotidine (pf)-nacl (iso-os) intravenous piggyback 20 mg/50 ml famotidine 20 mg/2 ml vial latexfree, p/f, sdv 20 mg/2 ml famotidine 40 mg/4 ml vial 25's,outer 10 mg/ml famotidine oral tablet 20 mg (Pepcid AC) famotidine oral tablet 40 mg (Pepcid) gnp acid reducer 10 mg tablet 10 mg * lansoprazole dr 15 mg capsule na/f (otc) 15 mg * (Heartburn Treatment 24 Hour) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 148

163 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Non Dwòg lansoprazole oral capsule,delayed release(dr/ec) 15 mg (Heartburn Treatment 24 Hour) lansoprazole oral capsule,delayed release(dr/ec) 30 mg (Prevacid) misoprostol oral tablet 100 mcg, 200 mcg (Cytotec) omeprazole dr 20 mg tablet 20 mg * omeprazole mag dr 20.6 mg cap two 14-days course 20 mg * omeprazole oral capsule,delayed release(dr/ec) 10 mg, 20 mg, 40 mg pantoprazole intravenous recon soln (Protonix) 40 mg pantoprazole oral tablet,delayed release (dr/ec) 20 mg, 40 mg (Protonix) PRILOSEC OTC 20.6 MG TABLET OTC 20 MG * pub famotidine 20 mg tablet max strength (otc) 20 mg * (Pepcid AC) pv acid relief 200 mg tablet 200 mg * ranitidine 75 mg tablet s/f, sodiumfree 75 mg * (ranitidine)) (Heartburn Relief ranitidine hcl injection solution 25 mg/ml, 50 mg/2 ml (25 mg/ml) (Zantac) ranitidine hcl oral capsule 150 mg, 300 mg ranitidine hcl oral syrup 15 mg/ml ranitidine hcl oral tablet 150 mg (Zantac Maximum Strength) ranitidine hcl oral tablet 300 mg (Zantac) sucralfate oral tablet 1 gram (Carafate) wal-zan 75 mg tablet 75 mg * zantac 75 mg tablet 75 mg * Gastrointestinal Agents, Other Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 149

164 acid gone antacid liquid mg/15 ml * almacone liquid mg/5 ml * almacone-2 liquid mg/5 ml * aluminum hydroxide gel sugar-free 320 mg/5 ml * AMITIZA ORAL CAPSULE 24 MCG, 8 MCG anti-diarrheal 2 mg caplet caplet 2 mg * bismatrol 525 mg/30 ml susp 262 mg/15 ml * BUPHENYL ORAL TABLET 500 MG calci-chew tablet 500 mg calcium (1,250 mg) * calcium 500 mg chewable tablet tab chew,p/f 500 mg calcium (1,250 mg) * calcium antacid 500 mg chw tab assorted fruit 200 mg calcium (500 mg) * calcium antacid 750 mg tb chew gluten-free 300 mg (750 mg) * cal-gest 500 mg tablet chew 200 mg calcium (500 mg) * CARBAGLU ORAL TABLET, DISPERSIBLE 200 MG child soothe 400 mg tab chew 400 mg * children pepto 400 mg tab chew bubble gum, na/f 400 mg * comfort gel max str susp max-str mg/5 ml * (Calcium 500) QL (60 per 30 days) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 150

165 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Non Dwòg comfort gel suspension regular str, cherry mg/5 ml * constulose oral solution 10 gram/15 ml cromolyn oral concentrate 100 mg/5 ml (Gastrocrom) cvs antacid ultra tab chew ultra strength 400 mg calcium (1,000 mg) * cvs antacid-antigas tab chew 1, mg * cvs anti-diarrheal 2 mg sftgel softgel 2 mg * cvs anti-diarrheal suspension 262 mg/15 ml * cvs flavor chew antacid 750 mg 300 mg (750 mg) * cvs loperamide 1 mg/7.5 ml liq mint 1 mg/7.5 ml * (Imodium A-D) diamode 2 mg tablet outer, f/c 2 mg * dicyclomine oral capsule 10 mg (Bentyl) dicyclomine oral solution 10 mg/5 ml dicyclomine oral tablet 20 mg diphenoxylate-atropine oral liquid mg/5 ml diphenoxylate-atropine oral tablet mg (Lomotil) enulose oral solution 10 gram/15 ml foaming antacid liquid mg/15 ml * GATTEX 5 MG 30-VIAL KIT 5 MG GATTEX ONE-VIAL SUBCUTANEOUS KIT 5 MG Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite PA PA 151

166 gelusil antacid & antigas liq mg/5 ml * gelusil tablet chewable cool mint mg * generlac oral solution 10 gram/15 ml geri-lanta liquid mg/5 ml * glycopyrrolate injection solution 0.2 mg/ml (Robinul) glycopyrrolate oral tablet 1 mg (Robinul) glycopyrrolate oral tablet 2 mg (Robinul Forte) imodium a-d 1 mg/7.5 ml liquid mint 1 mg/7.5 ml * imodium a-d 2 mg softgel 2 mg * kaopectate 262 mg/15 ml susp 262 mg/15 ml * kionex 15 gm/60 ml suspension gram/60 ml kionex oral powder lactulose oral solution 10 gram/15 ml (Enulose) LINZESS ORAL CAPSULE 145 MCG, 290 MCG, 72 MCG loperamide 1 mg/5 ml liquid 1 mg/5 (Anti-Diarrheal ml * (loperamide)) loperamide 1 mg/7.5 ml susp mint 1 mg/7.5 ml * (Imodium A-D) loperamide oral capsule 2 mg (Imodium A-D) maalox advanced suspension regular strength mg/5 ml * magnesium 250 mg tablet p/f 250 mg * magnesium 400 mg tablet glutenfree 400 mg * (MgO) QL (30 per 30 days) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 152

167 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Non Dwòg magnesium oxide 500 mg capsule 500 mg * magnesium oxide 500 mg tablet (Laxative Dietary p/f,s/f,lactose-free 500 mg * Supplement) magnesium-oxide 400 mg tablet 241.3mg elemental 400 mg * (MgO) masanti liquid mg/5 ml * medi-first pep-t-med tab chew 262 mg * methscopolamine oral tablet 2.5 mg, 5 mg metoclopramide hcl injection solution 5 mg/ml metoclopramide hcl oral solution 5 mg/5 ml metoclopramide hcl oral tablet 10 mg, 5 mg (Reglan) mgo 400 mg tablet 400 mg * mi acid suspension mg/5 ml, mg/5 ml * mi-acid ds tablet mg * mintox maximum strength susp max str, lemon creme mg/5 ml * mintox plus tablet chewable mg * mintox suspension mint creme mg/5 ml * MOVANTIK ORAL TABLET 12.5 MG, 25 MG NUTRESTORE ORAL POWDER IN PACKET 5 GRAM OCALIVA ORAL TABLET 10 MG, 5 MG phillips 500 mg caplet 500 mg * QL (30 per 30 days) PA; QL (30 per 30 days) Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 153

168 pink bismuth tablet chew 262 mg * ra magnesium 500 mg capsule 500 mg * RAVICTI ORAL LIQUID 1.1 GRAM/ML RELISTOR ORAL TABLET 150 MG RELISTOR SUBCUTANEOUS SOLUTION 12 MG/0.6 ML RELISTOR SUBCUTANEOUS SYRINGE 12 MG/0.6 ML, 8 MG/0.4 ML ri-gel ii suspension mg/5 ml * riginic suspension mg/5 ml * ri-mox suspension mg/5 ml * sm antacid anti-gas liquid mg/5 ml * sm foaming antacid tablet chew mg * sm stomach relief caplet 262 mg * sodium bicarb 650 mg tablet 10 gr 650 mg * sodium polystyrene (sorb free) oral suspension 15 gram/60 ml sodium polystyrene sulfonate rectal enema 30 gram/120 ml soothe 262 mg caplet caplet 262 mg * soothe 262 mg/15 ml suspension s/f,cherry 262 mg/15 ml * sps (with sorbitol) oral suspension gram/60 ml ursodiol oral capsule 300 mg (Actigall) PA PA; QL (90 per 30 days) PA; QL (28 per 28 days) PA; QL (28 per 28 days) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 154

169 bisac-evac 10 mg suppository 10 mg * bisacodyl 10 mg suppository 10 mg (Laxative * (bisacodyl)) bisacodyl ec 5 mg tablet 5 mg * (Alophen) biscolax 10 mg suppository 10 mg * clearlax powder 14 once-daily doses 17 gram/dose * cvs enema disposable 19-7 gram/118 ml * cvs fiber therapy 500 mg caplt soluble, caplet 500 mg * cvs kids 100 mg mini enema 100 mg/5 ml * cvs purelax powder 17 gram/dose * cvs purelax powder packet s/f, 10 daily doses 17 gram * doc-q-lace 100 mg softgel 100 mg * docu liquid 50 mg/5 ml 50 mg/5 ml * docusate sodium 100 mg tablet (DOK) crushable 100 mg * docusate sodium-senna tablet mg * docusol mini-enema outer 283 mg * 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Non Dwòg ursodiol oral tablet 250 mg (URSO 250) ursodiol oral tablet 500 mg (URSO Forte) VELTASSA ORAL POWDER IN PACKET 16.8 GRAM, 25.2 GRAM, 8.4 GRAM VIBERZI ORAL TABLET 100 MG, 75 MG XERMELO ORAL TABLET 250 MG Laxatives alophen pills 5 mg * QL (30 per 30 days) ST; QL (60 per 30 days) PA; QL (90 per 30 days) Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 155

170 dok 100 mg softgel softgel 100 mg * dok 100 mg tablet 100 mg * dulcolax ss 100 mg softgel 100 mg * enema disposable 19-7 gram/118 ml * enema ready to use latex-free 19-7 gram/118 ml * enemeez mini enema 5cc tubes, outer 283 mg/5 ml * enemeez plus mini enema outer mg/5 ml * eq fiber therapy powder * eql fiber therapy powder 3.4 gram/7 gram * equalactin 500 mg tab chew 500 mg * evac-u-gen 8.6 mg tablet 8.6 mg * fiber tablet unboxed 625 mg * fiber therapy powder 2 gram/19 gram * fiber-lax captabs 500mg polycarbophil 625 mg * FLEET BISACODYL 10 MG ENEMA 10 MG/30 ML * gavilyte-c oral recon soln gram gavilyte-g oral recon soln gram gavilyte-n oral recon soln 420 gram glycolax powder 31 doses (otc) 17 gram/dose * healthylax powder packet 14x17gm, outer 17 gram * hydrocil instant packet * KONSYL 6 GM PACKET S/F, GLUTEN-F, OUTER 6 GRAM * You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 156

171 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Non Dwòg konsyl fiber 625 mg caplet caplet, s/f 625 mg * konsyl psyllium fiber packet orange, gluten free 3.4 gram * kro gentlelax 17 gram powder 17 gram/dose * magic bullet 10 mg suppos 10 mg * milk of magnesia suspension 400 mg/5 ml * mineral oil laxative * MOVIPREP ORAL POWDER IN PACKET GRAM natural fiber lax powder * oral saline laxative liquid s/f, ginger lemon gram/15 ml * peg 3350-electrolytes oral recon soln gram (GaviLyte-G) peg 3350-electrolytes oral recon (Colyte with Flavor soln gram Packs) peg-electrolyte soln oral recon soln (TriLyte With 420 gram Flavor Packets) peri-colace tablet mg * phillips' lax liqui-gels 100 mg * phosphate oral saline laxative s/f, ginger lemon gram/15 ml * polyethylene glycol 3350 oral powder 17 gram/dose (GlycoLax) polyethylene glycol 3350 oral powder in packet 17 gram (Purelax) polyethylene glycol 3350 powd 14 once-daily doses (otc) 17 gram/dose (GlycoLax) * polyethylene glycol 3350 powd 17 grams pkts,outer (otc) 17 gram * (Purelax) polyethylene glycol 3350 powd outer (otc) 17 gram * (Purelax) Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 157

172 promolaxin 100 mg tablet 100 mg * pv fiber therapy powder * pv senna 8.6 mg softgel 8.6 mg * qc mineral oil heavy * (Mineral Oil Laxative) qc natura-lax 17 gm powder 17 gram/dose * ra enema twin pack 2 x 4.5oz, rtu 19-7 gram/118 ml * ra laxative peg 3350 powder 14 once-daily doses 17 gram/dose * reguloid powder * senexon 8.8 mg/5 ml liquid 8.8 mg/5 ml * senexon tablet 8.6 mg * senna 8.6 mg tablet 8.6 mg * senna 8.8 mg/5 ml syrup a/f, chocolate 8.8 mg/5 ml * senna-lax 8.6 mg tablet 8.6 mg * senokot-s tablet mg * silace 50 mg/5 ml liquid 50 mg/5 ml * silace 60 mg/15 ml syrup 60 mg/15 ml * sm fiber laxative 500 mg cplt 500 mg * sm fiber smooth powder * smoothlax powder packet s/f, 10 daily doses 17 gram * stool softener 240 mg softgel softgel 240 mg * SUPREP BOWEL PREP KIT ORAL RECON SOLN GRAM trilyte with flavor packets oral recon soln 420 gram You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 158

173 Phosphate Binders calcium acetate oral capsule 667 mg calcium acetate oral tablet 667 mg (Calphron) eliphos oral tablet 667 mg magnebind 400 oral tablet mg PHOSLYRA ORAL SOLUTION 667 MG (169 MG CALCIUM)/5 ML RENAGEL ORAL TABLET 400 MG, 800 MG RENVELA ORAL POWDER IN PACKET 0.8 GRAM, 2.4 GRAM RENVELA ORAL TABLET 800 MG sevelamer carbonate oral powder in packet 0.8 gram, 2.4 gram (Renvela) VELPHORO ORAL TABLET,CHEWABLE 500 MG Genitourinary Agents Antispasmodics, Urinary bethanechol chloride oral tablet 10 mg, 25 mg, 5 mg, 50 mg (Urecholine) MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR 25 MG, 50 MG oxybutynin chloride oral syrup 5 mg/5 ml oxybutynin chloride oral tablet 5 mg oxybutynin chloride oral tablet extended release 24hr 10 mg, 15 (Ditropan XL) mg, 5 mg tolterodine oral capsule,extended release 24hr 2 mg, 4 mg (Detrol LA) tolterodine oral tablet 1 mg, 2 mg (Detrol) 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 159

174 TOVIAZ ORAL TABLET EXTENDED RELEASE 24 HR 4 MG, 8 MG trospium oral capsule,extended release 24hr 60 mg trospium oral tablet 20 mg VESICARE ORAL TABLET 10 MG, 5 MG Genitourinary Agents, Miscellaneous alfuzosin oral tablet extended release 24 hr 10 mg (Uroxatral) dutasteride oral capsule 0.5 mg (Avodart) dutasteride-tamsulosin oral capsule, er multiphase 24 hr mg (Jalyn) finasteride oral tablet 5 mg (Proscar) tamsulosin oral capsule,extended release 24hr 0.4 mg (Flomax) terazosin oral capsule 1 mg, 10 mg, 2 mg, 5 mg Heavy Metal Antagonists Heavy Metal Antagonists CUPRIMINE ORAL CAPSULE 250 MG deferoxamine injection recon soln 2 gram, 500 mg (Desferal) DEPEN TITRATABS ORAL TABLET 250 MG EXJADE ORAL TABLET, DISPERSIBLE 125 MG, 250 MG, 500 MG FERRIPROX ORAL SOLUTION 100 MG/ML FERRIPROX ORAL TABLET 500 MG QL (30 per 30 days) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 160

175 SYPRINE ORAL CAPSULE 250 MG Hormonal Agents, Stimulant/Replacement/Modif ying Androgens ANADROL-50 ORAL TABLET 50 MG ANDRODERM TRANSDERMAL PATCH 24 HOUR 2 MG/24 HOUR, 4 MG/24 HR ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP MG/1.25 GRAM (1.62 %) ANDROGEL TRANSDERMAL GEL IN PACKET 1.62 % (20.25 MG/1.25 GRAM), 1.62 % (40.5 MG/2.5 GRAM) androxy oral tablet 10 mg danazol oral capsule 100 mg, 200 mg, 50 mg oxandrolone oral tablet 10 mg, 2.5 (Oxandrin) mg testosterone cypionate intramuscular oil 100 mg/ml, 200 mg/ml testosterone enanthate intramuscular oil 200 mg/ml testosterone transdermal gel 50 mg/5 gram (1 %) testosterone transdermal gel in metered-dose pump 12.5 mg/ 1.25 gram (1 %) testosterone transdermal gel in packet 1 % (25 mg/2.5gram) (Depo- Testosterone) (Vogelxo) (Vogelxo) (AndroGel) PA PA; QL (30 per 30 days) PA; QL (150 per 30 days) PA; QL (150 per 30 days) PA PA; QL (5 per 28 days) PA; QL (300 per 30 days) PA; QL (300 per 30 days) PA; QL (300 per 30 days) 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 161

176 testosterone transdermal gel in packet 1 % (50 mg/5 gram) Estrogens And Antiestrogens amabelz oral tablet mg, mg COMBIPATCH TRANSDERMAL PATCH SEMIWEEKLY MG/24 HR, MG/24 HR DUAVEE ORAL TABLET MG ESTRACE VAGINAL CREAM 0.01 % (0.1 MG/GRAM) estradiol oral tablet 0.5 mg, 1 mg, 2 mg estradiol transdermal patch semiweekly mg/24 hr, mg/24 hr, 0.05 mg/24 hr, mg/24 hr, 0.1 mg/24 hr estradiol transdermal patch weekly mg/24 hr, mg/24 hr, 0.05 mg/24 hr, 0.06 mg/24 hr, mg/24 hr, 0.1 mg/24 hr estradiol valerate intramuscular oil 20 mg/ml, 40 mg/ml estradiol-norethindrone acet oral tablet mg estradiol-norethindrone acet oral tablet mg estropipate oral tablet 0.75 mg, 1.5 mg, 3 mg FEMRING VAGINAL RING 0.05 MG/24 HR, 0.1 MG/24 HR MENEST ORAL TABLET 0.3 MG, MG, 1.25 MG, 2.5 MG (Vogelxo) (Estrace) (Minivelle) (Climara) (Delestrogen) (Mimvey Lo) (Activella) mimvey lo oral tablet mg PA; QL (300 per 30 days) PA-HRM; QL (8 per 28 days); AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; QL (8 per 28 days); AGE (Max 64 Years) PA-HRM; QL (4 per 28 days); AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) QL (1 per 84 days) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 162

177 mimvey oral tablet mg PA-HRM; AGE (Max 64 Years) PREMARIN INJECTION RECON SOLN 25 MG PREMARIN ORAL TABLET 0.3 MG, 0.45 MG, MG, 0.9 MG, PA-HRM; AGE (Max 64 Years) 1.25 MG PREMARIN VAGINAL CREAM MG/GRAM PREMPHASE ORAL TABLET PA-HRM; AGE (Max MG (14)/ 0.625MG-5MG(14) 64 Years) PREMPRO ORAL TABLET MG, MG, MG, MG PA-HRM; AGE (Max 64 Years) raloxifene oral tablet 60 mg (Evista) yuvafem vaginal tablet 10 mcg QL (18 per 28 days) Glucocorticoids/Mineralocorticoids a-hydrocort injection recon soln 100 mg betamethasone acet,sod phos (Celestone injection suspension 6 mg/ml Soluspan) cortisone oral tablet 25 mg dexamethasone oral elixir 0.5 mg/5 ml dexamethasone oral tablet 0.5 mg, 0.75 mg, 1 mg, 1.5 mg, 2 mg, 4 mg, 6 mg dexamethasone sodium phosphate injection solution 10 mg/ml, 4 mg/ml EMFLAZA ORAL SUSPENSION PA MG/ML EMFLAZA ORAL TABLET 18 PA; QL (30 per 30 MG EMFLAZA ORAL TABLET 30 MG, 6 MG days) PA; QL (60 per 30 days) 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 163

178 EMFLAZA ORAL TABLET 36 PA MG fludrocortisone oral tablet 0.1 mg hydrocortisone oral tablet 10 mg, 20 (Cortef) mg, 5 mg methylprednisolone acetate injection suspension 40 mg/ml, 80 mg/ml (Depo-Medrol) methylprednisolone oral tablet 16 (Medrol) mg, 32 mg, 4 mg, 8 mg methylprednisolone oral tablets,dose pack 4 mg (Medrol (Pak)) methylprednisolone sodium succ injection recon soln 125 mg, 40 mg methylprednisolone sodium succ intravenous recon soln 1,000 mg (Solu-Medrol) prednisolone sodium phosphate oral solution 15 mg/5 ml (3 mg/ml), 25 mg/5 ml (5 mg/ml) prednisolone sodium phosphate oral solution 5 mg base/5 ml (6.7 mg/5 ml) (Pediapred) prednisone oral solution 5 mg/5 ml prednisone oral tablet 1 mg, 2.5 mg, 5 mg, 50 mg prednisone oral tablet 10 mg prednisone oral tablet 20 mg (Deltasone) prednisone oral tablets,dose pack 10 mg, 10 mg (48 pack), 5 mg, 5 mg (48 pack) SOLU-CORTEF (PF) INJECTION RECON SOLN 100 MG/2 ML Pituitary desmopressin injection solution 4 mcg/ml (DDAVP) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 164

179 desmopressin nasal solution 0.1 mg/ml (refrigerate) desmopressin nasal spray,nonaerosol 10 mcg/spray (0.1 ml) desmopressin oral tablet 0.1 mg, 0.2 mg GENOTROPIN MINIQUICK SUBCUTANEOUS SYRINGE 0.2 MG/0.25 ML, 0.4 MG/0.25 ML, 0.6 MG/0.25 ML, 0.8 MG/0.25 ML, 1 MG/0.25 ML, 1.2 MG/0.25 ML, 1.4 MG/0.25 ML, 1.6 MG/0.25 ML, 1.8 MG/0.25 ML, 2 MG/0.25 ML GENOTROPIN SUBCUTANEOUS CARTRIDGE 12 MG/ML (36 UNIT/ML), 5 MG/ML (15 UNIT/ML) HUMATROPE INJECTION CARTRIDGE 12 MG (36 UNIT), 24 MG (72 UNIT), 6 MG (18 UNIT) HUMATROPE INJECTION RECON SOLN 5 (15 UNIT) MG INCRELEX SUBCUTANEOUS SOLUTION 10 MG/ML LUPRON DEPOT-PED (3 MONTH) INTRAMUSCULAR SYRINGE KIT 30 MG LUPRON DEPOT-PED INTRAMUSCULAR KIT MG, 15 MG, 7.5 MG (PED) (DDAVP) (DDAVP) QL (15 per 30 days) QL (15 per 30 days) PA PA PA PA QL (1 per 84 days) 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 165

180 NORDITROPIN FLEXPRO SUBCUTANEOUS PEN INJECTOR 10 MG/1.5 ML (6.7 MG/ML), 15 MG/1.5 ML (10 MG/ML), 30 MG/3 ML (10 MG/ML), 5 MG/1.5 ML (3.3 MG/ML) NUTROPIN AQ NUSPIN SUBCUTANEOUS PEN INJECTOR 10 MG/2 ML (5 MG/ML), 20 MG/2 ML (10 MG/ML), 5 MG/2 ML (2.5 MG/ML) NUTROPIN AQ SUBCUTANEOUS CARTRIDGE 10 MG/2 ML (5 MG/ML), 20 MG/2 ML (10 MG/ML) octreotide acet 50 mcg/ml syr outer,single-dose,10 50 mcg/ml (1 ml) octreotide acetate injection solution 1,000 mcg/ml, 100 mcg/ml, 200 mcg/ml, 500 mcg/ml octreotide acetate injection solution 50 mcg/ml OMNITROPE SUBCUTANEOUS CARTRIDGE 10 MG/1.5 ML (6.7 MG/ML), 5 MG/1.5 ML (3.3 MG/ML) OMNITROPE SUBCUTANEOUS RECON SOLN 5.8 MG SAIZEN CLICK.EASY SUBCUTANEOUS CARTRIDGE 8.8 MG/1.51 ML (FINAL CONC.) SAIZEN SUBCUTANEOUS RECON SOLN 5 MG, 8.8 MG (Sandostatin) (Sandostatin) PA PA PA PA PA PA PA You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 166

181 SANDOSTATIN LAR DEPOT INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 10 MG, 20 MG, 30 MG SEROSTIM SUBCUTANEOUS RECON SOLN 4 MG, 5 MG, 6 MG SOMATULINE DEPOT SUBCUTANEOUS SYRINGE 120 MG/0.5 ML, 60 MG/0.2 ML, 90 MG/0.3 ML SOMAVERT SUBCUTANEOUS RECON SOLN 10 MG, 15 MG, 20 MG, 25 MG, 30 MG SUPPRELIN LA IMPLANT KIT 50 MG (65 MCG/DAY) ZOMACTON SUBCUTANEOUS RECON SOLN 10 MG, 5 MG ZORBTIVE SUBCUTANEOUS RECON SOLN 8.8 MG Progestins DEPO-PROVERA INTRAMUSCULAR SOLUTION 400 MG/ML hydroxyprogesterone caproate intramuscular oil 250 mg/ml medroxyprogesterone intramuscular suspension 150 mg/ml medroxyprogesterone intramuscular syringe 150 mg/ml medroxyprogesterone oral tablet 10 mg, 2.5 mg, 5 mg megestrol oral suspension 400 mg/10 ml (40 mg/ml) megestrol oral suspension 625 mg/5 ml (Depo-Provera) (Depo-Provera) (Provera) (Megace ES) PA QL (1 per 28 days) QL (1 per 360 days) PA PA QL (10 per 28 days) PA NSO QL (1 per 84 days) QL (1 per 84 days) 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 167

182 norethindrone acetate oral tablet 5 mg (Aygestin) progesterone in oil intramuscular oil 50 mg/ml progesterone micronized oral capsule 100 mg, 200 mg (Prometrium) Thyroid And Antithyroid Agents levothyroxine intravenous recon soln 100 mcg, 200 mcg, 500 mcg levothyroxine oral tablet 100 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 75 mcg, 88 (Levoxyl) mcg levothyroxine oral tablet 112 mcg, 300 mcg, 50 mcg (Unithroid) liothyronine oral tablet 25 mcg, 5 mcg, 50 mcg (Cytomel) methimazole oral tablet 10 mg, 5 mg (Tapazole) propylthiouracil oral tablet 50 mg Immunological Agents Immunological Agents ACTEMRA INTRAVENOUS PA SOLUTION 200 MG/10 ML (20 MG/ML), 400 MG/20 ML (20 MG/ML), 80 MG/4 ML (20 MG/ML) ACTEMRA SUBCUTANEOUS PA SYRINGE 162 MG/0.9 ML ARCALYST SUBCUTANEOUS RECON SOLN 220 MG ASTAGRAF XL ORAL CAPSULE,EXTENDED RELEASE 24HR 0.5 MG, 1 MG, 5 MG azathioprine oral tablet 50 mg (Imuran) azathioprine sodium injection recon soln 100 mg You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 168

183 CARIMUNE NF NANOFILTERED INTRAVENOUS RECON SOLN 6 GRAM CIMZIA POWDER FOR RECONST SUBCUTANEOUS KIT 400 MG (200 MG X 2 VIALS) CIMZIA SUBCUTANEOUS SYRINGE KIT 400 MG/2 ML (200 MG/ML X 2) cyclosporine intravenous solution 250 mg/5 ml cyclosporine modified oral capsule 100 mg, 25 mg cyclosporine modified oral capsule 50 mg cyclosporine modified oral solution 100 mg/ml cyclosporine oral capsule 100 mg, 25 mg ENBREL SUBCUTANEOUS RECON SOLN 25 MG (1 ML) ENBREL SUBCUTANEOUS SYRINGE 25 MG/0.5ML (0.51), 50 MG/ML (0.98 ML) ENBREL SURECLICK SUBCUTANEOUS PEN INJECTOR 50 MG/ML (0.98 ML) ENVARSUS XR ORAL TABLET EXTENDED RELEASE 24 HR 0.75 MG, 1 MG, 4 MG FLEBOGAMMA DIF INTRAVENOUS SOLUTION 10 %, 5 % (Sandimmune) (Neoral) (Gengraf) (Neoral) (Sandimmune) PA PA PA PA PA 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 169

184 GAMASTAN S/D INTRAMUSCULAR SOLUTION % RANGE, % RANGE (10 ML), % RANGE (2 ML) GAMMAGARD LIQUID INJECTION SOLUTION 10 % GAMMAGARD S-D (IGA < 1 MCG/ML) INTRAVENOUS RECON SOLN 10 GRAM, 5 GRAM GAMMAPLEX (WITH SORBITOL) INTRAVENOUS SOLUTION 5 % GAMMAPLEX INTRAVENOUS SOLUTION 10 % gengraf oral capsule 100 mg, 25 mg, 50 mg gengraf oral solution 100 mg/ml HUMIRA PEDIATRIC CROHN'S PA START SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML, 40 MG/0.8 ML (6 PACK) HUMIRA PEN CROHN'S-UC-HS PA START SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML HUMIRA PEN PSORIASIS- PA UVEITIS SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML HUMIRA PEN SUBCUTANEOUS PA PEN INJECTOR KIT 40 MG/0.8 ML HUMIRA SUBCUTANEOUS SYRINGE KIT 10 MG/0.2 ML, 20 MG/0.4 ML, 40 MG/0.8 ML PA You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 170

185 HYPERRAB S/D (PF) INTRAMUSCULAR SOLUTION 150 UNIT/ML, 150 UNIT/ML (10 ML) HYQVIA IG COMPONENT SUBCUTANEOUS SOLUTION 10 GRAM/100 ML (10 %), 2.5 GRAM/25 ML (10 %), 20 GRAM/200 ML (10 %), 30 GRAM/300 ML (10 %), 5 GRAM/50 ML (10 %) HYQVIA SUBCUTANEOUS SOLUTION 10 GRAM /100 ML (10 %), 2.5 GRAM /25 ML (10 %), 20 GRAM /200 ML (10 %), 30 GRAM /300 ML (10 %), 5 GRAM /50 ML (10 %) ILARIS (PF) SUBCUTANEOUS RECON SOLN 180 MG/1.2 ML (150 MG/ML) ILARIS (PF) SUBCUTANEOUS SOLUTION 150 MG/ML IMOGAM RABIES-HT (PF) INTRAMUSCULAR SOLUTION 150 UNIT/ML KEVZARA SUBCUTANEOUS SYRINGE 150 MG/1.14 ML, 200 MG/1.14 ML KINERET SUBCUTANEOUS SYRINGE 100 MG/0.67 ML leflunomide oral tablet 10 mg, 20 mg mycophenolate mofetil hcl intravenous recon soln 500 mg mycophenolate mofetil oral capsule 250 mg (Arava) (CellCept Intravenous) (CellCept) PA PA PA; QL (2.28 per 28 days) PA; QL (18.76 per 28 days) 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 171

186 mycophenolate mofetil oral suspension for reconstitution 200 mg/ml mycophenolate mofetil oral tablet 500 mg mycophenolate sodium oral tablet,delayed release (dr/ec) 180 mg, 360 mg NULOJIX INTRAVENOUS RECON SOLN 250 MG OCTAGAM INTRAVENOUS SOLUTION 10 %, 5 % ORENCIA (WITH MALTOSE) INTRAVENOUS RECON SOLN 250 MG ORENCIA SUBCUTANEOUS SYRINGE 125 MG/ML, 50 MG/0.4 ML, 87.5 MG/0.7 ML (CellCept) (CellCept) (Myfortic) OTEZLA ORAL TABLET 30 MG OTEZLA STARTER ORAL TABLETS,DOSE PACK 10 MG (4)-20 MG (4)-30 MG (47), 10 MG (4)-20 MG (4)-30 MG(19) OTREXUP (PF) SUBCUTANEOUS AUTO- INJECTOR 10 MG/0.4 ML, 12.5 MG/0.4 ML, 15 MG/0.4 ML, 17.5 MG/0.4 ML, 20 MG/0.4 ML, 22.5 MG/0.4 ML, 25 MG/0.4 ML, 7.5 MG/0.4 ML PRIVIGEN INTRAVENOUS SOLUTION 10 % PROGRAF INTRAVENOUS SOLUTION 5 MG/ML RAPAMUNE ORAL SOLUTION 1 MG/ML You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit PA PA PA; QL (60 per 30 days) PA; QL (60 per 30 days) 172

187 RASUVO (PF) SUBCUTANEOUS AUTO-INJECTOR 10 MG/0.2 ML, 12.5 MG/0.25 ML, 15 MG/0.3 ML, 17.5 MG/0.35 ML, 20 MG/0.4 ML, 22.5 MG/0.45 ML, 25 MG/0.5 ML, 27.5 MG/0.55 ML, 30 MG/0.6 ML, 7.5 MG/0.15 ML RIDAURA ORAL CAPSULE 3 MG SIMPONI ARIA INTRAVENOUS SOLUTION 12.5 MG/ML SIMPONI SUBCUTANEOUS PEN INJECTOR 100 MG/ML, 50 MG/0.5 ML SIMPONI SUBCUTANEOUS SYRINGE 100 MG/ML, 50 MG/0.5 ML sirolimus oral tablet 0.5 mg, 1 mg, 2 mg STELARA INTRAVENOUS SOLUTION 130 MG/26 ML STELARA SUBCUTANEOUS SYRINGE 45 MG/0.5 ML, 90 MG/ML tacrolimus oral capsule 0.5 mg, 1 mg, 5 mg TYSABRI INTRAVENOUS SOLUTION 300 MG/15 ML (Rapamune) (Prograf) XELJANZ ORAL TABLET 5 MG XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HR 11 MG ZORTRESS ORAL TABLET 0.25 MG, 0.5 MG, 0.75 MG Vaccines PA PA PA PA PA PA; LA; QL (15 per 28 days) PA; QL (60 per 30 days) PA; QL (30 per 30 days) 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 173

188 ACTHIB (PF) INTRAMUSCULAR RECON SOLN 10 MCG/0.5 ML ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SUSPENSION 2 LF-( MCG)-5LF/0.5 ML ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SYRINGE 2 LF-( MCG)-5LF/0.5 ML BCG VACCINE, LIVE (PF) PERCUTANEOUS SUSPENSION FOR RECONSTITUTION 50 MG BEXSERO INTRAMUSCULAR SYRINGE MCG/0.5 ML BOOSTRIX TDAP INTRAMUSCULAR SUSPENSION LF-MCG- LF/0.5ML BOOSTRIX TDAP INTRAMUSCULAR SYRINGE LF-MCG-LF/0.5ML CERVARIX VACCINE (PF) INTRAMUSCULAR SYRINGE MCG/0.5 ML COMVAX (PF) INTRAMUSCULAR SUSPENSION MCG/0.5 ML DAPTACEL (DTAP PEDIATRIC) (PF) INTRAMUSCULAR SUSPENSION LF-MCG- LF/0.5ML You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 174

189 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Non Dwòg ENGERIX-B (PF) INTRAMUSCULAR SUSPENSION 20 MCG/ML ENGERIX-B (PF) INTRAMUSCULAR SYRINGE 20 MCG/ML ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SUSPENSION 10 MCG/0.5 ML ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SYRINGE 10 MCG/0.5 ML GARDASIL (PF) INTRAMUSCULAR SUSPENSION MCG/0.5 ML GARDASIL (PF) INTRAMUSCULAR SYRINGE MCG/0.5 ML GARDASIL 9 (PF) INTRAMUSCULAR SUSPENSION 0.5 ML GARDASIL 9 (PF) INTRAMUSCULAR SYRINGE 0.5 ML HAVRIX (PF) INTRAMUSCULAR SUSPENSION 1,440 ELISA UNIT/ML, 720 ELISA UNIT/0.5 ML HAVRIX (PF) INTRAMUSCULAR SYRINGE 1,440 ELISA UNIT/ML, 720 ELISA UNIT/0.5 ML HIBERIX (PF) INTRAMUSCULAR RECON SOLN 10 MCG/0.5 ML QL (1.5 per 365 days) QL (1.5 per 365 days) QL (1.5 per 365 days) QL (1.5 per 365 days) Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 175

190 IMOVAX RABIES VACCINE (PF) INTRAMUSCULAR RECON SOLN 2.5 UNIT INFANRIX (DTAP) (PF) INTRAMUSCULAR SUSPENSION LF-MCG- LF/0.5ML IPOL INJECTION SUSPENSION UNIT/0.5 ML IPOL INJECTION SYRINGE UNIT/0.5 ML IXIARO (PF) INTRAMUSCULAR SYRINGE 6 MCG/0.5 ML KINRIX (PF) INTRAMUSCULAR SUSPENSION 25 LF-58 MCG-10 LF/0.5 ML KINRIX (PF) INTRAMUSCULAR SYRINGE 25 LF-58 MCG-10 LF/0.5 ML MENACTRA (PF) INTRAMUSCULAR SOLUTION 4 MCG/0.5 ML MENHIBRIX (PF) INTRAMUSCULAR RECON SOLN MCG/0.5 ML MENOMUNE - A/C/Y/W-135 (PF) SUBCUTANEOUS RECON SOLN 50 MCG MENOMUNE - A/C/Y/W-135 SUBCUTANEOUS RECON SOLN 50 MCG MENVEO A-C-Y-W-135-DIP (PF) INTRAMUSCULAR KIT 10-5 MCG/0.5 ML M-M-R II (PF) SUBCUTANEOUS RECON SOLN 1,000-12,500 TCID50/0.5 ML QL (2 per 365 days) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 176

191 PEDIARIX (PF) INTRAMUSCULAR SYRINGE 10 MCG-25LF-25 MCG-10LF/0.5 ML PEDVAX HIB (PF) INTRAMUSCULAR SOLUTION 7.5 MCG/0.5 ML PENTACEL (PF) INTRAMUSCULAR KIT 15 LF UNIT-20 MCG-5 LF/0.5 ML PROQUAD (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 10EXP TCID50/0.5 QUADRACEL (PF) INTRAMUSCULAR SUSPENSION 15 LF-48 MCG- 5 LF UNIT/0.5ML RABAVERT (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 2.5 UNIT RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION 10 MCG/ML, 40 MCG/ML RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 10 MCG/ML, 5 MCG/0.5 ML RECOMBIVAX HB 5 MCG/0.5 ML VL OUTER, P/F, SDV 5 MCG/0.5 ML ROTARIX ORAL SUSPENSION FOR RECONSTITUTION 10EXP6 CCID50/ML ROTATEQ VACCINE ORAL SOLUTION 2 ML QL (2 per 365 days) 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 177

192 TENIVAC (PF) INTRAMUSCULAR SYRINGE 5-2 LF UNIT/0.5 ML TETANUS,DIPHTHERIA TOX PED(PF) INTRAMUSCULAR SUSPENSION 5-25 LF UNIT/0.5 ML TETANUS-DIPHTHERIA TOXOIDS-TD INTRAMUSCULAR SUSPENSION 2-2 LF UNIT/0.5 ML TICE BCG INTRAVESICAL SUSPENSION FOR RECONSTITUTION 50 MG TRUMENBA INTRAMUSCULAR SYRINGE 120 MCG/0.5 ML TWINRIX (PF) INTRAMUSCULAR SUSPENSION 720 ELISA UNIT - 20 MCG/ML TWINRIX (PF) INTRAMUSCULAR SYRINGE 720 ELISA UNIT -20 MCG/ML TYPHIM VI INTRAMUSCULAR SOLUTION 25 MCG/0.5 ML TYPHIM VI INTRAMUSCULAR SYRINGE 25 MCG/0.5 ML VAQTA (PF) INTRAMUSCULAR SUSPENSION 50 UNIT/ML VAQTA (PF) INTRAMUSCULAR SYRINGE 25 UNIT/0.5 ML, 50 UNIT/ML VAQTA 25 UNITS/0.5 ML VIAL SDV, OUTER 25 UNIT/0.5 ML You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 178

193 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Non Dwòg VARIVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 1,350 UNIT/0.5 ML YF-VAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 10 EXP4.74 UNIT/0.5 ML ZOSTAVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 19,400 UNIT/0.65 ML Inflammatory Bowel Disease Agents Inflammatory Bowel Disease Agents alosetron oral tablet 0.5 mg, 1 mg (Lotronex) APRISO ORAL CAPSULE,EXTENDED RELEASE 24HR GRAM balsalazide oral capsule 750 mg (Colazal) budesonide oral capsule,delayed,extend.release 3 mg (Entocort EC) colocort rectal enema 100 mg/60 ml DELZICOL ORAL CAPSULE (WITH DEL REL TABLETS) 400 MG DIPENTUM ORAL CAPSULE 250 MG hydrocortisone rectal enema 100 mg/60 ml (Cortenema) LIALDA ORAL TABLET,DELAYED RELEASE (DR/EC) 1.2 GRAM mesalamine oral tablet,delayed release (dr/ec) 800 mg (Asacol HD) QL (2 per 365 days) QL (1 per 365 days) Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite ST 179

194 calcitriol intravenous solution 1 mcg/ml calcitriol oral capsule 0.25 mcg, 0.5 mcg (Rocaltrol) calcitriol oral solution 1 mcg/ml (Rocaltrol) doxercalciferol intravenous solution 4 mcg/2 ml (Hectorol) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. UCERIS RECTAL FOAM 2 MG/ACTUATION Irrigating Solutions Irrigating Solutions acetic acid irrigation solution 0.25 % LACTATED RINGERS IRRIGATION SOLUTION ringer's irrigation solution sodium chloride irrigation solution 0.9 % (Sterile Saline) sorbitol irrigation solution 3 %, 3.3 % sorbitol-mannitol urethral solution g/100 ml water for irrigation, sterile irrigation solution (Curity Sterile Water) Metabolic Bone Disease Agents Metabolic Bone Disease Agents alendronate oral solution 70 mg/75 QL (300 per 28 days) ml alendronate oral tablet 10 mg, 40 mg, 5 mg alendronate oral tablet 35 mg QL (4 per 28 days) alendronate oral tablet 70 mg (Fosamax) QL (4 per 28 days) calcitonin (salmon) nasal spray,non-aerosol 200 (Miacalcin) QL (3.7 per 28 days) unit/actuation If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 180

195 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Non Dwòg doxercalciferol oral capsule 0.5 mcg, 1 mcg, 2.5 mcg (Hectorol) FORTEO SUBCUTANEOUS PEN INJECTOR 20 MCG/DOSE PA; QL (2.4 per 28 days) MCG/2.4 ML FORTICAL NASAL SPRAY,NON- AEROSOL 200 UNIT/ACTUATION QL (3.7 per 28 days) ibandronate intravenous solution 3 QL (3 per 84 days) mg/3 ml ibandronate intravenous syringe 3 QL (3 per 84 days) (Boniva) mg/3 ml ibandronate oral tablet 150 mg (Boniva) QL (1 per 28 days) MIACALCIN INJECTION SOLUTION 200 UNIT/ML NATPARA SUBCUTANEOUS PA; QL (2 per 28 days) CARTRIDGE 100 MCG/DOSE, 25 MCG/DOSE, 50 MCG/DOSE, 75 MCG/DOSE paricalcitol hemodialysis port injection solution 2 mcg/ml PARICALCITOL HEMODIALYSIS PORT INJECTION SOLUTION 5 MCG/ML paricalcitol intravenous solution 2 mcg/ml (Zemplar) paricalcitol oral capsule 1 mcg, 2 mcg (Zemplar) paricalcitol oral capsule 4 mcg PROLIA SUBCUTANEOUS QL (1 per 180 days) SYRINGE 60 MG/ML RAYALDEE ORAL QL (60 per 30 days) CAPSULE,EXTENDED RELEASE 24 HR 30 MCG risedronate oral tablet 150 mg (Actonel) QL (1 per 28 days) Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 181

196 risedronate oral tablet 30 mg, 5 mg (Actonel) QL (30 per 30 days) TYMLOS SUBCUTANEOUS PEN INJECTOR 80 MCG (3,120 PA; QL (1.56 per 30 days) MCG/1.56 ML) ZEMPLAR INTRAVENOUS SOLUTION 2 MCG/ML, 5 MCG/ML zoledronic acid intravenous solution 4 mg/5 ml (Zometa) zoledronic acid-mannitol-water QL (100 per 300 days) (Reclast) intravenous piggyback 5 mg/100 ml zoledronic ac-mannitol-0.9nacl intravenous piggyback 4 mg/100 ml ZOMETA INTRAVENOUS PIGGYBACK 4 MG/100 ML Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents ACTIMMUNE SUBCUTANEOUS SOLUTION 100 MCG/0.5 ML amifostine crystalline intravenous recon soln 500 mg (Ethyol) BENLYSTA INTRAVENOUS PA RECON SOLN 120 MG, 400 MG buspirone oral tablet 10 mg, 15 mg, 30 mg, 5 mg, 7.5 mg CERDELGA ORAL CAPSULE 84 PA MG CETYLEV ORAL TABLET, EFFERVESCENT 2.5 GRAM, 500 MG CYSTADANE ORAL POWDER 1 GRAM/1.7 ML droperidol injection solution 2.5 mg/ml You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 182

197 ELMIRON ORAL CAPSULE 100 MG ergoloid oral tablet 1 mg EXONDYS 51 INTRAVENOUS SOLUTION 50 MG/ML, 50 MG/ML (10 ML) fomepizole intravenous solution 1 gram/ml GLUCAGEN HYPOKIT INJECTION RECON SOLN 1 MG GLUCAGON EMERGENCY KIT (HUMAN) INJECTION KIT 1 MG guanidine oral tablet 125 mg hydroxyzine pamoate oral capsule 100 mg hydroxyzine pamoate oral capsule 25 mg, 50 mg (Vistaril) INFLECTRA INTRAVENOUS RECON SOLN 100 MG KEVEYIS ORAL TABLET 50 MG leucovorin calcium 200 mg vial sdv, p/f, latex-free 200 mg leucovorin calcium injection recon soln 100 mg, 350 mg, 50 mg leucovorin calcium oral tablet 10 mg, 15 mg, 25 mg, 5 mg levocarnitine (with sugar) oral solution 100 mg/ml (Carnitor) levocarnitine oral tablet 330 mg (Carnitor) LEVOLEUCOVORIN INTRAVENOUS RECON SOLN 175 MG levoleucovorin intravenous recon soln 50 mg (Fusilev) PA; LA PA PA; QL (120 per 30 days) 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 183

198 mesna intravenous solution 100 mg/ml (Mesnex) MESNEX ORAL TABLET 400 MG MESTINON ORAL SYRUP 60 MG/5 ML MINERAL OIL HEAVY * (Mineral Oil Heavy) ORENCIA CLICKJECT SUBCUTANEOUS AUTO- INJECTOR 125 MG/ML PROCYSBI ORAL CAPSULE, DELAYED REL SPRINKLE 25 MG, 75 MG pv extra cleansing douche * pyridostigmine bromide oral tablet 60 mg (Mestinon) pyridostigmine bromide oral tablet (Mestinon extended release 180 mg Timespan) ra feminine care douche * REMICADE INTRAVENOUS RECON SOLN 100 MG sb disp douche extra clns v&w * SENSIPAR ORAL TABLET 30 MG, 60 MG, 90 MG SIGNIFOR SUBCUTANEOUS SOLUTION 0.3 MG/ML (1 ML), 0.6 MG/ML (1 ML), 0.9 MG/ML (1 ML) summer's eve dche-xtra clns 12's,extra-cleansing * summer's eve douche-ultra clns 12's,2pk,ultra clns * SYNAREL NASAL SPRAY,NON- AEROSOL 2 MG/ML PA PA QL (60 per 30 days) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 184

199 THALOMID ORAL CAPSULE 100 PA NSO; QL (60 per MG, 150 MG, 200 MG, 50 MG 30 days) THIOLA ORAL TABLET 100 MG TYBOST ORAL TABLET 150 MG QL (30 per 30 days) Ophthalmic Agents Antiglaucoma Agents acetazolamide oral capsule, extended release 500 mg (Diamox Sequels) acetazolamide oral tablet 125 mg, 250 mg acetazolamide sodium injection recon soln 500 mg ALPHAGAN P OPHTHALMIC DROPS 0.1 % AZOPT OPHTHALMIC DROPS,SUSPENSION 1 % betaxolol ophthalmic drops 0.5 % bimatoprost ophthalmic drops 0.03 % brimonidine ophthalmic drops 0.15 % (Alphagan P) brimonidine ophthalmic drops 0.2 % COMBIGAN OPHTHALMIC DROPS % dorzolamide ophthalmic drops 2 % (Trusopt) dorzolamide-timolol ophthalmic drops mg/ml (Cosopt) latanoprost ophthalmic drops % (Xalatan) levobunolol ophthalmic drops 0.5 % (Betagan) LUMIGAN OPHTHALMIC QL (2.5 per 25 days) DROPS 0.01 % methazolamide oral tablet 25 mg, 50 (Neptazane) mg 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 185

200 metipranolol ophthalmic drops 0.3 % PHOSPHOLINE IODIDE OPHTHALMIC DROPS % pilocarpine hcl ophthalmic drops 1 %, 2 %, 4 % SIMBRINZA OPHTHALMIC DROPS,SUSPENSION % timolol maleate ophthalmic drops 0.25 %, 0.5 % timolol maleate ophthalmic gel forming solution 0.25 %, 0.5 % TRAVATAN Z OPHTHALMIC DROPS % travoprost (benzalkonium) ophthalmic drops % ZIOPTAN (PF) OPHTHALMIC DROPPERETTE % Replacement Preparations Replacement Preparations calcitrate + vit d caplet mg-unit * calcitrate 200 mg (950 mg) tab 200 mg (950 mg) * calcium +d & min chew tab 600 mg (1,500 mg)-400 unit * calcium 500+d tablet chew 500 mg(1,250mg) -400 unit * calcium vit d 400 softgl 600 mg(1,500mg) -400 unit * calcium 600 mg tablet 600 mg calcium (1,500 mg) * calcium 600+d softgel 600 mg calcium- 200 unit * (Isopto Carpine) (Timoptic) (Timoptic-XE) (Calcium D) (Calcium 600 with Vitamin D3) QL (2.5 per 25 days) QL (2.5 per 25 days) QL (30 per 30 days) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 186

201 calcium 600-vit d3 500 softgel rapid release, sftgl 600 mg(1,500mg) -500 unit * calcium carb 1,250 mg/5 ml sus 500 mg/5 ml (1,250 mg/5 ml) * calcium carbonate 648 mg tab 260 mg calcium (648 mg) * calcium chloride intravenous syringe 100 mg/ml (10 %) calcium citrate - vit d caplet caplet, coated mg-unit * calcium gluconate 500 mg tab 45 mg (500 mg) * calcium gluconate 648 mg tab 61 mg (648 mg) * CALCIUM-500 MG TABLET CHEWABLE SOY FREE, YEAST FREE MG-UNIT * CALTRATE D SOFT CHEW TAB CHOCOLATE TRUFFLE 600 MG (1,500 MG)-800 UNIT * citracal + d maximum caplet mg-unit * citrus calcium + d tablet mg-unit * cvs calcium citrate-vit d tab mg-unit * cvs magnesium 250 mg tablet 250 mg * (Calcium 600 with Vitamin D3) (Calcium Citrate + D) (Citracal + D Maximum) cvs pediatric electrolyte soln * cvs pediatric electrolyte soln a/f, p/f * d10 %-0.45 % sodium chloride intravenous parenteral solution d2.5 %-0.45 % sodium chloride intravenous parenteral solution 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 187

202 d5 % and 0.9 % sodium chloride intravenous parenteral solution d5 %-0.45 % sodium chloride intravenous parenteral solution dextrose 10 % and 0.2 % nacl intravenous parenteral solution dextrose 5 %-lactated ringers intravenous parenteral solution dextrose 5%-0.2 % sod chloride intravenous parenteral solution dextrose 5%-0.3 % sod.chloride intravenous parenteral solution dextrose with sodium chloride intravenous parenteral solution % dextrose-kcl-nacl intravenous solution % effer-k oral tablet, effervescent 25 meq electrolyte-48 in d5w intravenous parenteral solution eql cal 600-vit d3-min chew tb 600 mg (1,500 mg)-400 unit * eql calcium 600 mg + d softgel 600 mg(1,500mg) -100 unit * gnp calcium 600+d3+min chew tb p/f,gluten/f,yeast/f 600 mg calcium- 800 unit-40 mg * hm calcium 600+d plus tab chew gluten-free 600 mg calcium- 800 unit-40 mg * IONOSOL-B IN D5W INTRAVENOUS PARENTERAL SOLUTION 5 % IONOSOL-MB IN D5W INTRAVENOUS PARENTERAL SOLUTION 5 % You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 188

203 ISOLYTE-P IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION 5 % ISOLYTE-S INTRAVENOUS PARENTERAL SOLUTION kcl 10 meq in d5w-0.3% nacl singleuse 20 meq/l KLOR-CON 10 ORAL TABLET EXTENDED RELEASE 10 MEQ klor-con m10 oral tablet,er particles/crystals 10 meq klor-con m15 oral tablet,er particles/crystals 15 meq klor-con m20 oral tablet,er particles/crystals 20 meq klor-con sprinkle oral capsule, extended release 10 meq, 8 meq liquid calcium 600-vit d3 sfgl 600 mg(1,500mg) -400 unit * liquid calcium 600-vit d3 sfgl softgel,p/f,gluten-f 600 mg(1,500mg) -500 unit * liquid calcium with vitamin d softgel, s/f, p/f 600 mg calcium- 200 unit * mag delay dr 70 mg tablet 70 mg * mag64 dr 64 mg tablet 64 mg * mag-g 500 mg tablet 27 mg (500 mg) * magnesium 250 mg tablet 250 mg * magnesium 300 mg capsule 300 mg * magnesium gluc 500 mg tablet 27 mg (500 mg) * (Mag-G) 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 189

204 magnesium sulfate in d5w intravenous piggyback 1 gram/100 ml magnesium sulfate in water intravenous parenteral solution 20 gram/500 ml (4 %), 40 gram/1,000 ml (4 %) magnesium sulfate in water intravenous piggyback 2 gram/50 ml (4 %), 4 gram/100 ml (4 %), 4 gram/50 ml (8 %) magnesium sulfate injection solution 4 meq/ml (50 %) magnesium sulfate injection syringe 4 meq/ml natural calcium 500 mg tablet 500 mg calcium (1,250 mg) * NORMOSOL-M IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION NORMOSOL-R IV SOLUTION L/F, SINGLE-USE NORMOSOL-R PH 7.4 INTRAVENOUS PARENTERAL SOLUTION nu-mag 71.5 mg tablet 71.5 mg * oralyte freezer pops * oralyte solution * oysco-500 tablet 500 mg calcium (1,250 mg) * oyster shell calcium 500 mg tb 500mg elemental ca 500 mg calcium (1,250 mg) * oyster shell calcium-vit d tab 500 mg(1,250mg) -200 unit * pediatric electrolyte solution * You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 190

205 PLASMA-LYTE 148 INTRAVENOUS PARENTERAL SOLUTION PLASMA-LYTE A INTRAVENOUS PARENTERAL SOLUTION PLASMA-LYTE-56 IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION 5 % potassium acetate intravenous solution 2 meq/ml potassium chlorid-d5-0.45%nacl intravenous parenteral solution 10 meq/l, 20 meq/l, 30 meq/l, 40 meq/l potassium chloride in 0.9%nacl intravenous parenteral solution 20 meq/l, 40 meq/l potassium chloride in 5 % dex intravenous parenteral solution 20 meq/l, 30 meq/l, 40 meq/l potassium chloride in lr-d5 intravenous parenteral solution 20 meq/l potassium chloride intravenous piggyback 10 meq/100 ml, 20 meq/100 ml, 30 meq/100 ml, 40 meq/100 ml potassium chloride intravenous solution 2 meq/ml potassium chloride oral capsule, extended release 10 meq, 8 meq potassium chloride oral liquid 20 meq/15 ml, 40 meq/15 ml potassium chloride oral packet 20 meq (Klor-Con Sprinkle) (Klor-Con) 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 191

206 potassium chloride oral tablet extended release 10 meq, 8 meq (K-Tab) potassium chloride oral tablet extended release 20 meq (K-Tab) potassium chloride oral tablet,er particles/crystals 10 meq (Klor-Con M10) potassium chloride-0.45 % nacl intravenous parenteral solution 20 meq/l potassium chloride-d5-0.2%nacl intravenous parenteral solution 10 meq/l, 20 meq/l, 30 meq/l, 40 meq/l potassium chloride-d5-0.3%nacl intravenous parenteral solution 20 meq/l potassium chloride-d5-0.9%nacl intravenous parenteral solution 20 meq/l, 40 meq/l potassium citrate oral tablet extended release 10 meq (1,080 mg) (Urocit-K 10) potassium citrate oral tablet extended release 15 meq (Urocit-K 15) potassium citrate oral tablet extended release 5 meq (540 mg) (Urocit-K 5) potassium citrate-citric acid oral packet 3,300-1,002 mg (Cytra K Crystals) potassium cl 10 meq/50 ml sol single use 10 meq/50 ml potassium cl 20 meq/50 ml sol single use 20 meq/50 ml potassium cl er 20 meq tablet microencapsulated 20 meq (Klor-Con M20) ra cal 600-vit d3-min chew tab 600 mg calcium- 400 unit-40 mg * ra oyster shell-vitamin d tab s/f, p/f 250 (625)-125 mg-unit * ra pediatric electrolyte soln a/f * You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 192

207 ra pediatric freezer pops * ringer's intravenous parenteral solution sm calcium citrate-vit d cplt caplet, (Citracal + D gluten-free mg-unit * Maximum) sm magnesium 250 mg tablet 250 mg * sm pediatric electrolyte soln * sodium acetate intravenous solution 2 meq/ml sodium bicarbonate intravenous syringe 8.4 % (1 meq/ml) sodium chloride 0.45 % intravenous parenteral solution 0.45 % sodium chloride 0.9 % intravenous parenteral solution 0.9 % sodium chloride 3 % intravenous parenteral solution 3 % sodium chloride 5 % intravenous parenteral solution 5 % sodium chloride intravenous parenteral solution 2.5 meq/ml sodium lactate intravenous solution 5 meq/ml sodium phosphate intravenous solution 3 mmol/ml TPN ELECTROLYTES II IV SOLN 25'S,20ML/50ML FTV MEQ/20 ML TPN ELECTROLYTES INTRAVENOUS SOLUTION MEQ/20 ML Respiratory Tract Agents Anti-Inflammatories, Inhaled Corticosteroids 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 193

208 ADVAIR DISKUS INHALATION BLISTER WITH DEVICE MCG/DOSE, MCG/DOSE, MCG/DOSE ADVAIR HFA INHALATION HFA AEROSOL INHALER MCG/ACTUATION, MCG/ACTUATION, MCG/ACTUATION ARNUITY ELLIPTA INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 200 MCG/ACTUATION BREO ELLIPTA INHALATION BLISTER WITH DEVICE MCG/DOSE, MCG/DOSE budesonide inhalation suspension for nebulization 0.25 mg/2 ml, 0.5 mg/2 ml, 1 mg/2 ml DULERA INHALATION HFA AEROSOL INHALER MCG/ACTUATION, MCG/ACTUATION FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 50 MCG/ACTUATION FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 250 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 220 MCG/ACTUATION (Pulmicort) QL (60 per 30 days) QL (12 per 28 days) QL (30 per 30 days) QL (60 per 30 days) QL (13 per 28 days) QL (60 per 30 days) QL (120 per 30 days) QL (12 per 28 days) QL (24 per 28 days) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 194

209 FLOVENT HFA INHALATION HFA AEROSOL INHALER 44 MCG/ACTUATION QVAR INHALATION AEROSOL 40 MCG/ACTUATION, 80 MCG/ACTUATION SYMBICORT MCG INHALER 60 INHALATIONS MCG/ACTUATION SYMBICORT INHALATION HFA AEROSOL INHALER MCG/ACTUATION, MCG/ACTUATION Antileukotrienes montelukast oral granules in packet 4 mg (Singulair) montelukast oral tablet 10 mg (Singulair) montelukast oral tablet,chewable 4 (Singulair) mg, 5 mg zafirlukast oral tablet 10 mg, 20 mg (Accolate) Bronchodilators albuterol sulfate inhalation solution for nebulization 0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 mg /3 ml (0.083 %), 5 mg/ml albuterol sulfate oral syrup 2 mg/5 ml albuterol sulfate oral tablet 2 mg, 4 mg albuterol sulfate oral tablet extended release 12 hr 4 mg, 8 mg ANORO ELLIPTA INHALATION BLISTER WITH DEVICE MCG/ACTUATION QL (21.2 per 28 days) QL (17.4 per 25 days) QL (12 per 25 days) QL (11 per 25 days) QL (60 per 30 days) 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 195

210 ATROVENT HFA INHALATION HFA AEROSOL INHALER 17 MCG/ACTUATION COMBIVENT RESPIMAT INHALATION MIST MCG/ACTUATION INCRUSE ELLIPTA INHALATION BLISTER WITH DEVICE 62.5 MCG/ACTUATION ipratropium bromide inhalation solution 0.02 % metaproterenol oral syrup 10 mg/5 ml metaproterenol oral tablet 10 mg, 20 mg PROAIR HFA INHALATION HFA AEROSOL INHALER 90 MCG/ACTUATION PROAIR RESPICLICK INHALATION AEROSOL POWDR BREATH ACTIVATED 90 MCG/ACTUATION SEREVENT DISKUS INHALATION BLISTER WITH DEVICE 50 MCG/DOSE SPIRIVA RESPIMAT INHALATION MIST 1.25 MCG/ACTUATION, 2.5 MCG/ACTUATION SPIRIVA WITH HANDIHALER INHALATION CAPSULE, W/INHALATION DEVICE 18 MCG STIOLTO RESPIMAT INHALATION MIST MCG/ACTUATION QL (25.8 per 28 days) QL (8 per 30 days) QL (60 per 30 days) QL (4 per 28 days) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 196

211 STRIVERDI RESPIMAT INHALATION MIST 2.5 MCG/ACTUATION terbutaline oral tablet 2.5 mg, 5 mg terbutaline subcutaneous solution 1 mg/ml theophylline in dextrose 5 % intravenous parenteral solution 200 mg/100 ml, 200 mg/50 ml, 400 mg/250 ml, 400 mg/500 ml, 800 mg/250 ml theophylline oral solution 80 mg/15 ml theophylline oral tablet extended release 12 hr 100 mg, 200 mg, 300 (Theochron) mg theophylline oral tablet extended release 12 hr 450 mg theophylline oral tablet extended release 24 hr 400 mg, 600 mg VENTOLIN HFA INHALATION HFA AEROSOL INHALER 90 MCG/ACTUATION Respiratory Tract Agents, Other acetylcysteine intravenous solution 200 mg/ml (20 %) (Acetadote) acetylcysteine solution 100 mg/ml (10 %), 200 mg/ml (20 %) CINQAIR INTRAVENOUS SOLUTION 10 MG/ML cromolyn inhalation solution for nebulization 20 mg/2 ml cromolyn sodium nasal spray 5.2 mg/spray (4 %) * (Nasalcrom) DALIRESP ORAL TABLET 500 MCG QL (4 per 28 days) PA QL (30 per 30 days) 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 197

212 ESBRIET ORAL CAPSULE 267 MG ESBRIET ORAL TABLET 267 MG ESBRIET ORAL TABLET 801 MG KALYDECO ORAL GRANULES IN PACKET 50 MG, 75 MG KALYDECO ORAL TABLET 150 MG NUCALA SUBCUTANEOUS RECON SOLN 100 MG OFEV ORAL CAPSULE 100 MG, 150 MG ORKAMBI ORAL TABLET MG, MG PROLASTIN-C INTRAVENOUS RECON SOLN 1,000 MG sodium chloride 0.9% inhal vl u-d, suv, p/f (rx) 0.9 % * 3 $0 XOLAIR SUBCUTANEOUS RECON SOLN 150 MG Skeletal Muscle Relaxants Skeletal Muscle Relaxants baclofen oral tablet 10 mg, 20 mg carisoprodol oral tablet 250 mg, 350 mg (Soma) chlorzoxazone oral tablet 500 mg (Parafon Forte DSC) cyclobenzaprine oral tablet 10 mg, 5 mg dantrolene oral capsule 100 mg dantrolene oral capsule 25 mg, 50 mg (Dantrium) PA; QL (270 per 30 days) PA; QL (270 per 30 days) PA; QL (90 per 30 days) PA; QL (60 per 30 days) PA; QL (60 per 30 days) PA; LA; QL (1 per 28 days) PA; QL (60 per 30 days) PA; QL (120 per 30 days) PA PA-HRM; QL (120 per 30 days); AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 198

213 metaxall oral tablet 800 mg metaxalone oral tablet 400 mg metaxalone oral tablet 800 mg (Skelaxin) methocarbamol oral tablet 500 mg (Robaxin) methocarbamol oral tablet 750 mg (Robaxin-750) revonto intravenous recon soln 20 mg tizanidine oral capsule 2 mg, 4 mg, 6 mg (Zanaflex) tizanidine oral tablet 2 mg tizanidine oral tablet 4 mg (Zanaflex) Sleep Disorder Agents Sleep Disorder Agents armodafinil oral tablet 150 mg, 200 mg, 250 mg, 50 mg (Nuvigil) BELSOMRA ORAL TABLET 10 MG, 15 MG, 20 MG, 5 MG eszopiclone oral tablet 1 mg, 2 mg, 3 mg (Lunesta) HETLIOZ ORAL CAPSULE 20 MG ROZEREM ORAL TABLET 8 MG PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) QL (30 per 30 days) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any nonbenzodiazepine hypnotic drug); QL (30 per 30 days); AGE (Max 64 Years) PA; QL (30 per 30 days) 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 199

214 SILENOR ORAL TABLET 3 MG, 6 MG XYREM ORAL SOLUTION 500 MG/ML zaleplon oral capsule 10 mg, 5 mg (Sonata) zolpidem oral tablet 10 mg, 5 mg (Ambien) zolpidem oral tablet,ext release multiphase 12.5 mg, 6.25 mg (Ambien CR) QL (30 per 30 days) LA PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any nonbenzodiazepine hypnotic drug); QL (60 per 30 days); AGE (Max 64 Years) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any nonbenzodiazepine hypnotic drug); QL (30 per 30 days); AGE (Max 64 Years) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any nonbenzodiazepine hypnotic drug); QL (30 per 30 days); AGE (Max 64 Years) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 200

215 Vasodilating Agents Vasodilating Agents ADCIRCA ORAL TABLET 20 MG ADEMPAS ORAL TABLET 0.5 MG, 1 MG, 1.5 MG, 2 MG, 2.5 MG epoprostenol (glycine) intravenous recon soln 0.5 mg, 1.5 mg LETAIRIS ORAL TABLET 10 MG, 5 MG (Flolan) OPSUMIT ORAL TABLET 10 MG ORENITRAM ORAL TABLET EXTENDED RELEASE MG, 0.25 MG, 1 MG, 2.5 MG, 5 MG REMODULIN INJECTION SOLUTION 1 MG/ML, 10 MG/ML, 2.5 MG/ML, 5 MG/ML sildenafil intravenous solution 10 mg/12.5 ml (Revatio) sildenafil oral tablet 20 mg (Revatio) TRACLEER ORAL TABLET 125 MG, 62.5 MG TYVASO INHALATION SOLUTION FOR NEBULIZATION 1.74 MG/2.9 ML (0.6 MG/ML) UPTRAVI ORAL TABLET 1,000 MCG, 1,200 MCG, 1,400 MCG, 1,600 MCG, 400 MCG, 600 MCG, 800 MCG UPTRAVI ORAL TABLET 200 MCG PA; QL (60 per 30 days) PA; QL (90 per 30 days) PA; QL (30 per 30 days) PA; QL (30 per 30 days) PA PA PA; QL (37.5 per 1 day) PA; QL (90 per 30 days) PA; LA; QL (60 per 30 days) PA PA; QL (60 per 30 days) PA; QL (240 per 30 days) 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 201

216 UPTRAVI ORAL TABLETS,DOSE PACK 200 MCG (140)- 800 MCG (60) Vitamins And Minerals Vitamins And Minerals a thru z advanced formula tab gluten-free mg-mcg * a thru z advanced formula tab new formula * a thru z advanced formula tab w/ lutein & lycopene mg-mcg-mcg-mcg * a thru z select 50+ formula tb advanced formula mgmcg-mcg * a thru z select men 50+ tablet mcg * a thru z select multivit tab mcg * a thru z select multivit tab iron-free, 50+ form mg-mcg-mcg * a thru z select tablet new formulation * a thru z select women's tablet * abc plus tablet mgmcg-mcg * adult multi gummies 200 mcg * adult multivitamin gummies assorted flavors 200 mcg * adult one daily gummies 200 mcg * adults 50 plus daily formula mg-mcg-mcg * adults 50 plus multivitamin tb mg-mcg-mcg * animal chews tablet * PA; QL (400 per 365 days) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 202

217 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Non Dwòg antioxidant softgel softgel * apatate forte liquid * b complete tablet * b complex capsule * (Super B-50 Complex) b complex formula #1 tablet * b complex tablet * b mcg tablet 500 mcg * b-12 dots 500 mcg tablet 500 mcg * baby vitamin d3 400 unit/drop 400 unit/0.2 ml * baby vitamin d3 400 unit/drop 400 unit/drop * balance b-100 tablet * balance b-50 tablet * balance b-50 tablet inner,p/f,gluten/f * balanced b-100 tablet * balanced b-100 tablet 100 mg * balanced b-50 tablet * balanced b-complex caplet p/f,nolactose 400 mcg * b-complex plus vitamin c cplt caplet * (Vita-Bee with C) b-complex with b12 tablet * b-complex with c tablet * (Vita-Bee with C) b-complex with vit c caplet s/f,p/f,gluten-free 400 mcg * bee-zee tablet * biosupp liquid * biotin 300 mcg tablet 300 mcg * biovol syrup * calcidol drops 8,000 unit/ml * calcium 1,000 + d3 caplet 1,000 mg(2,500 mg)-800 unit * Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 203

218 calcium 250-vit d3 125 tablet 250- (Oyster Shell 125 mg-unit * Calcium-Vit D3) calcium vit d 400 caplet s/f, p/f, caplet 600 mg(1,500mg) -400 unit * calcium vit d tablet mg-unit * calcium 600-vit d3 200 tablet 600 mg(1,500mg) -200 unit * calcium 600-vit d3 400 tablet 600 (Calcium with mg(1,500mg) -400 unit * Vitamin D) centamin liquid 9 mg iron/15 ml * central-vite seniors tablet * centram-care multivit-min liq 9 mg iron/15 ml * centravites 50 plus tablet * centravites 50 plus tablet outer mg-mcg-mcg * centrum adults tablet mgmcg * centrum complete multivit tab mg-mcg * centrum multivit-mineral liq 9 mg iron/15 ml * centrum silver tablet adults mg-mcg-mcg * centrum women tablet mgmcg * century ultimate men's tablet mcg * century ultimate women's tab mg-mcg * cerovite advanced form tab mg-mcg * cerovite jr tablet chew * cerovite liquid 9 mg iron/15 ml * You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 204

219 cerovite senior tablet * certavite sr-antioxidant tab mg-mcg-mcg * certavite-antioxidant liquid 9 mg iron/15 ml * certavite-antioxidant tablet mg-mcg * chewable-vite tablet * chew-vites-iron tablet chew * child chew + iron tab chew * child chew vitamin tablet * child ferrous sulfate 15 mg/ml 15 mg iron (75 mg)/ml * (Children's Iron) child multivitamin plus iron 18 mg iron * childrens chew vitamin tab * children's chewable vitamin * childrens multivit tab chew * childrens vit-iron tab chew * compete tablet * complete multi 50+ tablet mcg * complete multi tablet mg-mcg-mcg-mcg * complete multivitamin tab * complete senior tablet * cvs bal b-100 tablet * cvs bal b-50 tablet * cvs balanced b-150 tablet * cvs b-complex-vit c caplet caplet * (Vita-Bee with C) cvs calcium vit d tablet oyster shell 500 mg(1,250mg) -125 unit * cvs calcium 600-vit d3 800 tab 600 (Caltrate with mg(1,500mg) -800 unit * Vitamin D3) 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 205

220 cvs calcium 600-vit d3 800 tab p/f, s/f,gluten-free 600 mg(1,500mg) unit * (Caltrate with Vitamin D3) cvs child vit-mineral tab * cvs children's chewable vit * cvs childs vit with c tab chew * cvs child's vitamin-iron tb * cvs daily gummies p/f, gluten-free 200 mcg * cvs daily multiple tablet * cvs daily multiple tablet for women * cvs gummy swirls chewable * cvs hair, skin and nails cplt * cvs iron 27 mg tablet 240 mg (27 mg iron) * cvs men's daily gummies p/f, glutenfree 200 mcg * cvs men's multi-vit tablet * cvs prenatal vitamin tablet * cvs spectravite adult 50+ tabs mg-mcg-mcg * cvs spectravite adult gummy 200 mcg * cvs spectravite advanced tab mg-mcg * cvs spectravite senior * cvs spectravite senior tab * cvs spectravite ultra men's tb mcg * cvs spectravite ultra women tb mg-mcg * cvs super b complx & c cplt caplet, p/f * cvs vitamin b-100 complx tb * You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 206

221 cvs vitamin c 1,000 mg tb chw 1,000 mg * cvs vitamin d3 1,000 unit sfgl softgel (Vitamin D3) 1,000 unit * cvs vitamin d3 400 unit/drop 400 unit/drop * (Baby Ddrops) cvs women's daily gummies p/f,gummies 200 mcg * cyanocobalamin 1,000 mcg/ml 25's 1,000 mcg/ml * (Vitamin B-12) 3 $0 d3 dots 2,000 unit tablet p/f 2,000 unit * daily multi vitamin-iron tab * daily multiple tablet mg-mcg * daily multiple vitamin tab sugar coated * daily multivitamin-iron tablet mg-mcg * daily value multivitamin tab s/f * daily vitamin + iron tablet * daily vitamin formula tablet * daily vitamin formula tablet * daily vitamin formula-iron tab mg-mcg * daily vite tablet s/f, p/f * daily vite tablet s/f,p/f * daily vite with iron tablet * daily-vite tablet * daily-vites with iron tablet * delta d3 400 unit tablet s/f,l/f,y/f,gluten/f 400 unit * dino-life extra c tab chew * dino-life iron-zinc tb chew * dino-life tablet chewable * 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 207

222 d-vi-sol 400 units/ml drop 400 unit/ml * eldertonic elixir mg * ellis tonic * eq child complete chew tablet 18 mg iron * eq complete multivitamin tab mg-mcg-mcg * eq complete multivitamin tab glutenfree mg-mcg * eq one daily men's tablet gluten free mcg * eql central-vite select tablet * eql central-vite tablet mg-mcg-mcg * eql century mature tablet mcg * eql century multi-vitamin tab mg * eql chewable multi vitamin tab * eql child's multivit tab chew with vitamin c * eql childs multivit-mineral tb * eql eye health plus lutein tab 1,000 unit-200 mg-60 unit-2 mg * eql one daily 50 plus tablet * eql one daily essential tablet * eql one daily maximum tablet mg * eql one daily men's tablet * eql prenatal vitamin tablet 28 mg iron- 800 mcg * eql super b complex tablet 400 mcg * ergocalciferol 8,000 units/ml 8,000 unit/ml * (Calcidol) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 208

223 essentia tablet mg-mcg * essential balance tablet * essential daily tablet w/iron & calcium mg * feosol 65 mg tablet 325 mg (65 mg iron) * ferate 27 mg tablet 240 mg (27 mg iron) * ferocon capsule mg * 3 $0 ferretts 325 mg tablet 325 mg (106 mg iron) * ferrex 150 capsule outer, u-d 150 mg iron * ferrex 150 plus capsule mg * ferric x-150 capsule 150 mg iron * ferrocite tablet 324 mg (106 mg iron) * ferrous fumarate 324 mg tab 324 mg (Ferrocite) (106 mg iron) * ferrous gluconate 240 mg tab 240mg=27mg elemental 240 mg (27 (Fergon) mg iron) * ferrous gluconate 324 mg tab 324 mg (36 mg iron), 324 mg (37.5 mg iron), 324 mg (38 mg iron) * ferrous sulf 220 mg/5 ml elix 220 mg (44 mg iron)/5 ml * ferrous sulf 300 mg/5 ml liq 300 mg (60 mg iron)/5 ml * ferrous sulf ec 324 mg tablet 324 mg (65 mg iron) * ferrous sulf ec 325 mg tablet 325 mg (65 mg iron) * 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 209

224 ferrous sulfate 325 mg tablet p/f,s/f,gluten-free 325 mg (65 mg (FeroSul) iron) * flintstones complete tablet * flintstones extra c tab chew * flintstones tablet chewable * flintstones with iron tab chew 18 mg iron * fluoride (sodium) oral tablet 1 mg (2.2 mg sod. fluoride) folic acid 1 mg tablet (rx) 1 mg * 3 $0 folic acid 1,000 mcg tablet p/f,s/f (otc) 1 mg * folic acid 400 mcg tablet s/f,p/f,lactose-free 400 mcg * fosfree tablet mg * geravim liquid * geriaton liquid * gnp calcium 500-vit d3 600 tab 500mg (1,250mg) -600 unit * (Os-Cal D3) gnp century mature tablet glutenfree mg-mcg-mcg * gnp century tablet adults mg-mcg-mcg * gnp century tablet gluten-free mg-mcg * gnp one daily essential tablet * gs prenatal vitamins tablet mg-mcg * gummi bear multivit tab chew multivit & minerals * hair vitamins * hemocyte tablet u-u,blister pk 324 mg (106 mg iron) * hi-b complex tablet * You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 210

225 hm animal shapes complete chew child's, w/ choline 18 mg iron * hm complete 50+ tablet mg-mcg-mcg * hm complete women tablet mg-mcg * hm one daily with iron tablet glutenfree mg-mcg * hm super vitamin b complex glutenfree 400 mcg * honey bears chew tab * honey bears-iron-zinc tab chew * icaps plus tablet lactose free * iferex 150 capsule 150 mg iron * iron 27 mg tablet 236 mg (27 mg iron) * iron 28 mg tablet 256 mg (28 mg iron) * kenwood therapeutic liquid * kids multivitamin complete tab 18 mg iron * kobee tablet 0.4 mg * kpn tablet * life-pack women's p/f,s/f 0.8 mg * little animals child tb chw * little animals-iron tab chew * lysiplex plus liquid * MACUVITE EYE CARE TABLET 7,160 UNIT-113 MG-100 UNIT * mega multivitamin-mineral tab * mega multivit-chelated min tab * men's multivitamin gummies 200 mcg * MEPHYTON 5 MG TABLET 5 MG * 3 $0 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 211

226 milltrium senior multivit tab * multi complete-iron tablet mg-mcg * multi for her tablet 18 mg iron-600 mcg-80 mcg * multi-day plus iron tablet mg-mcg * multi-delyn liquid s/f,a/f * multi-delyn with iron liquid 10 mg iron/5 ml * multilex tablet * multilex-t-m-minerals tab * multiple vitamin with iron tab * (Daily Vitamin with Iron) multiple vitamin w-minerals tb * multiple vitamins tablet one daily * multivitamin child tab chew * (Flintstones Multivitamin) multi-vitamin daily tablet * multivitamin-mineral liquid 9 mg iron/15 ml * multivitamins tablet * (Tab-A-Vite) multivit-fluor 0.25 mg/ml drop 0.25 mg/ml multivit-iron child tab chew children's * multivit-mineral hp cap * multivit-minerals tablet s/f,p/f * (Hair,Skin and Nails) my favorite multiple liquid * myvitalife soft-gel capsule * NASCOBAL 500 MCG NASAL SPRAY OUTER 500 MCG/SPRAY 3 $0 * nephplex rx tablet mg-mg-mcg-mg * 3 $0 You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 212

227 nephron fa tablet mg * 3 $0 nephro-vite rx tablet mgmg-mcg * 3 $0 niacinamide er 500 mg tablet 500 mg * nu-iron 150 capsule 150 mg iron * ocutabs tablet s/f, w/lutein * onccor tablet mcg * once daily tablet * once daily with iron tablet * oncovite tablet * one daily complete tablet * one daily complete tablet mg * one daily essential tablet * one daily for women tablet mg * one daily gummy vites gummie 200 mcg * one daily maximum tablet mg * one daily multivitamin tab * one daily multivitamin tablet * one daily multivitamin tablet 400 mcg * one daily multivitamin-iron tb mg-mcg * one daily plus iron tablet mg-mcg * one daily tablet * one daily tablet * one daily tablet men's formula * one daily with minerals tablet * one-a-day essential tablet * one-a-day max formula tab * 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 213

228 one-a-day men's tablet mcg * one-a-day teen advantage tab mg-mcg * one-a-day teen advantage tab 9 mg iron-400 mcg * oysco 500-vit d3 200 tablet 500 mg(1,250mg) -200 unit * oysco d tablet mg-unit * oyster shell 500-vit d3 200 tb 500 mg(1,250mg) -200 unit * oyster shell calcium tablet 500 mg(1,250mg) -400 unit * oyster shell calcium-vit d tab p/f,s/f,gluten-free 500 mg(1,250mg) -400 unit * oystercal-d 500 mg-400 unit tb 500 mg(1,250mg) -400 unit * perry prenatal capsule mg * pharmacist multi-vite tab * phytonadione 1 mg/0.5 ml syr latexfree, p/f,sdv 1 mg/0.5 ml * 3 $0 pnv prenatal plus multivit tab s/f, gluten-free 27 mg iron- 1 mg poly-iron 150 mg capsule 150 mg iron * poly-vita drops 1, unitmg-unit/ml * poly-vita with iron drops 1,500 unit- 400 unit-10 mg/ml * poly-vitamin drops 1, unit-mg-unit/ml * poly-vitamin tab chew * ALL RX PRENATAL VITAMINS COVERABLE UNDER PART D You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 214

229 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Non Dwòg polyvitamin w-iron drops 1,500 unit-400 unit-10 mg/ml * polyvitamin with iron tab chew * prenatal formula tablet 28 mg iron- 800 mcg * prenatal multivitamin tablet 28 mg iron- 800 mcg * prenatal multivitamin tablet 28 mg iron- 800 mcg * prenatal tablet (otc) 27 mg iron- 0.8 mg * prenatal tablet (otc) 27 mg iron- 0.8 mg * prenatal tablet 27 mg iron- 800 mcg * prenatal tablet 28 mg iron- 800 mcg * prenatal tablet 28 mg iron- 800 mcg * (Prenatal) prenatal tablet 28 mg iron- 800 mcg * (Prenatal Tablet) prenatal tablet outer (otc) 27 mg iron- 0.8 mg * prenatal vitamin plus low iron oral tablet 27 mg iron- 1 mg prenatal vitamin tablet 27 mg iron- 800 mcg * prenatal vitamins tablet phosphorus free 28 mg iron- 800 mcg * prosight tablet 5, unit-mgunit * pub multivitamin 50 plus tab * pv b-100 complex * pv b-50 complex * ALL RX PRENATAL VITAMINS COVERABLE UNDER PART D Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 215

230 pv kid's gummy bear tab chew chewable * pv kid's vit + extra c chew tb * pv kid's vit + iron tab chew * pv kid's vit complete tab chew * pv kid's vitamins chew tab * pv kids vitamins chew tab 300 mcg * pv kids vitamins complete mg-mcg * pv kids vitamins+iron tab chew 15 mg iron * pv multivital platinum tablet * pv multivital platinum tablet w/lutein & lycopene mcg * pv multivital tablet mg * pv multivital tablet mg-mcg-mcg-mcg * pv prenatal formula tablet 28 mg iron- 800 mcg * pv stress 500 plus zinc tab * pv stress 500 tablet * pyridoxine 100 mg/ml vial 25's 100 mg/ml * 3 $0 pyridoxine 250 mg tablet 250 mg * (Vitamin B-6) qc child complete vit chew tab 18 mg iron * qc children's chewable tablet * qc maximum daily multivit tab mg * qc multi-vite 50 & over tablet w/lycopene * qc multi-vite tablet mg-mcg * qc women's daily multivit tab mg * You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 216

231 ra balanced b-100 tablet 0.4 mg * ra balanced b-50 tablet natural,p/f * ra b-complex tablet p/f * ra b-complex tablet p/f * (Stress B-Biotin) ra central-vite senior tablet mg-mcg-mcg * ra central-vite tablet mgmcg * ra hi-cal plus vitamin d tab 500 mg(1,250mg) -200 unit * ra one daily energy tablet * ra one daily maximum tablet mg * ra one daily multi-vitamin tab p/f * ra one daily plus iron tablet * ra prenatal tablet 28 mg iron- 800 mcg * ra therapeutic m multivit tab mg * ra vit b-12 1,000 mcg/ml liq 1,000 mcg/ml * ra vitamin b-12 1,000 mcg tab timed-release 1,000 mcg * (Vitamin B-12) ra vitamin c 1,000 mg tab sa w/bioflavonoids 1,000 mg * ra vitamin c 500 mg tab chew p/f 500 mg * ra vitamin d3 1,000 unit tab s/f,gluten/f,yeast/f 1,000 unit * rena-vite rx tablet mg-mgmcg * 3 $0 right step prenatal vit tab 27 mg iron- 0.8 mg * scooby-doo one a day tablet * 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 217

232 senior tabs mg-mcgmcg * sentry multivit & mineral cplt mg-mcg-mcg-mcg * sentry senior multivitamin tab sodium/f,yeast/f mcg * sentry senior tablet mgmcg-mcg * sentry tablet mg-mcg * sm animal shapes complete chew gluten-free 18 mg iron * sm animal shapes tab chew * (Flintstones Multivitamin) sm animal shapes tab chew toddlers * sm animal shapes w-iron tab children's * sm b complex with vit c tablet gluten-free * (Vita-Bee with C) sm complete advanced tablet mg-mcg-mcg-mcg * sm complete multi-vit-mineral advanced formula mg-mcg * sm complete senior formula tab * sm complete senior formula tab mg-mcg-mcg * sm complete tablet mg * sm multivitamin w-iron tab * (Daily Vitamin with Iron) sm multivitamins tablet * (Tab-A-Vite) sm natural balanced b-100 tab 100 mg * sm prenatal vitamins tablet 28 mg iron- 800 mcg * sm super b complex-c caplet caplet * You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 218

233 sm therapeutic m tablet mg * sm ultimate men's complete tab mcg * sm vitamin b complex tablet glutenfree 0.4 mg * (B Complex 100) sm vitamin b-100 complex tab gluten-free 0.4 mg * sm vitamin d3 4,000 unit sftgl softgel, gluten-free 4,000 unit * stress b tablet * stress b with zinc tablet * stress formula tablet * stress formula with iron tab * stress formula with iron tab 500 mg- 400 mcg- 18 mg iron * stress formula with iron tab 500 mg- 400 mcg- 27 mg iron * stress formula with zinc tab * stress-c tablet * stress-c with iron tablet 500 mg-400 mcg- 18 mg iron * sunvite tablet 18 mg iron-400 mcg- 25 mcg * super b complex-c caplet caplet * super b maxi complex caplet 0.4 mg * super b with vit c capsule * super b-50 complex capsule * super b-50 complex plus tab * super b-complex folic-vit c tb p/f 400 mcg * super multiple vit-mineral tab * super multivitamin tablet * super quints b-50 tablet 0.4 mg * super quints b-50 tablets * 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 219

234 super thera vite m tablet * superior 35 vit-mineral tab sa * superplex-t tablet * support liquid * support-500 softgel * sv hair, skin and nails caplet 1 mg iron-66.7 mcg-1,000 mcg * tab-a-vite tablet * tab-a-vite with iron tablet * tab-a-vite-minerals tablet * thera caplet * thera m plus tablet 9 mg iron-400 mcg * thera tablet 400 mcg * thera-d 2000 tablet 2,000 unit * theradex m tablet mg * thera-m caplet * thera-m caplet caplet mg * thera-m tablet w/beta carotene 9 mg iron-400 mcg * therapeutic-m caplet caplet 9 mg iron-400 mcg * therapeutic-m tablet [ds] 9 mg iron- 400 mcg * thera-tabs tablet * theratrum complete 50 plus p/f,caplet * theratrum complete tablet w/lutein, p/f * therems tablet * total b with vit c caplet * totalday multiple tablet sa * tri-vi-sol drops 750 unit-35 mg -400 unit/ml * You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 220

235 tri-vita drops 1, unit-mgunit/ml * tri-vitamin drops 1, unitmg-unit/ml * ultra b-100 complex tablet * unicomplex-m tablet * v-c forte capsule 1 mg * 3 $0 vic-forte capsule 1 mg * 3 $0 vision plus lutein vitamin tab * vision vitamins * vit d mg (50,000 unit) capsule 50,000 unit * 3 $0 vitalets tablet chewable child, orange,s/f * vitamin a 10,000 units capsule soluble 10,000 unit * vitamin and minerals tablet * vitamin b complex capsule * vitamin b complex tablet 500 mg- 400 mcg- 18 mg iron * vitamin b complex-vit c cap * (Vitamin B Complex With C) vitamin b complex-vit c tablet * (Vita-Bee with C) vitamin b mg tablet 100 mg * vitamin b-1 50 mg tablet 50 mg * vitamin b-12 1,000 mcg tablet 1,000 mcg * vitamin b mcg tablet 100 mcg * vitamin b mcg tablet 250 mcg * vitamin b mcg tablet 500 mcg * vitamin b12-folic acid tablet mcg * 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 221

236 vitamin b-50 complex tablet s/f,p/f,dairy-free 0.4 mg * (B Complex 100) vitamin b mg tablet p/f 250 mg * vitamin b-6 50 mg tablet 50 mg * vitamin b-complex & c caplet p/f,lactose free mcg-mg * vitamin c 1,000 mg tablet 1,000 mg * vitamin c 1,500 mg tablet sa na/f,s/f,starch/free 1,500 mg * vitamin c 250 mg tablet 250 mg * vitamin c 250 mg tablet chew 250 mg * vitamin c 500 mg tablet chew 500 mg * vitamin c 500 mg/5 ml liquid 500 mg/5 ml * vitamin d 1,000 unit tablet 1,000 unit * vitamin d3 1,000 unit tablet s/f,p/f 1,000 unit * vitamin d3 10,000 unit softgel softgel 10,000 unit * (Maximum D3) vitamin d3 10,000 unit softgel softgel,p/f,s/f 10,000 unit * (Maximum D3) vitamin d3 2,000 unit tablet s/f,p/f 2,000 unit * (Vitamin D3) vitamin d3 400 unit tab chew orange, p/f 400 unit * (Kids Vitamin D3) vitamin d3 400 unit tablet s/f,p/f 400 unit * vitamin d3 400 unit/5 ml liq 400 unit/5 ml * vitamin d3 400 unit/ml drop a/f, s/f, fruit 400 unit/ml * (D-Vita) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at , 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit 222

237 vitamin d3 5,000 unit capsule s/f, p/f (Dialyvite Vitamin 5,000 unit * D) vitamin d3 5,000 unit/ml drops a/f, p/f,gluten-free 5,000 unit/ml * vitamin k 100 mcg tablet p/f,na/f,wheat-free 100 mcg * vitamin k-1 1 mg/0.5 ml ampul sdv,latex-free 1 mg/0.5 ml * 3 $0 vitamin k-1 10 mg/ml ampul sdv,latex-free 10 mg/ml * 3 $0 vitamins for hair tablet * vitatrum tablet mgmcg-mcg-mcg * vitrum 50+ senior tablet mcg * vitrum senior tablet f/f,p/f * vol-care rx tablet mg-mgmcg * 3 $0 vp-vite rx tablet mg-mgmcg * 3 $0 v-r calcium d 133 caplet mg-unit * v-r natural b-100 tablet * v-r vitamin c tr 500 mg caplet 500 mg * women's multivitamin gummies gluten-f, lactose-f 200 mcg * yelets tablet mg-mcg * zoo chews gummie tablet * 1 Ou ka jwenn enfòmasyon sou ki vle di senbòl ak abrevyasyon yo nan tablo sa a si ou li paj entwodiksyon yo nan dokiman sa a.? Si ou gen kesyon, tanpri rele Plan FIDA VillageCareMAX Full Advantage nan pandan 8:00 nan 20:00, 7 jou pà semèn. Apèl gratis. Itilizatè ATS ta dwe rele 711. Pou plis enfòmasyon, vizite 223

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239 INDEX 3 3 day vaginal day vaginal MOP A a thru z a thru z advanced formula a thru z high potency a thru z select a thru z select 50+ formula a thru z select women's abacavir abacavir-lamivudine abacavir-lamivudine-zidovudine abc plus ABELCET ABILIFY MAINTENA ABRAXANE ABREVA acamprosate acarbose acebutolol acephen... 3 acetaminophen... 3, 5 acetaminophen-codeine... 3 acetazolamide acetazolamide sodium acetic acid , 180 acetylcysteine acid gone antacid acid reducer (famotidine) acid reducer (ranitidine) acid relief (cimetidine) acitretin acne medication , 128, 130 ACNE MEDICATION ACTEMRA ACTHIB (PF) ACTIMMUNE actinel pediatric acyclovir... 79, 128 acyclovir sodium... 79, 80 ADACEL(TDAP ADOLESN/ADULT)(PF) 174 ADAGEN adapalene ADCETRIS ADCIRCA adefovir ADEMPAS adriamycin adrucil adt robitussin peak cld dm max adult multivitamin gummies 202 adult nasal decongestant adult one daily gummies adult robitussin peak cold dm adult wal-tussin adult wal-tussin dm max adults 50 plus ADVAIR DISKUS ADVAIR HFA ADVIL afeditab cr AFINITOR AFINITOR DISPERZ a-hydrocort AKTEN (PF) AKYNZEO ala-cort ala-scalp alavert alavert d-12 allergy-sinus ALBENZA albuterol sulfate alcaine alclometasone ALCOHOL PADS ALCOHOL PREP PADS ALDURAZYME ALECENSA alendronate alfuzosin ALIMTA ALINIA alka-seltzer plus mucus-conges aller-chlor allerclear d-12hr allerclear d-24hr allergy (chlorpheniramine) allergy relief (cetirizine) allergy relief (clemastine) allergy relief(diphenhydramin) allerhist aller-tec d allopurinol ALLZITAL... 3 almacone almacone aloe vesta antifungal (micon). 53 alophen alosetron ALPHAGAN P alprazolam ALREX altacaine altamist altavera (28) I-1

240 aluminum hydroxide gel ALUNBRIG alyacen 1/35 (28) alyacen 7/7/7 (28) amabelz amantadine hcl... 67, 68 ambi 10peh-4cpm-20dm ambi 20dm-4cpm ambi 40pse-400gfn-20dm ambi 60pse-4cpm ambi 60pse-4cpm-20dm AMBISOME amethia amethia lo amifostine crystalline amiloride amiloride-hydrochlorothiazide AMINO ACIDS 15 % AMINOSYN 10 % AMINOSYN 7 % WITH ELECTROLYTES AMINOSYN 8.5 % AMINOSYN 8.5 %- ELECTROLYTES AMINOSYN II 10 % AMINOSYN II 15 % AMINOSYN II 7 % AMINOSYN II 8.5 % AMINOSYN II 8.5 %- ELECTROLYTES AMINOSYN M 3.5 % AMINOSYN-HBC 7% AMINOSYN-PF 10 % AMINOSYN-PF 7 % (SULFITE-FREE) AMINOSYN-RF 5.2 % amiodarone AMITIZA amitriptyline amlactin amlodipine amlodipine-atorvastatin 101, 102 amlodipine-benazepril amlodipine-olmesartan amlodipine-valsartan amlodipine-valsartan-hcthiazid ammonium lactate amoxapine amoxicil-clarithromy-lansopraz amoxicillin amoxicillin-pot clavulanate... 25, 26 amphotericin b ampicillin ampicillin sodium ampicillin-sulbactam AMPYRA ANACAINE ANADROL anagrelide anastrozole ANDRODERM ANDROGEL androxy animal chews animal shape vitamins animal shapes complete 211, 218 animal shapes plus iron ANORO ELLIPTA antacid anti-gas (ca carb-sim) antacid ultra strength antacid-antigas ii anti-diarrheal anti-diarrheal (loperamide). 150, 151 antifungal (tolnaftate)... 53, 56 antifungal cream anti-gas maximum strength anti-itch (hc) antioxidant antitussive dm apatate forte APOKYN apraclonidine aprepitant... 64, 65 apri APRISO aprodine APTIOM APTIVUS aquanil hc aranelle (28) ARCALYST aripiprazole ARISTADA... 69, 70 armodafinil ARNUITY ELLIPTA ARTIFICIAL TEARS (PETRO/MIN) artificial tears (pf) artificial tears (polyvin alc) artificial tears(dext70-hypro) 140 artificial tears(glycerin-peg). 140 artificial tears(hypromellose) 142 ascomp with codeine... 3 ascorbic acid (vitamin c) , 222 ashlyna aspirin... 11, 12 aspirin, buffered aspirin-dipyridamole aspir-low ASSURE ID INSULIN SAFETY ASTAGRAF XL atenolol atenolol-chlorthalidone atomoxetine atorvastatin atovaquone atovaquone-proguanil ATRIPLA I-2

241 atropine... 40, 140 ATROVENT HFA AUBAGIO aubra AUSTEDO AVASTIN AVC VAGINAL aviane AVONEX AVONEX (WITH ALBUMIN) ayr saline azacitidine azathioprine azathioprine sodium azelastine azithromycin... 23, 24 AZOPT aztreonam azurette (28) B b complete b complex b complex b complex-vitamin b b complex-vitamin c-folic acid , 208, 211, 219 b-100 complex b-12 dots b-50 complex baby vitamin d bacitracin... 19, 131, 143 bacitracin-polymyxin b bacitraycin plus baclofen bal b bal b balance b balance b balanced b , 217 balanced b balanced b , 217 balsalazide balziva (28) banophen banophen allergy BANZEL... 40, 41 BAVENCIO baza antifungal BCG VACCINE, LIVE (PF) 174 b-complex b-complex with vitamin c , 205, 218, 221, 222 BD INSULIN PEN NEEDLE UF SHORT BD INSULIN SYRINGE ULTRA-FINE bee-zee bekyree (28) BELBUCA... 4 BELEODAQ BELSOMRA benadryl allergy benazepril benazepril-hydrochlorothiazide BENDEKA BENLYSTA benzonatate benzoyl peroxide benztropine BETADINE beta-hc betamethasone acet,sod phos 163 betamethasone dipropionate. 132 betamethasone valerate betamethasone, augmented BETASERON betaxolol... 93, 185 bethanechol chloride BETHKIS bexarotene BEXSERO bicalutamide bicarsim forte BICILLIN C-R BICILLIN L-A BIDIL bimatoprost bio-dtuss dmx bion tears (pf) bionel pediatric biospec dmx biosupp biotin biovol bisac-evac bisacodyl biscolax bismatrol bisoprolol fumarate bisoprolol-hydrochlorothiazide bleomycin bleph BLINCYTO blisovi 24 fe blisovi fe 1.5/30 (28) blisovi fe 1/20 (28) blis-to-sol (tolnaftate) BOOSTRIX TDAP BOSULIF bp 8 cough BREO ELLIPTA briellyn BRILINTA brimonidine BRINTELLIX BRIVIACT bromfed dm bromfenac bromocriptine brompheniramine-pseudoephdm , 119 brotapp dm budesonide , 194 I-3

242 bufferin bumetanide BUNAVAIL BUPHENYL buprenorphine... 4 buprenorphine hcl... 4, 15 buprenorphine-naloxone buproban bupropion hcl bupropion hcl (smoking deter)16 buspirone butalbital compound w/codeine 4 butalbital-acetaminop-caf-cod. 4 butalbital-acetaminophen... 4 butalbital-acetaminophen-caff. 4 butalbital-aspirin-caffeine... 4 BUTRANS... 4 BYSTOLIC BYVALSON C cabergoline CABOMETYX ca-d3-mag ox-zinc-cop-mangbor , 192 caffeine citrate calci-chew calcidol calcipotriene calcitonin (salmon) calcitrate calcitrate-vitamin d calcitrene calcitriol , 180 calcium d (d3) calcium calcium d(3) , 204 calcium 600 with vitamin d3 189 calcium acetate calcium antacid calcium carbonate , 187 calcium carbonate-vit d3-min , 188 calcium carbonate-vitamin d3. 186, 187, 188, 203, 204, 205, 206, 210 CALCIUM CARBONATE- VITAMIN D calcium chloride calcium citrate-vitamin d , 193 calcium gluconate calcium+d CALDOLOR cal-gest antacid CALTRATE D camila camrese camrese lo CANCIDAS candesartan candesartan-hydrochlorothiazid capacet... 5 CAPASTAT CAPRELSA captopril captopril-hydrochlorothiazide 91 CARAFATE CARBAGLU carbamazepine carbidopa carbidopa-levodopa carbidopa-levodopa-entacapone CARIMUNE NF NANOFILTERED carisoprodol carteolol cartia xt carvedilol CASTELLANI PAINT CAYSTON caziant (28) cefaclor cefadroxil cefazolin cefazolin in dextrose (iso-os). 21 cefdinir cefditoren pivoxil cefepime... 21, 22 CEFEPIME CEFEPIME IN DEXTROSE 5 % CEFEPIME IN DEXTROSE,ISO-OSM cefotaxime cefoxitin cefoxitin in dextrose, iso-osm 22 cefpodoxime cefprozil ceftazidime ceftibuten ceftriaxone ceftriaxone in dextrose,iso-os 22, 23 cefuroxime axetil cefuroxime sodium celecoxib CELONTIN centamin centergy dm central-vite central-vite for seniors central-vite select central-vite senior central-vite with lycopene centram-care centravites 50 plus centrum centrum complete centrum silver centrum women century , 210 century adults century mature , 210 century ultimate men's I-4

243 century ultimate women's cephalexin CEPROTIN (BLUE BAR) CERDELGA CEREZYME cerovite cerovite advanced formula cerovite jr cerovite senior certavite senior-antioxidant certavite-antioxid (iron gluc) 205 certavite-antioxidant CERVARIX VACCINE (PF) cetirizine cetirizine-pseudoephedrine CETYLEV cevimeline CHANTIX CHANTIX CONTINUING MONTH BOX CHANTIX STARTING MONTH BOX cheratussin ac cheratussin dac chest congestion relief + dm 120 chest congestion relief pe chewable multi vitamin chewable-vite chewable-vite with iron child chest congestion + cough child complete multivitamin 208 child cough and sore throat child mucinex chest congestion child multivitamin plus iron. 205 child plus cough and runnynose child triaminic cold-allergy child triaminic cough-congest child vitamin with minerals child wal-tap cold-allergy child wal-tussin cough relief 119 CHILDREN'S ADVIL children's allegra allergy children's aller-tec children's chest congestion children's chewable children's chewable complete children's chewable vitamin. 205 children's chewable w/minerals CHILDREN'S CLARITIN children's cold-cough daytime children's complete vitamin. 216 children's cough and runnynose children's cough dm er children's mapap... 5 children's mucinex cough children's multivit w/extra c. 208 children's non-aspirin... 5 children's pain reliever children's pain-fever relief... 5, 7 children's pepto children's robitussin er children's silfedrine children's soothe children's sudafed children's sudafed pe cough. 119 children's tactinal... 5 children's wal-fex children's wal-zyr CHILDREN'S ZYRTEC ALLERGY childs chew vite child's chewable vitamins/iron child's vitamin with iron child's vitamin with vitamin c childs/iron chlophedianol-guaifenesin chloramphenicol sod succinate chlordiazepoxide hcl chlorhexidine gluconate chloroquine phosphate chlorothiazide chlorothiazide sodium chlorpheniramine-phenyleph-dm chlorpromazine chlorthalidone chlorzoxazone cholecalciferol (vitamin d3) 203, 207, 222, 223 cholestyramine (with sugar). 102 cholestyramine light ciclopirox cilostazol cimetidine cimetidine hcl CIMZIA CIMZIA POWDER FOR RECONST CINQAIR CINRYZE CIPRODEX ciprofloxacin ciprofloxacin hcl... 27, 143 ciprofloxacin in 5 % dextrose 27, 28 ciprofloxacin lactate citalopram citracal + d maximum citrus calcium clarithromycin CLARITIN LIQUI-GEL CLARITIN REDITABS clearlax I-5

244 CLEVIPREX clindamycin hcl clindamycin in 5 % dextrose.. 19 clindamycin palmitate hcl clindamycin pediatric clindamycin phosphate... 19, 63, 131 CLINIMIX 5%/D15W SULFITE FREE CLINIMIX 5%/D25W SULFITE-FREE CLINIMIX 2.75%/D5W SULFIT FREE CLINIMIX 4.25%/D10W SULF FREE CLINIMIX 4.25%/D5W SULFIT FREE CLINIMIX 4.25%-D20W SULF-FREE CLINIMIX 4.25%-D25W SULF-FREE CLINIMIX 5%- D20W(SULFITE-FREE) CLINIMIX E 2.75%/D10W SUL FREE CLINIMIX E 2.75%/D5W SULF FREE CLINIMIX E 4.25%/D10W SUL FREE CLINIMIX E 4.25%/D25W SUL FREE CLINIMIX E 4.25%/D5W SULF FREE CLINIMIX E 5%/D15W SULFIT FREE CLINIMIX E 5%/D20W SULFIT FREE CLINIMIX E 5%/D25W SULFIT FREE CLINISOL SF 15 % clobetasol clobetasol-emollient clocortolone pivalate clofarabine clomipramine clonazepam clonidine clonidine hcl... 89, 106 clopidogrel clorazepate dipotassium clorpres clotrimazole clotrimazole clotrimazole-betamethasone clozapine COARTEM codeine sulfate... 5 codituss dm COLCRYS cold and cough (diphenhydr-pe) cold and cough (pe-dm) cold multi-symptom day/night cold multi-symptom nighttime cold relief m/s day/night cold-allergy-sinus cold-flu relief cold-flu relief, day/night colestipol colistin (colistimethate na) colocort COLY-MYCIN S COMBIGAN COMBIPATCH COMBIVENT RESPIMAT. 196 COMETRIQ comfort gel comfort gel extra strength compete COMPLERA complete complete complete multi complete multi complete multivitamin. 205, 208 complete multivitamin-mineral , 218 complete senior , 218 complete women compoz compro COMVAX (PF) CONDYLOX congestac congest-eze constulose COPAXONE coricidin hbp coricidin hbp cold-multi sympt CORLANOR cormax cortaid cortisone cortizone cortizone-10 with aloe COSENTYX COSENTYX (2 SYRINGES) COSENTYX PEN COSENTYX PEN (2 PENS) 129 COTELLIC cough and cold cough and runny nose cough control dm cough relief cough syrup cough syrup dm CREON critic-aid clear af CRIXIVAN cromolyn , 151, 197 cryselle (28) CUPRIMINE I-6

245 cutter backwoods cutter skinsations cyanocobalamin (vitamin b-12) , 207, 217, 221 cyclafem 1/35 (28) cyclafem 7/7/7 (28) cyclobenzaprine cyclopentolate cyclophosphamide CYCLOPHOSPHAMIDE CYCLOSET cyclosporine cyclosporine modified cyproheptadine CYRAMZA cyred CYSTADANE CYSTARAN D d10 %-0.45 % sodium chloride d2.5 %-0.45 % sodium chloride d3 dots d5 % and 0.9 % sodium chloride d5 %-0.45 % sodium chloride daily gummies daily multiple , 207 daily multi-vitamin daily multivitamin with iron 207 daily multi-vitamins/iron daily value daily vitamin formula daily vitamin formula-iron daily vitamin formula-minerals daily vitamin with iron daily vites/iron dailyhist daily-vite DAKLINZA DALIRESP danazol dantrolene dapsone DAPTACEL (DTAP PEDIATRIC) (PF) daptomycin DARAPRIM DARZALEX dasetta 1/35 (28) dasetta 7/7/7 (28) dayhist allergy daysee daytime cold and cough daytime cold-flu relief (pe) day-time cough daytime-nighttime daytime-nighttime cold-flu daytime-nighttime cough deblitane decitabine decongestant cough deep sea nasal deferoxamine delsym cough-chest congest dm delta d delyla (28) DELZICOL DEMSER DEPEN TITRATABS DEPO-PROVERA dermafungal dermarest eczema (hydrocort) DESCOVY desipramine desmopressin , 165 desog-e.estradiol/e.estradiol. 111 desogestrel-ethinyl estradiol 111 desonide desoximetasone despec-dm (pseudoeph-dmguaif) desvenlafaxine succinate dex4 glucose dexamethasone dexamethasone sodium phosphate , 163 dexmethylphenidate dextroamphetamine dextroamphetamineamphetamine , 107 dextromethorphan polistirex 121 dextrose 10 % and 0.2 % nacl dextrose 10 % in water (d10w) dextrose 20 % in water (d20w) dextrose 25 % in water (d25w) dextrose 40 % in water (d40w) dextrose 5 % in ringer's dextrose 5 % in water (d5w).. 87 dextrose 5 %-lactated ringers188 dextrose 5%-0.2 % sod chloride dextrose 5%-0.3 % sod.chloride dextrose 50 % in water (d50w) dextrose 70 % in water (d70w) dextrose with sodium chloride dextrose-kcl-nacl diabetic tussin dm diabetic tussin ex diamode diazepam... 17, 18 diazepam intensol I-7

246 diclofenac potassium diclofenac sodium.. 12, 129, 146 diclofenac-misoprostol dicloxacillin dicyclomine didanosine DIFICID diflunisal digitek digoxin... 96, 97 DIGOXIN dihydroergotamine DILANTIN diltiazem hcl dilt-xr dimaphen (pe) dimenhydrinate dimetapp cold-congestion DIMETAPP LONG-ACTING (CPM-DM) dino-life dino-life with extra c dino-life with iron-zinc DIPENTUM diphenhist diphenhydramine hcl diphenoxylate-atropine dipyridamole disopyramide phosphate disulfiram divalproex dobutamine dobutamine in d5w doc-q-lace docu docusate sodium docusol dofetilide dok donepezil dopamine dopamine in 5 % dextrose dorzolamide dorzolamide-timolol douche vinegar and water extra doxazosin doxepin doxercalciferol , 181 doxorubicin doxorubicin, peg-liposomal doxy doxycycline hyclate doxycycline monohydrate dramamine dramamine less drowsy driminate dristan long lasting dronabinol droperidol drospirenone-ethinyl estradiol DROXIA DUAVEE dulcolax stool softener (dss) 156 DULERA duloxetine DUPIXENT DUREZOL dutasteride dutasteride-tamsulosin d-vi-sol DYRENIUM E e.c. prin e.e.s e.e.s. granules econazole econtra ez ecotrin ed a-hist ed bron gp ed chlorped jr EDURANT effer-k EFFIENT ELAPRASE eldertonic electrolyte-48 in d5w ELIDEL ELIGARD ELIGARD (3 MONTH) ELIGARD (4 MONTH) ELIGARD (6 MONTH) elinest eliphos ELIQUIS ELITEK ELLA ellis tonic ELMIRON EMCYT EMEND EMFLAZA , 164 emoquette EMPLICITI EMSAM EMTRIVA enalapril maleate enalaprilat enalapril-hydrochlorothiazide 91 ENBREL ENBREL SURECLICK endocet... 5 endodan... 5 endur-acin enema , 158 enema disposable , 156 enemeez enemeez plus ENGERIX-B (PF) ENGERIX-B PEDIATRIC (PF) enoxaparin enpresse enskyce I-8

247 entacapone entecavir entre-cough ENTRESTO enulose ENVARSUS XR EPCLUSA epinastine epinephrine epinephrine hcl (pf) epitol EPIVIR HBV eplerenone EPOGEN epoprostenol (glycine) eq gentle equalactin ergocalciferol (vitamin d2). 208, 221 ergoloid ERGOMAR ERIVEDGE errin ery pads ery-tab ERY-TAB ERYTHROCIN erythrocin (as stearate) erythromycin... 24, 144 erythromycin ethylsuccinate.. 24 erythromycin with ethanol ESBRIET escitalopram oxalate esmolol esomeprazole sodium essentia essential balance with lutein 209 essential daily estarylla ESTRACE estradiol estradiol valerate estradiol-norethindrone acet. 162 estropipate eszopiclone ethambutol ethosuximide ethynodiol diac-eth estradiol 111 etodolac ETOPOPHOS etoposide EUCRISA evac-u-gen (sennosides) EVOTAZ exemestane EXJADE EXONDYS expectorant expectorant dm expectorant max strength EXTAVIA extra cleansing douche eye health plus lutein ezetimibe F FABRAZYME fallback solo falmina (28) famciclovir famotidine , 149 famotidine (pf) famotidine (pf)-nacl (iso-os) 148 FANAPT FARESTON FARYDAK FASLODEX felbamate felodipine feminine care douche FEMRING femynor fenofibrate fenofibrate micronized fenofibrate nanocrystallized. 102 fenofibric acid fenofibric acid (choline) fenoprofen fentanyl... 5, 6 fentanyl citrate... 5 feosol ferate ferocon ferretts ferrex ferrex 150 plus ferric x FERRIPROX ferrocite ferrous fumarate ferrous gluconate , 211 ferrous sulfate , 209, 210 FETZIMA feverall... 6 fexofenadine fiber (calcium polycarbophil) fiber (psyllium husk/sugar) fiber laxative (methylcellulo)158 fiber smooth fiber therapy (m-cell/sugar) fiber therapy (m-cellulose) fiber therapy sugar free fiber therapy(psyl seed-sugar) fiber-lax finasteride FIRAZYR flavor chews antacid FLEBOGAMMA DIF flecainide FLECTOR FLEET BISACODYL flintstones complete (iron) flintstones multivitamin flintstones with iron flintstones/extra c I-9

248 FLOVENT DISKUS FLOVENT HFA , 195 floxuridine flu formula daytime-nighttime flu hbp flu relief therapy daytime flu severe cold-congestion flucaine fluconazole fluconazole in nacl (iso-osm). 55 flucytosine fludrocortisone flumazenil flunisolide fluocinonide fluocinonide-e fluoride (sodium) fluorometholone fluorouracil... 33, 129 fluoxetine fluphenazine decanoate fluphenazine hcl flurbiprofen flurbiprofen sodium flutamide fluticasone , 146 fluvoxamine foaming antacid , 154 folic acid fomepizole fondaparinux foot odor control FORTEO FORTICAL foscarnet fosfree fosinopril fosinopril-hydrochlorothiazide fosphenytoin FREAMINE HBC 6.9 % FREAMINE III 10 % fungi cure fungoid-d furosemide FUZEON FYCOMPA G gabapentin GABITRIL galantamine GAMASTAN S/D GAMMAGARD LIQUID GAMMAGARD S-D (IGA < 1 MCG/ML) GAMMAPLEX GAMMAPLEX (WITH SORBITOL) ganciclovir sodium GARDASIL (PF) GARDASIL 9 (PF) gas relief gas relief gas relief extra strength gas-x ultra-strength gatifloxacin GATTEX 30-VIAL GATTEX ONE-VIAL GAUZE PAD gavilyte-c gavilyte-g gavilyte-n GAZYVA gelusil antacid and anti-gas gemfibrozil generlac gengraf GENOTROPIN GENOTROPIN MINIQUICK gentak gentamicin... 18, 131, 144 gentamicin in nacl (iso-osm).. 18 gentamicin sulfate (ped) (pf).. 18 gentamicin sulfate (pf) GENTEAL GEL GENTEAL MILD GENTEAL SEVERE genteal tears GENTEAL TEARS (DXTRN- HPM-GLY) gentlelax GENVOYA GEODON geravim geriaton geri-hydrolac geri-lanta geri-tussin dm gianvi (28) gildagia gildess 1.5/30 (21) gildess 1/20 (21) gildess 24 fe gildess fe 1.5/30 (28) gildess fe 1/20 (28) GILENYA GILOTRIF GLEOSTINE glimepiride glipizide... 52, 53 glipizide-metformin GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT (HUMAN) gluco burst glucose glucose gel glutose glyburide glyburide micronized glyburide-metformin glycolax glycopyrrolate glydo I-10

249 GLYXAMBI granisetron (pf) granisetron hcl GRANIX griseofulvin microsize guaifenesin guanfacine... 89, 107 guanidine gummi bear multivitamin , 216 gummy swirls H hair vitamins hair,skin and nails , 220 halobetasol propionate haloperidol haloperidol decanoate haloperidol lactate HARVONI HAVRIX (PF) head congestion day-night healthylax heather hemocyte heparin (porcine) heparin (porcine) in 5 % dex.. 81 heparin(porcine) in 0.45% nacl heparin, porcine (pf) HEPATAMINE 8% HERCEPTIN HETLIOZ HEXALEN hi-b complex HIBERIX (PF) hi-cal plus vit d homatropaire homatropine hbr honey bears honey bears with iron-zinc HUMATROPE HUMIRA HUMIRA PEDIATRIC CROHN'S START HUMIRA PEN HUMIRA PEN CROHN'S-UC- HS START HUMIRA PEN PSORIASIS- UVEITIS HUMULIN R U-500 (CONC) KWIKPEN HUMULIN R U-500 (CONCENTRATED) hydralazine hydrochlorothiazide hydrocil instant hydrocodone-acetaminophen... 6 hydrocodone-chlorpheniramine hydrocodone-homatropine hydrocodone-ibuprofen... 6 hydrocortisone , 135, 164, 179 hydrocortisone acetate hydrocortisone butyrate hydrocortisone butyr-emollient hydrocortisone valerate hydromet hydromorphone... 6, 7 hydromorphone (pf)... 6 hydroskin hydroxychloroquine hydroxyprogesterone caproate hydroxyurea hydroxyzine hcl hydroxyzine pamoate HYPERRAB S/D (PF) HYQVIA HYQVIA IG COMPONENT HYSINGLA ER... 7 I ibandronate IBRANCE ibuprofen... 12, 13, 14 ibuprofen jr strength icaps plus ICLUSIG iferex ifosfamide ifosfamide-mesna ILARIS (PF) ILEVRO imatinib IMBRUVICA IMFINZI imipenem-cilastatin imipramine hcl imipramine pamoate imiquimod IMLYGIC imodium a-d IMOGAM RABIES-HT (PF) IMOVAX RABIES VACCINE (PF) INCRELEX INCRUSE ELLIPTA indapamide indomethacin indomethacin sodium INFANRIX (DTAP) (PF) infant's advil infant's ibuprofen infants' non-aspirin cold infant's pain reliever... 7 INFLECTRA INGREZZA INLYTA INSECT REPELLENT (PICARIDIN) insta-glucose I-11

250 INSULIN SYRINGE-NEEDLE U INTELENCE INTRALIPID INTRON A introvale INVANZ INVEGA SUSTENNA INVEGA TRINZA... 71, 72 INVIRASE INVOKAMET INVOKAMET XR INVOKANA... 49, 50 inzo antifungal iodine IONOSOL-B IN D5W IONOSOL-MB IN D5W IPOL ipratropium bromide , 196 IPRIVASK irbesartan irbesartan-hydrochlorothiazide IRESSA iron high potency ISENTRESS ISENTRESS HD ISOLYTE-P IN 5 % DEXTROSE ISOLYTE-S isoniazid isopto tears isosorbide dinitrate , 105 isosorbide mononitrate isradipine itraconazole ivermectin IXEMPRA IXIARO (PF) J JAKAFI jantoven JANUMET JANUMET XR JANUVIA JARDIANCE jencycla JENTADUETO JENTADUETO XR jolessa jolivette juleber junel 1.5/30 (21) junel 1/20 (21) junel fe 1.5/30 (28) junel fe 1/20 (28) junel fe junior mapap... 7 JUXTAPID , 103 K KABIVEN KALETRA KALYDECO KANUMA kaopectate (bismuth subsalicy) kariva (28) kelnor 1/35 (28) ketoconazole ketoprofen ketorolac... 14, 146 KEVEYIS KEVZARA KEYTRUDA kidkare cough/cold kids mini enema kids multivitamin complete kid's vitamins kid's vitamins + extra c kids vitamins + iron kid's vitamins + iron kids vitamins complete kimidess (28) KINERET KINRIX (PF) kionex kionex (with sorbitol) KISQALI KISQALI FEMARA CO-PACK... 34, 35 KLOR-CON klor-con m klor-con m klor-con m klor-con sprinkle kobee konsyl (sugar) konsyl fiber KONSYL SUGAR-FREE KORLYM kpn KRYSTEXXA kurvelo KUVAN KYNAMRO KYPROLIS L l norgest/e.estradiol-e.estrad. 113 labetalol LACRISERT LACTATED RINGERS LACTINOL HX lactulose LAMISIL (AEROSOL) lamisil af LAMISIL AT lamivudine lamivudine-zidovudine lamotrigine LANOXIN... 98, 99 lansoprazole , 149 LANTUS LANTUS SOLOSTAR larin 1.5/30 (21) larin 1/20 (21) larin 24 fe I-12

251 larin fe 1.5/30 (28) larin fe 1/20 (28) larissia LARTRUVO latanoprost LATUDA laxative peg LAZANDA... 7 leena leflunomide LEMTRADA LENVIMA lessina LETAIRIS letrozole leucovorin calcium LEUKERAN LEUKINE leuprolide levetiracetam... 42, 43 levobunolol levocarnitine levocarnitine (with sugar) levocetirizine levofloxacin... 28, 144 levofloxacin in d5w levoleucovorin LEVOLEUCOVORIN levonest (28) levonorgestrel levonorgestrel-ethinyl estrad113, 114 levonorg-eth estrad triphasic 114 levora levothyroxine LEXIVA LIALDA lice cream rinse lice killing lice treatment lice treatment (permethrin) lidocaine lidocaine (pf)... 15, 92 lidocaine hcl lidocaine in 5 % dextrose (pf) 92 lidocaine viscous lidocaine-prilocaine life-pack women's linezolid... 19, 20 LINZESS liothyronine liquibid d-r liquid calcium with vitamin d lisinopril lisinopril-hydrochlorothiazide 91 lithium carbonate lithium citrate little animals little animals-iron little remedies LIVALO lobana bath lohist-dm lomedia 24 fe LONSURF loperamide , 152 lopinavir-ritonavir loratadine... 58, 60 loratadine-d... 59, 60 lorazepam lorcet (hydrocodone)... 7 lorcet hd... 7 lorcet plus... 7 lortuss ex loryna (28) losartan losartan-hydrochlorothiazide. 90 LOTEMAX lovastatin low-ogestrel (28) loxapine succinate lubricant dry eye relief lubricant eye lubricant eye (cmc-glycer)(pf) lubricant eye (cmc-glycerin) 141 lubricant eye (pg-peg 400) lubricant eye (polyv alcohol) 142 lubricant eye (propyl glycol) 140 lubricant gel lubricating drops lubricating plus lubrifresh pm LUMIGAN LUPRON DEPOT LUPRON DEPOT (3 MONTH) LUPRON DEPOT (4 MONTH) LUPRON DEPOT (6 MONTH) LUPRON DEPOT-PED LUPRON DEPOT-PED (3 MONTH) lutera (28) LYNPARZA LYRICA lysiplex plus LYSODREN lyza M maalox advanced MACUVITE EYE CARE mag mag-delay mag-g magnebind magnesium , 189, 193 magnesium (oxide/aa chelate) magnesium gluconate magnesium oxide. 152, 153, 154 magnesium sulfate magnesium sulfate in d5w magnesium sulfate in water I-13

252 malathion mapap (acetaminophen)... 7 mapap arthritis pain... 7 mapap extra strength... 7 maprotiline mar-cof bp mar-cof cg margesic... 8 marlissa MARPLAN masanti double strength MATULANE matzim la maximum daily multivitamin meclizine medi-meclizine medroxyprogesterone mefenamic acid mefloquine MEFOXIN IN DEXTROSE (ISO-OSM) mega multiple/chelated mineral mega multivitamin with mineral megestrol... 36, 167 MEKINIST meloxicam memantine MENACTRA (PF) MENEST MENHIBRIX (PF) MENOMUNE - A/C/Y/W MENOMUNE - A/C/Y/W-135 (PF) men's daily gummies men's multi-vitamin men's multivitamin gummies 211 men's one daily MENVEO A-C-Y-W-135-DIP (PF) MEPHYTON mercaptopurine meropenem mesalamine mesna MESNEX MESTINON metaproterenol metaxall metaxalone metformin methadone... 8 methadose... 8 methazolamide methenamine hippurate methimazole methocarbamol methotrexate sodium methotrexate sodium (pf) methoxsalen methscopolamine methyclothiazide methylphenidate , 108 methylprednisolone methylprednisolone acetate methylprednisolone sodium succ metipranolol metoclopramide hcl metolazone metoprolol succinate metoprolol ta-hydrochlorothiaz metoprolol tartrate metronidazole... 20, 63, 131 metronidazole in nacl (iso-os) 20 mexiletine mgo MIACALCIN mi-acid mi-acid gas relief micatin miconazole miconazole nitrate... 54, 55 miconazole microgestin 1.5/30 (21) microgestin 1/20 (21) microgestin fe 1.5/30 (28) microgestin fe 1/20 (28) midodrine miglitol milk of magnesia milltrium senior milrinone milrinone in 5 % dextrose mimvey mimvey lo mineral oil MINERAL OIL mineral oil laxative minitran minocycline minoxidil mintox mintox maximum strength mintox plus MIRCERA mirtazapine... 47, 48 misoprostol mitoxantrone M-M-R II (PF) moexipril moexipril-hydrochlorothiazide molindone mometasone MONISTAT monistat mono-linyah mononessa (28) montelukast morphine... 8, 9 I-14

253 MORPHINE... 8 morphine concentrate... 8 motion sickness motion sickness relief(mecliz)... 65, 66 MOVANTIK MOVIPREP MOXEZA moxifloxacin MOZOBIL MUCINEX FAST-MAX COLD-FLU-THRT mucinex fast-max dm max mucinex sinus-max mucus dm mucus dm max mucus relief , 124 mucus relief er MULTAQ multi complete with iron multi for her multi-day with iron multi-delyn multi-delyn with iron multilex multilex-t and m multiple vitamin-minerals multiple vitamins multiple vitamins with iron multi-symptom cold night time multivital multivital platinum multivitamin , 218 multivitamin 50 plus multi-vitamin hp/minerals multi-vitamin with fluoride multivitamin with iron. 212, 218 multivitamin with minerals multi-vite multi-vite 50 and over mupirocin mupirocin calcium muro my favorite multiple my way mycophenolate mofetil. 171, 172 mycophenolate mofetil hcl mycophenolate sodium MYOZYME MYRBETRIQ mytab gas mytab gas maximum strength my-vitalife myzilra N nabumetone nadolol nafcillin NAGLAZYME naloxone naltrexone NAMENDA XR NAMZARIC naphazoline naproxen naproxen sodium naratriptan NARCAN nasal and sinus decongestant 123 nasal spray (oxymetazoline). 140 NASCOBAL NATACYN nateglinide NATPARA NATRAPEL natural b natural b-100 complex natural balance natural balance tears natural calcium natural fiber laxative therapy 157 natura-lax nature's tears (hypromellose) 142 NEBUPENT necon 0.5/35 (28) necon 1/35 (28) necon 1/50 (28) necon 10/11 (28) necon 7/7/7 (28) nefazodone NEO DM neomycin neomycin-bacitracin-poly-hc 144 neomycin-bacitracin-polymyxin neomycin-polymyxin b gu neomycin-polymyxin b- dexameth neomycin-polymyxingramicidin neomycin-polymyxin-hc , 145 neo-polycin neo-polycin hc neosporin (neo-bac-polym) neosporin anti-itch neo-synephrine 12 h spr (oxym) neo-tuss nephplex rx NEPHRAMINE 5.4 % nephron fa nephro-vite rx NEULASTA NEUPOGEN... 82, 83 NEUPRO NEVANAC nevirapine NEXAVAR next choice one dose niacin niacinamide , 213 niacor nicardipine I-15

254 nicorelief NICORETTE nicotine... 16, 17 nicotine (polacrilex)... 16, 17 NICOTROL nifedical xl nifedipine night time night time cold medicine night time cold-flu night time cold-flu relief night time cough-sore throat 123 nighttime cough nighttime sleep aid (diphen) nikki (28) nilutamide NINLARO NITRO-BID nitrofurantoin macrocrystal nitrofurantoin monohyd/m-cryst nitroglycerin nitroglycerin in 5 % dextrose 105 NIX CREME RINSE nohist-dm non-aspirin cold non-aspirin extra strength.. 9, 10 non-aspirin flu non-aspirin jr strength... 5 nora-be NORDITROPIN FLEXPRO 166 norepinephrine bitartrate norethindrone (contraceptive) norethindrone acetate norethindrone ac-eth estradiol norethindrone-e.estradiol-iron norgestimate-ethinyl estradiol norlyda norlyroc NORMOSOL-M IN 5 % DEXTROSE NORMOSOL-R NORMOSOL-R PH nortemp... 9 NORTHERA nortrel 0.5/35 (28) nortrel 1/35 (21) nortrel 1/35 (28) nortrel 7/7/7 (28) nortriptyline NORVIR NOVOLIN 70/ NOVOLIN N NOVOLIN R NOVOLOG NOVOLOG FLEXPEN NOVOLOG MIX NOVOLOG MIX FLEXPEN NOVOLOG PENFILL NOXAFIL NUCALA NUCYNTA... 9 NUCYNTA ER... 9 NUEDEXTA nu-iron NULOJIX nu-mag NUPLAZID NUTRESTORE NUTRILIPID NUTROPIN AQ NUTROPIN AQ NUSPIN NUVARING nyamyc nyata nystatin nystatin-triamcinolone nystop nyt-time sleep O OCALIVA ocean nasal ocella OCREVUS OCTAGAM octreotide acetate ocutabs ODEFSEY ODOMZO OFEV off active off deep woods off deep woods dry off familycare (with deet) ofloxacin... 28, 145 ogestrel (28) olanzapine olanzapine-fluoxetine olmesartan olmesartan-amlodipin-hcthiazid olmesartan-hydrochlorothiazide olopatadine OLYSIO omega-3 acid ethyl esters omeprazole omeprazole magnesium OMNITROPE ONCASPAR onccor once daily oncovite ondansetron ondansetron hcl ondansetron hcl (pf)... 65, 66 one daily , 217 one daily 50 plus one daily complete one daily energy one daily essential 208, 210, 213 I-16

255 one daily for women one daily gummy vites one daily maximum , 217 one daily maximum (with ca) one daily multi-vit w-mineral one daily multivitamin one daily multivit-iron(folic) 213 one daily plus iron 211, 213, 217 one daily plus minerals one daily with iron one-a-day essential one-a-day maximum formula213 one-a-day men's multivitamin one-a-day teen advantage ONFI ONIVYDE opcicon one-step OPDIVO OPSUMIT option oral saline laxative oralone oralyte ORENCIA ORENCIA (WITH MALTOSE) ORENCIA CLICKJECT ORENITRAM ORFADIN ORKAMBI orsythia oseltamivir OTEZLA OTEZLA STARTER OTOVEL OTREXUP (PF) oxacillin oxacillin in dextrose(iso-osm) 27 oxandrolone oxcarbazepine OXTELLAR XR oxybutynin chloride oxycodone... 9 oxycodone-acetaminophen... 9 oxycodone-aspirin... 9 OXYCONTIN oxymorphone oysco 500/d oysco d oysco oyster shell calcium oyster shell calcium-vit d , 192 oyster shell calcium-vit d oystercal-d P pacerone pain relief... 5, 10 pain relief adult... 5 pain reliever jr strength paliperidone PANRETIN pantoprazole paricalcitol PARICALCITOL paromomycin paroxetine hcl PASER PATADAY PAXIL pecgen dmx pedia relief pedia relief infant pediacare multi-symptom cold PEDIARIX (PF) pediatric electrolyte , 190, 192, 193 pediatric freezer pops pediatric multivitamin.. 212, 218 PEDVAX HIB (PF) peg 3350-electrolytes PEGANONE PEGASYS PEGASYS PROCLICK peg-electrolyte soln PEGINTRON PEN NEEDLE, DIABETIC. 137 penicillin g pot in dextrose penicillin g potassium penicillin g procaine penicillin v potassium PENTACEL (PF) PENTAM pentoxifylline pep-t-med peri-colace PERIKABIVEN perindopril erbumine periogard permethrin perphenazine perphenazine-amitriptyline perry prenatal persa-gel pfizerpen-g pharbetol pharmacist favorite multi-vit 214 phenadoz phenelzine phenobarbital phenylephrine hcl... 89, 142 phenylhistine dh phenytoin phenytoin sodium phenytoin sodium extended philith phillips phillips' liqui-gels PHOSLYRA phosphate laxative PHOSPHOLINE IODIDE I-17

256 phytonadione (vitamin k1).. 214, 223 PICATO pilocarpine hcl , 186 pimozide pimtrea (28) pindolol pink bismuth pioglitazone pioglitazone-glimepiride pioglitazone-metformin piperacillin-tazobactam pirmella piroxicam PLASMA-LYTE PLASMA-LYTE A PLASMA-LYTE-56 IN 5 % DEXTROSE PLEGRIDY pnv cmb#95-ferrous fumarate-fa podofilox polyethylene glycol poly-iron polymyxin b sulfate polymyxin b sulf-trimethoprim poly-vita poly-vita (iron) poly-vitamin poly-vitamin with iron polyvitamin/iron poly-vitamins POMALYST portia PORTRAZZA potassium acetate potassium chlorid-d5-0.45%nacl potassium chloride , 192 potassium chloride in 0.9%nacl potassium chloride in 5 % dex potassium chloride in lr-d potassium chloride-0.45 % nacl potassium chloride-d5-0.2%nacl potassium chloride-d5-0.3%nacl , 192 potassium chloride-d5-0.9%nacl potassium citrate potassium citrate-citric acid. 192 potassium hydroxide POTIGA... 43, 44 PRADAXA PRALUENT PEN PRALUENT SYRINGE pramipexole pravastatin prazosin prednicarbate prednisolone acetate prednisolone sodium phosphate , 164 prednisone PREMARIN PREMASOL 10 % PREMASOL 6 % PREMPHASE PREMPRO prenatal , 215, 218 prenatal formula , 216 prenatal multivitamins prenatal plus (calcium carb). 214 prenatal tablet prenatal vitamin , 208, 215 prenatal vitamin plus low iron prenatal vit-iron fum-folic ac 215 prenatal vits96-iron fum-folic preparation h hydrocortisone 135 PREVAIL BLADDER CONTROL PAD prevalite previfem PREZCOBIX PREZISTA PRIFTIN PRILOSEC OTC PRIMAQUINE primidone PRISTIQ PRIVIGEN PROAIR HFA PROAIR RESPICLICK probenecid probenecid-colchicine procainamide PROCALAMINE 3% prochlorperazine prochlorperazine edisylate prochlorperazine maleate PROCRIT procto-med hc procto-pak proctosol hc proctozone-hc PROCYSBI progesterone in oil progesterone micronized PROGLYCEM PROGRAF PROLASTIN-C PROLENSA PROLEUKIN PROLIA PROMACTA promethazine... 61, 66 promethazine vc-codeine promethazine-codeine promethazine-dm promethegan I-18

257 promolaxin propafenone propantheline proparacaine propranolol propranolol-hydrochlorothiazid propylthiouracil PROQUAD (PF) prosight PROSOL 20 % protamine protriptyline pseudoephedrine hcl PULMOZYME pure and gentle eye purelax PURIXAN pyrazinamide pyridostigmine bromide pyridoxine (vitamin b6) Q QBRELIS q-dryl q-pap q-pap extra strength QUADRACEL (PF) quasense quetiapine quinapril quinapril-hydrochlorothiazide 92 quinidine gluconate quinidine sulfate quinine sulfate QVAR R RABAVERT (PF) RADICAVA raloxifene ramipril RANEXA ranitidine hcl RAPAMUNE rasagiline RASUVO (PF) RAVICTI RAYALDEE react REBIF (WITH ALBUMIN). 108 REBIF REBIDOSE REBIF TITRATION PACK 109 reclipsen (28) RECOMBIVAX HB (PF) recort plus refenesen refenesen pe REFRESH CELLUVISC REFRESH CLASSIC (PF) REFRESH LACRI-LUBE REFRESH OPTIVE ADVANCED REFRESH OPTIVE MEGA reguloid relcof c RELENZA DISKHALER RELISTOR remedy phytoplex antifungal. 56 REMICADE REMODULIN RENAGEL rena-vite rx RENVELA repaglinide repaglinide-metformin REPATHA PUSHTRONEX 103 REPATHA SURECLICK REPATHA SYRINGE repel sportsmen repel sportsmen max reprexain RESCRIPTOR RESTASIS RESTASIS MULTIDOSE retaine cmc retaine hpmc retaine pm RETROVIR revive plus REVLIMID revonto REXULTI REYATAZ REZIRA ribasphere ribavirin RIDAURA rifabutin rifampin RIFATER ri-gel ii right step prenatal vitamins riginic riluzole rimantadine ri-mox ringer's , 193 risedronate , 182 RISPERDAL CONSTA risperidone RITUXAN rivastigmine rivastigmine tartrate rizatriptan robafen robafen cough robafen dm robitussin cough-chest cong dm ROBITUSSIN LONG-ACTING robitussin pediatric ropinirole rosadan rosuvastatin ROTARIX I-19

258 ROTATEQ VACCINE ROWEEPRA ROZEREM RUBRACA RYDAPT rydex rynex dm S SABRIL safe tussin dm SAIZEN SAIZEN CLICK.EASY saline nose SANDOSTATIN LAR DEPOT SANTYL SAPHRIS (BLACK CHERRY) SAVELLA scooby-doo one a day scot-tussin dm scot-tussin expectorant sea soft nasal mist selegiline hcl selenium sulfide SELZENTRY... 76, 77 senexon senior tabs senna senna lax senna with docusate sodium. 155 senokot-s SENSIPAR sentry sentry (with lutein) sentry senior SEREVENT DISKUS SEROSTIM sertraline setlakin sevelamer carbonate sharobel SIGNIFOR silace siladryl sa sildenafil SILENOR SILIQ siltussin sa silver nitrate silver sulfadiazine SIMBRINZA simethicone simply sleep SIMPONI SIMPONI ARIA simvastatin sinus and allergy(pseudoephed) sirolimus SIRTURO skin treatment sleep aid (doxylamine) smoflipid smoothlax sochlor sodium acetate sodium bicarbonate , 193 sodium chloride , 180, 193, 198 sodium chloride 0.45 % sodium chloride 0.9 % sodium chloride 3 % sodium chloride 5 % sodium lactate sodium phosphate sodium polystyrene (sorb free) sodium polystyrene sulfonate SOLTAMOX SOLU-CORTEF (PF) SOMATULINE DEPOT SOMAVERT soothe (bismuth subsalicylate) soothe night time lubricant soothe regular strength sorbitol sorbitol-mannitol sorine sotalol sotalol af SOVALDI spectravite adult spectravite adult spectravite advanced formula spectravite senior spectravite senior w-lycopene spectravite ultra men's sr spectravite ultra women SPIRIVA RESPIMAT SPIRIVA WITH HANDIHALER spironolactone spironolacton-hydrochlorothiaz sprintec (28) SPRITAM SPRYCEL sps (with sorbitol) sronyx ssd st joseph aspirin st. joseph aspirin stavudine STELARA STERILE GAUZE PAD STIOLTO RESPIMAT STIVARGA stomach relief stool softener STRATTERA STRENSIQ I-20

259 streptomycin stress stress 500 plus zinc stress b with zinc stress b-biotin stress formula stress formula 600 c stress formula plus iron stress formula with iron stress formula with iron(sulf)219 stress formula with zinc STRIBILD STRIVERDI RESPIMAT SUBOXONE sucralfate sudafed sudogest sudogest sinus and allergy sulfacetamide sodium sulfacetamide sodium (acne) 132 sulfacetamide-prednisolone. 145 sulfadiazine sulfamethoxazole-trimethoprim sulfasalazine sulfatrim sulindac sumatriptan sumatriptan succinate summer's eve disposable douche summers eve extra cleansing 184 sunvite super b complex-vitamin c.. 206, 218, 219 super b maxi complex super b/c super b-50 complex super b-50 complex plus super multiple super multivitamin super quints super quints b super thera vite m superior superplex-t suphedrin suphedrine pe day-night suphedrine severe cold max str support support SUPPRELIN LA SUPRAX SUPREP BOWEL PREP KIT SURMONTIL SUSTIVA SUTENT syeda SYLATRON SYLVANT SYMBICORT SYMLINPEN SYMLINPEN SYNAGIS SYNAREL SYNERCID SYNJARDY SYNJARDY XR SYNRIBO SYPRINE SYSTANE GEL T tab-a-vite tab-a-vite/iron tab-a-vite-minerals TABLOID tacrolimus , 173 tactinal tactinal extra strength TAFINLAR TAGRISSO TALTZ AUTOINJECTOR TALTZ AUTOINJECTOR (3 PACK) TALTZ SYRINGE TAMIFLU tamoxifen tamsulosin TARCEVA TARGRETIN tarina fe 1/20 (28) TASIGNA tazarotene tazicef TAZORAC taztia xt tears again tears again (pva) tears naturale free (pf) TECENTRIQ TECFIDERA TECHNIVIE TEFLARO TEKAMLO TEKTURNA TEKTURNA HCT telmisartan telmisartan-hydrochlorothiazid TEMODAR tencon TENIVAC (PF) terazosin terbinafine hcl terbutaline terconazole testosterone , 162 testosterone cypionate testosterone enanthate TETANUS,DIPHTHERIA TOX PED(PF) TETANUS-DIPHTHERIA TOXOIDS-TD tetrabenazine I-21

260 tetracycline THALOMID the magic bullet theophylline theophylline in dextrose 5 % 197 thera thera m plus (ferrous fumarat) thera-d theradex m thera-m therapeutic liquid therapeutic m + beta-carotene therapeutic-m therapeutic-m vitamin/minerals thera-tabs theratrum complete 50 plus theratrum complete with lutein therems THIOLA thioridazine thiotepa thiothixene tiagabine TICE BCG tigecycline tilia fe timolol maleate... 94, 186 TIVICAY tizanidine TOBI PODHALER TOBRADEX TOBRADEX ST tobramycin tobramycin in % nacl tobramycin in 0.9 % nacl tobramycin sulfate tobramycin-dexamethasone. 145 TOLAK tolazamide tolbutamide tolmetin tolnaftate tolterodine topiramate toposar torsemide total b/c totalday multiple TOUJEO SOLOSTAR TOVIAZ TPN ELECTROLYTES TPN ELECTROLYTES II TRACLEER TRADJENTA tramadol tramadol-acetaminophen trandolapril tranexamic acid TRANSDERM-SCOP tranylcypromine TRAVASOL 10 % TRAVATAN Z travel sickness (meclizine) travoprost (benzalkonium) trazodone TREANDA TRECATOR TRELSTAR... 38, 39 tretinoin tretinoin (chemotherapy) tretinoin microspheres TREXALL tri femynor triacting m-sym cold/cough. 127 triamcinolone acetonide , 135, 136 triaminic cold and cough (pe) triamterene-hydrochlorothiazid trianex tri-buffered aspirin tridesilon tri-estarylla trifluoperazine trifluridine trihexyphenidyl tri-legest fe tri-linyah tri-lo-estarylla tri-lo-marzia tri-lo-sprintec trilyte with flavor packets trimethoprim trimipramine trinessa (28) TRINTELLIX triple antibiotic , 132 triple paste af tri-previfem (28) tri-sprintec (28) TRIUMEQ tri-vi-sol tri-vita tri-vitamin trivora (28) TROKENDI XR TROPHAMINE 10 % TROPHAMINE 6% trospium trueplus glucose with vit d TRULICITY TRUMENBA TRUVADA tusnel diabetic TUSNEL NEW FORMULA 126 TUSSI PRES-B tussin cf , 127 tussin cf (pe-dm-guaif) tussin cold-congestion tussin cough (dm only) tussin dm I-22

261 tussin dm cough and chest tussin pe TWINRIX (PF) TYBOST TYGACIL TYKERB TYMLOS TYPHIM VI TYSABRI TYVASO TYZEKA U UCERIS u-cort ULORIC ultimate men's complete ultra b-100 complex ultra fresh pm unicomplex-m unisom (diphenhydramine) unisom (doxylamine) unisom sleepgels UNITUXIN UPTRAVI , 202 ursodiol , 155 V vagistat valacyclovir VALCHLOR valganciclovir valproate sodium valproic acid valproic acid (as sodium salt) 44 valsartan valsartan-hydrochlorothiazide 90 VALSTAR vancomycin vancomycin in dextrose 5 %.. 20 VAQTA (PF) VARIVAX (PF) VASCEPA v-c forte VELCADE velivet triphasic regimen (28) VELPHORO VELTASSA VEMLIDY VENCLEXTA VENCLEXTA STARTING PACK venlafaxine VENTOLIN HFA verapamil... 95, 96 VERSACLOZ VESICARE vestura (28) VGO VIBERZI vic-forte vicks dayquil cold-flu relief. 126 vicks dayquil cough vicks nature fusion cough vicks nyquil cold/flu liquicap vicks qlearquil nighttime rlf vicks qlearquil(oxymetazoline) vicks sinex 12-hour vicodin vicodin es vicodin hp VICTOZA 3-PAK VIDEX 2 GRAM PEDIATRIC VIEKIRA PAK VIEKIRA XR vienva VIGAMOX VIIBRYD VIMIZIM VIMPAT vinorelbine viorele (28) VIRACEPT VIRAZOLE VIREAD virtussin ac virtussin dac vision vision plus lutein vit b complex-folic acid 219, 222 vitalets vitamin a vitamin b complex , 217 vitamin b vitamin b-100 complex vitamin b12-folic acid vitamin b vitamin c , 222, 223 vitamin d , 219, 222 vitamin k vitamin k vitamins and minerals vitamins b complex , 221 vitamins for hair vitatrum VITEKTA vitrum senior vol-care rx VOLTAREN voriconazole VOTRIENT VPRIV vp-vite rx VRAYLAR vyfemla (28) W wal-act d cold and allergy wal-dram wal-dryl allergy wal-fex allergy wal-finate wal-finate-d wal-flu severe cold-cough wal-itin I-23

262 wal-itin d wal-itin d 12 hour wal-phed... 62, 127 wal-phed pe day-night wal-phed pe sinus and allergy 62 wal-profen wal-sleep z wal-som (diphenhydramine).. 62 wal-som (doxylamine) wal-tap wal-tussin cough wal-tussin dm wal-tussin max strength cough wal-zan wal-zyr (cetirizine) wal-zyr d warfarin water for irrigation, sterile WELCHOL wera (28) womens daily gummies women's daily multivitamin. 216 women's multivitamin gummies X XADAGO XALKORI XARELTO XATMEP XELJANZ XELJANZ XR XERMELO XIFAXAN XOLAIR XTAMPZA ER XTANDI xulane xylon XYREM Y yelets YERVOY YF-VAX (PF) YONDELIS yuvafem Z zafirlukast zaleplon zantac zarah ZARXIO ZAVESCA zebutal ZEJULA ZELBORAF ZEMPLAR zenatane zenchent (28) ZENPEP ZEPATIER zephrex-d ZERIT ZIAGEN zidovudine ZINBRYTA zinc oxide ZIOPTAN (PF) ziprasidone hcl ZIRGAN ZOLADEX zoledronic acid zoledronic acid-mannitol-water zoledronic ac-mannitol-0.9nacl ZOLINZA zolmitriptan zolpidem ZOMACTON ZOMETA zonisamide zoo chews ZORBTIVE ZORTRESS ZOSTAVAX (PF) zovia 1/35e (28) zovia 1/50e (28) z-sleep... 60, 61 ZUBSOLV ZURAMPIC ZYDELIG ZYKADIA ZYLET zyncof ZYPREXA RELPREVV ZYRTEC ZYTIGA I-24

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