（）（區）縣衛生計生、人力資源社會保障局（蓋章）
　　序號（同省補充藥一通用名品備選目西藥/中只標記一錄表中序成藥個序號）號12345678910111213141516171819202122232425261417202326293032814148505254626466677273757678808182省基本醫療保險目錄內編號
　　通用名稱（中文/英文） 輔酶Q10膠囊 格列喹酮片 格列齊特緩釋片 洛伐他汀片 尼美舒利分散片 寧心寶膠囊 強力天麻杜仲膠囊曲安奈德益康唑乳膏麝香壯骨膏萬通筋骨片鹽酸川芎嗪注射液 腰痛寧膠囊 乙酰螺旋霉素片鎮腦寧膠囊 壯骨關節丸 阿魏酸哌嗪片 安神補腦液 補脾益腸丸肛泰栓桂附地黃丸健腦 補腎 丸金羚感冒片腦靈素片人參 歸脾丸 麝香壯骨膏伸筋片
　　膠囊劑素片緩釋片素片分散片膠囊劑膠囊劑乳膏劑橡膠膏劑薄膜衣片注射液膠囊劑糖衣片膠囊劑水丸素片合劑（含口服液）水蜜丸栓劑濃縮丸水丸薄膜衣片薄膜衣片大蜜丸橡膠膏劑糖衣片
　　10mg30mg30mg20mg0.1g0.25g0.4g15g:硝酸益康唑8cm*6cm0.28g2ml:40mg0.3g0.2g0.3g60g50mg10ml130g1g每8丸相當于原生30丸(每15丸重0.6g0.31g9g8cm*6cm0.25g
　　272829303132333435363738394041424344454647484950515253545556575859
　　128142143149161163177186194216241300315316317329330342352433434437478507509522600603622629658660684
　　安神補腦液奧硝唑片奧硝唑注射液奧扎格雷鈉注射液鼻淵通竅顆粒 吡諾克辛滴眼液
　　合劑（含口服液）素片注射液注射液顆粒劑滴眼劑
　　10ml0.25g5ml:0.25g4ml:80mg15g5ml:0.25mg20ml10ml
　　刺五加注射液丹紅注射液多索茶堿葡萄糖注射液 肺力咳合劑 復方 鮮竹瀝 液感冒靈顆粒格列齊特緩釋片葛根湯顆粒骨肽注射液冠脈寧片桂附地黃丸哈西奈德溶液 抗骨增生膠囊 抗骨質增生丸 枯草桿菌二聯活菌顆粒龍血竭膠囊注射用炎琥寧 蜜煉川貝枇杷膏 尼美舒利顆粒 伸筋丹膠囊 濕潤燒傷膏天麻素注射液 酮康唑乳膏 妥布霉素滴眼液維生素E膠丸小兒咳喘靈顆粒
　　100ml:多索茶堿合劑（含口150ml服液）合劑（含口100ml服液）顆粒劑10g緩釋片顆粒劑注射液糖衣片濃縮丸溶液劑膠囊劑小蜜丸顆粒劑膠囊劑凍干粉針煎膏劑顆粒劑膠囊劑軟膏劑注射液乳膏劑滴眼劑軟膠囊劑（膠丸）顆粒劑30mg6g2ml:10mg-每8丸相當于原生10ml:10mg0.35g3g1g0.3g80mg345g1g:50mg0.15g40g5ml:0.5g15g:0.3g8ml:24mg0.1g2g
　　606162636465666768697071727374757677787980818283848586878889909192
　　693882910912999106013071367137113721400144814591493
　　 新復方大青葉片 注射用阿莫西林鈉/舒巴坦鈉注射用氨曲南注射用奧硝唑注射用賴氨匹林注射用哌拉西林鈉/舒巴坦鈉感冒清膠囊氯霉素滴眼液礞石滾痰丸尼莫地平膠囊去痛片土霉素片皮炎平霜鹽酸多西環素片安乃近
　　薄膜衣片粉針劑粉針劑凍干粉針劑溶媒結晶粉針劑溶媒結晶粉針劑膠囊劑滴眼劑水丸膠囊劑素片糖衣片霜劑素片
　　-0.75g（0.5g/01.0g0.25g0.5g1.25g0.5g5ml:12.5mg6g30mg復方0.25g20g0.1g（10萬單位）2ml:0.25g-1ml:10mg60m
　　g0.1g復方90mg+4mg0.8g15g10ml11g50mg62.5g75mg葡萄糖酸鋅0.1g、10ml80mg10mg
　　166918672054216723322696279929142926303030473180326056325970636066606839
　　二羥丙茶堿注射液 金膽片 馬來酸氯苯那敏注射液曲克蘆丁片血塞通片氨咖黃敏膠囊復方鹽酸偽麻黃堿緩釋膠囊 健胃消食片 荊防顆粒清熱解毒口服液桑菊感冒顆粒維生素C片壯腰健腎丸厄貝沙坦片復方鋅布顆粒痰熱清注射液注射用炎琥寧 雷貝拉唑鈉腸溶片
　　注射液糖衣片注射液糖衣片糖衣片膠囊劑緩釋膠囊薄膜衣片顆粒劑合劑（含口服液）顆粒劑素片水蜜丸素片顆粒劑注射液凍干粉針劑腸溶片
　　消咳喘膠囊小兒肺咳顆粒注射用頭孢哌酮鈉/舒巴坦鈉
　　備注：1、醫保類別請填寫甲類、乙類；2、低價 藥品 請注明國家或山東省；3、本表可加頁，報送時需每頁加蓋公中采購網公告交流欄處下載。
　　縣級公立醫在備選目院綜合改革低價藥品醫保目錄分省掛網價錄表中試點醫院常（是/否）類（甲類/格（元）（是/ 用藥 品（是及類別乙類）否）/否）國家國家國家國家國家國家國家國家山東省國家國家國家國家國家國家山東省山東省山東省山東省山東省山東省山東省山東省山東省山東省山東省乙類乙類乙類乙類乙類乙類乙類乙類乙類乙類乙類乙類乙類乙類乙類乙類乙類乙類乙類乙類乙類乙類乙類乙類乙類乙類7.981949.466.1618.3911.1817.897.52.9416.20.13193.916.658.998.2917.515.722.884.325.2910.8816.895.92.9419.16
　　11.781118.318.8821.111.71
　　乙類乙類乙類乙類乙類乙類乙類乙類乙類乙類乙類乙類乙類乙類乙類乙類乙類乙類乙類乙類乙類乙類乙類乙類乙類乙類
　　740.6819.7228.25.524.68.93284.8716.94.31.8329.916.2620.3718.282.5522.429.54.9621.427.7714.963.451.882.5
　　乙類乙類乙類乙類乙類乙類國家國家國家國家國家國家國家國家甲類甲類甲類甲類甲類甲類甲類甲類
　　1.785.111.9819.263.9122.382.654.226.8114.433.3831.77.86.54
　　國家國家國家國家國家山東省山東省山東省山東省山東省山東省山東省山東省
　　乙類乙類乙類乙類乙類乙類乙類乙類乙類乙類乙類乙類乙類乙類乙類乙類乙類乙類
　　0.286.792.62.4628.080.68.183.37.294.80.955.1426.529.6292.5527.2
　　加頁，報送時需每頁加蓋公章。4、《補充藥品備選目錄表》在省藥品集