Formulary Reference FiIe Calendar Year 2016
`
`RXCUI
`I
`I
`
`ReIated SCDC
`205872 GLYBURIDE 1.25 MG
`861743 GLYBUREDE 125 MG/ METFORMIN HYDROCHLORIDE 250 MG
`314000 GLYBURIDE 1.5 MG
`881407 GLYBURIDE 1.5 MG
`310534 GLYBURIDE 2.5 MG
`205875 GLYBURIDE 2.5 MG
`861748 GLYBURIDE 2.5 MG/ METFORMIN HYDROCHLORIDE 500 MG
`861752 GLYBURIDE 2.5 MG / METFORMIN HYDROCHLORIDE 500 MG
`310536 GLYBURIDE 3 MG
`881409 GLYBURIDE 3 MG
`310537 GLYBURIDE 5 MG
`205879 GLYBURIDE 5 MG
`861753 GLVBURIDE 5 MG / METFORMIN HYDROCHLORIDE 500 MG
`861757 GLYBURIDE 5 MG / METFORMIN HYDROCHLORIDE 500 MG
`310539 GLYBURIDE 6 MG
`881411 GLYBURIDE 6 MG
`1368459 GLYCEROL PHENVLBUTYRATE 1100 MG/ML
`1721308 GLYCOPYRROLATE 0.0156 MG
`1720953 GLYCOPYRROLATE 0.0156 MG / INDACATEROI. 0.0275 MG
`238212IGLYCOPYRROLATE 0.2 MG/ML
`999965IGLYCOPYRROLATE 0.2 MG/ML
`1731591IGLVCOPYRROLATE 0.2 MG/ML
`I
`197738IGLYCOPYRROLATE 1 MG
`I
`205886 GLYCOPYRROLATE 1 MG
`
`197739 GLYCOPYRROLATE 2 MG
`
`102166 GLYCOPYRROLATE 2 MG
`
` 1653144 GOLIMUMAB 100 MG/ML
`1653166 GOLIMUMAB 100 MG/ML
`
`1482814 GOLIMUMAB 100 MG/ML
`
`848164 GOLIMUMAB 100 MG/ML
`1431647 GOLIMUMAB 12.5 MG/ML
`
`
`
`T
`
`*
`
`4
`
`Related DF
`ORAL TABLET
`ORAL TABLET
`ORAL TABLET
`ORAL TABLET
`ORAL TABLET
`ORAL TABLET
`ORAL TABLET
`ORAL TABLET
`ORAL TABLET
`ORAL TABLET
`ORAL TABLET
`ORAL TABLET
`ORAL TABLET
`‘ORAL TABLET
`ORAL TABLET
`ORAL TABLET
`ORAL SOLUTION
`INHALANT POWDER
`INHALANT POWDER
`INJECTABLE SOLUTION
`ORAL SOLUTION
`INJECTION
`ORAL TABLET
`
`ORAL TABLET
`ORAL TABLET
`AUTO-INJECTOR
`AUTO-IN) ECTOR
`PREFILLED SYRINGE
`PREFILLED SYRINGE
`INJECTABLE SOLUTION
`
`ORAL TABLET
`
`310594 GRAMICIDIN 0.025 MG/ML/ NEOMYCIN 1.75 MG/ML/ POLYMYXIN B 10000 UNT/ML
`
`OPHTHALMIC SOLUTION
`
`750191 GRAMICIDIN 0.025 MG/ML / NEOMYCIN 1.75 MG/ML/ POLYMYXIN B 10000 UNT/ML OPHTHALMIC SOLUTION
`INJECTABLE SOLUTION
`543218 GRANISETRON 0.1 MG/ML
`TRANSDERMAL PATCH
`825005 GRANISETRON 0.129 MG/HR
`310599 GRANISETRON 1 MG
`ORAL TABLET
`240912 GRANISETRON 1 MG/ML
`INJECTABLE SOLUTION
`242831 GRISEOFULVIN 125 MG
`205904 GRISEOFULVIN 125 MG
`239238 GRISEOFULVIN 25 MG/ML
`239239 GRISEOFULVIN 250 MG
`205906 GRISEOFULVIN 250 MG
`
`310600 GRISEOFULVIN 500 MG
`
`862006 GUANFACINE 1 MG
`
`197745 GUANFACINE 1 MG
`
`862010 GUANFACINE 1 MG
`
`206412 GUANFACINE 1 MG
`
`862013 GUANFACINE 2 MG
`
`197746 GUANFACINE 2 MG
`
`862015 GUANFACINE 2 MG
`
`206413 GUANFACINE 2 MG
`862019 GUANFACINE 3 MG
`862021 GUANFACINE 3 MG
`862025 GUANFACINE 4 MG
`862027 GUANFACINE 4 MG
`1298099 GUANIDINE HYDROCHLORIDE 125 MG
`HAEMOPHILUS INFLUENZAE B (ROSS STRAIN) CAPSULAR POLYSACCHARIDE
`7984S1LMENINGOCOCCAL PROTEIN CONJUGATE VACCINE 0.265 MG/ML
`HAEMOPHILUS INELUENZAE B (ROSS STRAIN) CAPSULAR POLYSACCHARIDE
`MENINGOCOCCAL PROTEIN CONJUGATE VACCINE 0.265 MG/ML / HEPATITIS B
`798443 SURFACE ANTIGEN VACCINE 0.01 MG/ML
`
`INJECTABLE SUSPENSION
`T.
`
`INJECTABLE SUSPENSION
`
`ORAL TABLET
`|ORAI. TABLET
`
`ORAL SUSPENSION
`
`ORAL TABLET
`
`ORAL TABLET
`
`ORAL TABLET
`
`EXTENDED RELEASE ORAL TABLET
`
`ORAL TABLET
`
`
`EXTENDED RELEASE ORAL TABLET
`
`ORAL TABLET
`EXTENDED RELEASE ORAL TABLET
`ORAL TABLET
`EXTENDED RELEASE ORAL TABLET
`ORAL TABLET
`EXTENDED RELEASE ORAL TABLET
`EXTENDED RELEASE ORAL TABLET
`EXTENDED RELEASE ORAL TABLET
`EXTENDED RELEASE ORAL TABLET
`ORAL TABLET
`
`HAEMOPHILUS INFLUENZAE TYPE 8 STRAIN 1482, CAPSULAR POLYSACCHARIDE
`130046_8IINACTIVATED TETANUS TOXOID CON)UGATE VACCINE 0.068 MG/ML
`2065484}-IALCINONIDE 0.001 MG/MG
`206546 HALCINONIDE 1 MG/ML
`
`L
`
`977978 HALOBETASOL PROPIONATE 0.0005 MG/MG
`977980 HALOBETASOL PROPIONATE 0.0005 MG/MG
`977990 HALOBETASOL PROPIONATE 0.5 MG/ML
`977992JHALOBETASOI. PROPIONATE 0.5 MG/ML
`310670 HALOPERIDOI. 0.5 MG
`310671 HALOPERIDOL 1 MG
`314035 HALOPERIDOL 10 M6
`
`JNJECTABLE SOLUTION
`TOPICAL OINTMENT
`
`[TOPICAL CREAM
`TOPICAL oxmmsm
`TOPICAL OINTMENT
`TOPICAL CREAM
`TOPICAL CREAM
`ORAL TABLET
`
`1.2.‘ ORAL TABLET
`
`ORAL TABLET
`
`NPS Ex. 2162
`
`Part 3
`
`.
`
`CFAD V. NPS
`
`IPR2015-00990
`
`Page 91
`
`
`Source https //www cms gov/Medicare/Presc!>p(s0n—Drug—Coverage/PrescrnptionDrugCovContra/RxContractmgjormuIaryGu:dance htmi
`
`90
`
`Page 91
`
`NPS Ex. 2162
`Part 3
`CFAD v. NPS
`IPR2015-00990
`
`

`

`FormuIary Reference Fiie Caiendar Year 2016
`
`IRXCUI
`I
`I
`I
`
`TFY
`
`314034 SCD
`141935 SCD
`197754 SCD
`310672 SCD
`204416 SCD
`201641 SBD
`859871 SCD
`859873 SBD
`859867 SCD
`859869 SBD
`1361048 SCD
`1361226 SCD
`1362831 SCD
`1361574 SCD
`1361607 SCD
`1361613 SCD
`1361615 SCD
`798367 SBD
`798482 SBD
`
`803367 SBD
`836634 SBD
`836636 SBD
`830214 SBD
`830245 SBD
`830253 SBD
`798424 SBD
`798428 SBD
`798430 SBD
`830263 SBD
`
`1301891 SBD
`
`798300 SBD
`905199 SCD
`
`,
`
`905222iSCD
`966571 SCD
`905225 SCD
`905379 SBD
`905395 SCD
`199903 SCD
`429503 SCD
`211759 SBD
`310792 SCD
`823934 SBD
`310793 SCD
`823938 SBD
`197885 SCD
`823985 SBD
`
`197885 SCD
`
`823982 SBD
`979464¢SCD
`979466§BD
`979468 SCD
`979470 SBD
`
`866455 SBD
`
`866464 SBD
`
`866475 580
`1299859 SCD
`1299871 SCD
`847060 SBD
`8470551580
`310796 SCD
`8O9854ISBD
`310797 SCD
`809858 SBD
`Z83316TESCD
`
`r
`
`II}xNorm Description
`‘HALOPERIDOL 2 MG ORAL TABLET
`HALOPERIDOL 2 MG/ML ORAL SOLUTION
`HALOPERIDOL 20 MG ORAL TABLET
`HALOPERIDOL 5 MG ORAL TABLET
`HALOPERIDOL S MG/ML INJECTABLE SOLUTION
`HALOPERIDOL 5 MG/ML IN)ECTABLE SOLUTION [HALDOLI
`HALOPERIDOL DECANOATE 100 MG/ML INIECTABLE SOLUTION
`HALOPERIDOL DECANOATE 100 MG/ML INJECTABLE SOLUTION [HALDOL]
`HALOPERIDOL DECANOATE S0 MG/ML INJECTABLE SOLUTION
`HALOPERIDOL DECANOATE 50 MG/ML INJECTABLE SOLUTION [HALDOLI
`HEPARIN SODIUM, PORCINE 100 UNT/ML INJECTABLE SOLUTION
`HEPARIN SODIUM, PORCINE 1000 UNT/ML INIECTABLE SOLUTION
`TTITEPARIN SODIUM, PORCINE 10000 UNT/ML INJECTABLE SOLUTION
`HEPARIN SODIUM, PORCINE 20000 UNT/ML INJECTABLE SOLUTION
`HEPARIN SODIUM, PORCINE 40 UNT/ML IN.IECTABLE SOLUTION
`I-IEPARIN SODIUM, PORCINE 50 UNT/ML INJECTABLE SOLUTION
`HEPARIN SODIUM, PORCINE 5000 UNT/ML INJECTABLE SOLUTION
`HEPATITIS A VACCINE (INACTIVATED) STRAIN HM175 1440 UNT/ML INJECTABLE SUSPENSION [HAVRIXI
`0.5 ML HEPATITIS A VACCINE (INACTIVATED) STRAIN HM175 1440 UNT/ML PREFILLED SYRINGE [HAVRIX]
`HEPATITIS A VACCINE (INACTIVATED) STRAIN HM175 720 UNT/ML/ HEPATITIS B SURFACE ANTIGEN VACCINE 0.02
`MG/ML INJECTABLE SUSPENSION [TWINRIX]
`1 ML HEPATITIS A VACCINE, INACTIVATED 50 UNT/ML PREFILLED SYRINGE [VAQTA]
`0.5 ML HEPATITIS A VACCINE, INACTIVATED 50 UNT/ML PREFILLED SYRINGE [VAQTA]
`HEPATITIS B SURFACE ANTIGEN VACCINE 0.01 MG/ML INJECTABLE SUSPENSION [RECOMBIVAX HB]
`1 ML HEPATITIS B SURFACE ANTIGEN VACCINE 0.01 MG/ML PREFILLED SYRINGE [RECOMBIVAX HB]
`0.5 ML HEPATITIS B SURFACE ANTIGEN VACCINE 0.01 MG/ML PREFILLED SYRINGE [RECOMBIVAX HB]
`HEPATITIS 8 SURFACE ANTIGEN VACCINE 0.02 MG/ML INJECTABLE SUSPENSION [ENGERIX-B]
`1 ML HEPATITIS B SURFACE ANTIGEN VACCINE 0.02 MG/ML PREFILLED SYRINGE [ENGERIX-B]
`0.5 ML HEPATITIS B SURFACE ANTIGEN VACCINE 0.02 MG/ML PREFILLED SYRINGE [ENGERIX-B]
`HEPATITIS B SURFACE ANTIGEN VACCINE 0.04 MG/ML INJECTABLE SUSPENSION [RECOMBIVAX H8]
`0.5 ML HUMAN PAPILLOMAVIRUS TYPE 16, L1 CAPSID PROTEIN (RESIDUES 2-471) VACCINE 0.04 MG/ML/ HUMAN
`PAPILLOMAVIRUS TYPE 18, L1 CAPSID PROTEIN (RESIDUES 2-472) VACCINE 0.04 MG/ML PREFILLED SYRINGE
`[CERVARIX]
`
`Related BN
`
`IHALDOL
`I
`II-IALDOL
`
`HALDOL
`
`HAVRIX
`HAVRIX
`
`T\NINRlX
`VAQTA
`VAQTA
`RECOMBIVAX HB
`RECOMBIVAX HB
`RECOMBIVAX HB
`ENGERIX~B
`ENGERIX~B
`ENGERIX—B
`RECOMBIVAX HB
`
`CERVARIX
`
`HUMAN-BOVINE REASSORTANT ROTAVIRUS STRAIN G1 VACCINE 1100000 UNT/ML/ HUMAN»BOVINE REASSORTANT
`ROTAVIRUS STRAIN G2 VACCINE 1400000 UNT/ML / HUMAN<BOVINE REASSORTANT ROTAVIRUS STRAIN G3 VACCINE
`1100000 UNT/ML/ HUMAN~BOVINE REASSORTANT ROTAVIRUS STRAIN G4 VACCINE 1000000 UNT/ML/ HUMAN»
`BOVINE REASSORTANT ROTAVIRUS STRAIN P1A[8] VACCINE 1150000 UNT/ML ORAL SUSPENSION [ROTATEQI
`HYDRALAZINE HYDROCHLORIDE 10 MG ORAL TABLET
`
`‘PI-IYDRALAZINE HYDROCHI OPIDE 100 MG ORAL TABLET
`HYDRALAZINE HYDROCHLORIDE 20 MG/ML INJECTABLE SOLUTION
`HYDRALAZINE HYDROCHLORIDE 25 MG ORAL TABLET
`HYDRALAZINE HYDROCHLORIDE 375 MG / ISOSORBIDE DINITRATE 20 MG ORAL TABLET [BIDIL]
`HYDRALAZINE HYDROCHLORIDE 50 MG ORAL TABLET
`HYDROCHLOROTH AZ DE 12.5 MG ORAL CAPSULE
`HYDROCHLOROTH AZ DE 12.5 MG ORAL TABLET
`HYDROCHLOROTHIAZIDE 12.5 MG ORAL CAPSULE [MICROZIDE]
`HYDROCHLOROTH AZ DE 12.5 MG / IRBESARTAN 150 MG ORAL TABLET
`HYDROCHLOROTH AZ DE 125 MG / IRBESARTAN 150 MG ORAL TABLET [AVALIDE]
`HYDROCHLOROTHIAZ DE 12.5 MG/ IRBESARTAN 300 MG ORAL TABLET
`HYDROCHLOROTH AZ DE 12.5 MG / IRBESARTAN 300 MG ORAL TABLET [AVALIDE]
`HYDROCHLOROTH AZIDE 12.5 MG / LISINOPRIL 10 MG ORAL TABLET
`HYDROCHLOROTH AZ DE 12.5 MG / LISINOPRIL 10 MG ORAL TABLET [ZESTORETIC]
`HYDROCHLOROTH AZ DE 125 MG / LISINOPRIL 20 MG ORAL TABLET
`
`HYDROCHLOROTH AZ DE 125 MG / LISINOPRIL 20 MG ORAL TABLET [ZESTORETIC]
`TEYDROCHLOROTH AZ DE 12.5 MG / LOSARTAN POTASSIUM 100 MG ORAL TABLET
`HYDROCHLOROTH AZ DE 125 MG / LOSARTAN POTASSIUM 100 MG ORAL TABLET [HYZAAR]
`HYDROCHLOROTH AZIDE 125 MG / LOSARTAN POTASSIUM 50 MG ORAL TABLET
`HYDROCHLOROTH AZ DE 125 MG / LOSARTAN POTASSIUM 50 MG ORAL TABLET [HYZAARI
`24 HR HYDROCHLOROTHIAZIDE 125 MG/ METOPROLOL SUCCINATE 100 MG EXTENDED RELEASE ORAL TABLET
`[DUTOPROL]
`24 HR HYDROCHLOROTHIAZIDE 125 MG/ METOPROLOL SUCCINATE 25 MG EXTENDED RELEASE ORAL TABLET
`[DUTOPROL]
`24 HR HYDROCHLOROTHIAZIDE 125 MG / METOPROLOL SUCCINATE 50 MG EXTENDED RELEASE ORAL TABLET
`[DUTOPROL]
`HYDROCHLOROTHIAZIDE 125 MG / MOEXIPRIL HYDROCHLORIDE 15 MG ORAL TABLET
`HYDROCHLOROTHIAZIDE 12.5 MG / MOEXIPRIL HYDROCHLORIDE 7.5 MG ORAL TABLET
`HYDROCHLOROTHIAZIDE 12.5 MG / OLMESARTAN MEDOXOMIL 20 MG ORAL TABLET {BENICAR HCT}
`HYDROCHLOROTHIAZIDE 12.5 MG / OLMESARTAN MEDOXOMIL 40 MG ORAL TABLET {BENICAR HCT}
`IHVDROCHLOROTHIAZIDE 12.5 MG / QUINAPRIL 10 MG ORAL TABLET
`HYDROCHLOROTHIAZIDE 125 MG / QUINAPRIL 10 MG ORAL TABLET EACCURETIC]
`HYDROCHLOROTHIAZIDE 125 MG / QUINAPRIL 20 MG ORAL TABLET
`’HYDROCHLOROTHIAZIDE 12.5 MG / QUINAPRIL 20 MG ORAL TABLET [ACCURETIC]
`LHYDROCHLOROTHIAZIDE 12.5 MG / TELMISARTAN 40 MG ORAL TABLET
`
`ROTATEQ
`
`4
`
`BIDIL
`
`MICROZIDE
`
`IAVALIDE
`
`AVALIDE
`
`ZESTORETIC
`
`TZESTORETIC
`
`ILL-IYZAAR
`L
`HYZAAR
`
`DUTOPROL
`
`DUTOPROL
`
`DUTOPROL
`
`BENICAR HC’
`BENICAR HG"
`
`ACCURETIC
`ACCURETIC
`
`J
`
`I
`
`1
`
`J
`
`J
`
`;
`I
`
`3
`
`I
`
`3
`
`Soume: https://www.cm5.gov/Medicare/PrescnptIon—Drug—Coverage/PrescrxptuonfirugCo\/Contra/RxContractmgjormuIaryGundan:e.hIml
`
`91
`
`Page 92
`
`
`Page 92
`
`

`

`f
`I
`
`f
`,
`
`.
`E
`
`I
`
`FormuIarV Reference Fife CaIerIdar Year 2016
`
`RXCUI
`
`Irzeiated SCDC
`314034 HALOPERIDOL2 MG
`
`F_
`
`L _
`
`__
`
`141935 HALOPERIDOL 2 MG/ML
`197754 HALOPERIDOL 20 MG
`310672 HALOPERIDOL 5 MG
`204416 HALOPERIDOL 5 MG/ML
`r— 201641 HALOPERIDOL 5 MG/ML
`859871 HALOPERIDOL DECANOATE 100 MG/ML
`859873 I-IALOPERIDOL DECANOATE 100 MG/ML
`859867 HALOPERIDOL DECANOATE 50 MG/ML
`859869 HALOPERIDOL DECANOATE 50 MG/ML
`1361048 HEPARIN SODIUM, PORCINE 100 UNT/ML
`1361226 HEPARIN SODIUM, PORCINE 1000 UNT/ML
`1362831 HEPARIN soomm, PORCINE 10000 UNT/ML
`1361574 HEPARIN SODIUM, PORCINE 20000 UNT/ML
`1361607 HEPARIN SODIUM, PORCINE 40 UNT/ML
`1361613 HEPARIN SODIUM, PORCINE 50 UNT/ML
`
`HEPARIN SODIUM, PORCINE 5000 UNT/ML
`798367 HEPATITIS A VACCINE (INACTIVATED) STRAIN HM175 1440 UNT/ML
`
`798482 HEPATITIS A VACCINE (INACTIVATED) STRAIN HM175 1440 UNT/ML
`
`
`- HEPATITIS A VACCINE (INACTIVATED) STRAIN HM175 720 UNT/ML/ HEPATITIS 8
`803367 SURFACE ANTIGEN VACCINE 0.02 MG/ML
`836634 HEPATITIS A VACCINE, INACTIVATED 50 UNT/ML
`836636 HEPATITI5 A VACCINE, INACTIVATED 50 UNT/ML
`
`830214 HEPATITIS B SURFACE ANTIGEN VACCINE 0.01 MG/ML
`
`830245 HEPATITIS 3 SURFACE ANTIGEN VACCINE 0.01 MG/ML
`830253 HEPATITIS B SURFACE ANTIGEN VACCINE 0.01 MG/ML
`798424 HEPATITIS B SURFACE ANTIGEN VACCINE 0.02 MG/ML
`798428 HEPATITIS B SURFACE ANTIGEN VACCINE 0.02 MG/ML
`798430 HEPATITIS 8 SURFACE ANTIGEN VACCINE 0.02 MG/ML
`830263 HEPATITIS B SURFACE ANTIGEN VACCINE 0.04 MG/ML
`
`HUMAN PAPILLOMAVIRUS TYPE 16, L1 CAPSID PROTEIN (RESIDUES 2-471) VACCINE
`
`0.04 MG/ML/ HUMAN PAPILLOMAVIRUS TYPE 18, L1 CAPSID PROTEIN (RESIDUES 2-
`1301891 472) VACCINE 0.04 MG/ML
`
`_
`
`'
`
`Related DF
`ORAL TABLET
`
`ORAL SOLUTION
`ORAL TABLET
`ORAL TABLET
`INJECTABLE SOLUTION
`INJECTABLE SOLUTION
`INJECTABLE SOLUTION
`INJECTABLE SOLUTION
`INJECTABLE SOLUTION
`INJECTABLE SOLUTION
`INJECTABLE SOLUTION
`IMECTABLE SOLUTION
`INJECTABLE SOLUTION
`INJECTABLE SOLUTION
`INIECTABLE SOLUTION
`INJECTABLE SOLUTION
`INJECTABLE SOLUTION
`INIECTABLE SUSPENSION
`PREFILLED SYRINGE
`
`INIECTABLE SUSPENSION
`PREFILLED SYRINGE
`PREFILLED SYRINGE
`INJECTABLE SUSPENSION
`IPREFILLED SYRINGE
`IPREEILLED SYRINGE
`INIECTABLE SUSPENSION
`
`PREFILLED SYRINGE
`
`HUMAN-BOVINE REASSORTANT ROTAVIRUS STRAIN G1 VACCINE 1100000 UNT/ML/
`HUMAN-BOVINE REASSORTANT ROTAVIRUS STRAIN G2 VACCINE 1400000 UNT/ML/
`HUMAN-BOVINE REASSORTANT ROTAVIRUS STRAIN G3 VACCINE 1100000 UNT/ML/
`HUMAN-BOVINE REASSORTANT ROTAVIRUS STRAIN G4 VACCINE 1000000 UNT/ML/
`798300 HUMAN-BOVINE REASSORTANT ROTAVIRUS STRAIN P1A[8] VACCINE 1150000 UNT/ML ORAL SUSPENSION
`
`"I
`
`905199 HYDRALAZINE HYDROCHLORIDE 10 MG
`905222 HYDIMLAZINE HYDROCHLORIDE 100 MG
`966571 HYDRALAZINE HYDROCHLORIDE 20 MG/ML
`905225 HYDRALAZINE HYDROCHLORIDE 25 MG
`905379 HYDRALAZINE HYDROCHLORIDE 375 MG / ISOSORBIDE DINITRATE 20 MG
`905395 HYDRALAZINE HYDROCHLORIDE 50 M6
`199903 HYDROCHLOROTHIAZIDE 12.5 MG
`429503 HYDROCHLOROTHIAZIDE 12.5 MG
`211759 HYDROCHLOROTHIAZIDE 12.5 MG
`310792 HYDROCHLOROTHIAZIDE 125 MG/ IRBESARTAN 150 MG
`823934 HYDROCHLOROTHIAZIDE 125 MG/ IRBESARTAN 150 MG
`310793 HYDROCHLOROTHIAZIDE 12.5 MG / IRBESARTAN 300 MG
`823938 HYDROCHLOROTHIAZIDE 125 MG/ IRBESARTAN 300 MG
`197885 HYDROCHLOROTHIAZIDE 12.5 MG/ LISINOPRIL 10 MG
`823986 HYDROCHLOROTHIAZIDE 12.5 MG/ LISINOPRIL 10 MG
`197886 HYDROCHLOROTHIAZIDE 12.5 MG / LISINOPRIL 20 MG
`823982 HYDROCHLOROTHIAZLDE 12.5 MG / LISINOPRIL 20 MG
`979464 HYDROCHLOROTHIAZIDE 12.5 MG/ LOSARTAN POTASSIUM 100 MG
`979466 HYDROCHLOROTHIAZIDE 12.5 MG / LOSARTAN POTASSIUM 100 MG
`979468 HYDROCHLOROTHIAZIDE 12.5 MG / LOSARTAN POTASSIUM 50 MG
`
`ORAL TABLET
`I
`IORALTABLET
`
`INJECTABLE SOLUTION
`
`
`ORAL TABLET
`
`ORAL TAB .ET
`
`
`ORAL CAPSULE
`
`
`ORAL TAB.ET
`
`
`ORAL CAPSULE
`
`ORAL TABLET
`
`
`ORAL TAB_ET
`
`
`ORAL TABLET
`
`
`ORAL TABJET
`
`
`ORAL TAB_ET
`
`
`ORAL TAB.ET
`
`ORAL TABLET
`ORAL TABLET
`ORAL TAB.ET
`ORAL TABLET
`ORAL TAB.ET
`
`979470 HYDROCHLOROTHIAZIDE 12.5 MG/ LOSARTAN POTASSIUM 50 MG
`866455 HYDROCHLOROTHIAZIDE 12.5 MG / METOPROLOL SUCCINATE 100 MG
`
`ORAL TABLET
`EXTENDED RELEASE ORAL TABLET
`
`866464 HYDROCHLOROTHIAZIDE 12.5 MG / METOPROLOL SUCCINATE 25 MG
`866475 HYDROCHLOROTHIAZIDE 12.5 MG / METOPROLOL SUCCINATE 50 MG
`1299859 HYDROCHLOROTHIAZIDE 12.5 MG / MOEXIPRIL HYDROCHLORIDE 15 MG
`1299871 I-IYDROCHLOROTHIAZIDE 12.5 MG / MOEXIPRIL HYDROCHLORIDE 7.5 MG
`847060 HYDROCHLOROTHIAZIDE 12.5 MG / OLMESARTAN MEDOXOMIL 20 MG
`847055 HYDROCHLOROTHIAZIDE 12.5 MG / OLMESARTAN MEDOXOMIL 40 MG
`310796 HYDROCHLOROTHIAZIDE 12.5 MG / QUINAPRIL 10 MG
`809854LHYDROCHLOROTHIAZIDE 12.5 MG/QUINAPRIL1O MG
`310797 HYDROCHLOROTHIAZIDE 12.5 MG / QUINAPRIL 20 MG
`
`EXTENDED RELEASE ORAL TABLET
`EXTENDED RELEASE ORAL TABLET
`ORAL TABLET
`ORAL TABLET
`ORAL TABLET
`ORAL TABLET
`ORAL TABLET
`ORAL TABLET
`ORAL TABLET
`
`_T
`
`_‘
`
`k
`L
`
`809858‘HYDROCHLOROTHIAZIDE 12.5 M6 /_QuINAPR;L 20 MG
`283316 HYDROCHLOROTHIAZIDE 125 MG / TELMISARTAN 40 MG
`
`‘ORAL TABLET
`ORAL TABLET
`
`M]
`
`Page 93
`
`
`Source: https://www.Cm5 gov/Medicare/PresCrIpLIOrI—DILIg—Coverage/PresCripL>orIDrugCoVCorItra/R><ComractingjormuIarVGuIdanCe.hLmI
`
`92
`
`Page 93
`
`

`

`TTY
`R><Norm Descriptiun
`
`749833 SBD
`HVDROCHLOROTHIAZ DE 12.5 MG / TELMISARTAN 40 MG ORAL TABLET [MICARDlS—HCT]
`
`283317 SCD
`HYDROCHLOROTH A2 DE 12.5 MG / TELMISARTAN 80 MG ORAL TABLET
`
`749837 SBD
`HYDROCHLOROTHIAZTDE 12.5 MG / TELMISARTAN 80 MG ORAL TABLET [M8CARDIS~HCI']
`
`200285 SCD
`HYDROCHLOROTH A2 DE 125 MG / VALSARTAN 160 MG ORAL TABLET
`
`809018 sBD
`HYDROCHLOROTH A2 DE 12.5 MG / VALSARTAN 160 MG ORAL TABLET [DIOVAN HCT}
`
`636042 SCD
`HYDROCHLOROTH A2 DE 125 MG / VALSARTAN 320 MG ORAL TABLET
`
`809026 SBD
`HYDROCHLOROTHIAZ DE 125 MG / VALSARTAN 320 MG ORAL TABLET [DIOVAN HCT}
`200284 SCD
`HYDROCHLOROTHIAZIDE 12.5 MG / VALSARTAN 80 MG ORAL TABLET
`809014 HYDROCHLOROTH AZIDE 125 MG / VALSARTAN 80 MG ORAL TABLET [DIOVAN HCT}
`197963 sco
`HYDROCHLOROTH A2 DE 15 MG / METHYLDOPA 250 MG ORAL TABLET
`310798 SCD
`HYDROCHLOROTH AZIDE 25 MG ORAL TABLET
`197887 SCD
`HYDROCHLOROTH AZIDE 25 MG / LISINOPRIL 20 MG ORAL TABLET
`823971 SBD
`HYDROCHLOROTHIAZIDE 25 M6 / LISINOPRIL 20 MG ORAL TABLET [2EsTORETTc1
`SCD
`HYDROCHLOROTH Az DE 25 MG / LOSARTAN POTASSIUM 100 MG ORAL TABLET
`SBD HYDROCHLOROTHLAZ DE 25 MG/ LOSARTAN POTASSIUM 100 MG ORAL TABLET [HYZAAR]
`197960 SCD
`HYDROCHLOROTHIAZIDE 25 MG / METHYLDOPA 250 MG ORAL TABLET
`866479
`HVDROCHLOROTHIAZIDE 25 MG / METOPROLOL TARTRATE 100 MG ORAL TABLET
`866482 500
`HYDROCHLOROTH A2;DE 25 MG / METOPROLOL TARTRATE 50 MG ORAL TABLET
`866502 SBD
`HYDROCHLOROTHIAZ DE 25 MG / METOPROLOL TARTRATE 50 MG ORAL TABLET {LOPRESSOR HCT)
`1299890 SCD
`HYDROCHLOROTHIAZ DE 25 MG / MOEXIPRIL HYDROCHLORIDE 15 MG ORAL TABLET
`347042 5BD
`HYDROCHLOROTH A2 DE 25 MG / OLMESARTAN MEDOXOMIL 40 MG ORAL TABLET [BENICAR HCF}
`856422 SCD
`HYDROCHLOROTH A2 DE 25 MG / PROPRANOLOL HYDROCHLORIDE 40 MG ORAL TABLET
`SCD
`HYDROCHLOROTHIAZ DE 25 MG / PROPRANOLOL HYDROCHLORIDE 80 MG ORAL TABLET
`310809 SCD
`HYDROCHLOROTHIAZ DE 25 MG / QUINAPRIL 20 MG ORAL TABLET
`882559 sBD
`HYDROCHLOROTHIAZIDE 25 MG/ QUINAPRIL 20 MG ORAL TABLET [ACCURETIC]
`198224 500
`HYDROCHLOROTHIAZIDE 25 MG / SPIRONOLACTONE 25 MG ORAL TABLET
`
`208112
`HYDROCHLOROTHIAZ DE 25 MG / SPIRONOLACTONE 25 MG ORAL TABLET [ALDACTAZIDE]
`
`HYDROCHLOROTHIAZ DE 25 MG / TELMISARTAN 80 MG ORAL TABLET
`HYDROCHLOROTHIAZIDE 25 MG /TELMISARTAN 80 MG ORAL TABLET {MlCARDlS~HCT}
`
`HYDROCHLOROTHIAZ DE 25 MG / TRTAMTERENE 37.5 MG ORAL CAPSULE
`198316
`__
`
`
`310812 SCD
`HYDROCHLOROTHIAZ DE 25 MG / TRIAMTERENE 375 MG ORAL TABLET
`__J
`
`
`DYAZIDE
`208124 SBD
`HYDROCHLOROTHLAZTDE 25 MG / TRIAMTERENE 37.5 MG ORAL CAPSULE [DYAZIDE]
`
` MAXZIDE
`
`
`93253 SBD
`HYDROCHLOROTHIAZIDE 25 MG / TRIAMTERENE 37.5 MG ORAL TABLET [MAXZIDE]
`
`
`198314
`HYDROCHLOROTHLAZIDE 25 MG / TRIAMTERENE 50 MG ORAL CAPSULE
`
`
`
`349353
`HYDROCHLOROTHIAZIDE 25 MG /VALSARTAN 160 MG ORAL TABLET
`
`
`
`DIOVAN HCT
`809022
`HYDROCHLOROTHIAZIDE 25 MG / VALSARTAN 160 MG ORAL TABLET [DIOVAN HCT}
`
`636045 SCD
`
`HYDROCHLOROTHIAZIDE 25 MG / VALSARTAN 320 MG ORAL TABLET
`809030 SBD
` HYDROCHLOROTHIAZIDE 25 MG / VALSARTAN 320 MG ORAL TABLET {DIOVAN HCT]
`197770 SCD
`HYDROCHLOROTHIAZIDE 50 MG ORAL TABLET
`866491 SCD
`
`HYDROCHLOROTHIAZIDE 50 MG/ METOPROLOL TARTRATE 100 MG ORAL TABLET
`
`L“ 208116 SBD
`OFHYDROCHLQROTI-TIAZIDE 50 MG _/ SPIRONOLACTONE 50 MG ORAL TABLET [ALDACTAZIDEI
`310818 SCD
`HYDROCHLOROTI-IIAZIDE 50 MG / TRIAMTERENE 75 MG ORAL TABLET
`
`93252 SBD
`HYDROCHLOROTHTAZIDE 50 MG / TRIAMTERENE 75 MG ORAL TABLET [MAXZIDE]
`
`_I
`7-‘
`
`Ifkeiated BN
`'MICARD¥S-HCT
`
`MICARDIS»HCT
`DIOVAN HCT
`
`DIOVAN HCT
`
`DIOVAN HCT
`
`ZESTORETIC
`
`HYZAAR
`
`LOPRESSOR HCT
`
`BENICAR HCT
`
`ACCURETIC
`
`ALDACTAZIDE
`
`MICARDIS~HCI'
`
`Formulary Reference Fxle Calendar Year 2016
`
`RXCUI
`
`
`
`DIOVAN HCI'
`
`JAI.DA(.‘I'AZ!0E
`MAXZIDE
`
`¥
`
`r
`
`1595766 SBD
`'24 HR HYDROCODONE 100 MG EXTENDED RELEASE ORAL TABLET [HYSINGLAI
`
`1595772 SBD
`24 HR HYDROCODONE 120 MG EXTENDED RELEASE ORAL TABLET [HYSINGLA]
`1595736 SBD
`24 HR HVDROCODONE 20 MG EXTENDED RELEASE ORAL TABLET IHYSINGLAI
`
`1595742 SBD
`24 HR HYDROCODONE 30 MG EXTENDED RELEASE ORAL TABLET [HYSINGLA]
`
`
`1595748 SBD
`24 HR HYDROCODONE 40 MG EXTENDED RELEASE ORAL TABLET [HYSINGLAI
`
`1595754 SBD
`24 HR HVDROCODONE 60 MG EXTENDED RELEASE OFML TABLET [HYSINGLA]
`1595760JSBD
`1442528 SBD
`859315 SCD
`859317 SBD
`859331 SBD
`1442532 SBD
`1442536 SBD
`1442540 SBD
`1442544 SBD
`858778 SCD
`858784 SBD
`1442548 SBD
`858798 SCD
`858838 SBD
`203105 SCD
`103401!-STCD
`310878 SCD
`802059 SBD
`197782 SCD
`208712 SBD
`106258 SCD
`206347 SBD
`543492 SBD
`204874 SCD
`
`24 HR HYDROCODONE 80 MG EXTENDED RELEASE ORAL TABLET [HYSINGLA]
`HYDROCODONE BITARTRATE 10 MG EXTENDED RELEASE ORAL CAPSULE [ZOHYDRO]
`HVDROCODONE BITARTRATE 10 MG / IBUPROFEN 200 MG ORAL TABLET
`HYDROCODONE BITARTRATE 10 MG/ IBUPROFEN 200 MG ORAL TABLET [IBUDONE]
`HYDROCODONE BITARTRATE 10 MG / IBUPROFEN 200 MG ORAL TABLET IREPREXATN]
`HYDROCODONE BITARTRATE 15 MG EXTENDED RELEASE ORAL CAPSULE [ZOHYDRO]
`HYDROCODONE BITARTRATE 20 MG EXTENDED RELEASE ORAL CAPSULE [ZOHYDROI
`HYDROCODONE BITARTRATE 30 MG EXTENDED RELEASE ORAL CAPSULE TZOHYDROI
`HYDROCODONE BITARTRATE 40 MG EXTENDED RELEASE ORAL CAPSULE [ZOHYDRO]
`HYDROCODONE BITARTRATE 5 MG/ IBUPROFEN 200 MG ORAL TABLET
`HYDROCODONE BITARTRATE 5 MG / IBUPROFEN 200 MG ORAL TABLET [REPREXAW]
`HYDROCODONE BITARTRATE 50 MG EXTENDED RELEASE ORAL CAPSULE [ZOHYDRO]
`HYDROCODONE BITARTRATE 7.5 MG / IBUPROFEN 200 MG ORAL TABLET
`LHYDROCODONE BITARTRATE 7.5 MG / IBUPROFEN 200 MG ORAL TABLET {VICOPROFENI
`HYDROCORTISONE 0.01 MG/MG TOPICAL OINTMENT
`HYDROCORTISONE 0.025 MG/MG TOPICAL OINTMENT
`HYDROCORTISONE 1.67 MG/ML ENEMA
`VHYDROCORTISONE 1.67 MG/ML ENEMA [COLOCORT]
`HYDROCORTISONE 10 MG ORAL TABLET
`HYDROCORTISONE 10 MG ORAL TABLET [CORTEFI
`HYDROCORTISONE 10 MG/ML TOPICAL CREAM
`HYDROCORTISONE 10 MG/ML TOPICAL CREAM [ALA~CORT]
`HYDROCORTISONE 10 MG/ML RECTAL CREAM [PROCTOPAK]
`HYDROCORTISONE 10 MG/ML/ NEOMYCIN 3.5 MG/ML / POLYMYXIN B 10000 UNT/ML OPHTHALMIC SUSPENSION
`
`FHYSINGLA
`ESINGM
`HYSINGLA
`1-HYSINGLA
`HYSINGLA
`HYSINGLA
`
`HYSINGLA
`ZOHYDRO
`
`IBUDONE
`REPREXAIN
`ZOHVDRO
`ZOHYDRO
`ZOHYDRO
`ZOHYDRO
`
`REPREXAIN
`ZOHYDRO
`
`I
`.V!COPROFEN
`
`4
`
`COLOCORT
`
`CORTEF
`
`ALA—CORT
`IPROCTOPAK
`
`I
`
`Source: https://www CmS.E§OV/Medical6/RTESCVEDLTOHADI ug~CO\/erage/Pre5Lr TptvOnDTugCOvCOntra/R><COOLraEt1ng “FormuIaryC—.u«dance.html
`
`93
`
`Page 94
`
`
`Page 94
`
`

`

`Formutary Reference Fiie Calendar Year 2016
`
` Related DF
`ORAL TABLET
`
`ORAL TABLET
`ORAL TABLET
`
`
`
`ORAL TABLET
`
`1
`
`
`
`
`RXCUL
`
`L 866482 HYDROCHLOROTHTAZ DE 25 MG/ METOPROLOL TARTRATE 50 MG
`
`Related SCDC
`749833LHVDROCHLOROTLHAZIDE 125 MG /TELMTSARTAN 40 MG
`283317 HYDROCHLOROTHTAZTDE 12.5 MG / TELMISARTAN 80 MG
`
`
`200285IHYDROCHLOROTHLAZLDE 12.5 MG / VALSARTAN 160 MG
`749837 HYDROCHLOROTHIAZ DE 12.5 MG / TELMISARTAN 80 MG
`809018 HYDROCHLOROTHTAZIDE 12.5 MG/VALSARTAN 160 MG
`636042 HYDROCHLOROTHLAZ DE 125 MG / VALSARTAN 320 MG
`
`
`
`809026lHYDROCHLOROTH!AZ DE 12.5 MG / VALSARTAN 320 MG
`|ORAL TABLET
`
`|oRAL TABLET
`200284[HYDROCHLOROTHlAZ DE 12.5 MG /VALSARTAN 80 MG
`ORAL TABLET
`
`BOQOMLHYDROCHLOROTHIAZ DE 12.5 MG / VALSARTAN 80 MG
`197963 HYDROCHLOROTHTAZIDE 15 MG/ METHYLDOPA 250 MG
`
`310798 HYDROCHLOROTHLAZ DE 25 MG
`197887 HYDROCHLOROTHTAZ DE 25 MG / LLSINOPRTL 20 MG
`823971 HYDROCHLOROTHLAZIDE 25 MG / USLNOPRLL 20 MG
`
`
`
`979471 HYDROCHLOROTRIAZ DE 25 MG / LOSARTAN POTASSIUM 100 MG
`
`979473 HYDROCHLOROTHIAZ DE 25 MG / LOSARTAN POTASSIUM 100 MG
`
`197960 HYDROCHLOROTHTAZ DE 25 MG / METHYLDOPA 250 MG
`ORAL TABLET
`
`866479 HYDROCHLOROTHIAZIDE 25 MG / METOPROLOL TARTRATE 100 MG
`
`[ORAL TABLET
`ORAL TABLET
`
`866502 HYDROCHLOROTH|AZlDE 25 MG / METOPROLOL TARTRATE 50 MG
`
`1299890 HYDROCHLOROTHIAZIDE 25 MG/ MOEXIPRIL HYDROCHLORIDE 15 MG
`
`847042 HYDROCHLOROTHIAZIDE 25 MG / OLMESARTAN MEDOXOMTL 40 MG
`
`856422 HYDROCHLOROTHIAZIDE 25 MG / PROPRANOLOL HYDROCHLORIDE 40 MG
`856429
`
` HYDROCHLOROTHIAZIDE 25 MG / PROPRANOLOL HYDROCHLORIDE 80 MG
`
`310809 HYDROCHLOROTHIAZIDE 25 MG/ QUINAPRIL 20 MG
`882559 HYDROCHLOROTHSAZTDE 25 MG / QUINAPRTL 20 MG
`198224 HYDROCHLOROTHIAZSDE 25 MG / SPLRONOLACTONE 25 MG
`208112 HYDROCHLOROTHTAZLDE 25 MG / SPTRONOLACTONE 25 MG
`477130 HYDROCHLOROTHIAZIDE 25 MG /TELMISARTAN 80 MG
`749841 HYDROCHLOROTHIAZIDE 25 MG /TELMISARTAN 80 MG
`198316 HYDROCHLOROTHTAZIDE 25 MG / TRIAMTERENE 375 MG
`310812 HYDROCHLOROTHIAZIDE 25 MG / TRIAMTERENE 37.5 MG
`208124 HYDROCHLOROTHLAZIDE 25 MG / TRIAMTERENE 375 MG
`93253 HYDROCHLOROTHIAZIDE 25 MG /TRIAMTERENE 37.5 MG
`
`198314 HYDROCHLOROTHIAZIDE 25 MG / TRIAMTERENE 50 MG
`
`349353 HYDROCHLOROTHIAZIDE 25 MG / VALSARTAN 160 MG
`
`809022 HYDROCHLOROTHTAZIDE 25 MG / VALSARTAN 160 MG
`
`636045 HYDROCHLOROTHIAZIDE 25 MG /VALSARTAN 320 MG
`
`809030 HYDROCHLOROTHIAZIDE 25 MG / \/ALSARTAN 320 MG
`
`197770 HYDROCHLOROTHLAZIDE 50 MG
`
`
`866491 HYDROCHLOROTHIAZIDE 50 MG / METOPROLOL TARTRATE 100 MG
`P
`208116 HYDROCHLOROIHEAZIDE 50 MG /' SPLRONOLACTDNE 50 MG
`310818 HYDROCHLOROTHTAZIDE 50 MG /TRIAMTERENE 75 MG
`93252 HYDROCHLOROTHTAZTDE 50 MG /TRLAMTERENE 75 MG
`1595766 HYDROCODONE 100 MG
`1595772 HYDROCODONE 120 MG
`1595736 HYDROCODONE 20 MG
`1595742 HYDROCODONE 30 MG
`1595748 HYDROCODONE 40 MG
`1595754 HYDROCODONE 60 MG
`1595760 HYDROCODONE 80 MG
`1442528 HYDROCODONE BITARTRATE 10 MG
`859315 HYDROCODONE BITARTRATE 10 MG / IBUPROFEN 200 MG
`859317 HYDROCODONE BTTARTRATE 10 MG / IBUPROFEN 200 MG
`859331 HYDROCODONE BITARTRATE 10 MG / IBUPROFEN 200 MG
`1442532 HYDROCODONE BTTARTRATE 15 MG
`1442536 H‘/DROCODONE BTTARTRATE 20 MG
`1442540 HYDROCODONE BITARTRATE 30 MG
`1442544 HYDROCODONE BITARTRATE 40 MG
`858778 HYDROCODONE BITARTRATE 5 MG / IBUPROFEN 200 MG
`858784 HVDROCODONE BITARTRATE 5 MG / (BUPROFEN 200 MG
`1442548 HYDROCODONE BITARTRATE 50 MG
`858798 HYDROCODONE BITARTRATE 7.5 MG/ TBUPROFEN 200 MG
`858838 HYDROCODONE BITARTRATE 7.5 MG/ FBUPROFEN 200 MG
`203105 HYDROCORTISONE 0.01 MG/MG
`103401 HYDROCORTISONE 0.025 MG/MG
`310878 HYDROCORTISONE 1.67 MG/ML
`802059 HYDROCORTISONE 1.67 MG/ML
`197782 HYDROCORTISONE 10 MG
`208712 HYDROCORTISONE 10 MG
`
`ORAL TABLET
`
`ORAL TABLET
`
`ORAL CAPSULE
`
`
`
`
`
`
`
`
`
`
`
`[ORAL TABLET
`[ORAL CAPSULE
`
`
`ORAL TABLET
`
`
`
`
`
`
`
`ORAL TABLET
`
`
`
`ORAL TABLET
`
`_LORAL TABLET
`
`EXTENDED RELEASE ORAL TABLET
`
`EXTENDED RELEASE ORAL TABLET
`
`EXTENDED RELEASE ORAL TABLET
`
`EXTENDED RELEASE ORAL TABLET
`
`EXTENDED RELEASE ORAL TABLET
`
`EXTENDED RELEASE ORAL TABLET
`
`EXTENDED RELEASE ORAL TABLET
`
`EXTENDED RELEASE ORAL CAPSULE
`
`ORAL TABLET
`ORAL TABLET
`
`ORAL TABLET
`
`
`
`
`
`
`
`
`
`
`EXTENDED RELEASE ORAL CAPSULE
`
`EXTENDED RELEASE ORAL CAPSULE
`
`EXTENDED RELEASE ORAL CAPSULE
`
`EXTENDED RELEASE ORAL CAPSULE
`ORAL TABLET
`ORAL TABLET
`EXTENDED RELEASE ORAL CAPSULE
`ORAL TABLET
`ORAL TABLET
`TOPICAL OINTMENT
`TOPICAL OTNTMENT
`ENEMA
`ENEMA
`ORAL TABLET
`ORAL TABLET
`
`106258 HYDROCORWSONE10 MG‘/‘ML
`206347 H‘/DROCORTISONE 10 MG/ML
`
`543492E1IYDROCORT|SONE 10 MG/ML
`204874 HYDROCORTISONE 10 MG/ML/ NEOMYCW 3.5 MG/ML/ POLYMYXIN B 10000 UNT/ML
`
`4
`TOPICAL CREAM
`$—
`TOPICAL CREAM
`LRECTAL CREAM
`OPHTHALMIC SUSPENSION
`
`
`
`3
`I
`
`Page 95
`
`
`Source. https://ww».~J Cms gov/Medrcare/Pre5CnpLxonvDrug—COverage/PrescfiptvonDrugCovConTra/RxCOntractingformufiaryGuxdanCe.hTm3
`
`94
`
`Page 95
`
`

`

`Formulary Reference FIIe CaIendar Year 2016
`
`RXCUI
`
`TTY
`
`RxNOrm Description
`
`204423 SCD
`
`HYDROCORTISONE 10 MG/I‘v’IL/ NEOMYCIN 3.5 I'V|6/ML/ POLYMYXIN B 10000 UNT/ML OTIC SOLUTION
`
`
`
`HYDROCORTISONE 10 MG/ML/ NEOMYCIN 3.5 MG/ML/ POLYMYXIN B 10000 UNT/ML OTIC SUSPENSION
`310687
`
`HYDROCORTISONE 125 MG/ML INJECTABLE SOLUTION {SOLU-CORTEFI
`208930
`
`
`197783 SCD
`IHYDROCORTISONE 20 MG ORAL TABLET
`208816
`IHYDROCORTISONE 20 MG ORAL TABLET [CORTEFI
`
`884077
`IHYDROCORTISONE 20 MG/ML TOPICAL LOTION [ALAASCALPI
`310891
`HYDROCORTISONE 25 MG/ML TOPICAL CREAM
`
`
`
`
`197785 SCD
`260318 SBD
`1540356 SBD
`1440936ISBD
`197787 SCD
`208680 SBD
`
`
`
`208947 SBD
`105398 SBD
`
`
`
`HYDROCORTISONE 25 MG/ML TOPICAL LOTION
`HYDROCORTISONE 25 MG/ML RECTAL CREAM IANUSOL HCI
`HYDROCORTISONE 25 MG/ML TOPICAL CREAM [PROCI'OSOL]
`HYDROCORTISONE 25 MG/ML TOPICAL CREAM IPROCTOZONE HC}
`HYDROCORTISONE 5 MG ORAL TABLET
`HYDROCORTISONE 5 MG ORALTABLETICORTEE]
`
`HYDROCORTISONE so MG/ML INIECTABLE SOLUTION [A-HYDROCORT]
`HYDROCORTISONE 50 MG/ML INIECTABLE SOLUTION [SOLU-CORTEFI
`HYDROCORTISONE ACETATE 5 MG/ML / NEOMYCIN 3.5 M6/Mu POLYMYXIN B 10000 UNT/ML TOPICAL CREAM
`[CORTISPORINI
`HYDROCORTISONE BUTYRATE 0.001 MG/MG TOPICAL OINTMENT
`
`HYDROCORTISONE BUTYRATE 0.001 MG/MG TOPICAL OINTMENT [LOCOIDI
`HYDROCORTISONE BUTYRATE 1 MG/ML TOPICAL CREAM
`HYDROCORTISONE BUTYRATE 1 MG/ML TOPICAL SOLUTION
`HYDROCORTISONE BUTYRATE 1 MG/ML TOPICAL CREAM [LOCOID]
`HYDROCORTISONE BUTYRATE 1 MG/ML TOPICAL LOTION [LOCOIDI
`HYDROCORTISONE BUTYRATE 1 MG/ML TOPICAL SOLUTION [LOCOI0]
`HYDROCORTISONE PROBUTATE 1 MG/ML TOPICAL CREAM [PANDEL]
`HYDROCORTISONE VALERATE 0.002 MG/MG TOPICAL OINTMENT
`HYDROCORTISONE VALERATE 2 MG/ML TOPICAL CREAM
`HYDROMORPHONE HYDROCHLORIDE 1 MG/ML ORAL SOLUTION
`HYDROMORPHONE HYDROCHLORIDE 1 MG/ML ORAL SOLUTION [DILAUDID]
`HYDROMORPHONE HYDROCHLORIDE 10 MG/ML INJECTABLE SOLUTION
`24 HR HYDROMORPHONE HYDROCHLORIDE 12 MG EXTENDED RELEASE ORAL TABLET
`
`1542806 SBD
`1370758 SCD
`
`1370760IS8D
`1370770 SCD
`1370767 SCD
`1370772 SBD
`1370765 SBD
`1370768 SBD
`1370748 SBD
`1370750 SCD
`1370754 SCD
`897657 SCD
`897658 SBD
`897663
`902729 SCD
`
`897696
`897698 SBD
`897747 SBD
`1306898 SCD
`1306900 580
`897702 SCD
`897704 580
`897755 SBD
`
`902741 SCD
`
`897710 SCD
`
`I
`897712 SBD
`I
`902743 SBD
`979097550
`979094 SBD
`
`902733 24 HR HYDROMORPHONE HYDROCHLORIDE 12 MG EXTENDED RELEASE ORAL TABLET [EXALGO]
`SCD
`24 HR HYDROMORPHONE HYDROCHLORIDE 16 MG EXTENDED RELEASE ORAL TABLET
`24 HR HYDROMORPHONE HYDROCHLORIDE 16 MG EXTENDED RELEASE ORAL TABLET [EXALGOI
`HYDROMORPHONE HYDROCHLORIDE 2 MG ORAL TABLET
`HYDROMORPHONE HYDROCHLORIDE 2 MG ORAL TABLET {DILAUDID}
`HYDROMORPHONE HYDROCHLORIDE 2 MG/ML INIECTABLE SOLUTION [DILAUDID]
`24 HR HYDROMORPHONE HYDROCHLORIDE 32 MG EXTENDED RELEASE ORAL TABLET
`24 HR HYDROMORPHONE HYDROCHLORIDE 32 MG EXTENDED RELEASE ORAL TABLET IEXALOOI
`HYDROMORPHONE HYDROCHLORIDE 4 MG ORAL TABLET
`HYDROMORPHONE HYDROCHLORIDE 4 MG ORAL TABLET [DILAUDID]
`HYDROMORPHONE HYDROCHLORIDE 4 MG/ML INJECTABLE SOLUTION IDILAUDIDI
`24 HR HYDROMORPHONE HYDROCHLORIDE 8 MG EXTENDED RELEASE ORAL TABLET
`HYDROMORPHONE HYDROCHLORIDE 8 MG ORAL TABLET
`
`HYDROMORPHONE HYDROCHLORIDE 8 MG ORAL TABLET [DILAUDID]
`24 HR HYDROMORPHONE HYDROCHLORIDE 8 M6 EXTENDED RELEASE ORAL TABLET [EXALGO]
`HYDROXYCHLOROQUINE SULFATE 200 MG ORAL TABLET
`HYDROXYCHLOROOUINE SULFATE 200 MG ORAL TABLET [PLAQUENIL]
`
`HYDROXYPROPYLCELLULOSE 5 MG DRUG IMPLANT [LACRISERTI
`HYDROXYUREA 200 MG ORAL CAPSULE [DROXIA]
`HYDROXYUREA 300 MG ORAL CAPSULE IDROXIAI
`HYDROXYUREA 400 MG ORAL CAPSULE [DROXIA]
`HYDROXYUREA 500 MG ORAL CAPSULE
`HYDROXYUREA 500 MG ORAL CAPSULE [HYDREAI
`HYDROXYZ NE HYDROCHLORIDE 10 MG ORAL TABLET
`
`HYDROXYZ NE HYDROCHLORIDE 2 MG/MLORALSOLUTION
`
`HYDROXYZ NE HVDROCHLORIDE 25 MG ORAL TABLET
`HYDROXYZ NE HYDROCHLORIDE 25 MG/ML INIECTABLE SOLUTION
`HYDROXYZ NE HYDROCHLORIDE 50 MG ORAL TABLET
`HYDROXYZ NE HYDROCHLORIDE 50 MG/ML INJECTABLE SOLUTION
`HYDROXYZINE PAMDATE 100 MG ORAL CAPSULE
`HYDROXYZ NE PAMOATE 25 MG ORAL CAPSULE
`HYDROXYZINE PAMOATE 25 MG ORAL CAPSULE [VISTARILI
`HYDROXYZINE PAMOATE 50 MG ORAL CAPSULE
`HYDROXYzINE PAMOATE 50 MG ORAL CAPSULE IVISTARILI
`IBANDRON C ACID 1 M6/ML INJECTABLE SOLUTION
`
`754512 SBD
`213282 SBD
`213283 SBD
`213284 580
`197797 SCD
`105602 SBD
`995218 SCD
`
`995241!SCD
`
`995258 SCD
`995270 SCD
`995281 SCD
`995285 SCD
`995232 SCD
`995253 SCD
`995255 SBD
`995278 SCD
`995280 580
`904955 SCD
`
`I
`
`I’
`V
`
`_
`I
`I
`
`904954LSBD
`904932 SCD
`
`904934ISBD
`1442992 SBD
`197803 SCD
`197805ISCD
`1O69S89ISCD
`
`3 ML IBANDRONIC ACID 1 MG/ML PREFILLED SYRINOE IBONIVAI
`RTANDRON C ACID 150 MG ORAL TABLET
`
`IBANDRONIC ACID 150 MG ORAL TABLET IBONIVAI
`IBRUTINIB 40 MG ORAL CAPSULE IIMBRUVICAI
`£BUPROI=EN 20 M6/ML ORAL SUSPENSION
`IBUPROEEN 400 MG ORAL TABLET
`FBUPROFEN 400 Me / OXYCODONE HYDROCHLORIDE 5 MG ORAL TABLET
`
`Related BN
`
`SOLU-CORTEF
`rflt
`CORTEF
`ALA-SCALP
`
`I___
`ANUSOL HC
`PROCTOSOL
`EROCTOZONE HC
`ICORTEF
`
`A-HYDROCORT
`SOLU-CORTEF
`
`CORTISPORIN
`
`LOCOI0
`
`LOCOI0
`LOCOI0
`LOCOI0
`PANDEL
`
`DILAUDID
`
`EXALGO
`
`DILAUDID
`DILAUDID
`“T
`4.EXAU3CI
`
`DILAUDID
`DILAUDID
`
`DILAUDID
`EXALGO
`L
`PLAOUENIL
`
`AFLACRISERT
`DROXIA
`IDROXIA
`DROXIA
`
`THYDREA
`
`VISTARIL
`
`VISTARIL
`
`BONIVA
`
`IMBRUVICA
`
`IBONI‘/A
`’
`A
`
`__I
`
`:I
`
`J
`
`I
`
`I
`
`I
`*
`
`;
`
`.
`
`I
`
`’
`
`,
`¢
`
`Source: https://www.Cm5 gov/Medccare/PIOSCIiDtIOn—Drug—Coverage/PreSCrIpLiOnDrUgCOvCOrTTIa/RXCOITLIanHTg_FOImLIIary(3uIdanCe.htmI
`
`95
`
`Page 96
`
`
`Page 96
`
`

`

`RXCUI
`
`Related SCDC
`
`Related DF
`
`Formmary Reference File Calendar Year 2016
`
`20442
`
`OTIC SOLUTION
`
`_?L___
`
`OTIC SUSPENSION
`INJECTABLE SOLUTION
`ORAL TABLET
`ORAL TABLET
`TOPICAL LOTION
`
`TOPICAL LOTION
`RECTAL CREAM
`TOPICAL CREAM
`TOPICAL CREAM
`ORAL TABLET
`ORAL TABLET
`INJECIABLE SOLUTION
`INJECTABLE SOLUTION
`
`3LI-IYDROCORTISONE 10 MG/ML/ NEOMYCIN 3.5 MG/ML/ POLYMYXIN B 10000 UNT/ML
`310687 HYDROCORTISONE 10 MG/ML/ NEOMYCIN 3.5 MG/ML/ POLYMYXIN B 10000 UNT/ML
`208930 HYDROCORTISONE 125 MG/ML
`197783 HYDROCORTISONE 20 MG
`208816 HYDROCORTISONE 20 MG
`884077 HYDROCORTISONE 20 MG/ML
`31089 1 HYDROCORTISONE Z5 MG/ML
`197785 HYDROCORTISONE 25 MG/ML
`260318 HYDROCORTISONE 25 MG/ML
`1540356 HYDROCORTISONE 25 MG/ML
`1440936 HYDROCORTISONE 25 MG/ML
`197787 HYDROCORTISONE 5 MG
`208680 HYDROCORTISONE 5 MG
`208947 HYDROCORTISONE 50 MG/ML
`105398 HYDROCORTISONE 50 MG/ML
` HYDROCORTISONE ACETATE 5 MG/ML/ NEOMYCIN 3.5 MG/ML/ POLYMYXIN B 10000
`1542806 UNT/ML
`1370758 HYDROCORTISONE BUTYRATE 0.001 MG/MG
`1370760 HYDROCORTISONE BUTYRATE 0.001 MG/MG
`1370770 HYDROCORTISONE BUTYRATE 1 MG/ML
`1370767 HYDROCORTISONE BUTYRATE 1 MG/ML
`1370772 HYDROCORTISONE BUTYRATE 1 MG/ML
`TOPICAL CREAM
`I
`1370765 HYDROCORTISONE BUWIRATE 1 MG/ML
`TOPICAL LOTION
`I
`1370768 HYDROCORTISONE BUTYRATE 1 MG/ML
`ITOPICAL SOLUTION
`TOPICAL CREAM
`1370748 HYDROCORTISONE PROBUTATE 1 MG/ML
`TOPICAL OINTMENT
`1370750 HYDROCORTISONE VALERATE 0.002 MG/MG
`ORAL SOLUTION
`TOPICAL CREAM
`1370754 HYDROCORTISONE VALERATE 2 MG/ML
`897657 HYDROMORPHONE HYDROCHLORIDE 1 MG/ML
`897658 HYDROMORPHONE HYDROCHLORIDE 1 MG/ML ORAL SOLUTION
`INJECTABLE SOLUTION