FormuIary Reference FIIe Calendar Year 2016
`
`RXCUI
`
`I
`I
`
`TTY
`884185 SCD
`884187 SBD
`884189ISCD
`884191 SBD
`749196 SCD
`749198 SBD
`309362 SCD
`213169ISBD
`197464 SCD
`197465 SCD
`
`R><NOrm Description
`CLONTDINE HYDROCHLORIDE 0.2 MG ORAL TABLET
`CLONIDINE HYDROCHLORIDE 0.2 MG ORAL TABLET [CATAPRESI
`CLONIDINE HYDROCHLORIDE 0.3 MG ORAL TABLET
`CLONIDINE HYDROCHLORIDE 0.3 MG ORAL TABLET [CATAPRESI
`CLOPIDOGREL 300 MG ORAL TABLET
`CLOPIDOGREL 300 MG ORAL TABLET [PLAVIXI
`CLOPIDOGREL 75 MG ORAL TABLET
`CLOPIDOGREL 75 MG ORAL TABLET IPLAVIXI
`CLORAZEPATE DIPOTASSIUM 15 MG ORAL TABLET
`CLORAZEPATE DIPOTASSIUM 375 MG ORAL TABLET
`
`TrReIated BN
`
`CATAPRES
`
`CATAPRES
`
`PLAVIX
`
`PLAVIX
`
`_'
`
`—-I
`
`TRANXENE
`TRANXENE
`
`
`
`ICLORAZEPATE DIPOTASSIUM 3.75 MG ORAL TABLET ITRANXENEI
`542967 SBD
`CLORAZEPATE DIPOTASSIUM 7.5 MG ORAL TABLET
`197466 SCD
`
`CLORAZEPATE DIPOTASSIUL/17.5 MG ORAL TABLET [TRANXENE]
`1149627 SBD
`CLOTRIMAZOLE 10 MG ORAL LOZENGE
`309371 SCD
`
`CLOTRIMAZOLE 10 MG/ML TOPICAL CREAM
`309367 SCD
`
`309370 SCD
`CLOTRIMAZOLE 10 MG/ML TOPICAL SOLUTION
`
`476177 SCD
`CLOZAP NE 100 MG DISINTEGRATING ORAL TABLET
`197535 SCD
`CLOZAP NE 100 MG ORAL TABLET
`
`104776 SBD
`NE 100 MG ORAL TABLET [CLOZARIL]
`
`542977 SBD
`CLOZAP NE 100 MG DISINTEGRATING ORAL TABLET [FAZACLO]
`721773 SCD
`NE 12.5 MG DISINTEGRATING ORAL TABLET
`721775 SBD
`CLOZAP NE 125 MG DISINTEGRATING ORAL TABLET [FAZACLO]
`1006801 SCD
`ICLOZAPINE 150 MG DISINTEGRATING ORAL TABLET
`1006803 SBD
`CLOZAP NE 150 MG DISINTEGRATING ORAL TABLET IFAZACLOI
`996921 SCD
`CLOZAPINE 200 MG DISINTEGRATING ORAL TABLET
`309374 SCD
`CLOZAP NE 200 MG ORAL TABLET
`996923 SBD
`ICLOZAP NE 200 MG DISINTEGRATING ORAL TABLET IFAZACLO]
`476179 SCD
`ICLOZAPINE 25 MG DISINTEGRATING ORAL TABLET
`197536 SCD
`CLOZAP NE 25 MG ORAL TABLET
`CLOZARIL
`104775 SBD
`CLOZAP NE 25 MG ORAL TABLET ICLOZARILI
`FAZACLO
`
`543013 SBD
`CLOZAP NE 25 MG DISINTEGRATING ORAL TABLET [FAZACLOI
`
`
`429212 SCD
`CLOZAP NE 50 MG ORAL TABLET
`
`1369831 SBD
`CLOZAP NE 50 MG/ML ORAL SUSPENSION [VERSACLOZ]
`VERSACLOZ
`1551999 SBD
`COBICISTAT 150 MG ORAL TABLET ITYBOST]
`TYBOST
`PREZCOBIX
`1600710 SBD
`COBICISTAT 150 MG / DARUNAVIR 800 MG ORAL TABLET [PREZCOBIXI
`
`COBICISTAT 150 MG/ ELVITEGRAVIR 150 MG / EMTRICITABINE 200 MG /TENOFOVIR ALAFENAMIDE 10 MG ORAL
`GENVOYA
`__ 1721619ISBD
`TABLET GENVOYA]
`COBICISTAT 150 MG / ELVITEGRAVIR 150 MG / EMTRICITABINE 200 MG / TENOFOVIR DISOPROXIL FUMARATE 300
`1306298 SBD
`MG ORAL TABLET [STRIBILDI
`STRIBILD
`
`COTELLIC
`1722376 SBD
`COBIMETINIB 20 MG ORAL TABLET [COTELLIC]
`
`;
`997170I$CD
`CODEINE SULFATE 15 I\./IF. ORAL TABLET
`.
`L
`997287 SCD
`CODEINE SULFATE 30 MG ORAL TABLET
`
`:
`
`.
`E
`I
`
`
`
`CLOZARIL
`
`
`
`
`
`FAZACLO
`
`FAZACLO
`
`FAZACLO
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`L
`
`997296ISCD
`198153 SCD
`
`JCODEINE SULFATE 60 MG ORAL TABLET
`COLCHICINE 0.5 MG / PROBENECID 500 MG ORAL TABLET
`
`
`
`
`COLESTID
`
`
`
`ICOLESTID
`ICOLY MYCIN S
`CORTISPORIN-TC
`
`A
`
`SANTYL
`ACTHAR
`
`XALKORI
`XALKORI
`FULYZAQ
`
`1550940 SCD
`197541 SCD
`858071 SBD
`1550946 SBD
`866907 SBD
`
`866912 SBD
`1048445 SCD
`1048447 SBD
`1048450 SCD
`1048452 SBD
`854995 SBD
`854997 SBD
`1117522 SCD
`1149617 SBD
`1040025 SBD
`828248 SCD
`
`1148502 SBD
`1148506 SBD
`1364460 SBD
`
`831246jSCD
`831261 SCD
`
`831269LSBD
`831109 SCD
`20786-4.SBD
`207894ISBD
`828348 SCD
`828359 SBD
`
`8283S5ISBD
`8Z8320LSCD
`
`7
`
`I
`
`I
`I
`
`COLCRYS
`MITIGARE
`WELCHOL
`WELCHOL
`
`
`
`4
`
`TICOLCHICINE 0.6 MG ORAL CAPSULE
`COLCHICINE 0.6 MG ORAL TABLET
`ICOLCHICINE 0.6 MG ORAL TABLET [COLCRVSI
`COLCHICINE 0.6 MG ORAL CAPSULE IMITIGAREI
`COLESEVELAM HYDROCHLORIDE 31.3 MG/ML ORAL SUSPENSION [WELCHOLI
`TICOLESEVELAM HYDROCHLORIDE 625 MG ORAL TABLET [WELCHOL]
`COLESTIPOL HYDROCHLORIDE 1000 MG ORAL TABLET
`COLESTIPOL HYDROCHLORIDE 1000 MG ORAL TABLET ICOLESTIDI
`COLESTIPOL HYDROCHLORIDE 5000 MG ORAL GRANULES
`COLESTIPOL HYDROCHLORIDE 5000 MG ORAL GRANULES ICOLESTIDI
`COLISTIN 3 MG/ML/ HYDROCORTISONE 10 MG/ML / NEOIVIYCIN 3.3 MG/ML/THONZONIUM BROMIDE 0.5 MG/ML
`OTIC SUSPENSION ICOLY MYCIN S]
`COLISTIN 3 MG/ML/ HYDROCORTISONE 10 MG/ML/ NEOMYCIN 3.3 MG/ML/THONZONIUM BROMIDE 0.5 MG/ML
`OTIC SUSPENSION ICORTISPORIN-TC]
`EOLISTIN 75 MG/ML INJECTABLE SOLUTION
`COLLAGENASE 0.25 UNT/MG TOPICAL OINTMENT [SANTYLI
`ACORTICOTROPIN 80 UNT/ML INTECTABLE SOLUTION IACTHAR]
`CORTISONE ACETATE 25 MG ORAL TABLET
`
`LCRIZOTINIB 200 MG ORAL CAPSULE [XALKORI]
`CRIZOTINIB 250 MG ORAL CAPSULE [XALKORI]
`CROFELEMER 125 MG DELAYED RELEASE ORAL TABLET [FULYZAQ]
`
`CROMOLYN SODIUM 10 MG/ML INHALANT SOLUTION
`CROMOLYN SODIUM 20 MG/ML ORAL SOLUTION
`
`EROMOLYN SODIUM 20 MG/ML ORAL SOLUTION [GASTROCROM]
`CROMOLYN SODIUM 40 MG/ML OPHTHALMIC SOLUTION
`CROTAMITON 100 MG/ML TOPICAL CREAM [EURAX]
`CROTAIVIITON 100 MG/ML TOPICAL LOTION IEURAX}
`CYCLOBENZAPRINE HYDROCHLORIDE 10 MG ORAL TABLET
`24 HR CYCLOBENZAPRINE HYDROCHLORIDE 15 MG EXTENDED RELEASE ORAL CAPSULE IAMRIX]
`
`$4 HR CYCLOBENZAPRINE HYDROCHLORIDE 30 MG EXTENDED RELEASE ORAL CAPSULE IAMRIXI
`CYCLOBENZAPRINE HYDROCHLORIDE 5 MG ORAL TABLET
`
`T
`
`TGASTROCROM
`
`EURAX
`EURAX
`AMRIX
`
`AMRIX
`
`EX_ 2 1
`
`2
`
`V
`
`IPR2015—O1093 I
`
`Source: Imus://www cms gov/Medecare/PrescrsptaorvDrug—COverage/PrescrrpteonDrugCovContra/R><Contractmg_Formu an/Gurdance.htrnI
`
`45
`
`Page 46
`
`
`Page 46
`
`NPS Ex. 2162
`Part 2
`CFAD v. NPS
`IPR2015-01093
`
`

`
`Formuiary Reference File Calendar Year 2016
`
`RxCUI
`
`Related SCDC
`884185 CLONIDINE HYDROCHLORIDE 0.2 MG
`
`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 LOZENGE
`
`
`
`
`’
`|
`I
`|
`|
`I
`
`
`
`884189 CLONIDINE HYDROCHLORIDE 0.3 MG
`88418L_CLONIDlNE HYDROCHLORIDE 0.2 MG
`884191 CLONIDINE HYDROCHLORIDE 0.3 MG
`749196 CLOPIDOGREL 300 MG
`749198 CLOPIDOGREL 300 MG
`309362 CLOP|DOGREL 75 MG
`213169 CLOPIDOGREL 75 MG
`197464 CLORAZEPATE DIPOTA5sIUM 15 MG
`197465 CLORAZEPATE DIPOTASSIUM 375 MG
`542967 CLORAZEPATE DIPOTAssIUM 3.75 MG
`197466 CLORAZEPATE DIPOTAssIUM 7.5 MG
`
`CLORAZEPATE DIPOTASSIUM 7.5 MG
`
`309371 CLOTRIMAZOLE 10 MG
`309367 CLOTRIMAZOLE 10 MG/ML
`309370 CLOTRIMAZOLE 10 MG/ML
`476177 CLOZAPINE 100 MG
`197535 CLOZAPINE 100 MG
`104776 CLOZAPINE 100 MG
`542977 CLOZAPINE 100 MG
`721773 CLOZAPINE 12.5 MG
`721775 CLOZAPINE 12.5 MG
`1006801 CLOZAPINE 150 MG
`1006803 CLOZAPINE 150 MG
`996921 CLOZAPINE 200 MG
`309374 CLOZAPINE 200 MG
`996923 CLOZAPLNE 200 MG
`476179 CLOZAPTNE 25 MG
`197536 CLOZAPINE 25 MG
`104775 CLOZAPINE 25 MG
`543013 CLOZAPINE 25 MG
`429212 CLOZAPINE 50 MG
`1369831 CLOZAPINE 50 MG/ML
`1551999 COBICISTAT 150 MG
`
`
`
`lTOPlCAL CREAM
`TOPICAL SOLUTLON
`D|S!NTEGRATlNG ORAL TABLET
`ORAL TABLET
`ORAL TABLET
`DLSLNTEGRATLNG ORAL TABLET
`D|SLNTEGRAT!NG ORAL TABLET
`DISINTEGRATING ORAL TABLET
`DISLNTEGRATING ORAL TABLET
`DISINTEGRATING ORAL TABLET
`DKSINTEGRATING ORAL TABLET
`ORAL TABLET
`DISINTEGRATING ORAL TABLET
`IDISINTEGRATLNG ORAL TABLET
`IORAL TABLET
`‘ORAL TABLET
`DISINTEGRATING ORAL TABLET
`[ORAL TABLET
`|ORAL SUSPENSION
`
`ORAL TABLET
`
`1600710 COBICISTAT 150 MG / DARUNAVIR 800 MG
`_’EOBICIsTAT 150 MG/ ELVITEGRAVIR 150 MG/ EMTRICITABINE 200 MG /TENOFOVIR
`1721619 ALAFENAMIDE 10 MG
`ORAL TABLET
`COBICISTAT 150 MG / ELVITEGRAVIR 150 MG / EMTRICITABINE 200 MG / TENOFOVIR
`ORAL TABLET
`1306298 DISOPROXIL FUMARATE 300 MG
`ORAL TABLET
`1722376 COBIMETTNIB 20 MG
`
`
`ORAL TABLET
`T
`ORAL TABLET
`ORAL TABLET
`
`
`
`
`
`
`
`ORAL TABLET
`ORAL CAPSULE
`
`ORAL TABLET
`ORAL TABLET
`ORAL CAPSULE
`
`'
`
`997170}CODEINE 5ULFATE 15 MG
`997287 CODEINE SULFATE 30 MG
`997296 CODEINE SULFATE 60 MG
`
`COLCHICINE 0.5 MG/ PROBENECID 500 MG
`1550940 COLCHICINE 0.6 MG
`
`
`__ 197541 COLCHICINE 0.6 MG
`‘_
`858071 COLCHICINE 0.6 MG
`1550946 COLCHICINE 0.6 MG
`
`L
`
`866907 COLESEVELAM HYDROCHLORIDE 31.3 MG/ML
`866912 COLEsEvELAM HYDROCHLORIDE 625 MG
`1048445 COLESTIPOL HYDROCHLORIDE 1000 M6
`
`COLESTIPOL HYDROCHLORIDE 1000 M6
`
`1048450 COLESTIPOL HYDROCHLORIDE 5000 MG
`1048452 COLESTIPOL HYDROCHLORIDE 5000 MG
`
`COLISTIN 3 MG/ML/ HVDROCORTISONE 10 MG/ML/ NEOMYCIN 3.3 MG/ML/
`854995 THONZONIUM BROMIDE 0.5 MG/ML
`COLISTIN 3 MG/ML/ HYDROCORTISONE 10 MG/ML/ NEOMYCIN 3.3 MG/ML/
`854997 THONZONIUM BROMIDE 0.5 MG/ML
`L 1117522 COLISTIN 75 MG/ML
`1149617 COLLAGENASE 0.25 UNT/MG
`
`ORAL SUSPENSION
`ORAL TABLET
`ORAL TABLET
`ORAL TABLET
`
`ORAL GRANULES
`ORAL GRANULES
`
`OTIC SUSPENSION
`
`OTIC SUSPENSION
`INJECTABLE SOLUTION
`TOPICAL OINTMENT
`
`4
`
`L
`
`1040_0_2_§JCORT|COTROPIN 80 UNT/ML
`828248 CORTISONE ACETATE 25 M6
`1148502 CRIZOTINIB 200 MG
`1148506 CRIZOTINIB 250 MG
`1364460 CROFELEMER 125 MG
`831246 CROMOLYN SODIUM 10 MG/ML
`831261 CROMOLYN SODIUM 20 MG/ML
`831269 CROMOLYN SODIUM 20 MG/ML
`831109 CROMOLYN 5ODIUM 40 MG/ML
`
`207864 CROTAMITON 100 MG/ML
`207894 CROTAMITON 100 MG/ML
`828348 CYCLOBENZAPRINE HYDROCHLORIDE 10 MG
`828359 CYCLOBENZAPRINE HYDROCHLORIDE 15 MG
`
`828355 CVCLOBENZAPRINE HYDROCHLORIDE 30 MG
`828320 CYCLOBENZAPRINE HYDROCHLORIDE 5 MG
`
`W‘
`
`INJECTABLE SOLUTION
`ORAL TABLET
`ORAL CAPSULE
`ORAL CAPSULE
`DELAYED RELEASE ORAL TABLET
`INHALANT SOLUTION
`ORAL SOLUTION
`ORAL SOLUTION
`OPHTHALMIC SOLUTION
`
`TOPICAL CREAM
`TOPICAL LOTION
`XORAL TABLET
`EXTENDED RELEASE ORAL CAP5ULE
`
`_¢
`
`EXTENDED RELEASE ORAL CAPSULE
`ORAL TABLET
`
`—’
`
`Page 47
`
`
`SOUTCB: hitp5://www.Cms.gov/Medrcare/PrescriOtiorI—Dmg—COverage/PTescnptIOnDrugCOvCOntra/RxCOnTraCtirIg_FOrmularyfiuidarme.mm}
`
`$6
`
`Page 47
`
`

`
`Formuiary Reference File Calendar Year 2016
`
`RXNorm Description
`CYCLORENZAPRINE HYDROCHLORIDE 7.5 MG ORAL TABLET
`CYCLOBENZAPRINE HYDROCHLORIDE 7.5 MG ORAL TABLET [FEXMIDI
`CYCLOPIIOSPHAMIDE 25 MG ORAL CAPSULE
`CYCLOPHOSPHAM|DE 50 MG ORAL CAPSULE
`CYCLOSPORINE 0.5 MG/ML OPHTHALMIC SUSPENSION [RESTASISI
`CYCLOSPORINE 100 MG ORAL CAPSULE
`
`Related BN
`
`FEXMID
`
`RESTASIS
`
`I
`|
`|
`
`1
`|
`
`SANDIMMUNE
`SANDIMMUNE
`
`SANDIMMUNE
`
`SANDIMMUNE
`
`
`
`CYCLOSPORINE 100 MG ORAL CAPSULE ISANDIMMUNEI
`CYCLOSPORINE 100 MG/ML ORAL SOLUTION [SANDIMMUNE]
`CYCLOSPORINE 25 MG ORAL CAPSULE
`CYCLOSPORINE 25 MG ORAL CAPSULE [SANDIMMUNE]
`CYCLOSPORINE 50 MG/ML INJECTABLE SOLUTION
`CYCLOSPORINE 50 MG/ML INJECFABLE SOLUTION [SANDIMMUNE1
`CYCLOSPORINE, MODIFIED 100 MG ORAL CAPSULE
`
`'
`
`I
`*
`_
`
`Q
`‘
`
`»
`i
`
`E
`
`212957 SBD
`197553 SCD
`212810 SBD
`205175 SCD
`212844 SBD
`241834 SCD
`835835 560
`CYCLOSPORINE, MODIFIED 100 MG ORAL CAPSULE [NEORAL]
`835911 SBD
`CYCLOSPORINE, MODIFIED 100 MG/ML ORAL SOLUTION
`835886
`CYCLOSPORINE, MODIFIED 100 MG/ML ORAL SOLUTION [GENGRAF]
`835892 SBD
`CYCLOSPORINE, MODIFIED 25 MG ORAL CAPSULE
`835894 SCD
`CYCLOSPORINE, MODIFIED 25 MG ORAL CAPSULE [GENGRAF]
`835896 SBD
`CYCLOSPORINE, MODIFIED 25 MG ORAL CAPSULE [NEORAL}
`835909 SBD
`CYCLOSPORINE, MODIFIED 50 MG ORAL CAPSULE
`835925 SCD
`866021 SCD—
`
`—
`
`NEORAL
`
`1313785 SBD
`
`CYSTEAMINE 150 MG ORAL CAPSULE [CYSTAGON]
`CYSTEAMINE 25 MG DELAYED RELEASE ORAL CAPSULE [PROCYSBI]
`CYSTEAMINE 4.4 MG/ML OPHTHALMIC SOLUTION [CYSTARAN]
`
`C‘/STAGON
`PROCYSBI
`CYSTARAN
`
`CYSTAGON
`PROCYSBI
`
`CYSTEAMINE 50 MG ORAL CAPSULE [CYSTAGON]
`CYSTEAMINE 75 MG DELAYED RELEASE ORAL CAPSULE [PROCYSBI]
`1421477 SBD
`CYTARABINE 100 MG/ML INJECTABLE SOLUTION
`249364 SCD
`ICYTARABINE 20 MG/ML INIECTABLE SOLUTION
`240416 SCD
`PRADAXA
`IDABIGATRAN ETEXILATE 110 MG ORAL CAPSULE [PRADAXA]
`1723478 SBD
`PRADAXA
`DARIGATRAN ETEXILATE 150 MG ORAL CAPSULE [PRADAXA]
`1037049 SBD
`PRADAXA
`DABIGATRAN ETEXILATE 75 MG ORAL CAPSULE {PRADAXAJ
`1037181 SBD
`TAFINLAR
`DABRAFENIB 50 MG ORAL CAPSULE [TAF|NLAR}
`1425228 SBD
`1425230 580 TAFINLAR
`309638 SCD
`DACLATASVIR 30 MG ORALTABLET [DAKLINZA]
`1660191
`DACLATASVIR 60 MG ORAL TABLET [DAKLINZA]
`1660196 SBD
`DACTINOMYCIN 045 MG/ML INJECTABLE SOLUTION {COSMEGENI
`105569 SBD
`DALBAVANCIN 20 MG/Ml. INIECTAELE SOLUTION {!}AL\JAN(E}
`153.9248 SBD
`12 HR DALFAMPRIDINE 10 MG EXTENDED RELEASE ORAL TABLET [AMPYRA]
`897025 SBD
`
`
`DALFOPRISTIN 70 MG/ML/ OUINUPRISTIN 30 MG/ML INJECTABLE SOLUTION [SYNERCID]
`261306 SBD
`
`
`
`978757 SBD
`|1 ML DALTEPARIN SODIUM 10000 UNT/ML PREFILLED SYRINGE [FRAGMIN]
`978727lSI3D
`0.2 ML DALTEPARIN SODIUM 12500 UNT/ML PREFILLED SYRINGE [FRAGMIN]
`97877§J§>
`DALTEPARIN SODIUM 25000 UNT/ML |N.!ECTABLE SOLUTION [FRAOMIN]
`978735 SBD
`0.2 ML DALTEPARIN SODIUM 25000 UNT/ML PREFILLED SYRINGE IFRAGMINI
`
`DAKUNZA
`DAI<LIN2A
`COSMEGEN
`DALVANCE
`AMPYRA
`SYNERCID
`FRAGMIN
`FRAGMIN
`_5RAGMIN
`FRAOMIN
`
`K
`
`978737 SBD
`978741 SBD
`978745 SBD
`978747 SBD
`197554 SCD
`197555 SCD
`197556 SCD
`856652 SCD
`856656 SCD
`856658 SBD
`856660 SCD
`
`
`
`0.3 ML DALTEPARIN SODIUM 25000 UNT/ML PREFILLED SYRINOE [FRAGMlN)
`0.5 ML DALTEPARIN SODIUM 25000 UNT/ML PREFILLED SYRINGE [FRAGM|N}
`0.6 ML DALTEPARIN SODIUM 25000 UNT/ML PREFILLED SYRINGE [FRAGMIN]
`0.72 ML DALTEPARIN SODIUM 25000 UNT/ML PREFILLED SYRWGE [FRAGMINI
`DANAzOL 100 MG ORAL CAPSULE
`DANAzOL 200 MG ORAL CAPSULE
`‘ DANAzOL 50 MG ORAL CAPSULE
`DANTROLENE SODIUM 100 MG ORAL CAPSULE
`DANTROLENE SODIUM 25 MG ORAL CAPSULE
`DANTROLENE SODIUM 25 MG ORAL CAPSULE [DANTR|UM}
`DANTROLENE SODIUM 50 MG ORAL CAPSULE
`
`[FEOMIN
`FRAGMIN
`FRAGMIN
`FRAGMIN
`
`_*
`¢
`
`DANTRIUM
`
`856662 SBD
`1593775 SBD
`
`IDANTRIUM
`DANTROLENE SODIUM 50 MG ORAL CAPSULE [DANTRIUM]
`24 HR DAPAGLIFLOZIN 10 MG / METFORMIN HYDROCHLORIDE 1000 MG EXTENDED RELEASE ORAL TABLET [XIGDUO} XIODUO
`
`1593835 SBD
`
`_24 HR DAPAOLIFLOZIN 10 MG / METFORMIN HYDROCHLORIDE 500 MG EXTENDED RELEASE ORAL TABLET [XIGDUO]
`
`XIGDUO
`
`r
`
`V
`
`1593833 SBD
`1593831 SBD
`1486977 SBD
`1486981 SBD
`701858 SBD
`
`197557 SCD
`197558 SCD
`404652 SBD
`1721956 SBD
`352044390
`
`24 HR DAPAGUFLOZIN 5 MG / METFORMIN HYDROCHLORIDE 1000 MG EXTENDED RELEASE ORAL TABLET [X|GDUO)
`24 HR DAPAGLIFLOZIN 5 MG/ METFORMIN HYDROCHLORIDE 500 M6 EXTENDED RELEASE ORAL TABLET [XIGDUO]
`DAPAGUFLOZIN PROPANEDIOL 10 MG ORAL TABLET {FARXIOAI
`DAPAGLIFLOZIN PROPANEDIOL 5 MG ORAL TABLET [FARXIGA]
`DAPSONE 0.05 MG/MG TOPICAL GEL [ACZONE]
`
`XIGDUO
`XIODUO
`FARXIGA
`FARXIGA
`ACZONE
`
`JDAPSONE 100 M6 ORAL TABLET
`DAPSONE 25 MG ORAL TABLET
`DAPTOMYCIN 50 MG/ML INIECTABLE SOLUTION [CUB!CIN}
`5 ML DARATUMUMAB 20 M6/ML INJECTION [DARZALEX]
`DARREPOETIN ALFA 0.025 M6/ML IFUECTABLE SO'LLi’;|O:\I [ARANESP]
`
`‘
`r
`CUBICIN
`DARZALEX
`IARAN-ESP
`
`"
`
`fl
`
`4
`
`Source: https //www,CmS gOV/I’:/IEGICBI8/PFQSC|’|pIiOf\~D(Ug*COVE|'3gE/pfEESCFipfiO7‘IDfugCO‘/COHIV8/R><COF1UaCIIl’Vg_AFO|'|'T'IU5aH/GU|danCe mm!
`
`47
`
`Page 48
`
`
`Page 48
`
`

`
`Formuiary Reference File Caiendar Year 2016
`
`Related DF
`ORAL TABLET
`ORAL TABLET
`
`ORAL CAPSULE
`ORAL CAPSULE
`
`|
`
`[
`
`‘OPHTHALMIC SUSPENSION
`[ORAL CAPSULE
`|oRAL CAPSULE
`|oRAL SOLUTION
`ORAL CAPSULE
`ORAL CAPSULE
`LNJECTABLE SOLUTION
`SNJECTABLE SOLUTION
`ORAL CAPSULE
`
`
`
`ORAL CAPSULE
`DELAYED RELEASE ORAL CAPSULE
`OPHTHALMIC SOLUTLON
`ORAL CAPSULE
`DELAYED RELEASE ORAL CAPSULE
`
`
`
`TRXCUL
`
`Related SCDC
`323299 CYCLOBENZAPRINE HYDROCHLOFUDE 7.5 MG
`323301 CvCLO3EN2APRLNE HYDROCHLORIDE 7.5 MG
`
`1437963 CYCLOPHOSPHAMIDE 25 MG
`1437969 CYCLOPHOSPHAMIDE 50 MG
`
`402092 CYCLOSPORINE 0.5 MG/ML
`323160 CYCLOSPORINE 100 MG
`1975,_52"CvCLoSPoR1NE 100 MG
`212957 CYCLOSPORINE 100 MG/ML
`197553 CYCLOSPORINE 25 MG
`212310 CYCLOSPORLNE 25 MG
`205175 CYCLOSPORINE 50 MG/ML
`212344 CvCLo5PoRLNE 50 MG/ML
`241334 CYCLOSPORINE, MODIFIED 100 MG
`335335 CYCLOSPORLNE, MODIFIED 100 MG
`335911 CVCLOSPORINE, MODIFIED 100 MG
`335336 CYCLOSPORINE, MODIFIED 100 MG/ML
`335392 CYCLOSPORINE, MODIFIED 100 MG/ML
`835899
`835894 CYCLOSPORINE, MODLELED 25 MG
`835896 CYCLOSPORINE, MODIFIED 25 MG
`335909 CYCLOSPORINE, MDDLELED 25 MG
`335925 CYCLOSPORJNE, MODIFIED 50 MG
`366021 CYPROHEPTADINE HYDROCHLORIDE 0.4 MG/ML
`866144 CYPROHEPTADINE HYDROCHLORSDE 4 MG
`209733 CYSTEAMINE 150 MG
`1421473 CYSTEAMINE 25 MG
`1313735 CYSTEAMLNE 4.4 MG/ML
`209739 CYSTEAMINE 50 MG
`1421477 CYSTEAMSNE 75 MG
`
`
`
`
`
`2493641CvTARA3LNE 100 MG/ML
`240416[CYTARAB|NE 20 MG/ML
`1723478 DABIGATRAN ETEXILATE 110 MG
`1037049 DABIGATRAN ETEXILATE 150 MG
`
`
`
`
`
`
`
`
`
`
`
`1037181|DABlGATRAN ETEXILATE 75 MG
`142S228|DABRAFENlB 50 MG
`142S230kDABRAFENlB 75 MG
`309638 DACARBAZWE 10 MG/ML
`1560191 DACLATASVIR 30 MG
`1660196 DACLATASVIR 60 MG
`105569 DACTINOMYCIN 0.5 MG/ML
`1539248 DALBAVANCEN 20 ivifs/ML
`
`397025 DALEAMPRLDLNE 10 MG
`261306 DALFOPR!ST|N 70 MG/ML] OULNUPRTSTLN 30 MG/ML
`973757 DALTEPARLN SODIUM 10000 UNT/ML
`973727 DALTEPARLN SODLUM 12500 UNT/ML
`DALTEPARLN SODIUM 25000 UNT/ML
`DALTEPARIN SODIUM 25000 UNT/ML
`DALTEPARIN SODIUM 25000 UNT/ML
`DALTEPARLN SODLUM 25000 UNT/ML
`973745 DALTEPARIN SODLUM 25000 UNT/ML
`973747 DALTEPARW SODIUM 25000 UNT/ML
`197554 DANAzoL 100 MG
`197S55[DANAZOL 200 MG
`197556 DANAZOL 50 MG
`
`IINJECTABLE SOLUTLON
`]TN1ECTA6LE SOLUTION
`ORAL CAPSULE
`
`ORAL CAPSULE
`ORAL CAPSULE
`ORAL CAPSULE
`ORAL CAPSULE
`INJECTABLE SOLUTION
`ORAL TABLET
`ORAL TABLET
`INJECTABLE SOLUTION
`SNSECWABLE SOLUTION
`EXTENDED RELEASE ORAL TABLET
`INJECTABLE SOLUTION
`PREFILLED SYRINGE
`PREELLLED SYRINGE
`INJECTABLE SOLUTION
`PREELLLED SYRINGE
`PREFILLED SYRWGE
`PREFILLED SYRINGE
`JREFELLED SYRLNGE
`PREFILLED SYRLNGE
`ORAL CAPSULE
`ORAL CAPSULE
`ORAL CAPSULE
`
`
`
`1
`
`_
`
`ORAL CAPSULE
`ORAL CAPSULE
`ORAL CAPSULE
`ORAL CAPSULE
`
`_'
`
`_[ORAL CAPSULE
`EXTENDED RELEASE oRAL TABLET
`
`EXTENDED RELEASE ORAL TABLET
`
`EXTENDED RELEASE ORALTABLET
`
`
`
`
`
`856652 DANTROLENE SODTUM 100 MG
`856656 DANTROLENE SODIUM 25 MG
`856658 DANTROLENE SODIUM 25 MG
`356660 DANTROLENE SODiUM 50 MG
`
`856662 DANTROLENE SODIUM 50 MG
`1593775 DAPAGUFLOZIN 10 MG/ METEORMLN HYDROCHLORIDE 1000 MG
`
`1593335 DAPAGLIFLOZIN 10 MG / METFORMIN HYDROCHLORIDE 500 MG
`
`L 1593333 DAPAGLLELOZLN 5 MG / METFORMIN HYDROCHLORIDE 1000 MG
`
`1436977 DAPAGLIFLOZIN PROPANEDLOL 10 MG
`}__1593331 DAPAGLLELOZLN 5 MG / METEORMLN HYDROCHLORIDE 500 MG
`1436931 DAPAGUFLOZIN PROPANEDIOL 5 MG
`
`
`ORAL TABLET
`EXTENDED RELEASE ORAL TABLET
`ORAL TABLET
`
`E» 7O18584DAPSONE0.05 MG/MG
`
`197557 DAPSONE 100 MG
`197553 DAPSONE 25 MG
`404652 DAPTOMYCIN 50 MG/ML
`
`L
`
`1721956 DARATUMUMAB 20 MG/ML
`352044 DARBEPOETIN ALEA 0.025 MG/ML
`
`L
`
`D
`
`‘TOPTCALGEL
`
`[ORAL TABLET
`BRAL TABLET
`INJECTABLE SOLUTLON
`
`TLNJECTTON
`LNUECTABLE SOLUTTON
`
`Page 49
`
`
`Source: hT!;E,~S://www Ems.gOv/Medicare/Presmpt$0030:Ug—COverage/Pres:npnorzorUgCDvContra/RxCOntraCxangformu|3ryGU1danCe.htm§
`
`48
`
`Page 49
`
`

`
`Formulary Reference FIIB Caiendar Year 2016
`
`RxNOrm Descrlpfion
`0.4 ML DARBEPOETIN ALFA 0.025 MG/ML PREFILLED SYRINGE [ARANESP]
`DARBEPOETIN ALFA 0.04 MG/ML INJECTABLE SOLUTION [ARANESP]
`DARBEPOETIN ALFA 0.06 MG/ML INJECTABLE SOLUTION [ARANESP]
`0.42 ML DARBEPOETIN ALFA 0.06 MG/ML PREFILLED SYRINGE IARANESP}
`DARBEPOETIN ALFA 0.1 MG/ML INJECTABLE SOLUTION [ARAHESPI
`0.4 ML DARBEPOETIN ALFA 0.1 MG/ML PREEILLED SYRINGE [ARANESP]
`DARBEPOETIN ALFA 0.2 MG/ML INJECTABLE SOLUTION [ARANESP1
`0.5 ML DARBEPOETIN ALFA 0.2 MG/ML PREFILLED SYRINGE [ARANESP]
`0.3 ML DARBEPOETIN ALFA 0.2 MG/ML PREFILLED SYRINGE [ARANESP]
`DARBEPOETIN ALEA 0.3 M6/ML INJECTABLE SOLUTION LARANESP}
`0.6 ML DARBEPOETIN ALEA 0.5 MG/ML PREFILLED SYRINGE [ARANESP]
`
`Related BN
`ARANESP
`ARANESP
`ARANESP
`ARANESP
`‘ARANESP
`ARANESP
`_'-/TRANESP
`ARANESP
`ARANESP
`ARANESP
`ARANESP
`
`I
`
`0.4 ML DARBEPOETIN ALEA 0.5 MG/ML PREFILLED SYRINGE [ARANESP3
`1 ML DARBEPOETIN ALEA 0.5 MG/ML PREFILLED SYRINGE [ARANESP]
`24 HR DARIFENACIN 15 MG EXTENDED RELEASE ORAL TABLET [ENABLEX]
`24 HR DARIFENACIN 7.5 MG EXTENDED RELEASE ORAL TABLET [ENABLEX]
`DARUNAVIR 100 MG/ML ORAL SUSPENSION [PREZISTA]
`
`
`
`
`ARANESP
`ARANESP
`ENABLEX
`ENABLEX
`PREZISTA
`PREZISTA
`PREZISTA
`PREZISTA
`PREZLSTA
`
`
`
`
`-- (2 (DASABUVIR 250 MG ORAL TABLET) / 2 (OMBITASVIR 12.5 MG / PARITAPREVIR 75 MG / RITONAVIR 50 MG ORAL
`1597388 BPCK
`TABLET) I PACK [VIEKIRA PAK]
`
`SBD
`
`DASATINIB 140 MG ORAL TABLET ISPRYCELI
`DASATINIB 20 MG ORAL TABLET [SPRYCEL)
`DASATINIB 50 MG ORAL TABLET [SPRYCEL]
`DASATINIB 70 MG ORAL TABLET [SPRYCEL]
`DASATINIB 80 MG ORAL TABLET [SPRYCEL]
`DAUNORUBICIN 5 MG/ML INJECTABLE SOLUTION
`DAUNORUBICIN LIPOSOMAL 2 MG/ML INJECTABLE SOLUTION [DAUNOXOME]
`DECITABINE 5 MG/ML INJECTABLE SOLUTION
`
`VIEKIRA PAK
`SPRYCEL
`SPRYCEL
`SPRYCEL
`SPRVCEL
`
`SPRYCEL
`'
`DAUNOXOME
`
`|
`
`EXJADE
`
`EXJADE
`JADENU
`EXJADE
`JADENU
`FERRIPROX
`EERRIRROY.
`FIRMAGON
`FIRMAGON
`RESCRIPTOR
`RESCRIPTOR
`
`
`
`XGEVA
`
`DESIPRAMINE HYDROCHLORIDE 10 MG ORAL TABLET INORPRAMINI
`DESIPRAMINE HYDROCHLORIDE 100 MG ORAL TABLET
`
`__INORPRAMIN
`
`IRXCUI
`TTTY
`I’
`1505172 SBD
`352045 SBD
`352046 SBD
`731245 SBD
`352047 SBD
`731227 SBD
`
`731250 SBD
`352262 SBD
`731229 SBD
`
`731235 SBD
`SBD
`543021 SBD
`
`SBD
`
`
`
`
`
`
`
`
`
`DEFERASIROX 1.25 MG/ML ORAL SUSPENSION [EXJADE]
`616159 SBD
`
`
`1607790 SBD
`IDEEERASIROX 180 MG ORAL TABLET [JADENU]
`
`DEFERASIROX 2.5 MG/ML ORAL SUSPENSION [E>OADE}
`616161
`
`SBD
`DEFERASIROX 360 MG ORAL TABLET [JADENU]
`SBD
`DEFERASIROX 5 MG/ML ORAL SUSPENSION [EXJADE]
`1607798 5BD
`DEFERASIROX 90 MG ORAL TABLET [JADENU]
`1716268 SBD
`DEFERIPRONE 100 MG/ML ORAL SOLUTION [FERRIPROX]
`1190357 SBD
`DEFERIDRONE 500 MG ORAL TABLET {FERRIPROX}
`858125 SBD
`DEGARELIX 20 MG/ML INJECTABLE SOLUTION [FIRMAGON]
`858127 SBD
`DEGARELIX 40 MG/ML INJECTABLE SOLUTION [FIRMAGON]
`856562 SBD
`DELAVIRDINE MESYLATE 100 MG ORAL TABLET {RESCRIPTOR}
`856612 SBD
`DELAVIRDINE MESYLATE 200 MG ORAL TABLET [RESCRIETOR]
`905341 SCD
`DEMECLOC‘/CLINE HYDROCHLORIDE 150 MG ORAL TABLET
`905347 SCD
`DEMECLOCVCLINE HYDROCHLORIDE 300 MG ORAL TABLET
`993456 SBD
`1 ML DENOSUMAB 60 MG/ML PREFILLED SYRINGE [PROLIA]
`1046402 SBD
`DENOSUMAB 70 MG/ML INJECTABLE SOLUTION [XGEVA]
`
`
`DESIPRAMINE HYDROCHLORIDE 10 MG ORAL TABLET
`1099288 SCD
`
`
`1099290 SBD
`
`
`1099292 SCD
`
`
` 1099294 SBD
`[DESIPRAMINE HYDROCHLORIDE 100 MG ORAL TABLET {NORPRAMINT
`1099296 SCD
`DESIPRAMINE HYDROCHLORIDE 150 MG ORAL TABLET
`1099298 SBD
`DESIPRAMINE HYDROCHLORIDE 150 MG ORAL TABLET [NORPRAMIN]
`DESIPRAMINE HYDROCHLORIDE 25 MG ORAL TABLET
`1099300 SCD
`1099302 SBD
`DESIPRAMINE HYDROCHLORIDE 25 MG ORAL TABLET [NORPRAMIN]
`1099304 SCD
`DESIPRAMINE HYDROCHLORIDE 50 MG ORAL TABLET
`1099306 SBD
`DESIPRAMINE HYDROCHLORIDE 50 MG ORAL TABLET [NORPRAMIN]
`
`DESIPRAMINE HYDROCHLORIDE 75 MG ORAL TABLET
`1099316 SCD
`755661 SBD1....
`DESLORATADINE 0.5 MG/ML ORAL SOLUTION ICLARINEX]
`DESLORATADINE 2.5 MG DISINTEGRATING ORAL TABLET
`577080 SCD
`12 HR DESLORATADINE 2.5 MG/ PSEUDOEPHEDRINE SULFATE 120 MG EXTENDED RELEASE ORAL TABLET [CLAR!NEX—
`D]
`DESLORATADINE 5 MG DISINTEGRATING ORAL TABLET
`
`NORPRAMIN
`
`NORPRAMIN
`
`NORPRAMIN
`
`NORPRAMIN
`
`CLARINEX
`
`CLARII\IE><vD
`
`CLARINEX
`
`T!-DDAVP
`
`‘1:DDA\/P
`DDAVP
`{
`TDDAVF
`
`A
`
`_{
`
`1
`T
`
`J
`
`
`
`1112250 SBD
` 403841 SCD
`
`34942_0‘SCD
`352086 SBD
`
`L 849501 SCD
`849503 SBD
`I‘
`849506 SCD
`849508 SBD
`849515 SCD
`849517 SBD
`849520 SCD
`849522LSBD
`
`k
`
`DESLORATADINE 5 MG ORAL TABLET
`DESLORATADINE 5 MG ORAL TABLET [CLARINEX]
`
`DESMOPRESSIN ACETATE 0.004 MG/MI. INJECTABLE SOLUTION
`DESMOPRESSIN ACETATE 0.004 MG/ML INJECTABLE SOLUTION [DDAVP]
`DESMOPRESSIN ACETATE 0.01 MG/ACTUAT NASAL SPRAY
`DESMOPRESSIN ACETATE 0.01 MG/ACTUAT NASAL SPRAY [DDAVP]
`+DESMOPRESSIN ACETATE 0.1 MG ORAL TABLET
`DESMOPRESSIN ACETATE 0.1 MG ORAL TABLET [DDAVP]
`|DESMOPRESSIN ACETATE 0.1 MG/ML NASAL SOLUTION
`IDESMOERESSIN ACETATE 0.1 MG/ML HASAL SOLUTION [DDAVP]
`
`Source’ htLpS'//W\NW.CFI’IS gOv/Medrcare/PrescnDtiOn~DrLzg—COverage/PresCrIptiOnDrugCOvCOntra/R><COntraCtmg>_ FOrmOIaryGuIdanCe html
`
`
`
`Page 50
`
`

`
`FDrmuIary Reference File Calendar Year 2016
`
`5;
`
`ReIated DP
`PREFILLED SYRINGE
`INIECTABLE SOLUTION
`INJECTABLE SOLUTION
`PREFILLED SYRINGE
`INJECTABLE SOLUTION
`
`PREFILLED SYRINGE
`INJECTABLE SOLUTION
`IPREFILLED SYRINGE
`IPREFILLED SYRINGE
`INIECTABLE SOLUTION
`PREFILLED SYRINGE
`PREFILLED SYRINGE
`PREFILLED SYRINGE
`PREFILLED SYRINGE
`EXTENDED RELEASE ORAL TABLET
`EXTENDED RELEASE ORAL TABLET
`ORAL SUSPENSION
`]ORAL TABLET
`|ORAL TABLET
`ORAL TABLET
`ORAL TABLET
`PACK
`
`
`
`
`
`
`Related SCDC
`RXCUI
`
`1605172 DARBEPOETIN ALFA 0.025 MG/ML
`352045 DARBEPOETIN ALFA 0.04 MG/ML
`352046 DARBEPOETIN ALFA 0.06 MG/ML
`731245 DARBEPOETIN ALFA 0.06 MG/ML
`352047 DARBEPOETIN ALFA 0.1 MG/ML
`731227 DARBEPOETIN ALFA 0.1 MG/MI.
`352048 DARBEPOETIN ALFA 0.2 MG/ML
`730046 DARBEPOETIN ALFA 0.2 MG/ML
`731250 DARBEPOETIN ALFA 0.2 MG/ML
`352262 DARBEPOETIN ALEA 0.3 MG/ML
`DARBEPOETIN ALEA 0.5 MG/MI.
`731231 DARBEPOETIN ALFA 0.5 MG/ML
`731235 DARBEPOETIN ALFA 0.5 MG/MI.
`731241 DARBEPOETIN ALFA 0.5 MG/ML
`DARIEENACIN 15 MG
`DARIFENACIN 7.5 MG
`DARUNAVIR 100 MG/ML
`850457 DARUNAVIR 150 MG
`794610 DARUNAVIR 600 MG
`DARUNAVIR 75 MG
`DARUNAVIR 800 MG
`- DASABUVIR 250 MG / OMBITASVIR 12.5 MG / PARITAPREVIR 75 MG / RITONAVIR 50
`1597388 MG
`DASATINIB 100 MG
`DASATINIB 140 MG
`DASATINIB 20 MG
`DASATINIB 50 MG
`DASATINIB 70 MG
`DASATINII3 80 MG
`309650 DAUNORUBICIN 5 MG/ML
`DAUNORUBICIN LIPOSOMAL 2 MG/ML
`DECITABINE 5 MG/ML
`DECITABINE 5 MG/ML
`616159 DEFERASIROX 1.25 MG/ML
`DEFERASIROX 180 MG
`616161 DEFERASIROX 2.5 MG/ML
`1607794 DEFERASIROX 360 MG
`616163 DEFERASIROX 5 MG/ML
`1607798 DEFERASIROX 90 MG
`1716268 DEEERIRRONE 100 MG/ML
`1190357 DEFERIPRONE 500 M6
`858125 DEGARELIx 20 MG/ML
`858127 DEGARELIX 40 MG/ML
`856562 DELAVIRDINE MESYLATE 100 MG
`856612 DELAVIRDINE MESYLATE 200 MG
`905341 DEMECLOCYCLINE HYDROCHLORIDE 150 MG
`905347 DEMECLOCYCLINE HYDROCHLORIDE 300 MG
`993456 DENOSUMAB 60 MG/ML
`1046402 DENOSUMAB 70 MG/ML
`1099288 DESIPRAMINE HYDROCHLORIDE 10 MG
`1099290 DES PRAMINE HYDROCHLORIDE 10 MG
`1099292 DES PRAMINE HYDROCHLORIDE 100 MG
`1099294 DES PRAMINE HYDROCHLORIDE 100 MG
`1099296 DES PRAMINE HYDROCHLORIDE 150 MG
`1099298 DES PRAMINE HYDROCHLORIDE 150 MG
`
`1099300 DES RRAMINE HYDROCHLORIDE 25 MG
`1099302 DESIPRAMINE HYDROCHLORIDE 25 MG
`1099304 DESIPRAMINE HYDROCHLORIDE 50 M6
`1099306 DES PRAMINE HYDROCHLORIDE 50 MG
`1099316 DES PRAMINE HYDROCHLORIDE 75 MG
`755661 DESLORATADINE 0.5 MG/ML
`577080 DES.ORATADINE 2.5 MG
`
`
`
`
`ORAL TABLET
`ORAL TABLET
`
`ORAL TABLET
`
`ORAL TABLET
`ORAL TABLET
`
`
`ORAL TABLET
`
`INJECTABLE SOLUTION
`INJECTABLE SOLUTION
`
`INIECTABLE SOLUTION
`
`IN}ECTABLE SOLUTION
`ORAL SUSPENSION
`
`ORAL TABLET
`
`ORAL SUSPENSION
`
`ORAL TABLET
`ORAL SUSPENSION
`
`ORAL TABLET
`ORAL SOLUTION
`
`ORAL TABLET
`+IT\I_JECTABLE SOLUTION
`IINIECTABLE SOLUTION
`|ORAL TABLET
`‘ORAL TABLET
`ORAL TABLET
`ORAL TABLET
`PREFILLED SYRINGE
`INJECTABLE SOLUTION
`ORAL TABLET
`ORAL TABLET
`ORAL TABLET
`ORAL TABLET
`ORAL TABLET
`ORAL TABLET
`ORAL TABLET
`ORAL TABLET
`ORAL TABLET
`ORAL TABLET
`ORAL TABLET
`ORAL SOLUTION
`DISINTEGRATING ORAL TABLET
`
`
`
`11122s0£)ESLORATADINE 2.5 MG/ PSEUDOERHEDRINE SULEATE 120 MG
`403841 DES.ORATADlNE 5 MG
`349420[c_>ES.ORATADINE 5 MG
`352086 DESLORATADINE 5 MG
`B49501 DESMOPRESSIN ACETATE 0.004 MG/ML
`B49503 DESMOPRESSIN ACETATE 0.004 MG/ML
`849506 DESMOPRESSIN ACETATE 0.01 MO/ACTUAT
`849508 DESMORRESSIN ACETATE 0.01 MG/ACTUAT
`849515 DESMOPRESSIN ACETATE 0.1 MG
`849517 DESMOPRESSIN ACETATE 0.1 MG
`B49520 DESMOPRESSIN ACETATE 0.1 MG/ML
`849S2?T)E5MOPRESSIN ACETATE 0.1 MG/ML
`
`EXTENDED RELEASE ORAL TABLET
`DISINTEGRATING ORAL TABLET
`ORAL TABLET
`ORAL TABLET
`TINJECTABLE SOLUTION
`INIECTABLE SOLUTION
`NASAL SPRAY
`NASAL SPRAY
`ORAL TABLET
`ORAL TABLET
`NASAL SOLUTION
`’NASAL SOLUTION
`
`1
`
`Page 51
`
`
`Source https //www CnIS.gOv/Medicare/PIBSCIIpIIOn—Drug—Coverage/PrescriptIOnDrI.IgCOvCOntI'a/RxCODtractIrIg_FOrmuIa:yGUIdanCe.htmI
`
`50
`
`Page 51
`
`

`
`.
`I
`
`—.
`E
`
`Formwary Reference Fiée Calendar Year 2010
`
`RXCUI
`
`TTY
`831460 SBD
`833008 SCD
`
`RxNOrm Description
`DESMOPRESSIN ACETATE 0.15 MG/ACTUAT NASAL SPRAY [STIMATEI
`DESMOPRESSIN ACETATE 0.2 MG ORAL TABLET
`
`)Related EN
`STIMATE
`
`DDAVP
`
`CYCLESSA 28 DAY
`
`I
`2
`
`vELIvET 28 DAY
`
`BEKYREE 28 DAY
`
`KARIVA 28 DAY
`
`KIMIDESS 28 DAY
`
`PIMTREA PACK
`
`APRI 28 DAY
`
`DESOGEN 28 DAY
`
`849524 SBD
`
`761974 BPCK
`
`762334 BPCK
`
`759743 GPCK
`
`1716037 BPCK
`
`762001 BPCK
`
`
`
`753367 BPCK
`
`1091828 BPCK
`
`1605086 BPCK
`
`_
`
`L
`
`F
`
`309679 SCD
`
`20869_1§_§D
`208821 SBD
`309686 SCD
`197577 SCD
`1011080 SBD
`343o33'SC0
`197579 SCD
`
`226343 SCD
`309684 SCD
`205669 SBD
`
`309680 SCD
`
`208591 580
`309683‘SCD
`208813 SBD
`197580][SCD
`
`gExAMETHASONE 0.001 MG/MG / NEOMYCIN 0.0035 MG/MG/ POLvMv><IN B 10 UNT/MG OPHTHALMIC OINTMENT L
`DEXAMETHASONE 0.001 MG/MG / NEOMYCIN 0.0035 MG/MG / POLYMYXIN B 10 UNT/MG OPHTHALMIC OINTMENT
`JMAXITROL)
`DEXAMETHASONE 0.001 MG/MG /TOBRAMYCIN 0.003 MG/MG OPHTHALMIC OINTMENT [TOBRADE>()
`DEXAMETHASONE 0.1 MG/ML ORAL SOLUTION
`DEXAMETHASONE 0.5 MG ORAL TABLET
`DEXAMETHASONE 0.5 MG/ML / TOBRAMYCIN 3 MG/ML OPHTHALMIC SUSPENSION [TOBRADEX]
`DEXAMETHASONE 0.75 MG ORAL TABLET
`DEXAMETHASONE 1 MG ORAL TABLET
`
`MAXITROL
`TOBRADEX
`
`TOBRADEX
`
`DEXAMETHASONE 1 MG/ML OPHTHALMIC SOLUTION
`DEXAMETHASONE 1 MG/ML ORAL SOLUTION
`DEXAMETHASONE 1 MG/ML OPHTHALMIC SUSPENSION [MA><IDExI
`
`DE><AMETHASONE 1 MG/ML / NEOMYCIN 3.5 MG/ML / POLYMYXIN B 10000 UNT/ML OPHTHALMIC SUSPENSION
`‘DExAMETHASONE 1 MG/ML / NEOMYCIN 3.5 MG/ML/ POLYMYXIN B 10000 UNT/ML OPHTHALMIC SUSPENSION
`((MA><ITROL}
`FDEXAMETHASONE 1 MG/ML / TOBRAMYCIN 3 MG/ML OPHTHALMIC SUSPENSION
`DExAMETHASONE 1 MG/ML / TOBRAMYCIN 3 M6/ML OPHTHALMIC SUSPENSION (TO8RADExI
`DEXAMETHASONE 1.5 MG ORAL TABLET
`
`{
`
`MAXIDEX
`
`MAXITROL
`L
`TOSRADEX
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`Source’ https //www.CmS gOV/IVI€d§CaI’€/PTGSCFI[3L|O'T‘DfUg-COV€fag€/Pf6$CI’IpIIOI')DI'UgCOVCOF!U5/RXCOHUBETIfig_FOFIT1UI3IyGLHd3r‘)C€
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`51
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`Page 52
`
`
`DESMOPRESSIN ACETATE 0.2 MG ORAL TABLET [DDAVP]
`{7 (DESOGESTREL 0.1 MG / ETHINYL ESTRADIOL 0025 MG ORAL TABLET) / 7 (DESOGESTREL 0.125 MG / ETHINYL
`ESTRADIOL 0025 MG ORAL TABLET) / 7 (DESOGESTREL 015 MG / ETHINYL ESTRADIOL 0.025 MG ORAL TABLET) / 7
`(INERT INGREDIENTS 1 MG ORAL TABLET) I PACK [CYCLESSA 28 DAY)
`(7 (DESOGESTREL 0.1 MG/ ETHINYL ESTRADIOL 0025 MG ORAL TABLET) / 7 (DESOGESTREL 0.125 MG/ ETHINYL
`ESTRADIOL 0.025 MG ORAL TABLET) / 7 (DESOGESTREL 015 MG/ ETHINYL ESTRADIOL 0025 MG ORAL TABLET) / 7
`(INERT INGREDIENTS 1 MG ORAL TABLET) I PACK [vELIvET 28 DAY)
`(21 DESOGESTREL 015 MG / ETHINYL ESTRADIOL 0.02 MG ORAL TABLET)/ 5 (ETHINYL ESTRADIOL 0.01 MG ORAL
`TABLET) / 2 (INERT INGREDIENTS 1 MG ORAL TABLET) I PACK
`(21 (DESOGESTREL 015 MG / ETHINYL ESTRADIOL 0.02 MG ORAL TABLET) / 5 (ETHINYL ESTRADIOL 001 MG ORAL
`TAB_ET) / 2 (INERT INGREDIENTS 1 MG ORAL TABLET) ) PACK [BEKYREE 28 DAY)
`{21(DESOGESTREL 0.15 MG / ETHINYL ESTRADIOL 0.02 MG ORAL TABLET) / 5 (ETHINYL ESTRADIOL 0.01 MG ORAL
`TABLET) / 2 (INERT INGREDIENTS 1 MG ORAL TABLET) ) PACK [KARIVA 28 DAY]
`(21 DESOGESTREI. 015 MG / ETHINYL ESTRADIOL 0.02 MG ORAL TABLET) / 5 (ETHINYL ESTRADIOL 0.01 MG ORAL
`1655489 BPCK
`TABLET) / 2 (INERT INGREDIENTS 1 MG ORAL TABLET) ) PACK [KIMIDESS 28 DAY)
`- (21 DESOGESTREL 0.15 MG / ETHINYL ESTRADIOL 0.02 MG ORAL TABLET)/ 5 (ETHINYL ESTRADIOL 0.01 MG ORAL
`1438778 BPCK
`TABLET) / 2 (INERT INGREDIENTS 1 MG ORAL TABLET) } PACK [PIMTREA PACK]
`{21 (DESOGESTREL 0.15 MG / ETHINYL ESTRADIOL 0.03 MG ORAL TABLET) / 7 (INERT INGREDIENTS 1 MG ORAL
`753482 BPCK
`TABLET) } PACK [APRI 28 DAY]
`{21 DESOGESTREL 0.15 MG / ETHINYL ESTRADIOL 0.03 MG ORAL TABLET) / 7 (INERT INGREDIENTS 1 MG ORAL
`TABLET) I PACK (DESOGEN 28 DAY]
`(21 (DESOGESTREL 015 MG / ETHINYL ESTRADIOL 003 MG ORAL TABLET) / 7 (INERT INGREDIENTS 1 MG ORAL
`TAB.ET) I PACK [EMOQUETTE)
`EMOOUETTE
`(21 (DESOGESTREL 0.15 MG / ETHINYL ESTRADIOL 003 MG ORAL TABLET) / 7 (INERT INGREDIENTS 1 MG ORAL —
`TAB.ET) I PACK [JULEBER 28 DAY)
`JULEBER 28 DAY
`(21 DESOGESTREL 0.15 MG/ ETHINYL ESTRADIOL 003 MG ORAL TABLET}/ 7 (INERT INGREDIENTS 1 MG ORAL
`TABLET) } PACK [RECLIPSEN 28 DAY]
`RECLIPSEN 28 DAY
`DESONIDE 0.0005 MG/MG TOPICAL OINTMENT
`DESONIDE 0.0005 MG/MG TOPICAL GEL (DESONATEI
`DESONIDE 0.5 MG/ML TOPICAL CREAM
`DESONIDE 0.5 MG/ML TOPICAL LOTION
`DESONIDE 0.5 MG/ML TOPICAL CREAM [DESOwEN]
`DESONIDE 0.5 MG/ML TOPICAL LOTION [DESOWEN]
`DESONIDE 0.5 MG/ML TOPICAL LOTION (LOKARA]
`DESOXIMETASONE 0.0005 MG/MG TOPICAL GEL
`DESOXIMETASONE 0.0005 MG/MG TOPICAL OINTMENT
`DESOXIMETASONE 0.0005 MG/MG TOPICAL GEL (TOPICORTI
`DESOXIMETASONE 0.0005 MG/MG TOPICAL OINTMENT (TOPICORT]
`DESOXIMETASONE 0 0025 MG/MG TOPICAL OINTMENT
`DESOXIMETASONE 0.0025 MG/MG TOPICAL OINTMENT [TOPICORT]
`DESOXIMETASONE 0.5 MG/ML TOPICAL CREAM
`DESOXIMETASONE 0.5 MG/ML TOPICAL CREAM (TOPICORT)
`DESOxIMETASONE 2.5 MG/ML TOPICAL CREAM
`DESOxIMETAsONE 2.5 MG/ML TOPICAL CREAM ITOPICORT}
`DESOXIMETASONE 2.5 MG/ML TOPICAL SPRAY ITOPICORT)
`24 HR DESVENLAFAXINE 100 MG EXTENDED RELEASE ORAL TABLET
`24 HR DESVENLAEAXINE 100 MG EXTENDED RELEASE ORAL TABLET (KHEDEzLAI
`24 HR DESVENLAFAXINE 100 MG EXTENDED RELEASE ORAL TABLET [PRlSTIQ}
`24 HR DESvENLAI=AxINE 25 MG EXTENDED RELEASE ORAL TABLET (PRISTIOI
`24 HR DESVENLAFAXINE 50 MG EXTENDED RELEASE ORAL TABLET
`24 HR DESVENLAFAXINE 50 MG ExTENDED RELEASE ORAL TABLET IKHEDEZLAI
`24 HR DESVENLAFAXINE 50 MG EXTENDED RELEASE ORAL TABLET (PRISTIOI
`
`753543 BPCK
`204135
`692757
`349351
`197572
`205529
`205534
`
`SBD
`
`315059
`141850 SCD
`94346 SBD
`1050394 SBD
`197575 SCD
`94348 SBD
`197573 SCD
`891631 SBD
`197574 SCD
`94345 SBD
`SBD
`790264 SCD
`1435480 SB!)
`790267 S80
`1607619 S80
`790288 SCD
`1435483 580
`790290 SBD
`
`
`
`IDESONATE
`[
`
`DESOWEN
`
`—
`
`TOPICORT
`TOPICORT
`
`
`
`TOPICORT
`
`TOPICORT
`TOPICORT
`
`KHEDEZLA
`PRISTIQ
`PRISTIO
`
`KHEDEZLA
`PRISTIO
`
`T
`
`)
`
`Page 52
`
`

`
`Formulary Reference FIIe Calendar Year 2016
`
`RXCUI
`
`Related SCDC
`
`831460 DESMOPRESSIN ACETATE 0.15 MG/ACTUAT
`833008;DESI\/IOPRESSIN ACETATE 0.2 MG
`849524 DESMOPRESSIN ACETATE 0.2 MG
`DESOGESTREL 0.1 MG/ DESOGESTREL 0.125 MG / DESOGESTREL 0.15 MG / ETHINVL
`761974 ESTRADIOL 0.025 MG/ INERT INGREDIENTS 1 MG
`
`Related DF
`NASAL SPRAY
`AORAL TABLET
`ORAL TABLET
`
`PACK
`
`DESOGESTREL 0.1 MG / DESOGESTREL 0125 MG/ DESOGESTREL 015 MG / ETHINYL
`PACK
`762334 ESTRADIOL 0.025 MG/ INERT INGREDIENTS 1 MG
`
`DESOGESTREL 0.15 MG/ ETHINYL ESTRADIOL 0.01 MG/ ETHINYL ESTRADIOL 0.02 MG /
`759743 INERT INGREDIENTS 1 MG
`DESOGESTREL 015 MG/ ETHINYL ESTRADIOL 0.01 MG/ ETHINYL ESTRADIOL 0.02 MG/
`1716037 INERT INGREDIENTS 1 MG
`DESOGESTREL 0.15 MG / ETHINYL ESTRADIOL 0.01 MG/ ETHINYL ESTRADIOL 0.02 MG/
`762001 INERT INGREDIENTS 1 MG
`DESOGESTREL 015 MG /