Eormulary Reference Fiie Calendar Year 2016
`
`RXCUI
`
`[
`
`
`
`
`
`
`317136 SCD
`209339 SBD
`198046 SCD
`209350 SBD
`198047 SCD
`209391 SBD
`311026 SBD
`847199 SBD
`311027 SBD
`
`RxNOrm Descrsption
`
`TNORTRIPWLINE 25 MG ORAL CAPSULE
`NORTRIPWLINE 25 M6 ORAL CAPSULE [PAMELOR]
`NORTRIPWLINE 50 MG ORAL CAPSULE
`NORTRIPT‘/LINE 50 MG ORAL CAPSULE [PAMELORI
`NORTRIPT‘/LINE 75 MG ORAL CAPSULE
`NORTRIPTYLINE 75 MG ORAL CAPSULE [PAMELOR]
`NPH INSULIN, HUMAN 100 UNT/ML IMECTABLE SUSPENSION [HUMULIN N1
`3 ML NPH INSULIN, HUMAN 100 UNT/ML PREFILLED SYRINGE [HUMULIN N]
`NPH INSULIN, HUMAN 100 UNT/ML INJECTABLE SUSPENSION [NOVOLIN N]
`
`Related BN
`
`PAMELOR
`
`‘I
`
`T
`
`PAMELOR
`
`PAMELOR
`
`HUMULIN N
`
`HUMULIN N
`NOVOLIN N
`
`106892 SBD
`
`NPH INSULIN, HUMAN 70 UNT/ML/ REGULAR INSULIN, HUMAN 30 UNT/ML INIECTABLE SUSPENSION {HUMULIN}
`
`HUMULIN
`
`HUMULIN
`NOVOLIN
`
`
`
`SANDOSTATIN
`
`NYAMYC
`
`I
`
`SANDOSTATIN
`
`SANDOSTATIN
`SANDOSTATIN
`
`SANDOSTATIN
`
`OCUFLOX
`
`ZYPREXA
`ZYPREXA
`
`Z‘/PREXA
`ZYPREXA
`ZYPREXA
`
`ZYPREXA
`
`ZYPREXA
`ZYPREXA
`
`
`
`ZYPREXA
`ZYPREXA
`
`ZYPREXA
`
`
`
`OLANZAPINE 15 MG DISINTEGRATING ORAL TABLET [ZYPREXA]
`OLANZAPINE 15 MG ORAL TABLET [ZYPREXA]
`OLANZAPINE 150 MG/ML INJECTABLE SUSPENSION [ZYPREXA]
`OLANZAPINE 2.5 MG ORAL TABLET
`OLANZAPINE 2.5 MG ORAL TABLET [ZVPREXA]
`OLANZAPINE 20 MG DISINTEGRATING ORAL TABLET
`OLANZAPINE 20 MG ORAL TABLET
`OLANZAPINE 20 M6 DISINTEGRATTNG ORAL TABLET [ZYPREXA]
`OLANZAPINE 20 MG ORAL TABLET IZYPREXAI
`OLANZAPINE 5 M6 DISINTEGRATING ORAL TABLET
`OLANZAPINE 5 MG ORAL TABLET
`OLANZAPINE 5 MG DISINTEGRATING ORAL TABLET [ZYPREXA]
`OLANZAPINE 5 MG ORAL TABLET [ZYPREXA]
`
`OLANZAPINE 5 MG/ML INJECTABLE SOLUTION
`OLANZAPINE 5 MG/ML INJECTABLE SOLUTION IZYPREXAI
`OLANZAPINE 7.5 MG ORAL TABLET
`OLANZAPINE 7.5 MG ORAL TABLET [ZYPREXAI
`OLAPARIB 50 MG ORAL CAPSULE ILYNPARZA]
`
`60 ACTUAT OLDATEROL 0.0025 MG/ACTUAT / TIOTROPIUM 0.0025 MG/ACTUAT METERED DOSE INHALER ISTIOLTOI
`TOLMESARTAN MEDOXOMIL 20 MG ORAL TABLET [BENICARI
`OLMESARTAN MEDOXOMIL 40 M6 ORAL TABLET IBENICARI
`OLMESARTAN MEDOXOMIL 5 MG ORAL TABLET [BENICARI
`60 ACTUAT OLODATEROL 0.0025 MG/ACTUAT METERED DOSE INHALER [STRIVERDI]
`OLOPATADINE 1 M6/ML OPHTHALMIC SOLUTION
`OLOPATADINE 1 MG/ML OPHTHALMIC SOLUTION IPATANOL}
`OLOPATADINE 2 MG/ML OPHTHALMIC SOLUTION [PATADAY]
`OLOPATADINE 7 MG/ML OPHTHALMIC SOLUTION [PAZEO]
`
`ZYPREXA
`LVNPARZA
`
`STLOLTO
`BENICAR
`BENICAR
`BENICAR
`STRIVERDT
`I
`PATANOL
`PATADAY
`IPAZEO
`
`PS EX. 2162
`
`art 4
`
`FAD V. NPS
`II>R2015—01093 ‘
`
`3 ML NPH INSULIN, HUMAN 70 UNT/ML / REGULAR INSULIN, HUMAN 30 UNT/ML PREFILLED SYRINGE [HUMULIN]
`847189 SBD
`NPH INSULIN, HUMAN 70 UNT/ML/ REGULAR INSULIN, HUMAN 30 UNT/ML INJECTABLE SUSPENSION [NOVOLINI
`SBD
`NYSTATIN 100 UNT/MG TOPICAL OINTMENT
`884308 SCD
`646456 SCD
`NVSTATIN 100 UNT/MG TOPICAL POWDER
`534414
`NYSTATIN 100 UNT/MG TOPICAL POWDER [NYAMYC]
`
`NYSTATIN 100 UNT/MG TOPICAL POWDER [NYSTOP]
`
`NYSTATIN 100 UNT/MG / TRIAMCINOLONE ACETONIDE 0.001 MG/MG TOPICAL OINTMENT —
`NYSTATIN 100000 UNT/ML ORAL SUSPENSION
`—
`NYSTATIN 100000 UNT/ML TOPICAL CREAM
`NYSTATIN 100000 UNT/ML/TRIAMCINOLONE ACETONIOE 1 MG/ML TOPICAL CREAM
`NYSTATIN 500000 um ORAL TABLET
`OCTREOTIDE 0.05 MG/ML INJECTABLE SOLUTION
`OCTREOTIDE 0.05 MG/ML INJECFABLE SOLUTION [SANDOSTATIN]
`OCTREOTIDE 0.1 MG/ML INJECTABLE SOLUTION
`OCTREOTIDE 0.1 MG/ML INJECTABLE SOLUTION [SANDOSTATIN]
`OCTREOTIDE 0.2 MG/ML INJECTABLE SOLUTION
`OCTREOTIDE 0.2 MG/ML INJECTABLE SOLUTION [SANDOSTATIN]
`OCTREOTIDE 0.5 MG/ML INJECTABLE SOLUTION
`OCTREOTIDE 0.5 MG/ML INJECTABLE SOLUTION ISANOOSTATIIII
`OCTREOTIDE 1 MG/ML INIECTABLE SOLUTION
`OCTREOTIDE 1 MG/ML INJECTABLE SOLUTION {sAN0O5TATIN]
`OCTREOTIDE 12 MG/ML INJECTABLE SUSPENSION [SANDOSTATIN]
`OCTREOTIDE 4 MG/ML INJECTABLE SUSPENSION {sAN0OsTATIN}
`OCTREOTIDE 8 MG/ML INJECTABLE SUSPENSION [SANDOSTATIN]
`OFLOXACIN 3 MG/ML OPHTHALMIC SOLUTION
`OFLOXACIN 3 MG/ML OTIC SOLUTION
`OFLOXACIN 3 MG/ML OPHTHALMIC SOLUTION [OCUFLOXI
`0TLO><A.CII.I 400 M6 ORAL TABLET
`OLANZAPINE 10 MG DISINTEGRATING ORAL TABLET
`OLANZAPINE 10 MG ORAL TABLET
`OLANZAPINE 10 MG DISINTEGRATING ORAL TABLET [ZYPREXA]
`OLANZAPINE 10 MG ORAL TABLET [ZYPREXA]
`IOLANZAPINE 15 MG DISINTEGRATING ORAL TABLET
`OLANZAPINE 15 MG ORAL TABLET
`
`
`
`
`
`SCD
`1053753 SCD
`312059 SCD
`312068 5C0
`207194 530
`312069 SCD
`
`5B0
`312070 SCD
`
`207201 SBD
`SBD
`
`898591 SBD
`312075 SCD
`242446 SCD
`207202 SBD
`193050 5C0
`312076 SCD
`314154 SCD
`754503 530
`153048 530
`351107 SCD
`312077 5C0
`
`|
`R
`I
`
`F
`
`7545041530
`261337 SBD
`885867 SBD
`200034 SCD
`212405 SBD
`351108 5C0
`283639IsC0
`754505 530
`2845141550
`314155 SCD
`312078’5C0
`754506 SBD
`153046 SBD
`
`48596Eg5CD
`545353 SBD
`312079 SCD
`153047 SBD
`1597593 SBD
`
`1651275 SBD
`352200 SBD
`352201 SBD
`352199 SBD
`1546083TSBD
`1111339 SCD
`1111341 SBD
`1111345 SBD
`1601091580
`
`Source" Imps://www.Cm5gov/MedICare/Prescript:On—DrLxg—COverage/Pre5criptIOnDrugCovCOrItTa/R><COntracting_FOrmuIaryGuIdanCe.html
`
`135
`
`Page
`
`
`136
`
`Page 136
`
`NPS Ex. 2162
`Part 4
`CFAD v. NPS
`IPR2015-01093
`
`

`
`RXCU!
`
`{Related scnc
`317136 NORTRIPSYLINE 25 MG
`209339 NORTRIP"{L|NE 25 MG
`198046 NORTRIP0/LINE 50 MG
`
`2092-350|NORTRIPTYLINE 50 MG
`198047INORTRIP‘YLINE 75 MG
`209391|NORTRIP"(LINE 75 MG
`311026 NPH INSULIN, HUMAN 100 UNT/ML
`847199 NPH INSULIN, HUMAN 100 UNT/ML
`311027 NPH INSULIN, HUMAN 100 UNT/ML
`
`t
`
`FormuIary Reference Fifie Caiendar Year 2016
`
`Related DP
`ORAL CAPSULE
`ORAL CAPSULE
`ORAL CAPSULE
`ORAL CAPSULE
`ORAL CAPSULE
`ORAL CAPSULE
`INIECTABLE SUSPENSION
`PREFILLED SYRINGE
`
`kIN)ECI'ABLE SUSPENSION
`
`106892 NPH INSULIN, HUMAN 70 UNT/ML / REGULAR INSULIN, HUMAN 30 UNT/ML
`
`INJECTABLE SUSPENSION
`
`847189 NPH INSULIN, HUMAN 70 UNT/ML / REGULAR INSULIN, HUMAN 30 UNT/ML
`
`PREFILLED SYRINGE
`
`INJECTABLE SUSPENSION
`TOPICAL OINTMENT
`TOPICAL POWDER
`TOPICAL POWDER
`TOPICAL POWDER
`TOPICAL OINTMENT
`ORAL SUSPENSION
`TOPICAL CREAM
`TOPICAL CREAM
`
`
`
`[ORAL TABLET
`INJECTABLE SOLUTION
`INJECTABLE SOLUTION
`INJECTABLE SOLUTION
`INJ ECTABLE SOLUTION
`INJ ECTABLE SOLUTION
`INJ ECTABLE SOLUTION
`INJECTABLE SOLUTION
`INJECTABLE SOLUTION
`INJECTABLE SOLUTION
`INJECTABLE SOLUTION
`INJECTABLE suspsnsuon
`INJECTABLE suspenszon
`INJECTABLE suspensnon
`
`IOPHTHALMIC SOLUTION
`OTIC SOLUTION
`OPHTHALMIC soumon
`ORAL TABLET
`
`I‘.
`
`213442 NPH INSULIN, HUMAN 70 UNT/ML/ REGULAR INSULIN, HUMAN 30 UNT/ML
`884308 NYSTATIN 100 UNT/MG
`646456 NYSTATIN 100 UNT/MG
`NYSTATIN 100 UNT/MG
`NYSTATIN 100 UNT/MG
`1053697 NYSTATIN 100 UNT/MG / TRIAMCINOLONE ACETONIDE 0.001 MG/MG
`312055 NYSTATIN 100000 UNT/ML
`543546 NYSTATIN 100000 UNT/ML
`1053753 NYSTATIN 100000 UNT/ML / TRIAMCINOLONE ACETONIDE 1 MG/ML
`312059 NYSTATIN 500000 UNT
`312068 OCTREOTIDE 0.05 MG/ML
`OCTREOTIDE 0.05 MG/ML
`312069 OCTREOTIDE 0.1 MG/ML
`207198 OCTREOTIDE 0.1 MG/ML
`314152 OCTREOTIDE 0.2 MG/ML
`207199 OCTREOTIDE 0.2 MG/ML
`312070 OCTREOTIDE 0.5 MG/ML
`OCFREOTIDE 0.5 MG/ML
`ocmeonos 1 MG/ML
`OCTREOTIDE 1 MG/ML
`OCTREOTIDE 12 MG/ML
`898607 OCTREOT DE 4 MG/ML
`898591 OCTREOT DE 8 MG/ML
`312075 OFLOXAC N 3 MG/ML
`242446 OFLOXAC N 3 MG/ML
`.____‘
`207202 OFLOXACIN 3 MG/ML
`198050 OFLOXAC N 400 MG
`312076 OLANZAP NE 10 MG
`314154 OLANZAP NE 10 MG
`754503 OLANZAPINE 10 MG
`153048 OLANZAPINE 10 MG
`351107 OLANZAP NE 15 MG
`312077 OLANZAPINE 15 MG
`754504 OLANZAPINE 15 MG
`261337 OLANZAP NE 15 MG
`885867 OLANZAPINE 150 MG/ML
`200034 OLANZAPINE 2.5 MG
`212405 OLANZAP NE 2.5 MG
`351108 OLANZAP NE 20 MG
`283639 OLANZAP NE 20 MG
`
`*
`
`L
`
`,
`
`754505 OLANZAP NE 20 MG
`284514 OLANZAP NE 20 MG
`314155 OLANZAP NE 5 MG
`312078 OLANZAP NE 5 MG
`754506 OLANZAP NE 5 MG
`153046 OLANZAP NE 5 MG
`
`485968 OLANZAP NE 5 MG/ML
`545353 OLANZAPINE 5 MG/ML
`312079 OLANZAPINE 7.5 MG
`153047 OLANZAP NE 7.5 MG
`1597593 OLAPARIB 50 MG
`
`1651275 OLDATEROL 0.0025 MG/ACTUAT/TIOTROPIUM 0.0025 MG/ACTUAT
`352200 OLMESARTAN MEDOXOMIL 20 MG
`352201 OLMESARTAN MEDOXOMIL 40 MG
`
`352199 OLMESARTAN MEDOXOMIL5 MG
`1546083 OLODATEROL 0.0025 MG/ACTUAT
`
`1111339 OLOPATADINE 1 MG/ML
`1111341 OLOPATADINE 1 MG/ML
`1111345iOLOPATADINE 2 MG/ML
`1601091 OLOPATADINE 7 MG/ML
`
`IDISINTEGRATING ORAL TABLET
`ORAL TABLET
`
`DISINTEGRATING ORAL TABLET
`
`
`ORAL TABLET
`
`
`DISINTEGRATING ORAL TABLET
`
`ORAL TABLET
`DISINTEGRATING ORAL TABLET
`ORAL TABLET
`INJECTABLE SUSPENSION
`ORAL TABLET
`ORAL TABLET
`DISINTEGRATING ORAL TABLET
`
` ORAL TABLET
`
`DISINTEGRATING ORAL TABLET
`ORAL TABLET
`DISINTEGRATING ORAL TABLET
`ORAL TABLET
`DISINTEGRATING ORAL TABLET
`ORAL TABLET
`INJECTABLE SOLUTION
`INJECTABLE SOLUTION
`ORAL TABLET
`ORAL TABLET
`ORAL CAPSULE
`
`METERED DOSE INHALER
`ORAL TABLET
`ORAL TABLET
`
`ORAL TABLET
`METERED DOSE INHALER
`
`LOPHTHALMIC SOLUTION
`OPHTHALMIC SOLUTION
`‘OPHTHALMIC SOLUTION
`OPHTHALMIC SOLUTION
`
`J
`
`{
`
`I
`
`Page 137
`
`
`Source: https://www.cms.gOv/Medacare/Prescrinven-Drugrcoverage/PrescrIptronDrugCOvCOntra/RxCOntrac£ing_FormuIaryGmdance.htmI
`
`136
`
`Page 137
`
`

`
`r
`
`F0rmuIary Reference FiIe CaIendar Year 2016
`
`ZEGERID REFORMULATED
`
`
`AUG 2006
`646352 SBD
`
`OMEPRAZOLE 40 MG / SODIUM BICARBONATE 1100 MG ORAL CAPSULE [ZEGERID REFORMULATED AUG 2006]
`
`BOTOX
`860195
`ONABOTU JNUMTOXINA 100 UNT/ML INJECTABLE SOLUTION [BOTOX]
`
`BOTOX
`897368 SBD
` ONABOTULINUMTOXINA 200 UNT/MI. INJECTABLE SOLUTION IBOTOX}
`
`312085
`ONDANSE"RON 0.8 MG/ML ORAL SOLUTION
`
`212447 SBD
`ZOFRAN
`ONDANSE"RON 0.8 MG/ML ORAL SOLUTION [ZOFRANI
`
`
`ZOFRAN
`
`283504 SCD
`1314133 SCD
`104897
`
`312084 SCD
`
`IONDANSERON 2 MG/ML INJECTABLE SOLUTION
`2 ML ONDANSETRON 2 MG/ML PREFILLED SYRINGE
`ONDANSE"RON 2 MG/ML INJECTABLE SOLUTION [ZOFRAN]
`ONDANSETRON 24 MG ORAL TABLET
`
`
`
`ZOFRAN
`ZOFRAN
`ZUPLENZ
`
`
`
`1
`
`J
`
`ZOFRAN
`_LZ_O_FRAN
`ZUPLENZ
`
`ORBACTIV
`
`TAMIFLU
`TAMIFLU
`TAMIFLU
`TAMIFLU
`TAGRISSO
`
`TAGRTSSO
`NA
`
`I
`
`_
`DAYPRO
`
`OXTELLAR
`TRILEPTAL
`
`OXTELLAR
`TRILEPTAL
`
`ITRILEPTAL
`
`4
`
`——1
`
`1
`
`*1
`
`104894‘I_SCD
`198052 SCD
`876690 SBD
`104895 SBD
`998035TSB‘D
`
`312087 SCD
`312086 SCD
`876693 SBD
`104896 SBD
`998032 SBD
`
`ONDANSETRON 4 MG DISINTEGRATING ORAL TABLET
`ONDANSETRON 4 MG ORAL TABLET
`ONDANSETRON 4 MG DISINTEGRATING ORAL TABLET [ZOFRAN]
`ONDANSETRON 4 MG ORAL TABLET [ZOFRANI
`ONDANSETRON 4 MG ORAL STRIP [ZUPLENZ]
`
`4ONDANSETRON 8 MG DISINTEGRATING ORAL TABLET
`ONDANSETRON 8 MG ORAL TABLET
`ONDANSETRON 8 MG DISINTEGRATING ORAL TABLET IZOFRAN]
`ONDANSETRON 8 MG ORAL TABLET {ZOFRAN]
`ONDANSETRON 8 MG ORAL STRIP [ZUPLENZ]
`
`L
`
`1547620 SBD
`994521 SCD
`
`ORITAVANCIN 1.2 MG/ML INJECTABLE SOLUTION [ORBACTIV]
`12 HR ORPHENADRINE CITRATE 100 MG EXTENDED RELEASE ORAL TABLET
`
`994541 SCD
`728111 SBD
`728115 SBD
`1115700lSBD
`261315lSBD
`1721571 SBD
`
`17215831580
`3686451!
`312127‘_S_CD
`312130 SCD
`
`312128ISCD
`240637 SCD
`
`351248LSCD
`351276 SCD
`198056 SCD
`312132 SCD
`207243 SBD
`198057 SCD
`
`ORPHENADRINE CITRATE 30 MG/ML INJECTABLE SOLUTION
`OSELTAMIVIR 30 MG ORAL CAPSULE [TAMIFLU]
`OSELTAMIVIR 45 MG ORAL CAPSULE [TAMIFLU]
`OSELTAMIVIR 6 MG/ML ORAL SUSPENSION UAMIFLU}
`OSELTAMIVIR 75 MG ORAL CAPSULE [TAMIFLU]
`OSIMERTINIB 40 MG ORAL TABLET [TAGRISSO]
`
`OSIMERTINIB 80 MG ORAL TABLET [TAGRISSO]
`+OTC-PRODUCT
`OXACILLIN 100 MG/ML INJECTABLE SOLUTION
`OXACILLIN 167 MG/ML INJECTABLE SOLUTION
`
`OXACILLIN 20 MG/ML IMECTABLE SOLUTION
`OXACILLIN 40 MG/ML INJECTABLE SOLUTION
`
`OXALIPLATIN 5 MG/ML INJECTABLE SOLUTION
`OXANDROLONE 10 MG ORAL TABLET
`OXANDROLONE 2.5 MG ORAL TABLET
`OXAPROZIN 600 MG ORAL TABLET
`OXAPROZIN 600 MG ORAL TABLET [DAYPRO]
`OXAZEPAM 10 MG ORAL CAPSULE
`
`312134ISCD
`198059 SCD
`
`LOXAZEPAM 15 MG ORAL CAPSULE
`OXAZEPAM 30 MG ORAL CAPSULE
`
`312136 SCD
`1365660 SBD
`261356 SBD
`312137 SCD
`1365847 SBD
`2613601580
`Z83536’SCD
`351992I5BD
`
`IOXCARBAZEPINE 150 MG ORAL TABLET
`24 HR OXCARBAZEPINE 150 MG EXTENDED RELEASE ORAL TABLET [OXTELLAR]
`OXCARBAZEPINE 150 MG ORAL TABLET [TRILEPTALI
`TOXCARBAZEPINE 300 MG ORAL TABLET
`24 HR OXCARBAZEPINE 300 MG EXTENDED RELEASE ORAL TABLET [OXTELLAR]
`TOXCARBAZEPINE 300 MG ORAL TABLET [TRILEPTAL]
`YOXCARBAZEPINE 60 MG/ML ORAL SUSPENSION
`LOXCARBAZEPINE 60 MG/ML ORAL SUSPENS§ON {TRILEPTALE
`
`P
`
`I
`
`I
`
`L
`
`L.‘
`
`Source https://wwwcms gov/Medicare/PrescrIption—Drug—Coverage/PrescripttonDrugCovC0ntra/Rxcontractmgjormularx/Guidanze mm!
`
`137
`
`Page 138
`
`
`
`
`
`
`RxNorm Description
`240 ACTUAT OLOPATADINE HYDROCHLORIDE 6.65 MG/ACTUAT NASAL INHALER
`I240 ACTUAT OLOPATADINE HYDROCHLORIDE 6.65 MG/ACTUAT NASAL INHALER [PATANASE]
`OLSALAZINE SODIUM 250 MG ORAL CAPSULE [DIPENTUM]
`OMACETAXINE MEPESUCCINATE 3.5 MG/ML INJECTABLE SOLUTION [SYNRIBOI
`IOMALIZUMAB 125 MG/ML INJECTABLE SOLUTION [XOLAIR]
`OMBITASVIR 12.5 MG / PARITAPREVIR 75 MG / RITONAVIR 50 MG ORAL TABLET [TECHNIVIEI
`TOMEGA-3 ACID ETHYL ESTERS (USP) 1000 MG ORAL CAPSULE
`OMEGA-3 ACID ETHYL ESTERS (USP) 1000 MG ORAL CAPSULE [LOVAZA]
`OMEPRAZOLE 0.5 MG/ML ORAL SUSPENSION IPRILOSEC]
`IOMEPRAZOLE 0.667 MG/ML ORAL SUSPENSION [PRILOSEC]
`OMEPRAZOLE 1.33 M6/ML/ SODIUM BICARBONATE 1.33 MEQ/ML ORAL SUSPENSION [ZEGERID REFORMULATED
`AUG 2006]
`OMEPRAZOLE 10 MG DELAYED RELEASE ORAL CAPSULE
`
`3eIated BN
`
`TPATANASE
`FDIPENTUM
`SYNRIBO
`XOLAIR
`TECHNIVIE
`
`_I
`
`——1
`
`LOVAZA
`PRILOSEC
`PRELOSEC
`ZEGERID REFORMULATED
`AUG 2006
`
`
`
`ZEGERID REFORMULATED
`AUG 2006
`
`OMEPRAZOLE 2.67 MG/MI. / SODIUM BICARBONATE 1.33 MEQ/ML ORAL SUSPENSION (ZEGERID REFORMULATED
`AUG 2006}
`OMEPRAZOLE 20 MG DELAYED RELEASE ORAL CAPSULE
`OMEPRAZOLE 20 MG / SODIUM BICARBONATE 1100 MG ORAL CAPSULE
`
`
`
`ZEGERID REFORMULATED
`AUG 2006
`
`.,._.____
`OMEPRAZOLE 20 MG /SODIUM BICARBONATE 1100 MG ORAL CAPSULE [ZEGERID REFORMULATED AUG 2006]
`OMEPRAZOLE 40 MG DELAYED RELEASE ORAL CAPSULE
`OMEPRAZOLE 40 MG / SODIUM BICARBONATE 1100 MG ORAL CAPSULE
`
`
`
`T
`
`‘
`
`L
`
`TTY
`RXCUI
`111133iSCD
`111133LSBD
`905164 SBD
`1356693 SBD
`404574 SBD
`1659656 SBD
`577208 SCD
`607044TSBD
`797065 SBD
`797061IS_BD
`
`753603 SBD
`199119 SCD
`
`753601 SBD
`198051 SCD
`616539 SCD
`
`646344 SBD
`200329 SCD
`616541 SCD
`
`Page 138
`
`

`
`Formulary Reference FIIe CaIendar Year 2016
`
`_TReIaLed DF
`NASAL INHALER
`INASAL INHALER
`TTORAL CAPSULE
`IINIECTABLE SOLUTION
`|INIECTABLE SOLUTION
`[ORAL TABLET
`IORAL CAPSULE
`ORAL CAPSULE
`ORAL SUSPENSION
`ORAL SUSPENSION
`
`|ReIated SCDC
`IRXCUI
`I
`1111335|OLOPATADINE HYDROCHLORIDE 6.65 Ms/ACTUAT
`1111337|OLOPATADINE HYDROCHLORIDE 6.65 MG/ACTUAT
`I
`905164 OLSALAZINE SODIUM 250 MG
`1356693 OMACETAXINE MEPESUCCINATE 3.5 MG/ML
`OMALIZUMAB 125 MG/ML
`OMBITASVIR 125 MG / PARITAPREVIR 75 MG / RITONAVIR 50 MG
`OMEGA-3 ACID ETHYL ESTERS (USP) 1000 MG
`OMEGAA3 ACID ETHYL ESTERS (USP) 1000 MG
`OMEPRAZOLE 0.5 MG/ML
`OMEPRAZOLE 0.667 MG/ML
`
`753603 OMEPRAZOLE 1.33 MG/ML / SODIUM BICARBONATE 1.33 MEQ/ML
`199119 OMEPRAZOLE 10 MG
`
`753601 OMEPRAZOLE 2.67 MG/ML / SODIUM BICARBONATE 1.33 MEQ/ML
`OMEPRAZOLE 20 MG
`OMEPRAZOLE 20 MG /SODIUM BICARBONATE 1100 MG
`
`646344 OMEPRAZOLE 20 MG / SODIUM BICARBONATE 1100 MG
`OMEPRAZOLE 40 MG
`OMEPRAZOLE 40 MG / SODIUM BICARBONATE 1100 MG
`
`646352 OMEPRAZOLE 40 MG / SODIUM BICARBONATE 1100 MG
`ONABOTULINUMTOXINA 100 UNT/ML
`897368 ONABOTULINUMTOXINA 200 UNT/ML
`312085 ONDANSETRON 0.8 MG/ML
`212447 ONDANSETRON 0.8 MG/ML
`283504 ONDANSETRON 2 MG/ML
`1314133 ONDANSETRON 2 MG/MI.
`104897 ONDANSETRON 2 MG/MI.
`312084 ONDANSETRON 24 MG
`104894 ONDANSETRON 4 MG
`198052 ONDANSETRON 4 MG
`876690 ONDANSETRON 4 MG
`104895 ONDANSETRON 4 MG
`
`998035IONDANSETRON 4 MG
`312087 ONDANSETRON 8 MG
`312086 ONDANSETRON 8 MG
`876693 ONDANSETRON 8 MG
`104896 ONDANSETRON 8 MG
`'4 998032 ONDANSETRON 3 MG
`L
`1547620 ORITAVANCIN 1.2 MG/ML
`F
`994521 ORPHENADRINE CITRATE 100 MG
`994541 ORPHENADRINE CITRATE 30 MG/ML
`728111 OSELTAMIVIR 30 MG
`728115 OSELTAMIVIR 45 MG
`1115700 OSELTAMIVIR 6 MG/ML
`261315 OSELTAMIVIR 75 MG
`
`1721571 OSIMERTINIB 40 MG
`1721583 OSIMERTINIB 80 MG
`
`
`
`
`
`3686 OTC-PRODUCT
`I:'312127IOxACILLIN 100 MG/ML
`312130 OxACILLIN 167 MG/ML
`312128 OXACILLIN 20 MG/ML
`240637 OXACILLIN 40 MG/ML
`351248 OXALIPLATIN 5 MG/ML
`"—351276 OxANDROLONE 10 MG
`I:
`198056 OXANDROLONE 2.5 MG
`312132 OxAPRozIN 600 MG
`E
`207243 OxAPROzIN 600 MG
`IT’ 198057 OxAzEPAM 10 MG
`312134 OXAZEPAM 15 MG
`198059 OxAzEPAM 30 MG
`312136 OxCAR8AzEPINE 150 MG
`1365660 OxCARBAzEPINE 150 MG
`261356 OXCARBAZEPINE 150 MG
`312137 OXCARBAZEPINE 300 MG
`1365847 OXCARBAZEPINE 300 MG
`261360 OXCARBAZEPINE 300 MG
`
`I L
`
`283536 OXCARBAZEPINE 60 MG/ML A
`351992 OXCARBAZEPINE 60 M6/ML
`
`_
`
`ORAL SUSPENSION
`IORAL SUSPENSION
`
`I Page 139
`
`
`Source’ https.//www.CmS gov/MediCare/PresuIpLIO:I«Drug-Coverage/PIeSCrIptIOnDrugLOvCOrILra/RxCOrItraCtIng_FOrmUIaryGuidanCe.hLm
`
`!—.L (.0CG
`
`
`
`ORAL SUSPENSION
`DELAYED RELEASE ORAL CAPSULE
`
`ORAL SUSPENSION
`DELAYED RELEASE ORAL CAPSULE
`ORAL CAPSULE
`
`ORAL CAPSULE
`DELAYED RELEASE ORAL CAPSULE
`ORAL CAPSULE
`
`ORAL CAPSULE
`INIECTABLE SOLUTION
`IINJECTABLE SOLUTION
`ORAL SOLUTION
`TIVORAL SOLUTION
`IINIECTABLE SOLUTION
`PREFILLED SYRINGE
`INIECTABLE SOLUTION
`ORAL TABLET
`DISINTEGRATIN6 ORAL TABLET
`ORAL TABLET
`DISINTEGRATING ORAL TABLET
`ORAL TABLET
`
`ORAL STRIP
`DISII‘»ITEGRA‘I‘IN<3 ORAL TABLET
`ORAL TABLET
`DISINTEGRATING ORAL TABLET
`ORAL TABLET
`ORAL STRIP
`INJECFABLE SOLUTION
`EXTENDED RELEASE ORAL TABLET
`INJECTABLE SOLUTION
`ORAL CAPSULE
`ORAL CAPSULE
`ORAL SUSPENSION
`ORAL CAPSULE
`~‘T)RAL TABLET
`ORAL TABLET
`
`L_I\_IA
`INIECTABLE SOLUTION
`INJECTABLE SOLUTION
`INJECTABLE SOLUTION
`INJECTABLE SOLUTION
`INJECTABLE SOLUTION
`ORAL TABLET
`
`ORAL TABLET
`ORAL TABLET
`ORAL TABLET
`ORAL CAPSULE
`ORAL CAPSULE
`ORAL CAPSULE
`ORAL TABLET
`EXTENDED RELEASE ORAL TABLET
`ORAL TABLET
`ORAL TABLET
`EXTENDED RELEASE ORAL TABLET
`ORAL TABLET
`
`
`
`I
`I
`
`I
`-—'I
`
`J
`
`1
`
`4
`
`Page 139
`
`

`
`‘RXCUI
`
`1'
`TTY
`312138 SCD
`
`RXNOrm Description
`OXCARBAZEPINE 600 MG ORAL TABLET
`
`Related BN
`
`Formulary Reference File Calendar Year 2016
`
`13658501580
`262090 SBD
`207248 SBD
`207249 SBD
`1250565 SBD
`404448 SBD
`864820 SBD
`863599 SCD
`863619 SCD
`863622 SBD
`863628 SCD
`863630 SBD
`863636 SCD
`863664 SCD
`863638 SBD
`1049604 SCD
`1049502 SCD
`1049683 SCD
`
`424 HR OXCARBAZEPINE 600 MG EXTENDED RELEASE ORAL TABLET IOXTELLAR]
`OXCARBAZEPINE 600 MG ORAL TABLET ITRILEPTAL]
`OXICONAZOLE 10 MG/ML TOPICAL CREAM [OXISTAT]
`OXICONAZOLE 10 MG/ML TOPICAL LOTION [OXISTAT]
`OXYBUTYNIN 0.03 MG/MG TOPICAL GEL [GELNIQUE]
`84 HR OXYBUTYNIN 0.162 MG/HR TRANSDERMAL PATCH IOXYTROLI
`OXYBUTYNIN CHLORIDE 0.1 MG/MG TOPICAL GEL {GELNIOUE1
`OXYBUTYNIN CHLORIDE 1 MG/ML ORAL SOLUTION
`24 HR OXYBUTYNIN CHLORIDE 10 MG EXTENDED RELEASE ORAL TABLET
`24 HR OXYBUTYNIN CHLORIDE 10 MG EXTENDED RELEASE ORAL TABLET [D|TROPAN]
`24 HR OXYBUTYNIN CHLORIDE 15 MG EXTENDED RELEASE ORAL TABLET
`24 HR OXYBUTYNIN CHLORIDE 15 MG EXTENDED RELEASE ORAL TABLET [DITROPAN}
`24 HR OXYBUTYNIN CHLORIDE 5 MG EXTENDED RELEASE ORAL TABLET
`OXYBUTYNIN CHLORIDE 5 MG ORAL TABLET
`24 HR OXYBUTYNIN CHLORIDE 5 MG EXTENDED RELEASE ORAL TABLET [DITROPAN]
`OXYCODONE HYDROCHLORIDE 1 MG/ML ORAL SOLUTION
`12 HR OXYCODONE HYDROCHLORIDE 10 MG EXTENDED RELEASE ORAL TABLET
`OXYCODONE HYDROCHLORIDE 10 MG ORAL TABLET
`
`
`
`“
`
`J
`
`OXTELLAR
`TRILEPTAL
`OXISTAT
`OXISTAT
`GELNIOUE
`OXYTROL
`GELNIOUE
`
`DITROPAN
`
`DITROPAN
`
`DITROPAN
`
`I
`
`F
`
`_
`*
`
`‘
`
`OXYCONTIN
`
`OXYCONTIN
`ROXICODONE
`
`12 HR OXYCODONE HYDROCHLORIDE 10 MG EXTENDED RELEASE ORAL TABLET [OXYCONTIN
`OXYCODONE HYDROCHLORIDE 15 MG ORAL TABLET
`12 HR OXYCODONE HYDROCHLORIDE 15 MG EXTENDED RELEASE ORAL TABLET [OXYCONTIN
`OXYCODONE HYDROCHLORIDE 15 MG ORAL TABLET [ROXICODONE]
`12 HR OXYCODONE HYDROCHLORIDE 20 MG EXTENDED RELEASE ORAL TABLET
`OXYCODONE HYDROCHLORIDE 20 MG ORAL TABLET
`12 HR OXYCODONE HYDROCHLORIDE 20 MG EXTENDED RELEASE ORAL TABLET [OXYCONTIN
`OXYCODONE HYDROCHLORIDE 20 MG/ML ORAL SOLUTION
`OXYCODONE HYDROCHLORIDE 30 MG ORAL TABLET
`12 HR OXYCODONE HYDROCHLORIDE 30 MG EXTENDED RELEASE ORAL TABLET LOXYCONTIN
`OXYCODONE HYDROCHLORIDE 30 MG ORAL TABLET [ROXICODONE]
`12 HR OXYCODONE HYDROCHLORIDE 40 MG EXTENDED RELEASE ORAL TABLET
`|12 HR OXYCODONE HYDROCHLORIDE 40 MG EXTENDED RELEASE ORAL TABLET [OXYCONTIN
`|OXYCODONE HYDROCHLORIDE 5 MG ORAL CAPSULE
`OXYCODONE HYDROCHLORIDE 5 MG ORAL TABLET
`ROXICODONE
`OXYCODONE HYDROCHLORIDE 5 MG ORAL TABLET [ROXICODONE]
`OXYCONTIN
`12 HR OXYCODONE HYDROCHLORIDE 60 MG EXTENDED RELEASE ORAL TABLET [OXYCONT|N
`12 HR OXYCODONE HYDROCHLORIDE 80 MG EXTENDED RELEASE ORAL TABLET —
`12 HR OXYCODONE HYDROCHLORIDE 80 MG EXTENDED RELEASE ORAL TABLET [OXYCONTIN
`OXYCONTIN
`OXYMETHOLONE 50 MG ORAL TABLET [ANADROL—S0]
`ANADROL-50
`12 HR OXYMORPHONE HYDROCHLORIDE 10 MG EXTENDED RELEASE ORAL TABLET
`
`VOXYCONTIN
`
`OXYCONTIN
`ROXICODONE
`
`OXYCONTIN
`
`QXYMORPHONE HYDROCHLORIDE 10 MG ORAL TABLET
`12 HR OXYMORPHONE HYDROCHLORIDE 10 MG EXTENDED RELEASE ORAL TABLET [OPANAI
`OXYMORPHONE HYDROCHLORIDE 10 MG ORAL TABLET [OPANA]
`12 HR OXYMORPHONE HYDROCHLORIDE 15 MG EXTENDED RELEASE ORAL TABLET
`12 HR OXYMORPHONE HYDROCHLORIDE 15 MG EXTENDED RELEASE ORAL TABLET IOPANA1
`12 I-IR OXYMORPHONE HYDROCHLORIDE 20 MG EXTENDED RELEASE ORAL TABLET
`12 HR OXYMORPHONE HYDROCHLORIDE 20 MG EXTENDED RELEASE ORAL TABLET [OPANA]
`12 HR OXYMORPHONE HYDROCHLORIDE 30 MG EXTENDED RELEASE ORAL TABLET
`12 HR OXYMORPHONE HYDROCHLORIDE 30 MG EXTENDED RELEASE ORAL TABLET [OPANA]
`12 HR OXYMORPHONE HYDROCHLORIDE 40 MG EXTENDED RELEASE ORAL TABLET
`12 HR OXYMORPHONE HYDROCHLORIDE 40 MG EXTENDED RELEASE ORAL TABLET [OPANA]
`12 HR OXYMORPHONE HYDROCHLORIDE 5 MG EXTENDED RELEASE ORAL TABLET
`
`OXYMORPHONE HYDROCHLORIDE 5 MG ORAL TABLET
`12 HR OXYMORPHONE HYDROCHLORIDE 5 MG EXTENDED RELEASE ORAL TABLET [OPANA]
`OXYMORPHONE HYDROCHLORIDE 5 MG ORAL TABLET [OPANA]
`12 HR OXYMORPHONE HYDROCHLORIDE 7.5 MG EXENDED RELEASE ORAL TABLET
`12 HR OXYMORPHONE HYDROCHLORIDE 7.5 MG EXENDED RELEASE ORAL TABLET [OPANA]
`PACUTAXEL 5 MG/ML INIECTABLE SUSPENSION {ABRAXANEI
`
`EACLITAXEL 6 MG/ML INIECTABLE SOLUTION
`LPALBOUCLIB 100 MG ORAL CAPSULE [IBRANCE]
`PALBOCICLIB 125 MG ORAL CAPSULE IIBRANCE]
`PALBOCICLIB 75 MG ORAL CAPSULE [IBRANCEI
`APALIFERMIN 5 MG/ML INIECTABLE SOLUTION [KEP|VANCE}
`24 HR PALIPERIDONE 1.5 MG EXTENDED RELEASE ORAL TABLET
`5 HR PALIPERIDONE 1.5 MG EXTENDED RELEASE ORAL TABLET [INVEGA]
`”'724 HR PALIPERIDONE 3 MG EXTENDED RELEASE ORAL TABLET
`#24 HR PALIPERIDONE 3 MG EXTENDED RELEASE ORAL TABLET IINVEGAI
`‘24 HR PALIPERIDONE 6 MG EXTENDED RELEASE ORAL TABLET
`24 HR PALIPERIDONE 6 MG EXTENDED RELEASE ORAL TABLET UNVEGA)
`24 HR PALIPERIDONE 9 MG EXTENDED RELEASE ORAL TABLET
`24 HR PALIPERIDONE 9 MG EXTENDED RELEASE ORAL TABLET I:INvEGA1
`0.5 ML PALIPERIDONE PALMITATE 156 MG/ML PREEILLED SYRINGE [INVEGA]
`1.5 ML PALIPERIDONE RALMITATE 156 MG/ML PREHLLED SYRINGE IINVEGAI
`
`1 ML PALIPERIDONE PALMITATE 156 MG/ML PREFILLED SYRINGE [INVEGA]
`"0325 ML I'—‘ALéPERiI'.‘IONE RALMITATE 156 MG/ML RREEILLED SYRINGE UNVEGA}
`
`1
`I
`
`]
`
`1'OPANA
`OPANA
`
`OPANA
`
`OPANA
`
`OPANA
`
`OPANA
`
`OPANA
`OPANA
`
`OPANA
`ABRAXANE
`
`IBRANCE
`‘IBRANCE
`IBRANCE
`I<EPIvANCE
`
`7
`4
`
`INVEGA
`
`INvEGA
`INVEGA
`
`INVEGA
`EINVEGA
`INVEGA
`
`[INVEGA
`INVEGA
`
`1049504
`1049611
`1049545 SBD
`1049613 SBD
`1049563 SCD
`1049686 SCD
`1049565 SBD
`1049615
`1049618
`1049576 SBD
`1049620 SBD
`1049584 SCD
`1049586 SBD
`1049696 SCD
`1049621 SCD
`1049623 SBD
`1049595 SBD
`1049599 SCD
`1049601 SBD
`91792 SBD
`
`977874 SCD
`
`
`
`977942.SCD
`,_
`977876 SBD
`977943 SBD
`977894 SCD
`977896 SBD
`977902 SCD
`977904 SBD
`977909 SCD
`977911 SBD
`977915 SCD
`977917 SBD
`977923 SCD
`
`977939 SCD
`977925 SBD
`977940 SBD
`977929 SCD
`977931 SBD
`583218 SBD
`
`312199 SCD
`1601386 SBD
`1601390 SBD
`1601394 SBD
`545357 SBD
`866103 SCD
`866105 SBD
`672S67+SCD
`686441 SBD
`672569 SCD
`686443 SBD
`672571 SCD
`686445 SBD
`8S8O51LSBD
`858053 SBD
`
`858055 SBD
`858057580
`
`L
`
`I
`
`Source: hnpsz//www CmS,gOv/Medicare/PrE>SCrIpIIOrIADrUg~COvE-rage/PrescriptIorIDrUgCOvCOntra/RXCOITLraC!Ing_F»OIITIU aryGuidarICe mm!
`
`139
`
`Page 140
`
`
`Page 140
`
`

`
`FormuIary Reference File Calendar Year 2016
`
`
`
`I
`
`
`
`
`
`
`
`
`IReIated DF
`[ORAL TABLET
`EXTENDED RELEASE ORAL TABLET
`ORAL TABLET
`TOPICAL CREAM
`TOPICAL LOTION
`TOPICAL GEL
`TRANSDERMAL PATCH
`TOPICAL GEL
`ORAL SOLUTION
`EXTENDED RELEASE ORAL TABLET
`EXTENDED RELEASE ORAL TABLET
`
`IEXTENDED RELEASE ORAL TABLET
`EXTENDED RELEASE ORAL TABLET
`EXTENDED RELEASE ORAL TABLET
`ORAL TABLET
`EXTENDED RELEASE ORAL TABLET
`ORAL SOLUTION
`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
`ORAL SOLUTION
`ORAL TABLET
`EXTENDED RELEASE ORAL TABLET
`ORAL TABLET
`EXTENDED RELEASE ORAL TABLET
`EXTENDED RELEASE ORAL TABLET
`ORAL CAPSULE
`ORAL TABLET
`ORAL TABLET
`EXTENDED RELEASE ORAL TABLET
`EXTENDED RELEASE 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
`EXTENDED RELEASE ORAL TABLET
`EXTENDED RELEASE ORAL TABLET
`EXTENDED RELEASE ORAL TABLET
`EXTENDED RELEASE ORAL TABLET
`EXTENDED RELEASE ORAL TABLET
`ORAL TABLET
`EXTENDED RELEASE ORAL TABLET
`ORAL TABLET
`EXTENDED RELEASE ORAL TABLET
`EXTENDED RELEASE ORAL TABLET
`INJECTABLE SUSPENSION
`
`INJECTABLE SOLUTION
`ORAL CAPSULE
`ORAL CAPSULE
`ORAL CAPSULE
`INJECTABLE SOLUTION
`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 TABLET
`
`PREFILLED SYRINGE
`PREFILLED SYRINGE
`PREFILLED SYRINGE
`PREFILLED SYRLNGE
`
`IReIated SCDC
`__RXCUI
`312138IOXCARBAZEPINE 600 MG
`1365850 OXCARBAZEPINE 600 MG
`262090 OXCARBAZEPINE 600 MG
`
`207248IOXICONAZOLE 10 MG/ML
`207249IOXICONAZOLE 10 MG/ML
`1250565IOXYBUTYNlN 0.03 MG/MG
`404448|OXYBUTYNIN 0.162 MG/HR
`864820 OXYBUTYNIN CHLORIDE 0.1 MG/MG
`863599 OXYBUTYNIN CHLORIDE 1 MG/ML
`863619 OXYBUTYNIN CHLORIDE 10 MG
`863622 OXYBUTYNIN CHLORIDE 10 MG
`863628 OXYBUTYNIN CHLORIDE 15 MG
`863630 OXYBUTYNIN CHLORIDE 15 MG
`863636 OXYBUTYNIN CHLORIDE 5 MG
`863664 OXYBUTYNIN CHLORIDE 5 MG
`863638 OXYBUTYNIN CHLORIDE 5 MG
`1049604 OXYCODONE HYDROCHLORIDE 1 MG/ML
`1049502 OXYCODONE HYDROCHLORIDE 10 MG
`1049683 OXYCODONE HYDROCHLORIDE 10 MG
`1049504 OXYCODONE HYDROCHLORIDE 10 MG
`1049611 OXYCODONE HYDROCHLORIDE 15 MG
`1049545 OXYCODONE HYDROCHLORIDE 15 MG
`1049613 OXYCODONE HYDROCHLORIDE 15 MG
`1049563 OXYCODONE HYDROCHLORIDE 20 MG
`1049686 OXYCODONE HYDROCHLORIDE 20 MG
`
`1049565 OXYCODONE HYDROCHLORIDE 20 MG
`1049615 OXYCODONE HYDROCHLORIDE 20 MG/ML
`1049618 OXYCODONE HYDROCHLORIDE 30 MG
`1049576 OXYCODONE HYDROCHLORIDE 30 MG
`1049620 OXYCODONE HYDROCHLORIDE 30 MG
`1049584 OXYCODONE HYDROCHLORIDE 40 MG
`1049586 OXYCODONE HYDROCHLORIDE 40 MG
`1049696 OXYCODONE HYDROCHLORIDE 5 MG
`1049621 OXYCODONE HYDROCHLORIDE 5 MG
`1049623 OXYCODONE HYDROCHLORIDE 5 MG
`1049595 OXYCODONE HYDROCHLORIDE 60 MG
`1049599 OXYCODONE HYDROCHLORIDE 80 MG
`1049601 OXYCODONE HYDROCHLORIDE 80 MG
`91792 OXYMETHOLONE 50 MG
`977874 OXYMORPHONE HYDROCHLORIDE 10 MG
`977942 OXYMORPHONE HYDROCHLORIDE 10 MG
`977876 OXYMORPHONE HYDROCHLOR DE 10 MG
`977943 OXYMORPHONE HYDROCHLORIDE 10 MG
`977894 OXYMORPHONE HYDROCHLOR DE 15 MG
`977896 OXYMORPHONE HYDROCHLOR DE 15 MG
`977902 OXYMORPHONE HYDROCHLORIDE 20 MG
`977904 OXYMORPHONE HYDROCHLOR DE 20 MG
`977909 OXYMORPHONE HYDROCHLOR DE 30 MG
`977911 OXYMORPHONE HYDROCHLOR DE 30 MG
`
`
`
`
`I
`
`
`
`977915lOXYMORPHONE HYDROCHLOR DE 40 MG
`977917 OXYMORPHONE HYDROCHLOR DE 40 MG
`977923 OXYMORPHONE HYDROCHLOR DE 5 MG
`977939 OXYMORPHONE HYDROCHLOR DE 5 MG
`977925 OXYMORPHONE HYDROCHLOR DE 5 MG
`977940 OXYMORPHONE HYDROCHLOR DE 5 MG
`977929 OXYMORPHONE HYDROCHLOR DE 75 MG
`977931 OXYMORPHONE HYDROCHLOR DE 7.5 MG
`_.______.._'_.....____...__._
`583218 PACLITAXEL 5 MG/ML
`312199LPACLITAXEL 6 MG/ML
`1601386 PALBOC CLI8 100 MG
`1601390 PALBOC CLIB 125 MG
`1601394 PALBOC CLIB 75 MG
`545357 PALIFERMIN 5 MG/ML
`866103 PALIPERIDONE 1.5 MG
`866105 PAUPERIDONE 115 MG
`672567 PALIPER DONE 3 MG
`686441 PALIPERIDONE 3 MG
`672569 PALIPER DONE 6 MG
`686443 PALIPER DONE 6 MG
`672571 PALIPER DONE 9 MG
`686445 PALIPER DONE 9 MG
`
`F
`
`858051 PAUPERIDONE PALMITATE 156 MG/ML
`858053 PALIPERIDONE PALMITATE 156 MG/ML
`858055kPALIPER DONE PALMITATE 156 MG/ML
`858057 PALIPERIDONE PALMITATE 156 MG/ML
`
`Page 141
`
`
`Source‘ Imps‘//www Ems gov/Medicare/PrescripnOn—Drug—Co\/erage/Prescripm)nDrugCOvContra/RxComractTng_7FOrmuIaryGuTdance.htmI
`
`140
`
`Page 141
`
`

`
`FOrmuIary Reference File CaIendar Year 2016
`
`ReIated BN
`INVEGA
`INVEGA
`INVEGA
`INVEGA
`INVEGA
`
`SYNAGIS
`
`
`
`
`VECTIBIX
`
`FARYDAK
`FARYDAK
`IEARVDAK
`I
`
`PROTONIX
`PROTONIX
`
`PROTONIX
`NATPARA
`NATPARA
`NATPARA
`NATPARA
`
`ZEMPLAR
`
`ZEMPLAR
`
`zEMPLAR
`
`I
`
`ZEMPLAR
`—
`—
`
`I
`
`PAXIL
`PAXIL
`
`PAXIL
`PEXEVA
`
`PAXIL
`
`PAXIL
`PEXEVA
`
`
`
`PAXIL
`
`
`
`
`PEXEVA
`
`BRISDELLE
`
`
`L-
`
`
`
`SIGNIFOR
`
`SIGNIFOR
`
`SIGNIFOR
`
`4VELTASSA
`VELTASSA
`VELTASSA
`VOTRIENT
`ADAGEN
`ONCASPAR
`NEULASTA
`PEGASYS
`PEGASYS
`fEGASYS
`PEGASYS
`LPEGINTRON
`PEGINTRON
`PEGINTRON
`FPEGINTRON
`
`
`
`‘IRXNOND Description
`TTY
`RXCUI
`0.25 ML PALIPERIDONE PALMITATE 156 MG/ML PREFILLED SYRINGE [LNVEGA1
`858074 SBD
`|0.B75 ML PALIPERIDONE PALMITATE 312 MG/ML PREFILLED SYRINGE [INVEGAI
`165096B|SBD
`1315 ML PALIPERIDONE PALMITATE 312 MG/ML PREFILLED SYRINGE [INVI-ZGA)
`1650972IS8D
`1.75 ML PALIPERLDONE PALMITATE 312 MG/ML PREFILLED SYRINGE IINVEGA]
`1650974|S9D
`1650976|SBD
`2.625 ML PALIPERIDONE PALMITATE 312 MG/ML PREFILLED SYRINGE [INVEGAI
`261359 SBD
`PALIVIZUMAB 100 MG/ML LNJECTABLE SOLUTION [SYNAGIS]
`
`404606 SBD
`PALONOSETRON 0.05 MG/ML INJECTABLE SOLUTION {ALOXII
`
`904919 SCD
`IPAMLDRONATE DISODIUM 3 MG/ML INJECTABLE SOLUTION
`904923 SCD
`PAMIDRONATE DISODIUM 6 MG/ML ENJECTABLE SOLUTION
`PAMIDRONATE DISODIUM 9 MG/ML INJECTABLE SOLUTION
`PANITUMUMAB 20 MG/ML INJECTABLE SOLUTION [VECTIBIX]
`PANOBINOSTAT 10 MG ORAL CAPSULE [FARYDAK}
`PANOBINOSTAT 15 MG ORAL CAPSULE IFARYDAKI
`PANOBINOSTAT 20 MG ORAL CAPSULE [FARYDAKI
`PANTOPRAZOLE 20 MG DELAYED RELEASE ORAL TABLET
`PANTOPRAZOLE 20 MG DELAYED RELEASE ORAL TABLET [PROTONIX]
`PANTOPRAZOLE 4 MG/ML INJECTABLE SOLUTION {PROTONIX}
`PANTOPRAZOLE 40 MG DELAYED RELEASE ORAL TABLET
`
`667897
`1603361
`1603365 SBD
`1603369 SBD
`251372 SCD
`352125
`885257 SBD
`314200
`284400 SBD
`
`PANTOPRAZOLE 40 MG ORAL GRANULES [PROTON1x)
`14 ACTUAT PARATHYROID HORMONE 0.025 M6/ACTUAT PREFILLED SYRINGE [NATPARA]
`1602028
`1602034 14 ACTUAT PARATHYROID HORMONE 0.05 MG/ACTUAT PREFILLED SYRINGE [NATPARA]
`1602040
`14 ACTUAT PARATHYROID HORMONE 0.075 MG/ACTUAT PREFILLED SYRINGE [NATPARA]
`1602046
`14 ACTUAT PARATHYROID HORMONE 0.1 MG/ACTUAT PREFILLED SYRINGE {NATPARA]
`577315 SCD
`PARICALCITDL 0.001 MG ORAL CAPSULE
`606854 SBD
`PARICALCITOL 0.001 MG ORAL CAPSULE [ZEMPLAR]
`577317 SCD
`PARICALCITOL 0002 MG ORAL CAPSULE
`606859 SBD
`PARICALCITOL 0002 MG ORAL CAPSULE [ZEMPLAR]
`351154 SCD
`PARICALCITOL 0.002 MG/ML INJECTABLE SOLUTION
`352076 SBD
`PARICALCITOL 0.002 MG/ML INJECTABLE SOLUTION [ZEMPLAR]
`577324 SCD
`PARICALCITOL 0.004 MG ORAL CAPSULE
`200321 SCD
`PARICALCITOL 0.005 MG/ML INJECTABLE SOLUTION
`213298 SSD
`PARICALCITOL 0.005 MG/ML INJECFABLE SOLUTION [ZEMPLAR}
`314184 SCD
`PAROMOMYCIN 250 MG ORAL CAPSULE
`312241 SCD
`PAROXETINE 10 MG ORAL TABLET
`211699
`PAROXETINE 10 MG ORAL TABLET [PAXILI
`541660 SBD
`PAROXETINE 10 MG ORAL TABLET [PEXEVA]
`562790 SCD
`PAROXETINE 12.5 MG EXTENDED RELEASE ORAL TABLET
`828446 SBD
`PAROXETINE 12.5 MG EXTENDED RELEASE ORAL TABLET [PAXILI
`213291 SBD
`PAROXETINE 2 MG/ML ORAL SUSPENSION [PAXIL]
`314.199 PAROXETLNE 20 MG ORAL TABLET
`207349 SBD
`PAROXETINE 20 MG ORAL TABLET [PAXIL]
`541662 SBD
`__PAROXETLNE 20 MG ORAL TABLET {PEXEvA}
`562791 SCD
`PAROXETINE 25 MG EXTENDED RELEASE ORAL TABLET
`828448 SBD
`PAROXETLNE 25 MG EXTENDED RELEASE ORAL TABLET [PAXIL]
`312243 SCD
`PAROXETINE 30 MG ORAL TABLET
`207350 SBD
`PAROXETINE 30 MG ORAL TABLET [PAXIL]
`541664 SBD
`PAROXETINE 30 MG ORAL TABLET [PExEvA}
`562815 SCD
`PAROXETINE 375 MG EXTENDED RELEASE ORAL TABLET
`
` 828451 SEE)
`PAROXETINE 37.5 MG EXTENDED RELEASE ORAL TABLET [PAXIL]
`312244 SCD
`PAROXETINE 40 MG ORAL TABLET
`
`
` 211700 SBD
`PAROXETINE 40 MG ORAL TABLET [PAXIL]
`541666 SBD
`PAROXETINE 40 MG ORAL TABLET [PEXEVA]
`
`
`
` 1430128 SBD
`PAROXETINE 7.5 MG ORAL CAPSULE [BRISDELLEI
`1364114 SBD
`PASIREOTIDE 0.3 MG/ML INJECTABLE SOLUTION ISIGNIFORI
`1364118 SBD
`PASIREOTIDE 0.6 MG/ML INJECTABLE SOLUTION [SIGNIFOR]
`
`1364122 SBD
`PASIREOTIDE 0.9 MG/ML INJECTABLE SOLUTION [SIGNIFOR]
`
`1597599 SBD
`PASIREOTIDE 10 MG/ML INJECTABLE SUSPENSION [SIGNIFOR]
`
`1597603 SBD
`PASIREOTIDE 20 MG/ML INJECTABLE SUSPENSION [SIGNIFOR]
`1597822 SBD
`PASIREOTIDE 30 MG/ML INJECTABLE SUSPENSION [SIGNIFOR]
`
`
`
`"
`
`171621iSBD
`1716223‘_SBD
`171621S_SBD
`867506 SBD
`207351 SBD
`213040 SBD
`727542 SBD
`352297 SBD
`1191665 S80
`1650940 SBD
`731328#S8D
`805007 SBD
`790247 SBD
`8O5OO8TSBD
`760039 S80
`
`_
`r
`
`L
`
`g
`
`PATIROMER 16800 MG POWDER FOR ORAL SUSPENSION [VELTASSA]
`PATIROMER 25200 MG POWDER FOR ORAL SUSPENSION [VELTASSA]
`PATIROMER 8400 MG POWDER FOR ORAL SUSPENSION EVELTASSAI
`PAZOPANIB 200 MG ORAL TABLET [VOTRIENT]
`PEGADEMASE BOVINE 250 UNT/ML INJECTABLE SOLUTION [ADAGEN]
`PEGASPARGASE 750 UNT/ML INTECTABLE SOLUTION [ONCASPAR]
`0.6 ML PEGFILGRASTIM 10 MG/ML PREFILLED SVRINGE [NEULAST/A}
`PEGINTERFERON ALFA-2A 0.18 MG/ML INJECTABLE SOLUTION [PEGASYS]
`0.5 ML PEGINTERFERON ALFA-2A 0.27 MG/ML PREFILLED SYRINGE [PEGASYS]
`0.5 ML PEGINTERFERON ALFA-2A 0.36 MG/ML AUTO—INJECTOR [PEGASYS]
`0.5 ML PEGINTERFERON ALFA~2A 0 36 MG/ML PREFILLED SYRINGE IPEGASVS}
`TPEGINTERFERON ALFA~2B 0.1 MG/ML INJECTABLE SOLUTION [PEGINTRON]
`‘0.5 ML PEGINTERFERON ALFA-2B 0.1 MG/ML PREFILLED SYRINGE [PEGINTRON]
`PEGINTERFERON ALFA-ZB 0.16 MG/ML INJECTABLE SOLUTION [PEGINTRON]
`{(1.5 ML PEGINTERFERON ALFAQB 0.16 MG/ML PREFILLED SYRINGE EPEGINTRON}
`
`Source’ https'//www.CmS gOv/Medncare/Prescript1On—DrUg—COverage/PrescnpnonDrL1gCOvCODtTa/Rxcomractzngjormu an/Guxdance-.hLmI
`
`141
`
`Page 142
`
`
`Page 142
`
`

`
`Formulary Reference FiIe CaIendar Year 2016
`
`Related DF
`PREFILLED SYRIN