throbber
Formulary Reference Fife CaIendar Year 2016
`
`Related DF
`EXTENDED RELEASE ORAL CAPSULE
`EXTENDED RELEASE ORAL CAPSULE
`EXTENDED RELEASE ORAL CAPSULE
`EXTENDED RELEASE ORAL CAPSULE
`ORAL TABLET
`
`ORAL TABLET
`ORAL TABLET
`ORAL SOLUTION
`ORAL TABLET
`ORAL TABLET
`
`PACK
`ORAL TABLET
`ORAL TABLET
`INJECTABLE SOLUTION
`INJECTABLE SOLUTION
`INJECTABLE SOLUTION
`
`ORALTAB
`
`ORAL SUS
`ORAL sus
`ORAL TAB
`ORAL TAB
`ORAL
`CAP
`
`LET
`PENSION
`PENSION
`LET
`LET
`SULE
`
`ORAL TABLET
`ORAL TABLET
`ORAL TABLET
`ORAL TABLET
`ORAL TABLET
`ORAL TABLET
`ORAL TABLET
`
`ORAL TABLET
`ORAL TABLET
`IORAL 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 TABLET
`ORAL TABLET
`ORAL TABLET
`ORAL TABLET
`ORAL TABLET
`IRRIGATION SOLUTION
`INJECTABLE SUSPENSION
`ORAL TABLET
`ORAL TABLET
`ORAL TABLET
`ORAL TABLET
`ORAL CAPSULE
`ORAL CAPSULE
`ORAL CAPSULE
`
`ORAL CAPSULE
`DRY POWDER INHALER
`AORAL SOLUTION
`INIECTABLE SOLUTION
`
`[ORAL SOLUTION
`ORAL CAPSULE
`‘ORAL CAPSULE
`
`I
`
`'
`
`I
`[
`
`J
`
`EX_
`
`Part 5
`
`V.
`1 5'0 1
`
`RXCUI
`
`——4
`
`Related SCDC
`VERAPAMIL HYDROCHLORIDE 300 MG
`VERAPAMIL HYDROCHLORIDE 300 MG
`897630
`VERAPAMIL HYDROCHLORIDE 360 MG
`VERAPAMIL HYDROCHLORIDE 360 MG
`897632
`
`897722 VERAPAMIL HYDROCHLORIDE 40 MG
`I
`897683 VERAPAMIL HYDROCHLORIDE 80 MG
`897685 VERAPAMIL HYDROCHLORIDE 80 MG
`860898 VIGABATRIN 50 MG/ML
`860895 VIOABATRIN 500 MG
`1086776 VILAZODONE HYDROCHLORIDE 10 MG
`
`
`
`1653470 VILAZODONE HYDROCHLORIDE 10 MG / vILA2ODONE HYDROCHLORIDE 20 MG
`VILAZODONE HYDROCHLORIDE 20 MG
`1086786 vILAzODONE HYDROCHLORIDE 40 MG
`239178 VINBLASTINE 1 MG/ML
`VINCRISTINE SULFATE 1 MG/ML
`894896 VINCRISTINE sULI=ATE 1 MG/ML
`VINORELBINE 10 MG/ML
`
`352219 VORICONAZOLE 200 MG
`
`VORICONAZOLE 40 MG/ML
`VORICONAZOLE 40 MG/ML
`349435 VORICONAZOLE 50 MG
`352218 VORICONAZOLE 50 MG
`668606 VORINOSTAT 100 MG
`
`—V
`
`ORTIOXETINE 10 MG
`VORTIOXETINE 20 MG
`VORTIOXETINE 5 MG
`WARFARIN SOD UM 1 MG
`WARFARIN SOD UM 1 MG
`WARFARIN SOD UM 1 MG
`855296 WARFAR N 500 UM 10 MG
`
`WARFARIN SOD UM 10 MG
`855300 WAREARIN SOD UM 10 MG
`855302 WARFARIN SOD UM 2 MG
`855304 WARFAR N SOD UM 2 MG
`855306 WARFAR N SOD UM 2 MG
`B55312 WARFAR N SODIUM 2.5 MG
`855314751/AREAR N SOD UM 2.5 MG
`855316 WAREAR N SOD UM 2.5 MG
`
`855318 WAREAR N SODIUM 3 MG
`855320 WARFAR N SOD UM 3 MG
`855322 WARFAR N SOD UM 3 MG
`855324 WARFAR N SOD UM 4 MG
`855326 WAREAR N SODIUM 4 MG
`855328 WAREAR N SOD UM 4 MG
`855332 WARFARIN SODIUM 5 MG
`855334 WARFAR N SODIUM 5 MG
`855336 WARFARIN SOD UM 5 MG
`855338 WARFARIN SODIUM 6 MG
`855340 WARFAR N SOD UM 6 MG
`855342 WARFARIN SOD UM 6 MG
`855344 WARFAR N SODIUM 7.5 MG
`855346 WARFAR N SOD UM 7.5 MG
`855348 WARFARIN SODIUM 7.5 MG
`150985 wATER 1000 MG/ML
`1292828 YELLOW-FEVER vIRUS VACCINE, 170-204 STRAIN 4000 UNT/ML
`313758 ZAFIRLUKAST 10 MG
`261313 ZAFIRLUKAST 10 MG
`199655 ZAFIRLUKAST 20 MG
`211776 ZAFIRLUKAST 20 MG
`313761 ZALEPLON 10 MG
`261286 ZALEPLON 10 MG
`313762 ZALEPLON 5 MG
`
`261285 ZALEPLON 5 MG
`759473 ZANAMIVIR 5 MG/ACTUAT
`756209 ZIDOVUDINE 10 MG/ML
`108396 ZIDOVUDTNE 10 MG/ML
`
`L 755298 ZIDOVUDINE 10 MG/ML
`198352 ZIDOVUDINE 100 MG
`201907'zIDOvUDINE 100 MG
`
`A A
`
`A
`
`Page 181
`
`
`Source: ITttps://www.Cms.gOv/fvIeascarefPrescTIpL:On—DTug—COverage/PrescrIptionDTugCOvCOntTa/R><COntTaEtIng_FOrmuiaryGuidance htmi
`
`180
`
`Page 181
`
`NPS Ex. 2162
`Part 5
`CFAD v. NPS
`IPR2015-01093
`
`

`

`Re|ated BN
`
`ZYFLO
`ZYFLO
`
`GEODON
`
`GEODON
`
`+_GEODON
`GEODON
`
`GEODON
`zALTRAP
`ZOMETA
`
`RECLAST
`
`ZOMETA
`
`Formufary Reference File Calendar Year 2016
`
`[RxNorm Description
`TTY
`|zL0OvUDmE 300 MG ORAL TABLET
`199663 SCD
`12 HR ZILEUTON 600 MG EXTENDED RELEASE ORAL TABLET [ZYFLO]
`790889 SBD
`211777 SBD
`ZILEUTON 600 MG ORAL TABLET [Z‘{FLO}
`314286 SCD
`ZLPRASLDONE 20 MG ORAL CAPSULE
`
`285127 SBD
`ZIPRASIDONE 20 MG ORAL CAPSULE [GEODON]
`
`3522281580
`ZLPRASTDONE 20 MG/ML INJECTABLE SOLUTION [GEODON]
`
`
`
`ZIPRASIDONE 40 MG ORAL CAPSULE
`313775|SC0
`284548|SBD
`|zLPRASTDONE 40 MG ORAL CAPSULE [GEODON]
`313777 SCD
`ZTPRASTDONE E0 M6 ORAL CAPSULE
`284549 SBD
`ZLPRASLDONE 60 MG ORAL CAPSULE [GEODONI
`313778 SCD
`ZIPRASIDONE 80 MG ORAL CAPSULE
`284550 SBD
`ZLPRASLOONE 80 MG ORAL CAPSULE {GEODON]
`1304484 SBD
`ZIV—AFLlBERCEPT 25 MG/ML INJECTABLE SOLUTION {ZALTRAP)
`1114037
`ZOLEDRONIC ACID 0.04 MG/ML WJECTABLE SOLUTION [ZOMETA]
`705824
`ZOLEDRONLC ACID 0.05 MG/ML INJECTABLE SOLUTION
`705875
`ZOLEDRONIC ACID 0.05 MG/ML INJECTABLE SOLUTION {RECLAST]
`351114
`ZOLEDRONIC ACID 0.8 MG/ML INJECTABLE SOLUTLON
`5
`
`
`
`RXCUI
`
`—9
`
`01802 580
`
`SBD
`
`
`
`
`
`ZOLMITRIPTAN 2.5 MG ORAL TABLET [ZOMlG}
`ZOLMITRIPTAN 2.5 MG/ACTUAT NASAL SPRAY [ZOM|G}
`ZOLMLTRTPTAN 5 MG DLSLNTEORATLNG ORAL TABLET
`
`
`
`
`ZOMIG
`ZOMIG
`—
`
`ZOMIG
`INTERMEZZO
`
`
`
`402169 SBD
`
`ZOLMITRIPTAN 5 MG/ACTUAT NASAL SPRAY [ZOMIG]
`ZOLPIDEM TARTRATE 175 MG SUBLINGUAL TABLET [INTERMEZZO]
`
`
`SCD ZOLPIDEM TARTRATE 10 MG ORAL TABLET
`SBD
`ZOLPIDEM TARTRATE 10 MG ORAL TABLET [AMBLEN]
`
`AMB|EN
`EDLUAR
`ZOLPLDEM TARTRATE 12.5 MG EXTENDED RELEASE ORAL TABLET —
`
`ZOLPLOEM TARTRATE 5 MG ORAL TABLET
`
`—
`
`‘
`
`SBD
`828696 SBD
`854894 SCD
`834895 530
`314285 SCD
`284408 SBD
`SCD
`
`403957 SCD
`
`ZOLPIDEM TARTRATE 5 MG/ACTUAT ORAL SPRAY [ZOLPTMLST]
`ZOLPIDEM TARTRATE 6.25 MG EXTENDED RELEASE ORAL TABLET —
`ZOLPLDEM TARTRATE 6.25 MG EXTENDED RELEASE OTDAL TABLET [AMBIENT
`
`ZONISAMIDE 100 MG ORAL CAPSULE
`ZONLSAMLDE 100 MG ORAL CAPSULE [ZONEGRAN}
`ZONlSAM|DE 25 MG ORAL CAPSULE
`ZONISAMIDE 25 MG ORAL CAPSULE [ZONEGRAN]
`ZONISAMIDE 50 MG ORAL CAPSULE
`
`ZONEGRAN
`
`|
`
`ZONEGRAN
`
`U
`;
`'
`.
`
`§
`1;
`*
`
`5 E
`
`I
`
`|
`
`Page 182
`
`
`Source: https://www.CmS.gOv/Medzcare/Pres:ription—Dmg—COverage/PreSCruptTOnDxugCOL/Contra/RxCOntraCtLng_FOrmUlaryGLndanCe.htrT:£
`
`181
`
`Page 182
`
`

`

`Formulary Reference File Calendar Year 2016
`
`RXCUI
`
`
`
`Related DF
`Related SCDC
`ORAL TABLET
`199663 ZIDOVUDINE 300 MG
`EXTENDED RELEASE ORAL TABLET
`790889 ZILEUTON 600 MG
`ORAL TABLET
`211777 ZILEUTON 600 MG
`ORA L CAPSULE
`314286 ZIPRASIDONE 20 MG
`:..4._._
`ORAL CAPSULE
`285127 ZIPRASIDONE 20 MG
`INIECTABLE SOLUTION
`352228 ZIPRASIDONE 20 MG/ML
`313776 ZIPRASIDONE 40 MG
`ORAL CAPSULE
`ORAL CAPSULE
`284548 ZIPRASIDONE 40 MG
`313777 ZIPRASIDONE 60 MG
`ORAL CAPSULE
`ORAL CAPSULE
`284549 ZIPRASIDONE 60 MG
`ORAL CAPSULE
`313778 ZIPRASIDONE 80 MG
`ORAL CAPSULE
`284550 ZIPRASIDONE 80 MG
`1
`INJECTABLE SOLUTION
`304484 ZIVEAFLIBERCEPT 25 MG/ML
`1 114087 ZOLEDRONIC ACID 0.04 MG/ML
`INJECTABLE SOLUTION
`
`INJECTABLE SOLUTION
` 705824 ZOLEDRONIC ACID 0105 MG/ML
`INJECTABLE SOLUTION
` 705875 ZOLEDRONIC ACID 0.05 MG/ML
`INJECTABLE SOLUTION
` 351114 ZOLEDRONIC ACID 0.8 MG/ML
`INJECTABLE SOLUTION
`351945 ZOLEDRONIC ACID 0.8 MG/ML
`
`DISINTEGRATING ORAL TABLET
`284201 ZOLMITRIPTAN 2.5 MG
`
`ORAL TABLET
`200193 ZOLMITRIPTAN 2.5 MG
`
`DISINTEG RATING ORAL TABLET
`901802 ZOLMITRIPTAN 2.5 MG
`
`ORAL TABLET
`153353 ZOLMITRIPTAN 2.5 MG
`
`1
`NASAL SPRAY
`483679 ZOLMITRIPTAN 215 MG/ACTUAT
`
`DISINTEGRATING ORAL TABLET
`351134 ZOLMITRIPTAN 5 MG
`
`ORAL TABLET
`200194 ZOLMITRIPTAN 5 MG
`DISINTEGRATING ORAL TABLET
`901803 ZOLMITRIPTAN 5 MG
`ORAL TABLET
`213167 ZOLMITRIPTAN 5 MG
`NASAL SPRAY
`402169 ZOLMITRIPTAN 5 MG/ACTUAT
`SUBLINGUAL TABLET
`1232200 ZOLPIDEM TARTRATE 1.75 MG
`ORAL TABLET
`854873 ZOLPIDEM TARTRATE 10 MG
`854875 ZOLPIDEM TARTRATE 10 MG
`ORAL TABLET
`SUBLINGUAL TABLET
`836645 ZOLPIDEM TARTPATE 10 MG
`EXTENDED RELEASE ORAL TABLET
`854880 ZOLPIDEM TARTRATE 1215 MG
`EXTENDED RELEASE ORAL TABLET
`854882 ZOLPIDEM TARTRATE 1215 MG
`SUBLINGUAL TABLET
`1232204 ZOLPIDEM TARTRATE 315 MG
`ORAL TABLET
`854876 ZOLPIDEM TARTRATE 5 MG
`ORAL TABLET
`854878 ZOLPIDEM TARTRATE 5 MG
`SUBLINGUAL TABLET
`836649 ZOLPIDEM TARTRATE 5 MG
`ORAL SPRAY
`828696 ZOLPIDEM TARTRATE 5 MG/ACTUAT
`EXTENDED RELEASE ORAL TABLET
`..2...._..,_..___.....,._M _. _. _.., __.2____-21.._._._1. ..__._.,__.._._..,,_..,_.1._.._.....,.._,,_.___.,.fi...,,_..__L__.......,. -_1 ._..__...._.,__.
`§§§§94 g_gLPIDEM TARTRATE 625 MG
`854896 ZOLPIDEM TARTRATE 6.25 MG
`EXTENDED RELEASE ORAL TABLET
`314285 ZONISAMIDE 100 MG
`ORAL CAPSULE
`7\lOEU)>E 0IT‘ 5"Q3 ga
`ORAL CAPSULE
`ORAL CAPSULE
`403966 ZONISAMIDE 25 MG
`404725 ZONISAMIDE 25 MG
`ORAL CAPSULE
`
`ORAL CAPSULE
`403967 ZONISAMIDE 50 MG
`
`
`'
`
`-1
`
`'___
`
`
`
`
`
`Source’ https://www.cms gov/Medicare/PrescrlptlorvDrug—Coverage/PrescrlprionDrugCovContra/RxContractmgjormuIaryGurdance.htmI Page 1
`
`
`182
`
`Page 183
`
`

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