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`Formulary Guidance
`
`This page prcvades important infonnation on presmpzcon drug ooverage poiicses under Medicare, the framewom for
`CMS’ review of Medicare piescnpiion drug pian formuiaries, and snstmmions csncemsng formuiary me uploads.
`
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`2038 Pncm D ta Guidelines and Caiendar v 06 18 15' ZIP 315KB
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`2015 Pncsgg Data Gutdeiines. and CaiendarjD4,24,14) [Z§P SSZKBL
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`NPS EX. 2162
`
`Part 1
`
`CFAD V. NPS
`
`IPR2015—O1093
`
`https:f;"w'wwv.c1ns.govfiivledicarefPrescription-Drug-C(average/PrescriptionDrugCovComrafR. ..
`
`Page 1
`
`NPS Ex. 2162
`Part 1
`CFAD v. NPS
`IPR2015-01093
`
`

`

`Formulary Reference File Calendar Year 2016
`
`N __
`
`'
`
`_
`
`RXCUI
`
`L__
`
`R><Norm DESUIDLIOH
`TYY
`ABACAVIR 20 MG/ML ORAL SOLUT|ON [ZIAGENI
`213461 SBD
`ABACAVIR 300 MG ORAL TABLET
`242679 SCD
`ABACAVIR 300 MG ORAL TABLET [ZIAGENI
`7“
`V
`213460 530
`ABACAVIR 300 MG / LAMIVUDINE 150 MG / ZIDOVUDINE 300 MG ORAL TABLET
`307650 SCD
`ABACAVIR 300 MG / LAMIVUDINE 150 MG / ZIDOVUDINE 300 MG ORAL TABLET [TRIZIVIR]
`285028 SBD
`ABACAVIR 600 MG / DOLUTEGRAVIR 50 MG/ LAMIVUDINE 300 MG ORAL TABLET [TRIUMEQ)
`1546894 SBD
`ABACAVIR 600 MG/ LAMIVUDKNE 300 MG ORAL TABLET [EPZICOM}
`602395 SBD
`J1 ML ABATACEPT 125 MG/ML PREFILLED SYRINGE [ORENCIA]
`1145932 SBD
`£BATACEPT 25 MG/ML INJECTABLE SOLUTION EORENCIAT
`616018 SBD
`ABIRATERONE ACETATE 250 MG ORAL TABLET [ZYTIGA]
`1100079 SBD
`ABOBOTULINUMTOXINA 500 UNT/ML INJECTABLE SOLUT|ON [DYSPORT]
`860174 SBD
`ACAMPROSATE CALCIUM 333 MG DELAYED RELEASE ORAL TABLET
`835726 SCD
`ACARBOSE 100 MG ORAL TABLET
`199150 SCD
`209248 SBD
`ACARBOSE 100 MG ORAL TABLET [PRECOSE]
`
` 200132 SCD ACARBOSE 25 MG ORAL TABLET
`
`213170 SBD
`ACARBOSE 25 MG ORAL TABLET [PRECOSE]
`199149 SCD
`ACARBOSE 50 MG ORAL TABLET
`209247 SBD
`ACARBOSE 50 MG ORAL TABLET [PRECOSE]
`998689 SCD
`ACEBUTOLOL HYDROCHLORIDE 200 MG ORAL CAPSULE
`998691 SBD
`ACEBUTOLOL HYDROCHLORIDE 200 MG ORAL CAPSULE [SECTRAL]
`998685 SCD
`ACEBUTOLOL HYDROCHLORIDE 400 MG ORAL CAPSULE
`998687 SBD
`ACEBUTOLOL HYDROCHLORIDE 400 MG ORAL CAPSULE [SECTRAL]
`
`1648584 SBD
`856940 SCD
`856942 SBD
`856946 SBD
`993755 SCD
`
`ACETAMINOPHEN 21.7 MG/ML/ BUTALBITAL 3.33 MG/ML/ CAFFEINE 2.67 MG/ML ORAL SOLUTION [VANATOLI
`ACETAMINOPHEN 21.7 MG/ML/ HYDROCODONE BITARTRATE 0.5 MG/ML ORAL SOLUTION
`ACETAMINOPHEN 21.7 MG/ML/ HYDROCODONE BITARTRATE 0.5 MG/ML ORAL SOLUTION [HYCET]
`ACETAMINOPHEN 21.7 MG/ML/ HYDROCODONE BITARTRATE 0.67 MG/ML ORAL SOLUTION [ZAMICETI
`ACETAMINOPHEN 24 MG/ML / CODEINE PHOSPHATE 2.4 MG/ML ORAL SOLUTION
`
`ACETAMINOPHEN 24 MG/ML / CODEINE PHOSPHATE 2.4 MG/ML ORAL SUSPENSION {CAPITAL AND CODEINE]
`ACETAMINOPHEN 300 MG / BUTALBITAL 50 MG ORAL TABLET [BUPAP]
`ACETAMINOPHEN 300 MG / BUTALBITAL 50 MG / CAFFEINE 40 MG ORAL CAPSULE
`ACETAMINOPHEN 300 MG / BUTALBITAL 50 MG / CAFFEINE 40 MG ORAL CAPSULE [FIORICET]
`
`ZTAGEN
`
`iiielated BN
`ZIAGEN
`
`L
`|TRIZIVIR
`ITRIUMEQ
`EPZICOM
`ORENCIA
`ORENCIA
`ZYTIGA
`DYSPORT
`
`PRECOSE
`
`PRECOSE
`
`PRECOSE
`
`SECTRAL
`
`SECTRAL
`
`VANATOL
`
`HYCET
`ZAMICET
`
`J
`____J
`
`_|
`
`CAPITAL AND CODEINE
`BUPAP
`
`FIORICET
`
`ACETAMINOPHEN 300 MG / BUTALBITAL 50 MG / CAFFEINE 40 MG / CODEINE PHOSPHATE 30 MG ORAL CAPSULE
`ACETAMINOPHEN 300 MG / BUTALBITAL 50 MG / CAFFEINE 40 MG / CODEINE PHOSPHATE 30 MG ORAL CAPSULE
`[FIORICET WITH CODEINE]
`ACETAMINOPHEN 300 MG / CODEINE PHOSPHATE 15 MG OPAL TABLET
`ACETAMINOPHEN 300 MG / CODEINE PHOSPHATE 30 MG ORAL TABLET
`
`FIORICET WITH CODEINE
`‘T
`‘
`
`993890 SCD
`
`993837 SBD
`993892 SBD
`
`856980 SCD
`1310270JSBD
`856984 SBD
`
`F
`
`K
`
`ACETAMINOPHEN 300 MG / CODEINE PHOSPHATE 60 MG ORAL TABLET
`
`‘J_A_CETAM!:’\£OPHEI\.1 300 MG,’CODEINE PHOSPHATE 30MGORAL TAB1.ET[TY‘.ENOL'~.»‘\.-‘IT‘I
`ACETAMINOPHEN300MG/CODEINEPHOSPHATE60MGORALTABLET[TYLENOLWITHCODEINE}
`
`ACETAMINOPHEN 300 MG/ HYDROCODONE BITARTRATE 10 MG ORAL TABLET
`ACETAMINOPHEN 300 MG/ HYDROCODONE BITARTRATE 10 MG ORAL TABLET [VICODIN]
`ACETAM NOPHEN 300 MG / HYDROCODONE BITARTRATE 10 MG ORAL TABLET [XODOL]
`
`T’
`
`A
`
`7:‘/LEv’\£OL ’-:’V?TI~E CO’.‘—E$;"-EE
`TYLENOLWITHCODEINE
`
`VICODIN
`XODOL
`
`993767 SBD
`1428622 SBD
`889520 SCD
`1432261 SBD
`
`1431286 SCD
`
`1433802 SBD
`
`
`
`993770 SCD
`
`993781 SCD
`
`I
`I
`
`1
`|
`
`.
`
`+
`
`4
`
`I
`‘
`
`[
`
`T-LACETAM NOPHEN 300 MG / HYDROCODONE BITARTRATE 5 MG ORAL TABLET
`856987 SCD
`[ACETAM NOPHEN 300 MG / HYDROCODONE BITARTRATE 5 MG ORAL TABLET [VICODIN]
`1310202 SBD
`f_C_E_TAM NOPHEN 300 MG/ HYDROCODONE BITARTRATE 5 MG ORAL TABLET [XODOL]
`856991LSBD
`ACETAM NOPHEN 300 MG/ HYDROCODONE BITARTRATE 7.5 MG ORAL TABLET
`856992 SCD
`
`J_A_C_ETAM NOPHEN 300 MG/ HYDROCODONE BITARTRATE 7.5 MG ORAL TABLET [VICODIN]
`1310212
`856996
`_+A_CETAM NOPHEN 300 MG/ HYDROCODONE BITARTRATE 7.5 MG ORAL TABLET [XODOL]
`
`1537120 SBD
`*ACETAM NOPI- EN 300 MG / OXYCODONE HYDROCHLORIDE 10 MG ORAL TABLET [PRIMLEVT
`1537116 SBD
`ACETAM NOPHEN 300 MG / OXYCODONE HYDROCHLORIDE 5 MG ORAL TABLET [PRIMLEV]
`
`1537122 SBD
`
`lACETAM NOPI- EN 300 MG / OXYCODONE HYDROCHLORIDE 7.5 MG ORAL TABLET [PRIMLEV]
`
`4ACETAM|NOPI- EN 320.5 MG / CAFFEINE 30 MG / DIHYDROCODEINE BITARTRATE 16 MG ORAL CAPSULE [TREZIX]
`ACETAM NOPI~ EN 325 MG / BUTALBITAL 25 MG ORAL TABLET
`
`ACETAM NOPI- EN 325 MG / BUTALBITAL 50 MG ORAL TABLET
`ACETAMINOPE EN 325 MG / BUTALBITAL 50 MG / CAFFEINE 40 MG ORAL CAPSULE
`ACETAM NOPI> EN 325 MG / BUTALBITAL 50 MG / CAFFEINE 40 MG ORAL TABLET
`ACETAMINOPHEN 325 MG / BUTALBTTAL 50 MG / CAFFEINE 40 MG ORAL TABLET [ESGIC]
`ACETAMINOPHEN 325 MG / BUTALBITAL 50 MG / CAFFEINE 40 MG / CODEINE PHOSPHATE 30 MG ORAL CAPSULE
`ACETAMINOPE EN 325 MG / HYDROCODONE BITARTRATE 10 MG ORAL TABLET
`ACETAMINOPHEN 325 MG / HYDROCODONE BITARTRATE 10 MG ORAL TABLET [LORCET]
`‘ACETAMINOPE EN 325 MG / HYDROCODONE BITARTRATE 10 MG ORAL TABLET ILORTAB}
`AACETAMINOPHEN 325 MG/ HYDROCODONE BITARTRATE 10 MG ORAL TABLET [NORCO]
`1ACETAMINOPHEN 325 MG / HYDROCODONE BITARTRATE 2.5 MG ORAL TABLET
`ACETAMINOPHEN 325 MG / HYDROCODONE BITARTRATE 5 MG ORAL TABLET
`
`VICODIN
`FXODOL
`
`VICODIN
`XODOL
`PRIMLEV
`PRIMLEV
`
`PRIMLEV
`
`TREZIX
`
`4
`
`ESGIC
`
`LORCET
`LORTAB
`NORCO
`
`1190201 SBD
`1724446 SCD
`
`197426 SCD
`238153 SCD
`238154 SCD
`211189 SBD
`9939431SCD
`8569991SCD
`1492671‘FSBD
`1495472'SBD
`857001.380
`857391 SCD
`857002 SCD
`
`1492673‘SBD
`1495474 SBD
`857004 SBD
`
`L
`L
`
`I
`
`ACETAMINOPHEN 325 MG / HYDROCODONE BITARTRATE 5 MG ORAL TABLET [LORCETI
`+ACETAMINOPHEN 325 MG / HYDROCODONE BITARTRATE 5 MG ORAL TABLET [LORTABI
`ACETAMINOPHEN 325 MG / HYDROCODONE BITARTRATE 5 MG ORAL TABLET [NORCO]
`
`V
`
`TLORCET A__
`LORTAB
`NORCO
`
`85700aSC~'3
`
`_LACETAI\/TINOPHEN 325 MG /‘ HYDROCODONE BTTARTRP-TE 7.5 MG ORAL TABLET
`
`Source V-tips //www cm; gov/M9cIe.r,are/‘P:es:r:ptTon—Drug—Coverage/Pres:rup:nonDrugCo\/ComTa/Rxtomracteng;“Formularyfiugdance htmi
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`1
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`Page 2
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`Page 2
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`

`

`Formulary Reference F'LIe Calendar ‘(ear 2016
`
`L
`
`RXCUI
`
`Related SCDC
`213461 ABACAVIR 20 MG/ML
`242679 ABACAVIR 300 M6
`213460 ABACAVIR 300 MG
`307650 ABACAVIR 300 MG / LAMIVUDINE 150 MG / ZIDOVUDINE 300 MG
`285028 ABACAVIR 300 MG / LAMIVUDINE 150 MG / ZIDOVUDINE 300 MG
`1546894 ABACAVIR 600 MG / DOLUTEGRAVIR 50 MG / LAMIVUDINE 300 MG
`602395 ABACAVIR 600 MG / LAMIVUDINE 300 MG
`1145932 ABATACEPT 125 MG/ML
`616018 ABATACEPT 25 MG/ML
`1100079 ABIRATERONE ACETATE 250 MG
`860174 ABOBOTULINUMTOXINA 500 UNT/ML
`835726IACAML>RosATE CALCIUM 333 MG
`199150|ACARBosE 100 MG
`209248|ACARB05E 100 MG
`20o132|ACARBosE 25 MG
`213170 ACARBosE 25 MG
`199149 ACARBOSE 50 MG
`209247 ACARBOSE 50 MG
`998689 ACEBUTOLOL HYDROCHLORIDE 200 MG
`998691 ACEBUTOLOL HYDROCHLORIDE 200 MG
`998685 ACEBUTOLOL HYDROCHLORIDE 400 MG
`
`L
`
`998687 ACEBLJTOLOL HYDROCHLORIDE 400 MG
`
`Related OF
`
`
`ORAL SOLUTION
`ORAL TABLET
`
`ORAL TABLET
`
`ORAL TABLET
`
`|oRAL TABLET
`oRAL TABLET
`ORAL TABLET
`
`PREFILLED SYRINGE
`
`INJECTABLE SOLUTION
`
`ORAL TABLET
`INJECTABLE SOLUTION
`
`DELAYED RELEASE ORAL TABLET
`|oRAL TABLET
`
`|oRAL TABLET
`
`ORAL TABLET
`ORAL TABLET
`
`ORAL TABLET
`ORAL TABLET
`ORAL CAPSULE
`ORAL CAPSULE
`ORAL CAPSULE
`
`
`
`
`
`
`
`
`
`
`ORAL CAPSULE
`
`
`ORAL SOLUTION
`
`|ORAL SOLUTION
`[ORAL SOLUTION
`ORAL SOLUTION
`ORAL SOLUTION
`
`1648584 ACETAMINOPHEN 21.7 MG/ML/ BUTALBITAL 3.33 MG/ML / CAFFEINE 2.67 MG/ML
`856940 ACETAMINOPHEN 21.7 MG/ML/ HVDROCODONE BITARTRATE 0.5 MG/ML
`856942 ACETAMINOPHEN 21.7 MG/ML/ HYDROCODONE BITARTRATE 0.5 MG/ML
`856946 ACETAMINOPHEN 21.7 MG/ML/ HYDROCODONE BITARTRATE 0.67 MG/ML
`993755 ACETAMINOPHEN 24 MG/ML / CODELNE PHOSPHATE 2.4 MG/ML
`
`9937671/ACETAMINOPHEN 24 MG/ML/ CODEINE PHOSPHATE 2.4 MG/ML
`1428622 ACETAMINOPHEN 300 MG / BUTALBITAL 50 MG
`889520 ACETAMINOPHEN 300 MG / BUTALBITAL 50 MG / CAFFEINE 40 MG
`1432261 ACETAMINOPHEN 300 MG / BUTALBITAL 50 MG / CAFFEINE 40 MG
`ACETAMINOPHEN 300 MG / BUTALBITAL 50 MG / CAFFEINE 40 MG / CODEINE
`1431286 PHOSPHATE 30 MG
`ACETAMINOPHEN 300 MG / BUTALBITAL 50 MG / CAFFEINE 40 MG / CODEINE
`1433802 PHOSPHATE 30 MG
`
`993770 ACETAMINOPHEN 300 MG / CODEINE PHOSPHATE 15 MG
`993781 ACETAMINOPHEN 300 MG / CODEINE PHOSPHATE 30 MG
`
`993837 ACETAMINOPHEN 300 MG / CODEINE PHOSPHATE 30 MG
`993890 ACETAMINOPHEN 300 MG / CODEINE PHOSPHATE 60 MG
`
`993892 ACETAMINOPHEN 300 MG / CODEINE PHOSPHATE 60 MG
`856980 ACETAMINOPHEN 300 MG / HYDROCODONE BITARTRATE 10 MG
`1310270 ACETAMINOPHEN 300 MG / H‘./DROCODONE BITARTRATE 10 I‘/I6
`856984 ACETAMINOPHEN 300 MG / HYDROCODONE BITARTRATE 10 MG
`856987 ACETAMINOPHEN 300 MG/ HYDROCODONE BITARTRATE 5 MG
`1310202 ACETAMINOPHEN 300 MG / HVDROCODONE BITARTRATE 5 MG
`856991 ACETAMINOPHEN 300 MG/ HYDROCODONE BITARTRATE 5 MG
`856992 ACETAMINOPHEN 300 MG/ HYDROCODONE BITARTRATE 7.5 MG
`1310212 ACETAMINOPHEN 300 MG/ HYDROCODONE BITARTRATE 7.5 MG
`856996 ACETAMINOPHEN 300 MG / HYDROCODONE BITARTRATE 7.5 MG
`1537120 ACETAMINOPHEN 300 MG / OXYCODONE HYDROCHLORIDE 10 MG
`1S37116+ACETAI\/IINOPHEN 300 MG / OXVCODONE HYDROCHLORIDE 5 MG
`1537122 ACETAMINOPHEN 300 MG / OXYCODONE HYDROCHLORIDE 7.5 MG
`TACETAMINOPHEN 320.5 MG / CAFFEINE 30 MG / DIHYDROCODEINE BITARTRATE 16
`1190201 MG
`1724446 ACETAMINOPHEN 325 MG / BUTALBITAL 25 MG
`197426 ACETAMINOPHEN 325 MG / BUTALBITAL 50 MG
`238153 ACETAMINOPHEN 325 MG / BUTALBITAL 50 MG / CAFFEINE 40 MG
`238154 ACETAMINOPHEN 325 MG / BUTALBITAL 50 MG / CAFFEINE 40 MG
`211189 ACETAMINOPHEN 325 MG / BUTALBITAL 50 MG / CAFFEINE 40 MG
`ACETAMINOPHEN 325 MG / BUTALBITAL 50 MG / CAFFEINE 40 MG / CODEINE
`
`993943 PHOSPHATE 30 MG
`856999 ACETAMINOPHEN 325 MG / HYDROCODONE BITARTRATE 10 MG
`1492671 ACETAMINOPHEN 325 MG / HYDROCODONE BITARTRATE 10 MG
`1495472YACETAMINOPHEN 325 MG / H‘/DROCODONE BITARTRATE 10 MG
`857O014ACETAMINOPHEN 325 MG/ HYDROCODONE BITARTRATE 10 MG
`857391 ACETAMINOPHEN 325 MG / HYDROCODONE BITARTRATE 2.5 MG
`857002 ACETAMINOPHEN 325 MG/ HYDROCODONE BITARTRATE 5 MG
`1492673VACETAf\/IINOPHEN 325 MG ,’ HYDROCODONE BITARTRATE 5 MG
`1495474YACETAMINOPHEN 325 MG / HYDROCODONE BITARTRATE 5 MG
`857004 ACETAMINOPHEN 325 MG/‘ HYDROCODONE BITARTRATE 5 MG
`857005 ACETAMINOPHEN 325 MG ,/ HYDROCODONE BITARTRATE 7.5 MG
`
`ORAL SUSPENSION
`ORAL TABLET
`ORAL CAPSULE
`ORAL CAPSULE
`
`ORAL CAPSULE
`
`
`
`ORAL CAPSULE
`
`[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 TAB.ET
`ORAL TAB.ET
`ORAL TABLET
`ORAL TABLET
`Y-ORAL TAB.ET
`ORAL CAPSULE
`ORAL TAB .ET
`ORAL TAB.ET
`ORAL CAPSULE
`ORAL TAB.ET
`ORAL TAB_ET
`
`ORAL CAPSULE
`ORAL TAB.ET
`ORAL TABLET
`ORAL TABLET
`‘ORAL TAB_ET
`ORAL TABLET
`rORAL TABLET
`LCLEAL TABLET
`LORAL TAB_ET
`ORAL TAB ET
`ORAL TAB.ET
`
`‘
`
`I
`
`J
`
`1
`
`4
`
`J
`
`L
`7
`
`L
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`Page 3
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`
`Source https //www.Cm5.gov/Medncare/PrescrIption—Drug—Coverage/PrescrIptionDrugCovContra/R><ContraCtmgformU|aryGULdance html
`
`2
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`Page 3
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`

`

`FOrmUIary Reference File CaIendar Year 2016
`
`I
`|
`|
`
`1491834 SBD
`836395 SCD
`836397 SBD
`
`800979 SBD
`307702 SCD
`197303 SCD
`197304 SCD
`562524ISCD
`876439 SBD
`197305 SCO
`313786 SCD
`213525 SBD
`213557 SBD
`307718 SCD
`307719 SCD
`
`213069 SBD
`SCD
`SBD
`199690 SCD
`213070 SBD
`1303107 SBD
`1E07112,SBD
`1112246ISBD
`197312 SCD
`209977 SBD
`197310 SCD
`
`RxNorm Descnption
`TTY
`RXCUI
`
`ACETAMINOPHEN 325 MG / HYDROCODONE BITARTRATE 7.5 MG ORAL TABLET [LORCET]
`1492675 SBD
`
`
`ACETAMINOPHEN 325 MG / HYDROCODONE BITARTRATE 7.5 MG ORAL TABLET ILORTAB}
`1495476 SBD
`
`
`
`ACETAMINOPHEN 325 MG/ HYDROCODONE BITARTRATE 7.5 MG ORAL TABLET INORCOI
`857007
`ACETAMINOPHEN 325 MG / OXYCODONE HYDROCHLORIDE 10 MG ORAL TABLET
`1049214 SCD
`It
`1049216 SBD
`IACETAMINOPHEN 325 MG / OXYCODONE HYDROCHLORIDE 10 MG ORAL TABLET [ENDOCET]
`F
`1O49625TSBD
`IACETAMINOPHEN 325 MG / OXYCODONE HYDROCHLORIDE 10 MG ORAL TABLET [PERCOCET]
`1049635 SCD
`ACETAMINOPHEN 325 MG / OXYCODONE HYDROCHLORIDE 2.5 MG ORAL TABLET
`1049637 SBD
`ACETAMINOPHEN 325 MG / OXYCODONE HYDROCHLORIDE 2.5 MG ORAL TABLET [PERCOCET]
`1049221 SCD
`ACETAMINOPHEN 325 MG / OXYCODONE HYDROCHLORIDE 5 MG ORAL TABLET
`1049223 SBD
`ACETAMINOPHEN 325 M6 / OXYCODONE HYDROCHLORIDE 5 MG ORAL TABLET [ENDOCETI
`1049640 SBD
`ACETAMINOPHEN 325 MG / OXYCODONE HYDROCHLORIDE 5 MG ORAL TABLET IPERCOCET}
`1049225 SCD
`ACETAMINOPHEN 325 MG / OXYCODONE HYDROCHLORIDE 7.5 MG ORAL TABLET
`1049227 SBD
`ACETAMINOPHEN 325 MG / OXVCODONE HYDROCHLORIDE 7.5 MG ORAL TABLET [ENDOCET]
`1049642 SBD
`ACETAMINOPHEN 325 MG / OXYCODONE HYDROCHLORIDE 7.5 MG ORAL TABLET [PERCOCET]
`12 HR ACETAMINOPHEN 325 MG / OXYCODONE HYDROCHLORIDE 7.5 MG EXTENDED RELEASE ORAL TABLET
`{XARTEMIS}
`IACETAMINOPHEN 325 MG / TRAMADOL HYDROCHLORIDE 37.5 MG ORAL TABLET
`ACETAMINOPHEN 325 MG / TRAMADOL HYDROCHLORIDE 375 MG ORAL TABLET {ULTRACET}
`ACETATE 0.044 MEQ/ML/CYSTEINE 0.2 MG/ML/ HISTIDINE 2.5 MG/ML/ ISOLEUCINE 5.6 MG/ML/ LEUCINE 8.8
`MG/ML/ LYSINE 9 MG/ML/ METHIONINE 8.8 MG/ML/ PHENVLALANINE 8.8 MG/ML/ SODIUM BISULFITE 0.5
`MG/ML/SODIUM CHLORIDE 0.005 MEQ/ML/THREONINE 4 MG/ML/TRYPTOPHAN 2 MG/ML/VALINE 6.4 MG/ML
`INIECTABLE SOLUTION [NEPHRAMINE]
`ACETAZOLAMIDE 100 MG/ML INJECTABLE SOLUTION
`ACETAZOLAMIDE 125 MG ORAL TABLET
`ACETAZOLAMIDE 250 MG ORAL TABLET
`12 HR ACETAZOLAMIDE 500 MG EXTENDED RELEASE ORAL CAPSULE
`12 HR ACETAZOLAMIDE 500 MG EXTENDED RELEASE ORAL CAPSULE [DIAMO><)
`ACETIC ACID 20 MG/ML OTIC SOLUTION
`ACETIC ACID 20 MG/ML/ HYDROCORTISONE 10 MG/ML OTIC SOLUTION
`ACETIC ACID 20 MG/ML/ HYDROCORTISONE 10 MG/ML OTIC SOLUTION [ACETASOL HC]
`ACETOHYDROXAMIC ACID 250 MG ORAL TABLET [LITHOSTAT]
`ACETYLCYSTEINE 100 MG/ML INHALANT SOLUTION
`ACETYLCYSTEINE 200 MG/ML INHALANT SOLUTION
`ACITRETIN 10 MG ORAL CAPSULE
`ACITRETIN 10 MG ORAL CAPSULE [SORIATANE)
`ACITRETIN 175 MG ORAL CAPSULE
`ACITRETIN 175 MG ORAL CAPSULE [SORIATANE]
`|ACITRETIN 25 MG ORAL CAPSULE
`ACITRETIN 25 MG ORAL CAPSULE [SORIATANE]
`60 ACTUAT ACLIDINIUM BROMIDE 0.4 MG/ACTUAT DRY POWDER INHALER [TUDORZA]
`30 ACTLIAT .r:CLIDINILIM BROMIDE 0 4 MG,/ACTLIAT DRY POwD=.R I’\IHAI.ER [TL*DC.\R?.A}
`ACRIVASTINE 8 MG/ PSEUDOEPHEDRINE HYDROCHLORIDE 50 MC. ORAL CAPSULE [SER4PRE‘><7I§}“M
`IACYCLOVIR 0.05 MG/MG TOPICAL OINTMENT
`IACYCLOVIR 0.05 MG/MG TOPICAL OINTMENT [ZOVIRAX]
`ACYCLOVIR 200 MG ORAL CAPSULE
`
`ReIated BN
`LORCET
`LORTAB
`TNORCO
`ENDOCET
`PERCOCET
`PERCOCET
`
`ENDOCET
`PERCOCET
`
`ENDOCET
`PERCOCET
`
`XARTEMIS
`
`ULTRACET
`
`NEPHRAMINE
`
`I
`I
`1
`I
`
`|
`I
`
`ACETASOL HC
`LITHOSTAT
`
`SORIATANE
`L
`SORIATANE
`
`
`
`
`
`SORIATANE
`TUDORZA
`
`
`
`213694 SBD
`307730 SCD
`201903 SBD
`197311 SCD
`313812 SCD
`825321 SBD
`_ 998426 SBD
`197313 SCD
`
`213706 SBD
`15S572§I§D
`1551888 SBD
`
`727705+SBD
`r
`763565 SBD
`
`I
`
`ACYCLOVIR 200 MG ORAL CAPSULE [ZOVIRAX]
`ACYCLOVIR 40 MG/ML ORAL SUSPENSION
`ACYCLOVIR 40 MG/ML ORAL SUSPENSION [ZOVIRAX]
`ACYCLOVIR 400 MG ORAL TABLET
`ACYCLOVIR 50 MG/ML INJECTABLE SOLUTION
`ACYCLOVIR 50 MG/ML TOPICAL CREAM [ZOVIRAX]
`ACYCLOVIR 50 MG/ML / HVDROCORTISONE 10 MG/ML TOPICAL CREAM {XERESE}
`ACYCLOVIR 800 MG ORAL TABLET
`
`ACYCLOVIR 800 MG ORAL TABLET [ZOVIRAX]
`0.8 ML ADALIMUMAB 50 MG/ML AUTOINIECTOR [HUMIRA]
`0.2 ML ADALIMUMAB 50 MG/ML PREFILLED SYRINGE {HUMIRAI
`
`T08 ML ADALIMUMAB 50 MG/ML PREFILLED SYRINGE IHUMIRAI
`0.4 ML ADALIMUMAB 50 MG/ML PREFILLED SYRINGE [HUMIRA]
`
`1594358 BPCK
`
`{3 (0.8 ML ADALIMUMAB 50 MG/ML PREFILLED S‘/RINGE [HUMIRAD } PACK [HUMIRA PEDIATRIC CROHN‘S DISEASE
`STARTER PACKAGE I3 COUNTII
`
`(6 (0.8 ML ADALIMUMAB 50 MG/ML PREFILLED SYRINGE [HUMIRAD } PACK [HUMIRA PEDIATRIC CROHN'S DISEASE
`STARTER PACKAGE [6 COUNTI]
`(6 (0.8 ML ADALIMUMAB 50 MG/ML PREFILLED SYRINGE [HUMIRAD } PACK [HUMIRA PEN » CROHNS DISEASE
`STARTER PACK}
`ADAPALENE 0.001 MG/MG TOPICAL GEL
`
`1594352 BPCK
`
`825170 BPCK
`307731 SCD
`
`153183 SBD
`8306-48%SBD
`722111 SCD
`722113 SBD
`1663747 SBD
`
`ADAPALENE 0.001 MG/MG TOPICAL GEL IDIFFERINI
`ADAFALENE 0.001 MG/MG /’ BENZOYL PEROXIDE 0.025 MG/MG TOPICAL GEL {EPIDUO}
`ADAPALENE 0.003 MG/IVIG TOPICAL GEL
`ADAPALENE 0.003 MG/MG TOPICAL GEL [DIFFERIN]
`ADAPALENE 0.003 MG/MG / BENZOYL PEROXIDE 0.025 MG/MG TOPICAL GEL {EPIDUOI
`
`313852 SCD
`
`EIADAPALENE 1 MG/I‘-.»".‘L TOPICAL CREAM
`
`A
`
`LDIEFERIN
`LEPIDUO
`'DIFFERIN
`EPIDUO
`
`1
`
`SOLIrCe: https://www.CmS.gOv/Ix/Iedscare/PreScrIpLIOn—Dr ug—C0-«erage,’9rE>SCIIOLIOITDIUgCOvCOntra/RxioniraaingformLIIa:yGLIIdanEe.htmI
`
`O1
`
`Page 4
`
`
`4zOvIRAx
`
`IzOvIRAx
`*
`ZOVIRAX
`
`I
`
`‘zOvIRAx
`XERESE
`
`EOVIRAX
`VHUMIRA
`HUMIRA
`
`HUMIRA
`HUMIRA
`HUMIRA PEDIATRIC
`CROHN‘S DISEASE STARTER
`LPACKAGE (3 COUNT)
`HUMIRA PEDIATRIC
`CROHN‘S DISEASE STARTER
`PACKAGE (6 COUNT)
`HUMIRA PEN ~ CROHN'S
`DISEASE STARTER PACK
`
`Page 4
`
`

`

`Formulary Reference FIIe Calendar Year 2016
`
`L
`
`RXCUI
`Related 5c0c
`1492675t\CETAMINOPHEN 325 MG / HYDROCODONE BITARTRATE 7.5 MG
`1495475 ACETAMINOPHEN 325145/wzoaocooome BITARTRATE 7.5 MG
`557007 ACETAMINOPHEN 325 MG / HYDROCODONE BITARTRATE 7.5 MG
`1049214 ACETAMINOPHEN 325 MG / oxvcooowe HYDROCHLORIDE 10 MG
`1049215 ACETAMINOPHEN 325 MG / oxvcooowe HYDROCHLORIDE 10 MG
`1049525 ACETAMINOPHEN 325 MG / oxvcouowe HYDROCHLORIDE 10 MG
`1049535 ACETAMINOPHEN 325 MG / oxvcooome HYDROCHLORIDE 2.5 MG
`
`1049537 ACETAMINOPHEN 325 MG / oxvcoooms HYDROCHLORIDE 2.5 MG
`1049221 ACETAMINOPHEN 325 MG / oxvcoooms HYDROCHLORIDE 5 MG
`1049223 ACETAMINOPHEN 325 MG / oxvcooome HYDROCHLORIDE 5 MG
`1049540 ACETAMINOPHEN 325 MG / oxvcooowe HVDROCHLORIDE 5 MG
`1049225 ACETAMINOPHEN 325 MG / oxvcoooms HYDROCHLORIDE 7.5 MG
`1049227 ACETAMINOPHEN 325 MG / oxvcoooms HYDROCHLORIDE 7.5 MG
`1049542 ACETAMINOPHEN 325 MG / oxvcooous HYDROCHLORIDE 7.5 MG
`
`|ReIated DF
`[ORAL TABLET
`ORAL TABLET
`ORAL TABLET
`ORAL TABLET
`ORAL TABLET
`ORAL TABLET
`ORAL TABLET
`
`IORAL TABLET
`IORAL TABLET
`IORAL TABLET
`ORAL TABLET
`ORAL TABLET
`ORAL TABLET
`ORAL TABLET
`
`’
`
`A
`
`T‘
`
`__
`
`J
`
`1491534 ACETAMINOPHEN 325 MG / oxvcooows HYDROCHLORIDE 7.5 MG
`836395 ACETAMINOPHEN 325 MG / TRAMADOL HYDROCHLORIDE 375 MG
`535397 ACETAMINOPHEN 325 MG / TRAMADOL HYDROCHLORIDE 37.5 MG
`
`EXTENDED RELEASE ORAL TABLET
`ORAL TABLET
`ORAL TABLET
`
`ACETATE 0.044 MEQ/MI./CYSTEINE 0.2 MG/ML/ HISTIDINE 2.5 MG/ML / ISOLEUCINE
`800979 5.6 MG/ML/ LEUCINE 8.8 MG/ML
`307702 ACETAZOLAMIDE 100 MG/ML
`197303 ACETAZOLAMIDE 125 MG
`197304 ACETAZOLAMIDE 250 MG
`562524 ACETAZOLAMIDE 500 MG
`8764391ACETAZOLAMIDE 500 MG
`197305 ACETIC ACID 20 MG/ML
`313786 ACETIC ACID 20 MG/ML/ HYDROCORTISONE 10 MG/ML
`213525 ACETIC ACID 20 MG/ML/ HYDROCORTISONE 10 MG/ML
`213557 ACETOHYDROXAMIC ACID 250 MG
`307718 ACETYLCYSTEINE 100 MG/MI.
`307719 ACETYLCYSTEINE 200 MG/ML
`199689 ACITRETIN 10 MG
`213069 ACITRETIN 10 MG
`
`894859 ACITRETIN 17.5 MG
`
`894861 ACITRETIN 17.5 MG
`
`199690 ACITRETIN 25 MG
`213070 ACITRETIN 25 MG
`.}..3.9§.1_97 ”:C.E.IEL‘{?E!.‘Y'.PEQM!R€_QiM§fiiCTU‘~T
`.
`H. 1607112IACLIDINIUM BROMIDE 0.4 MG/ACTUAT
`1112246 ACRIVASTINE 8 MG / PSEUDOEPHEDRINE HYDROCHLORIDE 60 MG
`
`I
`
`197312I_ACYCLOVIR 0.05 MG/MG
`209977 ACYCLOVIR 0.05 MG/MG
`197310‘AC‘/CLOVIR 200 MG
`213694 ACYCLOVIR 200 MG
`307730 ACYCLOVIR 40 MG/ML
`201903 ACYCLOVIR 40 MG/ML
`197311 ACYCLOVIR 400 MG
`313812 ACYCLOVIR 50 MG/ML
`825321 ACYCLOVIR 50 MG/ML
`998426 ACYCLOVIR 50 MG/ML / HYDROCORTISONE 10 MG/ML
`197313 ACYCLOVIR 800 MG
`213706 ACYCLOVIR 800 MG
`1655728 ADALIMUMAB 50 MG/ML
`1551888 ADALIMUMAB 50 MG/ML
`727705 ADALIMUMAB 50 MG/ML
`763565 ADALIMUMAB 50 MG/ML
`
`INJECTABLE SOLUTION
`INJECTABLE SOLUTION
`ORAL TABLET
`ORAL TABLET
`EXTENDED RELEASE ORAL CAPSULE
`EXTENDED RELEASE ORAL CAPSULE
`OTIC SOLUTION
`OTIC SOLUTION
`OTIC SOLUTION
`ORAL TABLET
`INHALANT SOLUTION
`IINHALANT SOLUTION
`IORAL CAPSULE
`IORAL CAPSULE
`IORAL CAPSULE
`ORAL CAPSULE
`
`ORAL CAPSULE
`
`__J
`ORAL CAPSULE
`
`DRY POWDER INIWER
`
`
`DRY POWDER INHALER
`ORAL CAPSULE
`
`TOPICAL OINTMENT
`
`TOPICAL OINTMENT
`J
`ORAL CAPSULE
`
`
`ORAL CAPSULE
`I
`ORAL SUSPENSION
`
`ORAL SUSPENSION
`
`ORAL TABLET
`INJECTABLE SOLUTION
`
`TOPICAL CREAM
`TOPICAL CREAM
`ORAL TABLET
`ORAL TABLET
`AUTO—INJECTOR
`PREFILLED SYRINGE
`PREFILLED SYRINGE
`PREFILLED SYRINGE
`
`1594358 ADALIMUMAB 50 MG/ML
`
`1594352 ADALIMUMAB SO MG/ML
`
`825170 ADALIMUMAB 50 MG/ML
`307731;/XDAPALENE 0.001 MG/MG
`A
`-__
`_
`_
`153183?/ADAPALENE 0.001 MG/MG
`830648 ADAPALENE 0.001 MG/MG / BENZOYL PEROXIDE 0.025 MG/MG
`
`>
`
`V_
`
`722111:ADA.PALENE 0.003 MG/MG
`722113‘/ADAPALENE 0.003 MG/MG
`166374ZLADAPALENE 0.003 MG/MG / BENZOYL PEROXIDE 0.025 MG/MG
`313852‘ADAPALENE 1 MG/ML T
`T
`
`PACK
`
`PACK
`
`PACK
`TOPICAL GEL
`TOPICAL GEL
`TOPICAL GEL
`
`TOPICAL GEL
`TOPICAL GEL
`TOPICAL GEL
`TOPICAL CREAM
`
`J
`
`Page 5
`
`
`Source: httos‘//www.cms.g<w/Medicare/PrescriptIon—Drug—Coverage/PrescrLptLonDrugCovConLra/Rxconiractrngformularyéundance him!
`
`6
`
`Page 5
`
`

`

`Formulary Reference FIIe Calendar Year 2016
`
`1RxNorm Description
`ADAPALENE 1 MG/ML TOPICAL CREAM [DIFEERIN]
`ADEFOVIR DIPIVOXIL 10 MG ORAL TABLET
`*ADAPALENE 1 MG/ML TOPICAL LOTION {DIFFERINI
`ADEFOVIR DIPIVOXIL 10 MG ORAL TABLET IHEPSERA}
`ADO-TRASTUZUMAB EMTANSINE 20 MG/ML INJECTABLE SOLUTION IKADCYLA]
`AFATINIB 20 MG ORAL TABLET IGILOTRIF]
`AFATINIB 30 MG ORAL TABLET IGILOTRIFI
`AFATINIB 40 MG ORAL TABLET [GILOTRIFI
`
`A
`
`AGALSIDASE BETA S MG/ML INJECTABLE SOLUTION [FABRAZYME]
`ALANINE 10.4 MG/ML / ARGININE 5.75 MG/ML / CALCIUM CHLORIDE 0.004 MEO/ML/ DIBASIC POTASSIUM
`PHOSPHATE 2.61 MG/ML / GLUCOSE 150 MG/ML/ GLYCINE 5.15 MG/ML/ HISTIDINE 2.4 MG/ML/ ISOLEUCINE 3
`MG/ML / LEUCINE 3.65 MG/ML/ LYSINE 2.9 MG/ML / MAGNESIUM CHLORIDE 0.01 MEQ/ML/ METHIONINE 2
`MG/ML/ PHENYLALANINE 2.8 MG/ML/ PROLINE 3.4 MG/ML / SERINE 2.5 MG/ML / SODIUM ACETATE TRIHYDRATE
`3.4 MG/ML / SODIUM CHLORIDE 0.01 MEQ/ML/THREONINE 2.1 MG/ML/TRYPTOPHAN 0.9 MG/ML/TYROSINE 0.2
`MG/ML/VALINE 2.9 MG/ML INJECTABLE SOLUTION [CLINIMIx E 5/15]
`
`RXCUI
`
`[TTY
`284420ISBD
`881341 SCD
`905387FBD _
`88l343}SBD
`1371050 SBD
`1430449 SBD
`1430453 SBD
`1430457 SBD
`
`404491 SBD
`
`
`'
`
`{
`
`801021 SBD
`
`
`
`
`
`
`ALANINE 10.4 MG/ML / ARGININE 5.75 MG/ML/ CALCIUM CHLORIDE 0.004 MEQ/ML/ DIBASIC POTASSIUM
`
`PHOSPHATE 2.61 MG/ML / GLUCOSE 200 MG/ML / GLYCINE 5.15 MG/ML/ HISTIDINE 2.4 MG/ML/ ISOLEUCINE 3
`MG/ML/ LEUCINE 3.65 MG/ML/ LYSINE 2.9 MG/ML/ MAGNESIUM CHLORIDE 0.01 MEQ/ML/ METHIONINE 2
`MG/ML/ PHENYLALANINE 2.8 MG/ML/ PROLINE 3.4 MG/ML / SERINE 2.5 MG/ML/SODIUM ACETATE TRIHYDRATE
`3.4 MG/ML/SODIUM CHLORIDE 0.01 MEO/ML/THREONINE 2.1 MG/ML/TRYPTOPHAN 0.9 MG/ML / TYROSINE 0.2
`MG/ML/VALINE 2.9 MG/ML INJECTABLE SOLUTION [CLINIMIx E 5/20]
`
`Related BN
`DIFFERIN
`DIFFERIN
`HEPSERA
`KADCVLA
`IGILOTRIF
`IGILOTRIF
`GILOTRIF
`
`FABRAZYME
`
`CLINIMIX E 5/15
`
`CLINIMIX E 5/20
`
`CLINIMIX E 5/25
`
`
`ALANINE 10.4 MG/ML / ARGININE 5.75 MG/ML/ CALCIUM CHLORIDE 0.004 MEO/ML/ DIBASIC POTASSIUM
`
`PHOSPHATE 2.61 MG/ML/GLUCOSE 250 MG/ML / GLYCINE 5.15 MG/ML/ HISTIDINE 2.4 MG/ML/ ISOLEUCINE 3
`MG/ML/ LEUCINE 3.65 MG/ML/ LYSINE 2.9 MG/ML/ MAGNESIUM CHLORIDE 0.01 MEQ/ML/ METHIONINE 2
`
`MG/ML/ PHENYLALANINE 2.8 MG/ML/ PROLINE 3.4 MG/ML / SERINE 2.5 MG/ML/SODIUM ACETATE TRIHYDRATE
`3.4 MG/ML/SODIUM CHLORIDE 0.01 MEQ/ML/THREONINE 2.1 MG/ML/TRYPTOPHAN 0.9 MG/ML/TYROSINE 0.2
`
`MG/ML/vALINE 2.9 MG/ML INJECTABLE SOLUTION ICLINIMIX E 5/25}
` ALANINE 10.4 MG/ML/ARGININE 5.75 MG/ML / GLUCOSE 200 MG/ML / GLYCINE 5.15 MG/ML/ HISTIDINE 2.4
`
`801031
`
`801034
`
`800438
`
`
`
`ALANINE 10.4 MG/ML / ARGININE 5.75 MG/ML / GLUCOSE 150 MG/ML / GLYCINE 5.15 MG/ML/ HISTIDINE 2.4
`MG/ML / ISOLEUCINE 3 MG/ML/ LEUCINE 3.65 MG/ML/ LVSINE 2.9 MG/ML/ METHIONINE 2 MG/ML/
`PHENYLALANINE 2.8 MG/ML / PROLINE 3.4 MG/ML/ SERINE 2.5 MG/ML/THREONINE 2.1 MG/ML/TRYPTOPHAN 0.9
`MG/ML / TYROSINE 0.2 MG/ML / VALINE 290 MG/ML INJECTABLE SOLUTION [CLINIMIX 5/15]
`__I.
`
`MG/ML/ ISOLEUCINE 3 MG/ML/ LEUCINE 3.65 MG/ML/ LYSINE 2.9 MG/ML/ METHIONINE 2 MG/ML/
`PHENYLALANINE 2.8 MG/ML / PROLINE 3.4 MG/ML/ SERINE 2.5 MG/ML/THREONINE 2.1 MG/ML / TRYPTOPHAN 0.9
`MG/ML/TYROSINE 0.2 MG/ML / VALINE 2.9 MG/ML INJECTABLE SOLUTION [CLINIMIX 5/201
`
`ALAN NE 10.4 MG/ML/ARGININE 5.75 MG/ML / GLUCOSE 250 MG/ML / GL‘/CINE 5.15 MG/ML/ HISTIDINE 2.4
`MG/ML/ ISOLEUCINE 3 MG/ML/ LEUCINE 3.65 MG/ML/ LYSINE 2.9 MG/ML/ METHIONINE 2 MG/ML/
`PHENYLALANINE 2.8 MG/ML / PROLINE 3.4 MG/ML / SERINE 2.5 MG/ML / THREONINE 2.1 MG/ML/TRYPTOPHAN 0.9
`MG/ML/TYROSINE 0.2 MG/ML / VALINE 2.9 MG/ML INJECTABLE SOLUTION {CLINIMIX 5/25)
`ALAN NE 11 MG/ML/ ARGININE 8.5 MG/ML / GLYCINE 11 MG/ML/ HISTIDINE 2.6 MG/ML / ISOLEUCINE 6.2 MG/ML/
`LEUCINE 8.1 MG/ML/ LYSINE 6.24 MG/ML/ MAGNESIUM CHLORIDE 0.00502 MEQ/ML/ METHIONINE 3.4 MG/ML/
`PHENYLALANINE 3.8 MG/ML / POTASSIUM CHLORIDE 0.0654 MEQ/ML/ PROLINE 7.5 MG/ML / SERINE 3.7 MG/ML/
`SODIUM CHLORIDE 0.00479 MEQ/ML / SODIUM PHOSPHATE 0.0299 MEQ/ML / THREONINE 4.6 MG/ML/
`TRYP ’OPHAN 1.5 MG/ML / TYROSINE 0.44 MG/ML / VALINE 6.8 MG/ML INIECTABLE SOLUTION [AMINOSYN 8.5 %
`WITH ELECTROLYTES, SULFITE-FREE]
`
`CLINIMIX 5/15
`
`CLINIMIX 5/20
`
`CLINIMIX 5/25
`
`AMINOSYN 8.5 % WITH
`ELECTROLYTES, SULFITE-
`FREE
`
`800444 SBD
`
`800449 SBD
`
`1189611 SBD
`
`801417LSBD
`
`801648 SBD
`
`800588 S80
`
`ALAN NE 14.9 MG/ML / ARGININE 15.3 MG/ML / ASPARTATE 10.5 MG/ML/ GLUTAMATE 11.1 MG/ML / GLYCINE 7.5
`MG/ML/ HISTIDINE 4.5 MG/ML/ ISOLEUCINE 9.9 MG/ML / LEUCINE 15 MG/ML/ LYSINE 15.8 MG/ML/ METHIONINE
`2.58 MG/ML/ PHENVLALANINE 4.47 MG/ML / PROLINE 10.8 MG/ML / SERINE 7.95 MG/ML/THREONINE 6 MG/ML/
`TRYP OPHAN 3 MG/ML /TYROSINE 4.05 MG/ML/VALINE 7.5 MG/ML INJECTABLE SOLUTION {AMINOSYN II 15%}
`
`AMINOSYN II 15%
`
`800192‘SBD
`
`1
`
`ALAN NE 2.1 MG/ML / ARGININE 2.9 MG/MI. / CALCIUM ACETATE 0.003 MEQ/ML / CYSTEINE 0.2 MG/ML / GLYCERIN
`30 MG/ML / GLYCINE 4.2 MG/ML/ HISTIDINE 0.85 MG/ML / ISOLEUCINE 2.1 MG/ML/ LEUCINE 2.7 MG/ML/ LYSINE
`3.1 MG/ML/ MAGNESIUM ACETATE 0.008 MEQ/ML / METHIONINE 1.6 MG/"ML / PHENYLALANINE 1.7 MG/ML/
`PHOSPHORIC ACID 0.41 MG/ML/ POTASSIUM CHLORIDE 0.02 MEQ/ML / PROLINE 3.4 MG/ML / SERINE 1.8 MG/IVII./
`SODIUM ACETATE 0.025 MEQ/ML / SODIUM CHLORIDE 0.014 MEQ/ML / THREONINE 1.2 MG/ML/TRYPTOPHAN 0.46
`MG/ML / \/ALINE 2 MG/ML INJECTABLE SOLUTION [PROCALAMINE 3)
`
`ALANINE 20.7 MG/ML / ARGININE 11.5 MG/ML / GLYCINE 10.3 MG/ML / HISTIDINE 4.8 MG/ML/ ISOLEUCINE 6
`MG/ML/ LEUCINE 7.3 MG/ML/ LYSINE 5.8 MG/ML/ METHIONINE 4 MG/ML / PHENYLALANINE 5.6 MG/ML/
`PROLINE 6.8 MG/ML / SERINE 5 MG/ML / THREONINE 4.2 MG/ML / TRYPTOPHAN 1.8 MG/ML/TYROSINE 0.4 MG/ML
`/VALINE 5.8 MG/ML INJECTABLE SOLUTION [TRAVASOL 10]
`ALANINE 21.7 MG/ML / ARGININE 14.7 MG/ML/ASPARTATE 4.34 MG/ML / GLUTAMATE 7.49 MG/ML / GLYCINE 10.4
`MG/ML/ HISTIDINE 8 94 MG/ML/ ISOLEUCINE 7.49 MG/ML/ LEUCINE 10.4 MG/ML / LVSINE 11.8 MG/ML/
`METHIONINE 7.49 MG/ML / PHENYLALANINE 10 4 MG/ML/ PROLINE 8.94 MG/ML / SERINE 5.92 MG/I'v'I'L/
`THREONINE 7.49 MG/ML / TRYPTOPHAN 2.5 MG/ML / WROSINE 0.39 MG/MI /VALINE 9 6 MG/ML INJECTABLE
`SOLUTION ICLINISOL 15}
`
`PROCALAMINE 3
`1,.
`
`LTRAVASOL 10
`
`JCLINISOL 15
`
`Sc-L.-me" httpsz,-’,/www Cm; gO\//I\/IGECIICBEE/‘VPFPSCI€;)t!OI'I—D!Ug—C‘OvE’ag9/PTESCTEDTICITOTLig(CVCOF¥U3/RXCOY‘tT€)C{lI'1gMFO(mUISTVGUILTERCE
`
`hmxi
`
`Ln
`
`Page 6
`
`
`Page 6
`
`

`

`RXCUI
`
`Related SCDC
`284420 ADAPALENE 1 MG/MI.
`905387 ADAPALENE 1 MG/ML
`881341 ADEFOVIR DIPIVOXIL 10 MG
`
`881343:/XDEFOVIR DIPIVOXIL 10 MG
`1371050 ADOTRASTUZUMAB EMTANSINE Z0 MG/ML
`143O449LAFATINIB 20 MG
`1430453 AFATINIB 30 MG
`1430457 AFATINIB 40 MG
`
`404491 AGALSIDASE BETA 5 MG/ML
`
`Formulary Reference File CaIendar Year 2016
`
`Related DP
`TOPICAL CREAM
`TOPECAL LOTION
`ORAL TABLET
`
`ORAL TABLET
`IMECTABLE SOLUTION
`FCEAL TABLET
`ORAL TABLET
`ORAL TABLET
`INJECTABLE SOLUTION 1
`
`
`
`1
`I
`
`ALANINE 10.4 MG/ML/ARGININE 5.75 MG/ML/CALCIUM CHLORIDE 0.004 MEQ/ML/
`801021 DIBASIC POTASSIUM PHOSPHATE 2.61 MG/ML/GLUCOSE 150 MG/ML
`
`INJECTABLE SOLUTION
`
`TI
`
`ALANINE 10.4 MG/MI. / ARGININE 5.75 MG/ML / CALCIUM CHLORIDE 0.004 MEQ/ML/
`
`801O311DIBASIC POTASSIUM PHOSPHATE 2.61 MG/MI. / GLUCOSE 200 MG/ML
`
`INJECTABLE SOLUTION
`
`__I
`
`ALANINE 10.4 MG/ML / ARGININE 5.75 MG/ML/ CALCIUM CHLORIDE 0.004 MEQ/ML/
`801034 DIBASIC POTASSIUM PHOSPHATE 2.61 MG/ML / GLUCOSE 250 MG/ML
`
`INJECTABLE SOLUTION
`
`ALANINE 10.4 MG/ML / ARGININE 5.75 MG/ML/GLUCOSE 150 MG/ML/GLVCINE 5.15
`800438 MG/ML/ HISTIDINE 2.4 MG/ML
`
`INJECTABLE SOLUTION
`___T,.5”____
`
`ALANINE 10.4 MG/ML/ ARGININE 5.75 MG/ML / GLUCOSE 200 MG/ML/ GLYCINE 5.15
`800444
`
`INJECTABLE SOLUTION
`
`ALANINE 10.4 MG/ML / ARGININE 5.75 MG/ML/GLUCOSE 250 MG/ML / GLYCINE 5.15
`800449 MG/ML/ HISTIDINE 2.4 MG/ML
`
`INJECTABLE SOLUTION
`
`ALANINE 11 MG/ML/ARGININE 8.5 MG/ML / GLYCINE 11 MG/ML / HISTIDINE 2.6
`1189611 MG/ML/ ISOLEUCINE 6.2 MG/ML
`
`INJECTABLE SOLUTION
`
`ALANINE 14.9 MG/ML/ARGININE 15.3 MG/ML / ASPARTATE 10.5 MG/ML/
`8001921-SLUTAMATE 11.1 MG/ML / GLYCINE 7.5 MG/ML
`
`IINJECTABLE SOLUTION
`
`ALANINE 2.1 MG/ML / ARGININE 2.9 MG/ML/ CALCIUM ACETATE 0.003 MEQ/ML/
`801417 C‘/STEINE 0.2 MG/ML/ GLYCERIN 30 MG/ML
`
`INJECTABLE SOLUTION
`
`ALANINE 20.7 MG/ML / ARGININE 11.5 MG/ML / GLYCINE 10.3 MG/ML/ HISTIDINE 4.8
`
`801648 MG/ML/ ISOLEUCINE 6 MG/ML
`
`{'INJECTABLE SOLUTION
`
`ALANINE 21.7 MG,/MI, / ARGININE 14.7 IVIG/ML ,/ ASPARTATE 4 34 MG/ML /
`800588 GLUTAMATE 7.49 MG/ML / GLYCINE 10.4 MG/ML
`
`INJECTABLE SOLUTION
`
`Page 7
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`
`Source: Imps://www cms.gov/Medxcare/PrescrIpt:on—Drug—Coverage/PrescrnptionDrugCovContra/RxContractIngjormuIaryGuxdance.htmI
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`6
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`Page 7
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`

`

`Formwary Reference File Caiendar Vear Z016
`
`RxNorm Description
`TALANINE 21.7 MG/ML/ ARGININE 14.7 MG/ML / ASPARTATE 4.34 MG/ML/ GLUTAMATE 7.49 MG/ML/ GLYCINE 10.4
`MG/ML/ HISTIDINE 8.94 MG/ML/ ISOLEUCINE 7.49 MG/ML/ LEUCINE 10.4 MG/ML/ LYSINE 11.8 MG/ML/
`METHIONINE 7.49 MG/ML/ PHENYLALANINE 10.4 MG/ML / PROLINE 8.94 MG/ML / SERINE 5.92 MG/ML/
`THREONINE 7.49 MG/ML/TRYPTOPHAN 2.5 MG/ML / TYROSINE 0.39 MG/ML/ VALINE 9.6 MG/ML INJECTABLE
`SOLUTION [PLENAMINE]
`IALANINE 27.6 MG/ML / ARGININE 19.6 MG/ML/ASPARTATE 6 MG/ML/GLUTAMATE 10.2 MG/ML/GLYCINE 20.6
`MG/ML / I-IISTIDINE 11.8 MG/ML/ ISOLEUCINE 10.8 MG/ML/ LEUCINE 10.8 MG/ML / LYSINE 13.5 MG/ML/
`METHIONINE 7.6 MG/ML/ PHENYLALANINE 10 MG/ML/ PROLINE 13.4 MG/ML/SERINE 10.2 MG/ML/THREONINE
`9.8 MG/ML / TRYPTOPHAN 3.2 MG/ML / TYROSINE 0.5 MG/ML/ VALINE 14.4 MG/ML INJECTABLE SOLUTION
`[PROSOLI
`IALANINE 3.2 MG/ML/ARGININE 7.3 MG/ML/ASPARTATE 1.9 MG/MI. / CYSTEINE 0.14 MG/ML/GLUTAMATE 3
`MG/ML / GLYCINE 2.2 MG/ML/ HISTIDINE 2.9 MG/ML/ ISOLEUCINE 4.9 MG/ML/ LEUCINE 8.4 MG/ML/ LYSINE 4.9
`MG/ML/ METHIONINE 2 MG/ML / PHENYLALANINE 2.9 MG/ML/ PROLINE 4.1 MG/ML/ SERINE 2.3 MG/ML/
`TAURINE 0.15 MG/ML/THREONINE 2.5 MG/ML/TRYPTOPHAN 1.2 MG/ML/TVROSINE 1.4 MG/ML/VALINE 4.7
`MG/ML INJECTABLE SOLUTION [PREMASOL]
`ALANINE 3.2 MG/ML/ARGININE 7.3 MG/ML/ASPARTATE 1.9 MG/ML/ C‘/STEINE 0.2 MG/ML / GLUTAMATE 3
`MG/ML / GLYCINE 2.2 MG/ML/ HISTIDINE 2.9 MG/ML/ ISOLEUCINE 4.9 MG/ML/ LEUCINE 8.4 MG/ML / LYSINE 6.9
`MG/ML/ METHIONINE Z MG/ML / PHENYLALANINE 2.9 MG/ML/ PROLINE 4.1 MG/ML / SERINE 2.3 MG/ML/
`SODIUM ACETATE 0.0544 MEQ/ML / SODIUM CHLORIDE 0.003 MEQ/ML / SODIUM METABISULFITE 0.5 MG/ML/
`TAURINE 0.15 MG/ML / THREONINE 2.5 MG/ML / TRYPTOPHAN 1.2 MG/ML / TYROSINE 1.64 MG/ML / VALINE 4.7
`MG/ML INJECTABLE SOLUTION [TROPHAMINE 6 %]
`ALANINE 4 MG/ML / ARGININE 5.8 MG/ML / CYSTEINE 0.2 MG/ML/GLYCINE 3.3 MG/ML/ HISTIDINE 1.6 MG/ML/
`ISOLEUCINE 7.6 MG/ML/ LEUCINE 13.7 MG/ML/ LYSINE 5.8 MG/ML/ METHIONINE 2.5 MG/ML/ PHENYLALANINE
`3.2 MG/ML/ PROLINE 6.3 MG/ML / SERINE 3.3 MG/ML/THREONINE 2 MG/ML/TRYPTOPHAN 0.9 MG/ML / VALINE
`8.8 MG/ML INJECTABLE SOLUTION [FREAMINE 6.9]
`ALANINE 4.48 MG/ML/ARGININE 3.43 MG/ML / GLYCINE 4.48 MG/ML / HISTIDINE 1.05 MG/ML/ ISOLEUCINE 2.52
`MG/ML/ LEUCINE 3.29 MG/ML/ LYSINE 2.52 MG/ML / MAGNESIUM ACETATE 0.003 MEQ/ML/ METHIONINE 1.4
`MG/ML/ PHEN‘/LALANINE 1.54 MG/ML/ PHOSPHORIC ACID 0.4 MG/ML/ POTASSIUM ACETATE 0.01 MEQ/ML/
`PROLINE 3 MG/MI. / SERINE 1.47 MG/ML/SODIUM CHLORIDE 0.04 MEQ/ML / THREONINE 1.82 MG/ML/
`TRYPTOPHAN 0.56 MG/ML / TYROSINE 0.31 MG/ML / VALINE 2.8 MG/ML INJECTABLE SOLUTION IAMINOSYN 3.5 %
`M, SULFITE FREE]
`ALANINE 4.9 MG/ML/ARGININE 8.61 MG/ML/ASPARTATE 3.7 MG/ML/GLUTAMATE 5.76 MG/ML / GLYCINE 2.7
`MG/ML / HISTIDINE 2.2 MG/ML/ ISOLEUCINE 5.34 MG/ML/ LEUCINE 8.31 MG/ML/ LYSINE 4.75 MG/ML/
`MET