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Home , Alglucerase, Alitretinoin, Bazedoxifene, Clorazepate, Echothiophate, Estramustine

USP Medicare Model Guidelines v6.0 Page 1 of 30

Example Part D USP Category USP Class /Ester Eligible Drugs* Anti-inflammatory Drugs Indomethacin Tromethamine Meclofenamate Analgesics, Long-acting Tartrate Hydrochloride Sulfate Hydrochloride Hydrochloride Hydrochloride Opioid Analgesics, Short-acting Tartrate Fentanyl Citrate Hydromorphone Hydrochloride Meperidine Hydrochloride Hydrochloride Oxycodone Hydrochloride Oxymorphone Hydrochloride Lactate Tramadol Hydrochloride Anesthetics Local Anesthetics Hydrochloride Lidocaine and

Anti-/ Treatment Agents Deterrents/Anti-craving Acamprosate Calcium Hydrochloride Opioid Dependence Treatments Buprenorphine/ Naltrexone Hydrochloride Opioid Reversal Agents

* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage USP Medicare Model Guidelines v6.0 Page 2 of 30

Example Part D USP Category USP Class Salt/Ester Eligible Drugs* Naloxone Hydrochloride Cessation Agents Hydrochloride Varenicline Tartrate Antibacterials Sulfate Sulfate Kanamycin Sulfate Sulfate Sulfate Sulfate Tobramycin Sulfate Tobramycin and

Beta-lactam,

Cefadroxil Cephalexin

Cefaclor Axetil

Cefdinir Pivoxil Proxetil Dihydrate

Cefepime Hydrochloride Beta-lactam,

Amoxicillin and Clavulanate Potassium Ampicillin Sodium and Sodium

Piperacillin Sodium Sodium and Sodium Disodium and Clavulanate Potassium

Penicillin G Benzathine Potassium Sodium V Potassium

Dicloxacillin Sodium Sodium

* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage USP Medicare Model Guidelines v6.0 Page 3 of 30

Example Part D USP Category USP Class Salt/Ester Eligible Drugs* Sodium Beta-lactam, Other Sodium and Sodium Azithromycin Estolate Ethylsuccinate Lactobionate Stearate Telithromycin Quinolones Mesylate Hydrochloride Sulfonamides Sodium and

Tetracyclines Hydrochloride Doxycycline Calcium Hyclate Minocycline Hydrochloride Hydrochloride Antibacterials, Other

Trimethoprim

Vancomycin Hydrochloride

Clindamycin Hydrochloride Palmitate Lincomycin Hydrochloride

Nitrofurantoin

Linezolid

Acetic Acid Sodium Succinate Tromethamine Methenamine Hippurate Mandelate Hydrochloride Calcium

* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage USP Medicare Model Guidelines v6.0 Page 4 of 30

Example Part D USP Category USP Class Salt/Ester Eligible Drugs* B Sulfate Retapamulin Modifying Agents Methsuximide Gamma-aminobutyric Acid (GABA) Augmenting Agents

Clobazam Dipotassium

Mephobarbital

Divalproex Sodium Hydrochloride Sodium Glutamate Reducing Agents Agents Sodium Sodium

Lacosamide Anticonvulsants, Other

Ezogabine Antidementia Agents Inhibitors Hydrochloride Hydrochloride Tartrate N-methyl-D-aspartate (NMDA) Antagonist Memantine Hydrochloride Antidementia Agents, Other

* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage USP Medicare Model Guidelines v6.0 Page 5 of 30

Example Part D USP Category USP Class Salt/Ester Eligible Drugs* Mesylates Monoamine Oxidase Inhibitors Sulfate Selegiline Sulfate

SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/ Serotonin and Norepinephrine Reuptake Inhibitors) Hydrobromide Desvenlafaxine Hydrochloride Hydrochloride Maleate Levomilnacipran Hydrochloride Hydrochloride Hydrochloride Hydrochloride Hydrochloride Hydrochloride Hydrochloride Hydrochloride Tricyclics Hydrochloride Hydrochloride Hydrochloride Hydrochloride Hydrochloride Pamoate Hydrochloride Hydrochloride Maleate Antidepressants, Other Bupropion Hydrochloride

Aripiprazole Fumarate Antiemetics Emetogenic Therapy Adjuncts

Dolasetron Mesylate Granisetron Hydrochloride Ondansetron Hydrochloride Palonosetron Hydrochloride

Aprepitant

Dronabinol Antiemetics, Other Hydrochloride Hydrochloride Succinate/ Pyridoxine Hydrochloride Pamoate

* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage USP Medicare Model Guidelines v6.0 Page 6 of 30

Example Part D USP Category USP Class Salt/Ester Eligible Drugs* Hydrochloride Perphenazine Edisylate Maleate Hydrochloride Trimethobenzamide Hydrochloride

Naftifine Hydrochloride Terbinafine Hydrochloride

Butoconazole Nitrate Econazole Nitrate Fluconazole Itraconazole Luliconazole Nitrate Oxiconazole Nitrate Posaconazole Sertaconazole Nitrate Sulconazole Nitrate Terconazole Voriconazole

Anidulafungin Caspofungin Acetate Micafungin Sodium

Natamycin

Butenafine Hydrochloride Flucytosine Griseofulvin Antigout Agents

Probenecid

Allopurinol Febuxostat

Colchicine

Anti-inflammatory Agents Nonsteroidal Anti-inflammatory Drugs Celecoxib Diclofenac Potassium Diflunisal Etodolac Fenoprofen Calcium Flurbiprofen Ibuprofen Indomethacin

* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage USP Medicare Model Guidelines v6.0 Page 7 of 30

Example Part D USP Category USP Class Salt/Ester Eligible Drugs* Ketoprofen Ketorolac Tromethamine Meclofenamate Sodium Mefenamic Acid Meloxicam Nabumetone Naproxen Sodium Oxaprozin Piroxicam Sulindac Tolmetin Sodium Antimigraine Agents Ergot Alkaloids Mesylate Ergotamine Tartrate Serotonin (5-HT) 1b/1d Receptor Almotriptan Malate Eletriptan Frovatriptan Succinate Naratriptan Hydrochloride Rizatriptan Benzoate Sumatriptan Zolmitriptan Prophylactic

Timolol Maleate

Divalproex Sodium Topiramate Valproic Acid Antimyasthenic Agents Parasympathomimetics Ambenonium Guanidine Hydrochloride Antimycobacterials Antituberculars Fumarate Capreomycin Sulfate Ethambutol Hydrochloride Ethionamide Pyrazinamide Rifampin Rifampin and Isoniazid Rifampin, Isoniazid, and Pyrazinamide Antimycobacterials, Other Antineoplastics Alkylating Agents

Altretamine

Chlorambucil Mechlorethamine Hydrochloride

* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage USP Medicare Model Guidelines v6.0 Page 8 of 30

Example Part D USP Category USP Class Salt/Ester Eligible Drugs*

Lomustine

Busulfan Hydrochloride

Enzalutamide

Abiraterone Acetate Antiangiogenic Agents Lenalidomide Pomalidomide /Modifiers

Estramustine Phosphate Sodium

Tamoxifen Citrate Citrate

Mercaptopurine Thioguanine

Hydroxyurea

Aromatase Inhibitors, 3rd Generation Inhibitors Molecular Target Inhibitors

Vemurafenib Dabrafenib Trametinib

Ibrutinib

Afatinib Dimaleate Erlotinib Hydrochloride

Vismodegib

Ruxolitinib

Everolimus

Crizotinib

* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage USP Medicare Model Guidelines v6.0 Page 9 of 30

Example Part D USP Category USP Class Salt/Ester Eligible Drugs* Bosutinib Dasatinib Imatinib Mesylate Nilotinib Ponatinib Hydrochloride

Lapatinib

Axitinib Cabozantinib Pazopanib Regorafenib Sorafenib Tosylate Sunitinib Malate Vandetanib Monoclonal Antibodies

Rituximab Ofatumumab Alitretinoin Antineoplastics, Other Leucovorin Hydrochloride Antiparasitics Anthelmintics Albendazole Mebendazole Praziquantel Antiprotozoals

Artemether and Lumefantrine Atovaquone and Proguanil Hydrochloride Chloroquine Phosphate Hydroxychloroquine Sulfate Hydrochloride Primaquine Phosphate Quinine Sulfate

Atovaquone Nitazoxanide Pentamidine Isethionate Pediculicides/Scabicides Benzyl alcohol Antiparkinson Agents Benztropine Mesylate Diphenhydramine Hydrochloride

* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage USP Medicare Model Guidelines v6.0 Page 10 of 30

Example Part D USP Category USP Class Salt/Ester Eligible Drugs* Hydrochloride Dopamine Agonists Apomorphine Hydrochloride Bromocriptine Mesylate Pramipexole Dihydrochloride Monohydrate Ropinirole Hydrochloride Rotigotine Dopamine Precursors/ L- Decarboxylase Inhibitors Carbidopa Carbidopa and Levodopa Monoamine Oxidase B (MAO-B) Inhibitors Rasagiline Mesylate Selegiline Hydrochloride Antiparkinson Agents, Other

Entacapone Tolcapone

Amantadine Hydrochloride 1st Generation/Typical Chlorpromazine Hydrochloride Fluphenazine Hydrochloride Lactate Succinate Perphenazine Prochlorperazine Edisylate Maleate Hydrochloride Thiothixene Hydrochloride Hydrochloride 2nd Generation/Atypical Aripiprazole Asenapine Iloperidone Lurasidone Quetiapine Fumarate Paliperidone Ziprasidone Hydrochloride Mesylate Treatment-Resistant Antispasticity Agents Dantrolene Sodium Tizanidine Hydrochloride Antivirals Anti-cytomegalovirus (CMV) Agents Cidofovir Foscarnet Sodium Ganciclovir Sodium Valganciclovir Hydrochloride

* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage USP Medicare Model Guidelines v6.0 Page 11 of 30

Example Part D USP Category USP Class Salt/Ester Eligible Drugs* Anti-hepatitis B (HBV) Agents Adefovir Dipivoxil Entecavir Lamivudine Ribavirin Telbivudine Tenofovir Disoproxil Fumarate

Interferon Alfa-2b, Recombinant Interferon Alfa-2b and Ribavirin Interferon Alfa-n3 Peginterferon Alfa-2a Peginterferon Alfa-2b Anti-hepatitis C (HCV) Agents Ribavirin

Interferon Alfa-2b, Recombinant Interferon Alfa-2b and Ribavirin Interferon Alfa-n3 Interferon Alfacon-1 Peginterferon Alfa-2a Peginterferon Alfa-2b

Boceprevir Simeprevir Telaprevir

Sofosbuvir Antiherpetic Agents Acyclovir Famciclovir Foscarnet Sodium Trifluridine Sodium Valacyclovir Hydrochloride Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI) Delavirdine Mesylate Etravirine Nevirapine Rilpivirine Efavirenz/ Emtricitabine/ Tenofovir disoproxil fumarate Emtricitabine/ Rilpivirine / Tenofovir disoproxil fumarate Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI) Abacavir Sulfate Abacavir and Lamivudine Abacavir, Lamivudine, and Zidovudine Didanosine

Emtricitabine Emtricitabine and Tenofovir Disoproxil Fumarate

* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage USP Medicare Model Guidelines v6.0 Page 12 of 30

Example Part D USP Category USP Class Salt/Ester Eligible Drugs* Lamivudine Lamivudine and Zidovudine Stavudine Tenofovir Disoproxil Fumarate

Zidovudine

Anti-HIV Agents, Protease Inhibitors Atazanavir Sulfate Darunavir Ethanolate Fosamprenavir Calcium Indinavir Sulfate Lopinavir and Ritonavir Nelfinavir Mesylate Ritonavir Saquinavir Mesylate Tipranavir Anti-HIV Agents, Integrase Inhibitors (INSTI) Dolutegravir Sodium Elvitegravir/ Cobicistat/ Emtricitabine/ Tenofovir disoproxil fumarate Raltegravir Anti-HIV Agents, Other Enfuvirtide Maraviroc Anti-influenza Agents Amantadine Hydrochloride Oseltamivir Phosphate Rimantadine Hydrochloride SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/ Serotonin and Norepinephrine Reuptake Inhibitors) Duloxetine Hydrochloride Escitalopram Oxalate Paroxetine Hydrochloride Sertraline Hydrochloride Venlafaxine Hydrochloride Clonazepam Clorazepate Dipotassium Diazepam Lorazepam Anxiolytics, Other Hydrochloride Doxepin Hydrochloride Hydroxyzine Hydrochloride Bipolar Agents Mood Stabilizers Carbamazepine Divalproex Sodium Lamotrigine Carbonate

* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage USP Medicare Model Guidelines v6.0 Page 13 of 30

Example Part D USP Category USP Class Salt/Ester Eligible Drugs* Valproic Acid Bipolar Agents, Other Aripiprazole Asenapine Olanzapine Quetiapine Fumarate Risperidone Ziprasidone Hydrochloride Mesylate

Blood Glucose Regulators Antidiabetic Agents

Acarbose Miglitol

Pramlintide Acetate

Metformin Hydrochloride

Colesevelam Hydrochloride

Alogliptin Linagliptin Saxagliptin Sitagliptin Phosphate

Bromocriptine Mesylate

Exenatide Liraglutide

Nateglinide

Canagliflozin

Chlorpropamide Glyburide

Pioglitazone Hydrochloride Rosiglitazone Maleate Glycemic Agents Diazoxide Glucagon Insulins

Insulin Aspart Insulin Glulisine Insulin Lispro

Insulin Human (Regular)

Isophane Insulin (Human)

* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage USP Medicare Model Guidelines v6.0 Page 14 of 30

Example Part D USP Category USP Class Salt/Ester Eligible Drugs* Insulin Detemir Insulin Glargine

Insulin Aspart Rapid-acting and Insulin Aspart Protamine Insulin Lispro Rapid-acting and Insulin Lispro Protamine

Insulin Human Regular and Isophane Insulin

Blood Products/Modifiers/ Volume Expanders

Dabigatran

Apixaban Rivaroxaban

Fondaparinux Sodium

Dalteparin Sodium Enoxaparin Sodium

Warfarin Sodium Blood Formation Modifiers

Filgrastim Pegfilgrastim Sargramostim

Darbepoetin Alfa Epoetin Alfa

Anagrelide

Eltrombopag Olamine Romiplostim

Plerixafor Coagulants

Tranexamic Acid Platelet Modifying Agents

Clopidogrel Bisulfate Prasugrel Ticlopidine Hydrochloride Ticagrelor

Dipyridamole Dipyridamole and

Cilostazol Cardiovascular Agents Alpha-adrenergic Agonists Hydrochloride Hydrochloride Methyldopate Hydrochloride

* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage USP Medicare Model Guidelines v6.0 Page 15 of 30

Example Part D USP Category USP Class Salt/Ester Eligible Drugs* Midodrine Hydrochloride Phenylephrine Hydrochloride

Alpha-adrenergic Blocking Agents Mesylate Phenoxybenzamine Hydrochloride Hydrochloride Terazosin Hydrochloride Angiotensin-converting Enzyme (ACE) Inhibitors Hydrochloride Captopril Enalapril Maleate Fosinopril Sodium Moexipril Hydrochloride Perindopril Erbumine Hydrochloride Ramipril Trandolapril

Angiotensin II Receptor Antagonists Azilsartan Medoxomil Cilexetil Eprosartan Mesylate Potassium Olmesartan Medoxomil Telmisartan Antiarrhythmics Hydrochloride Phosphate Acetate Hydrochloride Hydrochloride Hydrochloride Hydrochloride Hydrochloride Beta-adrenergic Blocking Agents Acebutolol Hydrochloride Hydrochloride Bisoprolol Fumarate Carvedilol Phosphate Labetalol Hydrochloride Succinate Tartrate Nadolol Penbutolol Sulfate Pindolol Hydrochloride Maleate

Calcium Channel Blocking Agents

Amlodipine

* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage USP Medicare Model Guidelines v6.0 Page 16 of 30

Example Part D USP Category USP Class Salt/Ester Eligible Drugs* Hydrochloride

Diltiazem Hydrochloride Hydrochloride , Carbonic Anhydrase Inhibitors Sodium Diuretics, Loop Ethacrynate Sodium Ethacrynic Acid Torsemide Diuretics, Potassium-sparing Hydrochloride Diuretics, Sodium Chlorthalidone Dyslipidemics, Fibric Acid Derivatives Fenofibrate Fenofibrate Fenofibric Acid Gemfibrozil Dyslipidemics, HMG CoA Reductase Inhibitors Atorvastatin Calcium Fluvastatin Sodium Lovastatin Pitavastatin Pravastatin Sodium Rosuvastatin Calcium Simvastatin Dyslipidemics, Other Cholestyramine Colesevelam Hydrochloride Hydrochloride Ezetimibe Icosapent ethyl Lomitapide Mesylate Mipomersen Sodium Omega-3-acid Ethyl Esters

Vasodilators, Direct-acting Arterial Hydralazine Hydrochloride

* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage USP Medicare Model Guidelines v6.0 Page 17 of 30

Example Part D USP Category USP Class Salt/Ester Eligible Drugs* Vasodilators, Direct-acting Arterial/Venous Isosorbide Dinitrate Isosorbide Mononitrate Nitroglycerin Cardiovascular Agents, Other Aliskiren Pentoxifylline Central Agents Attention Deficit Hyperactivity Disorder Agents, Dextroamphetamine Sulfate Dextroamphetamine and Mixed Lisdexamfetamine Hydrochloride Attention Deficit Hyperactivity Disorder Agents, Non- amphetamines Hydrochloride Clonidine Hydrochloride Dexmethylphenidate Hydrochloride Guanfacine Hydrochloride Hydrochloride Agents Duloxetine Hydrochloride Pregabalin Multiple Sclerosis Agents

Interferon Beta-1a Interferon Beta-1b

Dalfampridine

Teriflunomide

Fingolimod

Dimethyl fumarate Glatiramer Acetate Mitoxantrone Hydrochloride Natalizumab Central Nervous System, Other Tetrabenazine / Quinidine Dental and Oral Agents Hydrochloride Chlorhexidine Gluconate Doxycycline Hyclate Minocycline Hydrochloride Palifermin Hydrochloride Prilocaine Hydrochloride

* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage USP Medicare Model Guidelines v6.0 Page 18 of 30

Example Part D USP Category USP Class Salt/Ester Eligible Drugs* Acetonide Dermatological Agents

Isotretinoin

Adapalene Azelaic Acid Benzoyl Peroxide Dapsone

Doxycycline Calcium Hyclate

Doxepin Hydrochloride

Pimecrolimus

Podofilox

Ammonium Lactate

Imiquimod Sinecatechins

Selenium Sulfide

Diclofenac Sodium

Methoxsalen

Acitretin Calcitriol Ustekinumab

Calcipotriene

Becaplermin Collagenase

Brimonidine Tartrate Enzyme Replacement/ Modifiers

Cysteamine Bitartrate

Agalsidase Beta

Alglucerase

Miglustat

Nitisinone

* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage USP Medicare Model Guidelines v6.0 Page 19 of 30

Example Part D USP Category USP Class Salt/Ester Eligible Drugs*

Betaine Anhydrous

Idursulfase

Galsulfase Laronidase

Pancrelipase

Sapropterin

Pegademase Bovine

Sacrosidase

Sodium Phenylbutyrate Phenylbutyrate Gastrointestinal Agents Antispasmodics, Gastrointestinal Sulfate Dicyclomine Hydrochloride Glycopyrrolate Mepenzolate Bromide Methscopolamine Bromide Scopolamine Histamine2 (H2) Receptor Antagonists Hydrochloride Famotidine Nizatidine Ranitidine Hydrochloride Irritable Bowel Syndrome Agents

Alosetron Hydrochloride

Linaclotide Laxatives Lactulose Polyethylene Glycol 3350 NF Sodium picosulfate, oxide and Protectants Sucralfate Proton Pump Inhibitors Dexlansoprazole Esomeprazole Magnesium Lansoprazole Omeprazole Pantoprazole Sodium Rabeprazole Sodium Gastrointestinal Agents, Other Alvimopan Hydrochloride and Atropine Sulfate Hydrochloride and Atropine Sulfate

* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage USP Medicare Model Guidelines v6.0 Page 20 of 30

Example Part D USP Category USP Class Salt/Ester Eligible Drugs* Hydrochloride Methylnaltrexone Metoclopramide Rifaximin Ursodiol

Glutamine Somatropin Genitourinary Agents Antispasmodics, Urinary

Mirabegron

Darifenacin Hydrobromide Fumarate Hydrochloride Chloride Succinate Tartrate

Benign Prostatic Hypertrophy Agents

Alfuzosin Hydrochloride Doxazosin Mesylate Prazosin Hydrochloride Silodosin Tamsulosin Hydrochloride Terazosin Hydrochloride

Dutasteride

Tadalafil Phosphate Binders Calcium Acetate Carbonate Sevelamer Hydrochloride Sucroferric Oxyhydroxide Genitourinary Agents, Other Penicillamine Pentosan Polysulfate Hormonal Agents, / Replacement/ Modifying (Adrenal)

Corticotropin

Betamethasone Sodium Phosphate

Budesonide Cortisone Acetate Dexamethasone Acetate Sodium Phosphate

Hydrocortisone Acetate Sodium Succinate Methylprednisolone Acetate

* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage USP Medicare Model Guidelines v6.0 Page 21 of 30

Example Part D USP Category USP Class Salt/Ester Eligible Drugs* Sodium Succinate Acetate Sodium Phosphate

Prednisone Triamcinolone Acetonide Diacetate Hexacetonide

Alclometasone Dipropionate Clocortolone Pivalate Desonide Dexamethasone Sodium Phosphate

Hydrocortisone

Betamethasone Valerate Desoximetasone Fluocinolone Acetonide Flurandrenolide Fluticasone Propionate Hydrocortisone Butyrate Probutate Valerate Mometasone Furoate Prednicarbate Triamcinolone Acetonide

Amcinonide Betamethasone Dipropionate Desoximetasone Diflorasone Diacetate Fluocinolone Acetonide Fluocinonide Halcinonide Triamcinolone Acetonide

Betamethasone Dipropionate Clobetasol Propionate Diflorasone Diacetate Halobetasol Propionate

Fludrocortisone Acetate Hormonal Agents, Stimulant/Replacement/ Modifying (Pituitary)

Chorionic

Somatropin, Recombinant Tesamorelin

Mecasermin Rinfabate

Desmopressin Acetate

* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage USP Medicare Model Guidelines v6.0 Page 22 of 30

Example Part D USP Category USP Class Salt/Ester Eligible Drugs* Hormonal Agents, Stimulant/ Replacement/ Modifying () Alprostadil Tromethamine Misoprostol Hormonal Agents, Stimulant/ Replacement/ Modifying (Sex Hormones/ Modifiers) Anabolic Cypionate Enanthate Propionate Acetate Cypionate Hemihydrate Valerate Estrogens, , Conjugated Synthetic

Estrogens, Esterified Ethinyl Estradiol

Progesterone Agonists/Antagonists Ulipristal Progestins Medroxyprogesterone Acetate Norethindrone Acetate Selective Receptor Modifying Agents Hydrochloride / conjugated estrogens Hormonal Agents, Stimulant/Replacement/ Modifying (Thyroid) Levothyroxine Sodium Liothyronine Sodium Liotrix Hormonal Agents, Suppressant (Adrenal)

* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage USP Medicare Model Guidelines v6.0 Page 23 of 30

Example Part D USP Category USP Class Salt/Ester Eligible Drugs* Hormonal Agents, Suppressant (Parathyroid)

Cinacalcet Hydrochloride Hormonal Agents, Suppressant (Pituitary)

Bromocriptine Mesylate Cabergoline

Leuprolide Acetate Nafarelin Acetate Triptorelin Pamoate

Degarelix

Pegvisomant

Lanreotide Pasireotide Hormonal Agents, Suppressant (Thyroid) Antithyroid Agents Methimazole Propylthiouracil Immunological Agents Angioedema (HAE) Agents

Icatibant Acetate

C1 esterase inhibitor (human) Immune Suppressants

Mycophenolic Acid

Tacrolimus Cyclosporine

Tofacitinib

Sirolimus

6- Abatacept Anakinra Everolimus Sodium Penicillamine

Azathioprine

Adalimumab Certolizumab Pegol Etanercept Golimumab

* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage USP Medicare Model Guidelines v6.0 Page 24 of 30

Example Part D USP Category USP Class Salt/Ester Eligible Drugs* Infliximab Immunizing Agents, Passive

Anti-thymocyte Globulin Immune Globulin Intramuscular (Human) Immune Globulin Intravenous (Human) Immunomodulators

Belimumab

Interferon Gamma-1b, Recombinant

Canakinumab Rilonacept Tocilizumab

Auranofin Leflunomide Natalizumab Vaccines

Diphtheria and Tetanus Toxoids Adsorbed (DT) Diphtheria and Tetanus Toxoids and Acellular Pertussis Vaccine Adsorbed (DTaP) Diphtheria and Tetanus Toxoids and Acellular Pertussis Vaccine Adsorbed, Hepatitis B (Recombinant) and Inactivated Poliovirus Vaccine Diphtheria and Tetanus Toxoids and Acellular Pertussis Absorbed and Inactivated Poliovirus (DTaP-IPV) Vaccine Tetanus and Diphtheria Toxoids Adsorbed for Adult Use (Td) Tetanus Toxoid, Reduced Diphtheria Toxoid and Acellular Pertussis Vaccine, Adsorbed (Tdap)

Haemophilus B Conjugate Vaccine

Haemophilus B Conjugate Vaccine and Hepatitis B Vaccine (Recombinant)

Hepatitis A Vaccine Inactivated Virus Vaccine Inactivated and Hepatitis B Virus Vaccine Recombinant

Diphtheria and Tetanus Toxoids and Acellular Pertussis Vaccine Adsorbed, Hepatitis B (Recombinant) and Inactivated Poliovirus Vaccine Haemophilus B Conjugate Vaccine and Hepatitis B Vaccine (Recombinant) Hepatitis B Virus Vaccine Recombinant

Japanese Encephalitis Virus Vaccine Inactivated

Measles Virus Vaccine Live Measles, Mumps, and Rubella Virus Vaccine Live Measles, Mumps, Rubella, and Varicella Virus Vaccine Live

* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage USP Medicare Model Guidelines v6.0 Page 25 of 30

Example Part D USP Category USP Class Salt/Ester Eligible Drugs* Meningococcal Oligosaccharide Diphtheria CRM197 Conjugate Vaccine Meningococcal Polysaccharide Vaccine Meningococcal Polysaccharide Diphtheria Toxoid Conjugate Vaccine

Measles, Mumps, and Rubella Virus Vaccine Live Measles, Mumps, Rubella, and Varicella Virus Vaccine Live

Human Papillomavirus Bivalent (type 16 and 18) Vaccine Recombinant Human Papillomavirus Quadrivalent (types 6, 11, 16 and 18) Vaccine Recombinant

Diphtheria and Tetanus Toxoids and Acellular Pertussis Vaccine Adsorbed (DTaP) Diphtheria and Tetanus Toxoids and Acellular Pertussis Vaccine Adsorbed, Hepatitis B (Recombinant) and Inactivated Poliovirus Diphtheria and Tetanus Toxoids and Acellular Pertussis Absorbed and Inactivated Poliovirus (DTaP-IPV) Vaccine Tetanus Toxoid, Reduced Diphtheria Toxoid, and Acellular Pertussis Vaccine, Adsorbed (Tdap)

Diphtheria and Tetanus Toxoids and Acellular Pertussis Absorbed and Inactivated Poliovirus (DTaP-IPV) Vaccine Diphtheria and Tetanus Toxoids and Acellular Pertussis Vaccine Adsorbed, Hepatitis B (Recombinant) and Inactivated Poliovirus Poliovirus Vaccine Inactivated

Rabies Vaccine

Rotavirus Vaccine Live

Measles, Mumps, and Rubella Virus Vaccine Live Measles, Mumps, Rubella, and Varicella Virus Vaccine Live Rubella Virus Vaccine

Diphtheria and Tetanus Toxoids Adsorbed (DT) Diphtheria and Tetanus Toxoids and Acellular Pertussis Vaccine Adsorbed (DTaP) Diphtheria and Tetanus Toxoids and Acellular Pertussis Vaccine Adsorbed, Hepatitis B (Recombinant) and Inactivated Poliovirus Vaccine Diphtheria and Tetanus Toxoids and Acellular Pertussis Absorbed and Inactivated Poliovirus (DTaP-IPV) Vaccine Tetanus and Diphtheria Toxoids Adsorbed for Adult Use (Td) Tetanus Toxoid Tetanus Toxoid Adsorbed Tetanus Toxoid, Reduced Diphtheria Toxoid, and Acellular Pertussis Vaccine, Adsorbed (Tdap)

Typhoid Vaccine Live Oral Typhoid Vi Polysaccharide Vaccine

Measles, Mumps, Rubella, and Varicella Virus Vaccine Live

* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage USP Medicare Model Guidelines v6.0 Page 26 of 30

Example Part D USP Category USP Class Salt/Ester Eligible Drugs* Varicella Virus Vaccine

Yellow Fever Vaccine

Zoster Virus Vaccine Live

Inflammatory Bowel Disease Agents Glucocorticoids Betamethasone Cortisone Acetate Dexamethasone Acetate Sodium Phosphate

Hydrocortisone Sodium Succinate Methylprednisolone Acetate Sodium Succinate Prednisolone Acetate Sodium Succinate Triamcinolone Acetonide Diacetate Disodium Mesalamine Sodium Sulfonamides Metabolic Disease Agents

Alendronate Sodium Etidronate Disodium Ibandronate Sodium Risedronate Sodium Tiludronate Disodium

Ibandronate Sodium Pamidronate Disodium Zoledronic Acid

Calcitonin, Salmon

Teriparatide

Denosumab

Calcitriol Doxercalciferol Ophthalmic Agents Ophthalmic Anti-allergy Agents Azelastine Hydrochloride Bepotastine Cromolyn Sodium Emedastine Difumarate Epinastine Hydrochloride Lodoxamide Tromethamine

* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage USP Medicare Model Guidelines v6.0 Page 27 of 30

Example Part D USP Category USP Class Salt/Ester Eligible Drugs* Nedocromil Sodium Hydrochloride Ophthalmic Antiglaucoma Agents

Apraclonidine Hydrochloride Tartrate

Betaxolol Hydrochloride Hydrochloride Hydrochloride Hydrochloride Timolol Hemihydrate Maleate

Acetazolamide Hydrochloride Methazolamide

Echothiophate Iodide Pilocarpine Hydrochloride Nitrate Ophthalmic Anti-inflammatories

Dexamethasone Difluprednate Fluorometholone Acetate Loteprednol Etabonate Prednisolone Acetate Sodium Phosphate

Rimexolone

Bromfenac Sodium Diclofenac Sodium Flurbiprofen Sodium Ketorolac Tromethamine Ophthalmic and Prostamide Analogs Ophthalmic Agents, Other Hydroxypropyl Cellulose Naphazoline Hydrochloride

Cyclosporine Otic Agents

Fluocinolone Acetonide Respiratory Tract/ Pulmonary Agents

* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage USP Medicare Model Guidelines v6.0 Page 28 of 30

Example Part D USP Category USP Class Salt/Ester Eligible Drugs*

Azelastine Hydrochloride Cetirizine Hydrochloride Desloratadine Levocetirizine Olopatadine Hydrochloride

Carbinoxamine Fumarate Hydrochloride Diphenhydramine Hydrochloride Hydroxyzine Hydrochloride Pamoate Promethazine Hydrochloride Anti-inflammatories, Inhaled Beclomethasone Dipropionate Dipropionate Monohydrate Budesonide Ciclesonide Flunisolide Fluticasone Propionate Mometasone Furoate Monohydrate Triamcinolone Acetonide Antileukotrienes Montelukast Sodium Zafirlukast Zileuton Bronchodilators, Monohydrate

Bronchodilators, Sympathomimetic Albuterol Sulfate Arformoterol Tartrate Epinephrine Bitartrate Formoterol Fumarate Dihydrate

Indacaterol Maleate Levalbuterol Hydrochloride Metaproterenol Sulfate Salmeterol Xinafoate Terbutaline Sulfate Cystic Fibrosis Agents

Ivacaftor

Tobramycin dry-powder inhaler Aztreonam solution Mast Cell Stabilizers Cromolyn Sodium Phosphodiesterase Inhibitors, Airways Disease Aminophylline Dihydrate Dyphylline

* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage USP Medicare Model Guidelines v6.0 Page 29 of 30

Example Part D USP Category USP Class Salt/Ester Eligible Drugs* Roflumilast Pulmonary Antihypertensives

Ambrisentan

Sildenafil Citrate Tadalafil

Epoprostenol

Riociguat Respiratory Tract Agents, Other Acetylcysteine Alpha-1 Proteinase Inhibitor, Human Budesonide/ Formoterol fumarate

Fluticasone furoate/ Vilanterol trifenatate Fluticasone propionate/ Salmeterol

Mometasone furoate/ Formoterol fumarate dihydrate Tetrahydrozoline Hydrochloride

Skeletal Muscle Relaxants Hydrochloride Metaxalone Citrate Hydrochloride Sleep Disorder Agents GABA Receptor Modulators

Flurazepam

Eszopiclone Tartrate Sleep Disorders, Other Armodafinil Doxepin Hydrochloride Therapeutic Nutrients/ Minerals/ /Mineral Modifiers

Deferasirox Deferiprone

Penicillamine

* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage USP Medicare Model Guidelines v6.0 Page 30 of 30

Example Part D USP Category USP Class Salt/Ester Eligible Drugs* Sodium Polystyrene Sulfonate Succimer Trientine Hydrochloride Electrolyte/Mineral Replacement Chloride Chromic Chloride Citric Acid, , and Sodium Citrate Fluoride Sodium Stannous Magnesium Chloride Sulfate Manganese Chloride Potassium Acetate Bicarbonate Chloride Citrate Gluconate Potassium Bicarbonate and Potassium Citrate Potassium Citrate and Citric Acid

Potassium Citrate and Sodium Citrate Potassium Gluconate and Potassium Chloride Potassium Gluconate and Potassium Citrate Potassium Phosphate and Sodium Phosphate Sodium Acetate Bicarbonate Lactate Chloride Ferric Gluconate Complex Phosphate Vitamins

* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage