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Medicare Model Guidelines Draft V8.0 1 of 97 Medicare Model Guidelines Draft v8.0 1 of 97 USP Category USP Class Example Drugs Combination Track Changes Drug Product Analgesics Cat Nonsteroidal Anti-inflammatory Class Drugs Celecoxib no Diclofenac Potassium no Diclofenac Epolamine no Diflunisal no Etodolac no Fenoprofen Calcium no Flurbiprofen no Ibuprofen no Indomethacin no Ketoprofen no Ketorolac Tromethamine no Meclofenamate Sodium no Mefenamic Acid no Meloxicam no Nabumetone no Naproxen no Oxaprozin no Piroxicam no Sulindac no Tolmetin Sodium no Opioid Analgesics, Long-acting Class Buprenorphine no Fentanyl no Fentanyl Citrate no Fentanyl Hydrochloride no Manufacturer Discontinued * This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage. Medicare Model Guidelines Draft v8.0 2 of 97 Hydrocodone Bitartrate no Hydromorphone Hydrochloride no Levorphanol Tartrate no Methadone Hydrochloride no Morphine Sulfate no Oxycodone Hydrochloride no Oxymorphone Hydrochloride no Tapentadol Hydrochloride no Tramadol Hydrochloride no Opioid Analgesics, Short-acting Class Butorphanol Tartrate no Codeine Phosphate no Fentanyl Citrate no Hydromorphone Hydrochloride no Meperidine Hydrochloride no Morphine Sulfate no Additional Placement Nalbuphine Hydrochloride no Oxycodone Hydrochloride no Oxymorphone Hydrochloride no Pentazocine Lactate no Manufacturer Discontinued Tapentadol Hydrochloride no Tramadol Hydrochloride no Analgesics Combinations Class New class to include analgesic combination drug products Acetaminophen/ Codeine yes Phosphate Benzhydrocodone/ yes At i h * This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage. Medicare Model Guidelines Draft v8.0 3 of 97 Hydrocodone Bitartrate/ yes Acetaminophen Hydrocodone Bitartrate/ Ibuprofen yes Morphine Sulfate/ Naltrexone yes Hydrochloride Oxycodone Hydrochloride/ yes Acetaminophen Oxycodone Hydrochloride/ Aspirin yes Oxycodone Hydrochloride/ yes Ibuprofen Tramadol Hydrochloride/ yes Acetaminophen Butalbital/ Acetaminophen yes Butalbital/ Acetaminophen/ yes Caffeine Butalbital/ Acetaminophen/ yes Caffeine/ Codeine Phosphate Butalbital/ Aspirin/ Caffeine yes Butalbital/ Aspirin/ Caffeine/ yes Codeine Anesthetics Cat Local Anesthetics Class Lidocaine Hydrochloride no Lidocaine/ Epinephrine yes Lidocaine/ Prilocaine yes Lidocaine/ Tetracaine yes * This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage. Medicare Model Guidelines Draft v8.0 4 of 97 Anti-Addiction/ Substance Cat Abuse Treatment Agents Alcohol Deterrents/Anti-craving Class Acamprosate Calcium no Disulfiram no Naltrexone Hydrochloride no Opioid Dependence Treatments Class Renamed class to "Opioid Dependence" to avoid redundancy Opioid Dependence in category name, since the concept of "treatment agents" is already included Buprenorphine no Buprenorphine/ Naloxone yes Hydrochloride Lofexidine no Naltrexone Hydrochloride no Opioid Reversal Agents Class Naloxone Hydrochloride no Smoking Cessation Agents Class Bupropion Hydrochloride no Nicotine Polacrilex no Varenicline Tartrate no Antibacterials Cat Antibacterials Aminoglycosides Class Antibacterials Amikacin Sulfate no Antibacterials Gentamicin Sulfate no Antibacterials Neomycin Sulfate no Antibacterials Paromomycin Sulfate no Antibacterials Plazomicin no Antibacterials Streptomycin Sulfate no Antibacterials Tobramycin Sulfate no * This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage. Medicare Model Guidelines Draft v8.0 5 of 97 Antibacterials Beta-lactam, Cephalosporins Class Antibacterials Antibacterials Cefadroxil no Antibacterials Cefazolin no Antibacterials Cephalexin no Antibacterials Antibacterials Cefaclor no Antibacterials Cefoxitin Sodium no Antibacterials Cefprozil no Antibacterials Cefuroxime Axetil no Antibacterials Sodium no Antibacterials Antibacterials Cefdinir no Antibacterials Cefixime no Antibacterials Cefotaxime Sodium no Antibacterials Cefpodoxime Proxetil no Antibacterials Ceftazidime no Antibacterials Ceftazidime/ Avibactam yes Antibacterials Ceftibuten Dihydrate no Manufacturer Discontinued Antibacterials Ceftriaxone Sodium no Antibacterials Antibacterials Cefepime Hydrochloride no Antibacterials Antibacterials Ceftaroline Fosamil no Antibacterials Ceftolozane Sulfate/ Tazobactam yes Antibacterials Beta-lactam, Penicillins Class Antibacterials Antibacterials Amoxicillin no Antibacterials Amoxicillin/ Clavulanate yes Antibacterials Ampicillin no * This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage. Medicare Model Guidelines Draft v8.0 6 of 97 Antibacterials Ampicillin Sodium/ Sulbactam yes Antibacterials Sdi Antibacterials Piperacillin Sodium/ Tazobactam yes Sodium Antibacterials Antibacterials Penicillin G Benzathine no Antibacterials Penicillin G Potassium no Antibacterials Penicillin G Procaine no Antibacterials Penicillin G Sodium no Antibacterials Penicillin G Benzathine/ Penicillin yes G Procaine Antibacterials Penicillin V Potassium no Antibacterials Antibacterials Dicloxacillin Sodium no Antibacterials Nafcillin Sodium no Antibacterials Oxacillin Sodium no Antibacterials Beta-lactam, Other Carbapenems Class Renamed class to add specification Antibacterials Aztreonam no Moved example drug to USP Class, "Antibacterials, Other" Antibacterials Doripenem no Manufacturer Discontinued Antibacterials Ertapenem Sodium no Antibacterials Imipenem/ Cilastatin Sodium yes Imipenem/ Cilastatin/ Relebactam yes New FDA approved drug, 7/16/19 Antibacterials Meropenem no Antibacterials Meropenem/ Vaborbactam yes Antibacterials Macrolides Class Antibacterials Azithromycin no Antibacterials Clarithromycin no Antibacterials Erythromycin no * This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage. Medicare Model Guidelines Draft v8.0 7 of 97 Antibacterials Erythromycin Ethylsuccinate no Antibacterials Erythromycin Lactobionate no Antibacterials Erythromycin Stearate no Antibacterials Fidaxomicin no Antibacterials Quinolones Class Antibacterials Besifloxacin Hydrochloride no Antibacterials Ciprofloxacin no Antibacterials Delafloxacin Meglumine no Antibacterials Finafloxacin no Manufacturer Discontinued Antibacterials Gatifloxacin no Antibacterials Gemifloxacin Mesylate no Antibacterials Levofloxacin no Antibacterials Moxifloxacin Hydrochloride no Antibacterials Ofloxacin no Antibacterials Sulfonamides Class Antibacterials Sulfacetamide Sodium no Antibacterials Sulfadiazine no Antibacterials Sulfamethoxazole/ Trimethoprim yes Antibacterials Tetracyclines Class Antibacterials Demeclocycline Hydrochloride no Antibacterials Doxycycline Calcium no Antibacterials Doxycycline Hyclate no Eravacycline no Antibacterials Minocycline Hydrochloride no Antibacterials Omadacycline no Antibacterials Sarecycline no Antibacterials Tetracycline Hydrochloride no Antibacterials Antibacterials, Other Class Antibacterials * This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage. Medicare Model Guidelines Draft v8.0 8 of 97 Antibacterials Silver Sulfadiazine no Antibacterials Antibacterials Trimethoprim no Antibacterials Dalbavancin no Antibacterials Vancomycin Hydrochloride no Antibacterials Antibacterials Clindamycin Hydrochloride no Antibacterials Clindamycin Palmitate no Hydrochloride Antibacterials Lincomycin Hydrochloride no Antibacterials Antibacterials Nitrofurantoin no Antibacterials Antibacterials Linezolid no Antibacterials Tedizolid Phosphate no Antibacterials Antibacterials Acetic Acid no Aztreonam no Moved example drug from USP Class, "Beta-lactam, Other" Antibacterials Bacitracin no Antibacterials Chloramphenicol Sodium no Antibacterials DaptomycinSit no Antibacterials Fosfomycin Tromethamine no Antibacterials Mafenide Acetate no Antibacterials Methenamine Hippurate no Antibacterials Metronidazole no Antibacterials Mupirocin Calcium no Antibacterials Polymyxin B Sulfate no Antibacterials Retapamulin no Antibacterials Rifaximin no * This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage. Medicare Model Guidelines Draft v8.0 9 of 97 Antibacterials Secnidazole no Antibacterials Tinidazole no Antibacterials Tigecycline no Anticonvulsants Cat Anticonvulsants Calcium Channel Modifying Agents Class Anticonvulsants Ethosuximide no Anticonvulsants Methsuximide no Anticonvulsants Gamma-aminobutyric Acid (GABA) Class Augmenting Agents Anticonvulsants Anticonvulsants Clobazam no Anticonvulsants Clonazepam no Anticonvulsants Clorazepate Dipotassium no Anticonvulsants Diazepam no Anticonvulsants Lorazepam no Anticonvulsants Anticonvulsants Phenobarbital no Anticonvulsants Primidone no Anticonvulsants Anticonvulsants Gabapentin no Anticonvulsants Pregabalin no Anticonvulsants Tiagabine no Anticonvulsants Vigabatrin no Glutamate Reducing Agents Class Removed class due to multiple mechanism of actions of example drugs. Example drugs with multiple mechanism of actions moved to USP Class, "Anticonvulsants, Other.“ Examples drugs moved to USP Class, "Anticonvulsants, Other." Anticonvulsants Sodium Channel Agents Class Anticonvulsants Carbamazepine no * This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage. Medicare Model Guidelines Draft v8.0 10 of 97 Anticonvulsants Eslicarbazepine no Ethotoin no Anticonvulsants Fosphenytoin no Anticonvulsants Lacosamide no Anticonvulsants Oxcarbazepine no Anticonvulsants Phenytoin no Anticonvulsants Rufinamide no Anticonvulsants Zonisamide no Anticonvulsants Anticonvulsants, Other Class Anticonvulsants
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