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

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USP Category USP Class Example Part D Eligible Drugs* Salt/Ester USP Medicare Model Guidelines v7.0 Page 1 of 38 A B D E F Example Part D Eligible 1 USP Category USP Class Drugs* Salt/Ester Change Language 2 Analgesics 3 Analgesics Nonsteroidal Anti-inflammatory Drugs 4 Analgesics Celecoxib 5 Analgesics Diclofenac Potassium 6 Analgesics Diflunisal 7 Analgesics Etodolac 8 Analgesics Fenoprofen Calcium 9 Analgesics Flurbiprofen 10 Analgesics Ibuprofen 11 Analgesics Indomethacin 12 Analgesics Ketoprofen 13 Analgesics Ketorolac Tromethamine 14 Analgesics Meclofenamate 15 Analgesics Mefenamic Acid 16 Analgesics Meloxicam 17 Analgesics Nabumetone 18 Analgesics Naproxen 19 Analgesics Oxaprozin 20 Analgesics Piroxicam 21 Analgesics Sulindac 22 Analgesics Tolmetin Analgesics Opioid Analgesics, Long-acting 23 Analgesics Buprenorphine FDA approved 10/23/2015; New indication for 24 pain 25 Fentanyl 26 Analgesics Hydromorphone 27 Analgesics Levorphanol Tartrate 28 Analgesics Methadone Hydrochloride 29 Analgesics Morphine Sulfate 30 Analgesics Oxycodone Hydrochloride 31 Analgesics Oxymorphone Hydrochloride 32 Analgesics Tramadol Hydrochloride 33 Analgesics Opioid Analgesics, Short-acting 34 Analgesics Butorphanol Tartrate 35 Analgesics Codeine Phosphate 36 Analgesics Fentanyl Citrate 37 Analgesics Hydromorphone Hydrochloride 38 Analgesics Meperidine Hydrochloride 39 Analgesics Nalbuphine Hydrochloride 40 Analgesics Oxycodone Hydrochloride 41 Analgesics Oxymorphone Hydrochloride 42 Analgesics Pentazocine Lactate 43 Analgesics Tapentadol 44 Analgesics Tramadol Hydrochloride 45 Anesthetics 46 Anesthetics Local Anesthetics 47 Anesthetics Lidocaine Hydrochloride 48 Anesthetics Lidocaine/Prilocaine Anti-Addiction/ Substance Abuse 49 Treatment Agents 50 Alcohol Deterrents/Anti-craving 51 Acamprosate Calcium * This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage Changes from USP MMG v6.0 marked in red USP Medicare Model Guidelines v7.0 Page 2 of 38 A B D E F Example Part D Eligible 1 USP Category USP Class Drugs* Salt/Ester Change Language 522 Disulfiram 53 Naltrexone Hydrochloride 54 Opioid Dependence Treatments 55 Buprenorphine 56 Buprenorphine/Naloxone 57 Naltrexone Hydrochloride 58 Opioid Reversal Agents 59 Naloxone Hydrochloride 60 Smoking Cessation Agents 61 Bupropion Hydrochloride 62 Nicotine 63 Varenicline Tartrate 64 Antibacterials 65 Antibacterials Aminoglycosides 66 Antibacterials Amikacin Sulfate 67 Antibacterials Gentamicin Sulfate 68 Antibacterials Kanamycin Sulfate 69 Antibacterials Neomycin Sulfate 70 Antibacterials Paromomycin Sulfate 71 Antibacterials Streptomycin Sulfate 72 Antibacterials Tobramycin Sulfate Antibacterials Tobramycin/ Dexamethasone 73 74 Antibacterials Beta-lactam, Cephalosporins 75 Antibacterials 76 Antibacterials Cefadroxil 77 Antibacterials Cefazolin 78 Antibacterials Cephalexin 79 Antibacterials 80 Antibacterials Cefaclor 81 Antibacterials Cefoxitin 82 Antibacterials Cefprozil 83 Antibacterials Cefuroxime Axetil 84 Antibacterials 85 Antibacterials Cefdinir 86 Antibacterials Cefditoren Pivoxil 87 Antibacterials Cefixime 88 Antibacterials Cefotaxime 89 Antibacterials Cefpodoxime Proxetil 90 Antibacterials Ceftazidime 91 Antibacterials Ceftazidime/Avibactam New FDA Approved Drug, 2/25/15 92 Antibacterials Ceftibuten Dihydrate 93 Antibacterials Ceftriaxone Sodium 94 Antibacterials 95 Antibacterials Cefepime Hydrochloride Antibacterials Ceftolozane Sulfate/ New FDA Approved Drug, 12/19/14 96 Tazobactam 97 Antibacterials 98 Antibacterials Ceftaroline fosamil 99 Antibacterials Beta-lactam, Penicillins 100 Antibacterials 101 Antibacterials Amoxicillin * This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage Changes from USP MMG v6.0 marked in red USP Medicare Model Guidelines v7.0 Page 3 of 38 A B D E F Example Part D Eligible 1 USP Category USP Class Drugs* Salt/Ester Change Language 2 Antibacterials Amoxicillin/Clavulanate 102 Potassium 103 Antibacterials Ampicillin Antibacterials Ampicillin Sodium/ Sulbactam 104 Sodium 105 Antibacterials 106 Antibacterials Piperacillin Sodium Antibacterials Piperacillin Sodium/ 107 Tazobactam Sodium Antibacterials Ticarcillin Disodium/ Discontinued by manufacturer 108 Clavulanate Potassium 109 Antibacterials 110 Antibacterials Penicillin G Benzathine 111 Antibacterials Potassium 112 Antibacterials Procaine 113 Antibacterials Sodium 114 Antibacterials Penicillin V Potassium 115 Antibacterials 116 Antibacterials Dicloxacillin Sodium 117 Antibacterials Nafcillin Sodium 118 Antibacterials Oxacillin Sodium 119 Antibacterials Beta-lactam, Other 120 Antibacterials Aztreonam 121 Antibacterials Doripenem 122 Antibacterials Ertapenem Sodium 123 Antibacterials Imipenem/Cilastatin Sodium 124 Antibacterials Meropenem 125 Antibacterials Macrolides 126 Antibacterials Azithromycin 127 Antibacterials Clarithromycin 128 Antibacterials Erythromycin Estolate 129 Antibacterials Ethylsuccinate 130 Antibacterials Lactobionate 131 Antibacterials Stearate 132 Antibacterials Fidaxomicin 133 Antibacterials Telithromycin Discontinued by manufacturer 134 Antibacterials Quinolones 135 Antibacterials Besifloxacin 136 Antibacterials Ciprofloxacin 137 Antibacterials Finafloxacin New FDA Approved Drug, 12/17/14 138 Antibacterials Gatifloxacin 139 Antibacterials Gemifloxacin Mesylate 140 Antibacterials Levofloxacin 141 Antibacterials Moxifloxacin Hydrochloride 142 Antibacterials Norfloxacin Discontinued by manufacturer 143 Antibacterials Ofloxacin 144 Antibacterials Sulfonamides 145 Antibacterials Sulfacetamide Sodium 146 Antibacterials Sulfadiazine Antibacterials Sulfamethoxazole/ 147 Trimethoprim 148 Antibacterials Tetracyclines 149 Antibacterials Demeclocycline Hydrochloride * This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage Changes from USP MMG v6.0 marked in red USP Medicare Model Guidelines v7.0 Page 4 of 38 A B D E F Example Part D Eligible 1 USP Category USP Class Drugs* Salt/Ester Change Language 1502 Antibacterials Doxycycline Calcium 151 Antibacterials Hyclate 152 Antibacterials Minocycline Hydrochloride 153 Antibacterials Tetracycline Hydrochloride 154 Antibacterials Antibacterials, Other 155 Antibacterials 156 Antibacterials 157 Antibacterials Trimethoprim 158 Antibacterials 159 Antibacterials Vancomycin Hydrochloride 160 Antibacterials Dalbavancin New FDA Approved Drug, 5/23/14 161 Antibacterials 162 Antibacterials Clindamycin Hydrochloride 163 Antibacterials Palmitate 164 Antibacterials Lincomycin Hydrochloride 165 Antibacterials 166 Antibacterials Nitrofurantoin 167 Antibacterials 168 Antibacterials Linezolid 169 Antibacterials Tedizolid Phosphate New FDA Approved Drug, 6/20/14 170 Antibacterials 171 Antibacterials Acetic Acid 172 Antibacterials Bacitracin Antibacterials Chloramphenicol Sodium Succinate 173 174 Antibacterials Daptomycin 175 Antibacterials Fosfomycin Tromethamine 176 Antibacterials Gramicidin 177 Antibacterials Mafenide Acetate 178 Antibacterials Methenamine Hippurate 179 Antibacterials Mandelate 180 Antibacterials Metronidazole Hydrochloride 181 Antibacterials Mupirocin Calcium 182 Antibacterials Polymyxin B Sulfate 183 Antibacterials Retapamulin 184 Antibacterials Rifaximin 185 Antibacterials Telavancin 186 Antibacterials Tinidazole 187 Antibacterials Tigecycline 188 Antibacterials Oritavancin New FDA Approved Drug, 8/9/14 189 Anticonvulsants 190 Anticonvulsants Calcium Channel Modifying Agents 191 Anticonvulsants Ethosuximide 192 Anticonvulsants Methsuximide 193 Anticonvulsants Pregabalin 194 Anticonvulsants Zonisamide Anticonvulsants Gamma-aminobutyric Acid (GABA) 195 Augmenting Agents 196 Anticonvulsants 197 Anticonvulsants Clobazam 198 Anticonvulsants Clonazepam 199 Anticonvulsants Clorazepate Dipotassium 200 Anticonvulsants Diazepam 201 Anticonvulsants Lorazepam * This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage Changes from USP MMG v6.0 marked in red USP Medicare Model Guidelines v7.0 Page 5 of 38 A B D E F Example Part D Eligible 1 USP Category USP Class Drugs* Salt/Ester Change Language 2022 Anticonvulsants 203 Anticonvulsants Mephobarbital Discontinued by manufacturer 204 Anticonvulsants Phenobarbital 205 Anticonvulsants Primidone 206 Anticonvulsants 207 Anticonvulsants Divalproex Sodium 208 Anticonvulsants Gabapentin 209 Anticonvulsants Tiagabine Hydrochloride 210 Anticonvulsants Valproate Sodium 211 Anticonvulsants Vigabatrin 212 Anticonvulsants Glutamate Reducing Agents 213 Anticonvulsants Felbamate 214 Anticonvulsants Lamotrigine 215 Anticonvulsants Perampanel 216 Anticonvulsants Topiramate 217 Anticonvulsants Sodium Channel Agents 218 Anticonvulsants Carbamazepine 219 Anticonvulsants Eslicarbazepine Acetate 220 Anticonvulsants Ethotoin 221 Anticonvulsants Fosphenytoin Sodium 222 Anticonvulsants Oxcarbazepine 223 Anticonvulsants Phenytoin Sodium 224 Anticonvulsants Rufinamide 225 Anticonvulsants 226 Anticonvulsants Lacosamide 227 Anticonvulsants Anticonvulsants, Other 228 Anticonvulsants Briavaracetam New FDA Approved Drug, 2/18/16 229 Anticonvulsants Levetiracetam 230 Anticonvulsants 231 Anticonvulsants Ezogabine 232 Antidementia Agents 233 Antidementia Agents Cholinesterase Inhibitors 234 Antidementia Agents Donepezil Hydrochloride 235 Antidementia Agents Galantamine Hydrochloride 236 Antidementia Agents Rivastigmine Tartrate Antidementia Agents N-methyl-D-aspartate (NMDA) Receptor 237 Antagonist 238 Antidementia Agents Memantine Hydrochloride 239 Antidementia Agents Antidementia Agents, Other 240 Antidementia Agents Ergoloid Mesylates 241 Antidepressants 242 Antidepressants
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