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 5 Analgesics Potassium 6 Analgesics 7 Analgesics 8 Analgesics Calcium 9 Analgesics 10 Analgesics 11 Analgesics Indomethacin 12 Analgesics 13 Analgesics Tromethamine 14 Analgesics Meclofenamate 15 Analgesics 16 Analgesics 17 Analgesics 18 Analgesics 19 Analgesics 20 Analgesics 21 Analgesics 22 Analgesics Analgesics Analgesics, Long-acting 23 Analgesics FDA approved 10/23/2015; New indication for 24 pain 25 Fentanyl 26 Analgesics Hydromorphone 27 Analgesics Tartrate 28 Analgesics Hydrochloride 29 Analgesics Sulfate 30 Analgesics Oxycodone Hydrochloride 31 Analgesics Oxymorphone Hydrochloride 32 Analgesics Hydrochloride 33 Analgesics Opioid Analgesics, Short-acting 34 Analgesics Butorphanol Tartrate 35 Analgesics 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 Hydrochloride 48 Anesthetics Lidocaine/ Anti-Addiction/ Substance Abuse 49 Treatment Agents 50 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 63 Varenicline Tartrate 64 Antibacterials 65 Antibacterials 66 Antibacterials Sulfate 67 Antibacterials Sulfate 68 Antibacterials Kanamycin Sulfate 69 Antibacterials Sulfate 70 Antibacterials Sulfate 71 Antibacterials 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 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 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 /Cilastatin Sodium 124 Antibacterials 125 Antibacterials 126 Antibacterials Azithromycin 127 Antibacterials 128 Antibacterials Estolate 129 Antibacterials Ethylsuccinate 130 Antibacterials Lactobionate 131 Antibacterials Stearate 132 Antibacterials 133 Antibacterials Telithromycin Discontinued by manufacturer 134 Antibacterials Quinolones 135 Antibacterials Besifloxacin 136 Antibacterials 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 149 Antibacterials 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 Hydrochloride 153 Antibacterials Hydrochloride 154 Antibacterials Antibacterials, Other 155 Antibacterials 156 Antibacterials 157 Antibacterials Trimethoprim 158 Antibacterials 159 Antibacterials 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 Antibacterials Sodium Succinate 173 174 Antibacterials Daptomycin 175 Antibacterials Fosfomycin Tromethamine 176 Antibacterials Gramicidin 177 Antibacterials Acetate 178 Antibacterials Methenamine Hippurate 179 Antibacterials Mandelate 180 Antibacterials Hydrochloride 181 Antibacterials Calcium 182 Antibacterials Sulfate 183 Antibacterials Retapamulin 184 Antibacterials 185 Antibacterials Telavancin 186 Antibacterials Tinidazole 187 Antibacterials Tigecycline 188 Antibacterials Oritavancin New FDA Approved Drug, 8/9/14 189 190 Anticonvulsants Modifying Agents 191 Anticonvulsants 192 Anticonvulsants Methsuximide 193 Anticonvulsants 194 Anticonvulsants Anticonvulsants Gamma-aminobutyric Acid (GABA) 195 Augmenting Agents 196 Anticonvulsants 197 Anticonvulsants 198 Anticonvulsants 199 Anticonvulsants Dipotassium 200 Anticonvulsants 201 Anticonvulsants

* 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 205 Anticonvulsants 206 Anticonvulsants 207 Anticonvulsants Divalproex Sodium 208 Anticonvulsants 209 Anticonvulsants Hydrochloride 210 Anticonvulsants Sodium 211 Anticonvulsants 212 Anticonvulsants Glutamate Reducing Agents 213 Anticonvulsants 214 Anticonvulsants 215 Anticonvulsants 216 Anticonvulsants 217 Anticonvulsants Agents 218 Anticonvulsants 219 Anticonvulsants 220 Anticonvulsants 221 Anticonvulsants Sodium 222 Anticonvulsants 223 Anticonvulsants Sodium 224 Anticonvulsants 225 Anticonvulsants 226 Anticonvulsants 227 Anticonvulsants Anticonvulsants, Other 228 Anticonvulsants Briavaracetam New FDA Approved Drug, 2/18/16 229 Anticonvulsants 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) 237 Antagonist 238 Antidementia Agents Hydrochloride 239 Antidementia Agents Antidementia Agents, Other 240 Antidementia Agents Ergoloid Mesylates 241 Antidepressants 242 Antidepressants Monoamine Oxidase Inhibitors 243 Antidepressants Phenelzine Sulfate 244 Antidepressants Selegiline 245 Antidepressants Sulfate Antidepressants SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/ Serotonin and Norepinephrine Reuptake Inhibitors) 246 247 Antidepressants Citalopram Hydrobromide 248 Antidepressants Desvenlafaxine 249 Antidepressants Duloxetine Hydrochloride 250 Antidepressants Escitalopram Oxalate 251 Antidepressants 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 6 of 38

A B D E F Example Part D Eligible 1 USP Category USP Class Drugs* Salt/Ester Change Language 2522 Antidepressants Maleate 253 Antidepressants Hydrochloride 254 Antidepressants Maprotiline Hydrochloride 255 Antidepressants Nefazodone Hydrochloride 256 Antidepressants Hydrochloride 257 Antidepressants Sertraline Hydrochloride 258 Antidepressants Trazodone Hydrochloride 259 Antidepressants Venlafaxine Hydrochloride 260 Antidepressants Vilazodone Hydrochloride 261 Antidepressants Vortioxetine 262 Antidepressants Tricyclics 263 Antidepressants Hydrochloride 264 Antidepressants Amoxapine 265 Antidepressants Hydrochloride 266 Antidepressants Hydrochloride 267 Antidepressants Hydrochloride 268 Antidepressants Hydrochloride 269 Antidepressants Imipramine Pamoate 270 Antidepressants Hydrochloride 271 Antidepressants Protriptyline Hydrochloride 272 Antidepressants Trimipramine Maleate 273 Antidepressants Antidepressants, Other 274 Antidepressants Bupropion Hydrochloride 275 Antidepressants Mirtazapine 276 Antidepressants 277 Antidepressants Aripiprazole 278 Antidepressants Quetiapine Fumarate 279 Antiemetics 280 Antiemetics Emetogenic Therapy Adjuncts 281 Antiemetics Netupitant/Palonosetron Hydrochloride New FDA Approved Drug, 10/10/14 282 Antiemetics Rolapitant New FDA Approved Drug, 9/1/15 283 Antiemetics 284 Antiemetics Dolasetron Mesylate 285 Antiemetics Granisetron Hydrochloride 286 Antiemetics Ondansetron Hydrochloride 287 Antiemetics Palonosetron Hydrochloride 288 Antiemetics 289 Antiemetics Aprepitant 290 Antiemetics 291 Antiemetics Dronabinol 292 Antiemetics Nabilone 293 Antiemetics Antiemetics, Other 294 Antiemetics Hydrochloride 295 Antiemetics Hydrochloride Antiemetics Doxylamine Succinate/ 296 Pyridoxine Hydrochloride 297 Antiemetics Hydroxyzine Pamoate 298 Antiemetics Hydrochloride 299 Antiemetics Metoclopramide 300 Antiemetics Perphenazine 301 Antiemetics Prochlorperazine Edisylate 302 Antiemetics Maleate 303 Antiemetics Hydrochloride 304 Antiemetics Scopolamine

* 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 7 of 38

A B D E F Example Part D Eligible 1 USP Category USP Class Drugs* Salt/Ester Change Language 3052 Antiemetics Trimethobenzamide Hydrochloride 306 Antifungals 307 Antifungals 308 Antifungals Naftifine Hydrochloride 309 Antifungals Terbinafine Hydrochloride 310 Antifungals 311 Antifungals Butoconazole Nitrate 312 Antifungals Clotrimazole 313 Antifungals Econazole Nitrate 314 Antifungals Efinaconazole New FDA Approved Drug, 6/6/14 315 Antifungals 316 Antifungals Isavuconazonium New FDA Approved Drug, 3/6/15 317 Antifungals Itraconazole 318 Antifungals 319 Antifungals Luliconazole 320 Antifungals Nitrate 321 Antifungals Oxiconazole Nitrate 322 Antifungals Posaconazole 323 Antifungals Sertaconazole Nitrate 324 Antifungals Sulconazole Nitrate 325 Antifungals Terconazole 326 Antifungals Voriconazole 327 Antifungals 328 Antifungals 329 Antifungals Anidulafungin 330 Antifungals Caspofungin Acetate 331 Antifungals Micafungin Sodium 332 Antifungals 333 Antifungals 334 Antifungals 335 Antifungals 336 Antifungals Butenafine Hydrochloride 337 Antifungals Ciclopirox 338 Antifungals Flucytosine 339 Antifungals Griseofulvin 340 Antifungals Tavaborole New FDA Approved Drug, 7/7/14 341 Antigout Agents 342 Antigout Agents 343 Antigout Agents Probenecid 344 Antigout Agents 345 Antigout Agents Allopurinol 346 Antigout Agents Febuxostat 347 Antigout Agents 348 Antigout Agents 349 Antigout Agents 350 Antigout Agents Lesinurad New FDA Approved Drug, 12/22/15 351 Anti-inflammatory Agents 352 Anti-inflammatory Agents Glucocorticoids Anti-inflammatory Agents Nonsteroidal Anti-inflammatory Drugs 353 354 Anti-inflammatory Agents Celecoxib 355 Anti-inflammatory Agents Diclofenac Potassium 356 Anti-inflammatory Agents Diflunisal 357 Anti-inflammatory Agents Etodolac

* 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 8 of 38

A B D E F Example Part D Eligible 1 USP Category USP Class Drugs* Salt/Ester Change Language 3582 Anti-inflammatory Agents Fenoprofen Calcium 359 Anti-inflammatory Agents Flurbiprofen 360 Anti-inflammatory Agents Ibuprofen 361 Anti-inflammatory Agents Indomethacin 362 Anti-inflammatory Agents Ketoprofen 363 Anti-inflammatory Agents Ketorolac Tromethamine 364 Anti-inflammatory Agents Meclofenamate Sodium 365 Anti-inflammatory Agents Mefenamic Acid 366 Anti-inflammatory Agents Meloxicam 367 Anti-inflammatory Agents Nabumetone 368 Anti-inflammatory Agents Naproxen Sodium 369 Anti-inflammatory Agents Oxaprozin 370 Anti-inflammatory Agents Piroxicam 371 Anti-inflammatory Agents Sulindac 372 Anti-inflammatory Agents Tolmetin Sodium 373 Antimigraine Agents 374 Antimigraine Agents Ergot Alkaloids 375 Antimigraine Agents Dihydroergotamine Mesylate 376 Antimigraine Agents Ergotamine Tartrate Antimigraine Agents Serotonin (5-HT) 1b/1d Receptor Agonists 377 378 Antimigraine Agents Almotriptan Malate 379 Antimigraine Agents Eletriptan 380 Antimigraine Agents Frovatriptan Succinate 381 Antimigraine Agents Naratriptan Hydrochloride 382 Antimigraine Agents Rizatriptan Benzoate 383 Antimigraine Agents Sumatriptan 384 Antimigraine Agents Zolmitriptan 385 Antimigraine Agents Prophylactic 386 Antimigraine Agents 387 Antimigraine Agents Timolol Maleate 388 Antimigraine Agents 389 Antimigraine Agents Divalproex Sodium 390 Antimigraine Agents Topiramate 391 Antimigraine Agents Valproic Acid 392 Antimyasthenic Agents 393 Antimyasthenic Agents Parasympathomimetics 394 Antimyasthenic Agents Ambenonium Discontinued by manufacturer 395 Antimyasthenic Agents Hydrochloride 396 Antimyasthenic Agents Pyridostigmine 397 Antimycobacterials 398 Antimycobacterials Antituberculars 399 Antimycobacterials Fumerate 400 Antimycobacterials Capreomycin Sulfate 401 Antimycobacterials 402 Antimycobacterials Ethambutol Hydrochloride 403 Antimycobacterials Ethionamide 404 Antimycobacterials 405 Antimycobacterials Pyrazinamide 406 Antimycobacterials Rifampin 407 Antimycobacterials Rifampin/Isoniazid Antimycobacterials Rifampin/Isoniazid/ 408 Pyrazinamide

* 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 9 of 38

A B D E F Example Part D Eligible 1 USP Category USP Class Drugs* Salt/Ester Change Language 4092 Antimycobacterials Rifapentine 410 Antimycobacterials Antimycobacterials, Other 411 Antimycobacterials Dapsone 412 Antimycobacterials Rifabutin 413 Antineoplastics 414 Antineoplastics Alkylating Agents 415 Antineoplastics 416 Antineoplastics Altretamine 417 Antineoplastics 418 Antineoplastics Chlorambucil 419 Antineoplastics Mechlorethamine hydrochloride 420 Antineoplastics Melphalan 421 Antineoplastics 422 Antineoplastics Lomustine 423 Antineoplastics 424 Antineoplastics Busulfan 425 Antineoplastics Cyclophosphamide 426 Antineoplastics Procarbazine Hydrochloride 427 Antineoplastics Trabectedin New FDA approved drug, 10/23/15 428 Antineoplastics Antiandrogens 429 Antineoplastics 430 Antineoplastics Enzalutamide 431 Antineoplastics Bicalutamide 432 Antineoplastics Flutamide 433 Antineoplastics Nilutamide 434 Antineoplastics 435 Antineoplastics Abiraterone Acetate 436 Antineoplastics Antiangiogenic Agents 437 Antineoplastics 438 Antineoplastics 439 Antineoplastics 440 Antineoplastics Antiestrogens/Modifiers 441 Antineoplastics Antineoplastics Estramustine Phosphate 442 Sodium 443 Antineoplastics 444 Antineoplastics Tamoxifen Citrate 445 Antineoplastics Toremifene Citrate 446 Antineoplastics 447 Antineoplastics 448 Antineoplastics Mercaptopurine 449 Antineoplastics Thioguanine 450 Antineoplastics 451 Antineoplastics Hydroxyurea 452 Antineoplastics Aromatase Inhibitors, 3rd Generation 453 Antineoplastics Anastrozole 454 Antineoplastics Exemestane 455 Antineoplastics Letrozole 456 Antineoplastics Inhibitors 457 Antineoplastics Etoposide 458 Antineoplastics Topotecan 459 Antineoplastics Molecular Target Inhibitors 460 Antineoplastics Gefitinib New FDA approved drug, 7/13/15

* 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 10 of 38

A B D E F Example Part D Eligible 1 USP Category USP Class Drugs* Salt/Ester Change Language 4612 Antineoplastics 462 Antineoplastics Cobimetinib New FDA Approved Drug, 11/10/15 463 Antineoplastics 464 Antineoplastics Alectinib New FDA Approved Drug, 12/11/15 465 Antineoplastics Ceritinib New FDA Approved Drug, 4/28/14 466 Antineoplastics Crizotinib 467 Antineoplastics 468 Antineoplastics Vemurafenib 469 Antineoplastics Dabrafenib 470 Antineoplastics Trametinib 471 Antineoplastics 472 Antineoplastics Ibrutinib 473 Antineoplastics 474 Antineoplastics Palbociclib New FDA Approved Drug, 2/3/15 475 Antineoplastics 476 Antineoplastics Ramucirumab New FDA Approved Drug, 4/24/15 477 Antineoplastics 478 Antineoplastics Afatinib Dimaleate 479 Antineoplastics Erlotinib Hydrochloride 480 Antineoplastics Osimertinib New FDA Approved Drug, 11/13/15 481 Antineoplastics 482 Antineoplastics Sonidegib New FDA Approved Drug, 7/24/15 483 Antineoplastics Vismodegib 484 Antineoplastics 485 Antineoplastics Ruxolitinib 486 Antineoplastics 487 Antineoplastics Cabazitaxel Part D eligibile drug (CY16 FRF v09.26.16) 488 Antineoplastics 489 Antineoplastics 490 Antineoplastics 491 Antineoplastics Bosutinib 492 Antineoplastics Dasatinib 493 Antineoplastics Imatinib Mesylate 494 Antineoplastics Nilotinib 495 Antineoplastics Ponatinib Hydrochloride 496 Antineoplastics 497 Antineoplastics Lapatinib 498 Antineoplastics 499 Antineoplastics Axitinib 500 Antineoplastics Cabozantinib Updated nomenclature to include salt 501 Antineoplastics Cabozantinib S-Malate Updated nomenclature to include salt 502 Antineoplastics Lenvatinib New FDA Approved Drug, 2/13/15 503 Antineoplastics Pazopanib 504 Antineoplastics Regorafenib 505 Antineoplastics Sorafenib Tosylate 506 Antineoplastics Sunitinib Malate 507 Antineoplastics Vandetanib 508 Antineoplastics 509 Antineoplastics Idelalisib New FDA Approved Drug, 7/23/14 510 Antineoplastics 511 Antineoplastics Olaparib New FDA Approved Drug, 12/19/14 512 Antineoplastics 513 Antineoplastics Venetoclax New FDA Approved Drug, 4/11/16 514 Antineoplastics 515 Antineoplastics Belinostat New FDA Approved Drug, 7/3/14

* 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 11 of 38

A B D E F Example Part D Eligible 1 USP Category USP Class Drugs* Salt/Ester Change Language 5162 Antineoplastics Panobinostat New FDA Approved Drug, 2/23/15 Antineoplastics Monoclonal Monoclonal Nomenclature change; Renamed class to /Antibody-Drug Conjugate reflect inclusion of Antibbody-Drug Conjugate drugs 517 518 Antineoplastics Elotuzumab New FDA Approved Drug, 11/30/15 519 Antineoplastics 520 Antineoplastics Olaratumab New FDA Approved Drug, 10/19/2016 521 Antineoplastics 522 Antineoplastics Atezolizumab New FDA Approved Drug, 5/18/16 523 Antineoplastics Nivolumab New FDA Approved Drug, 12/22/14 524 Antineoplastics 525 Antineoplastics 526 Antineoplastics Ofatumumab 527 Antineoplastics 528 Antineoplastics Alitretinoin 529 Antineoplastics Bexarotene 530 Antineoplastics Tretinoin 531 Antineoplastics Treatment Adjuncts New class to reflect therapeutics Antineoplastics Allopurinol Additional Classification; drug added to new 532 class 533 Antineoplastics Mesna Part D eligible drug (CY16 FRF v09.26.16) 534 Antineoplastics Rasburicase Part D eligible drug (CY16 FRF v09.26.16) 535 Antineoplastics Antineoplastics, Other 536 Antineoplastics Fludarabine 537 Antineoplastics Ixazomib New FDA Approved Drug, 11/20/15 538 Antineoplastics Leucovorin 539 Antineoplastics Mitoxantrone Hydrochloride 540 Antineoplastics Pegaspargase Part D eligibile drug (CY16 FRF v09.26.16) 541 Antineoplastics Tiperacil/ New FDA Approved Drug, 09/22/15 542 Antineoplastics Vorinostat 543 Antiparasitics 544 Antiparasitics Anthelmintics 545 Antiparasitics Albendazole 546 Antiparasitics Ivermectin 547 Antiparasitics Mebendazole 548 Antiparasitics Praziquantel 549 Antiparasitics Antiprotozoals 550 Antiparasitics 551 Antiparasitics Miltefosine New FDA Approved Drug, 3/19/14 552 Antiparasitics 553 Antiparasitics Artemether/Lumefantrine Antiparasitics Atovaquone/Proguanil 554 Hydrochloride 555 Antiparasitics Chloroquine Phosphate 556 Antiparasitics Hydroxychloroquine Sulfate 557 Antiparasitics Hydrochloride 558 Antiparasitics Primaquine Phosphate 559 Antiparasitics Pyrimethamine 560 Antiparasitics Quinine Sulfate 561 Antiparasitics 562 Antiparasitics Atovaquone 563 Antiparasitics Nitazoxanide 564 Antiparasitics Isethionate

* 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 12 of 38

A B D E F Example Part D Eligible 1 USP Category USP Class Drugs* Salt/Ester Change Language 5652 Antiparasitics Pediculicides/Scabicides 566 Antiparasitics Benzyl alcohol 567 Antiparasitics Crotamiton 568 Antiparasitics Lindane 569 Antiparasitics Malathion 570 Antiparasitics Permethrin 571 Antiparasitics Spinosad 572 Antiparkinson Agents 573 Antiparkinson Agents Anticholinergics 574 Antiparkinson Agents Benztropine Mesylate 575 Antiparkinson Agents Diphenhydramine Hydrochloride 576 Antiparkinson Agents Trihexyphenidyl Hydrochloride 577 Antiparkinson Agents Dopamine Agonists 578 Antiparkinson Agents Apomorphine Hydrochloride 579 Antiparkinson Agents Mesylate Antiparkinson Agents Pramipexole Dihydrochloride 580 Monohydrate 581 Antiparkinson Agents Ropinirole Hydrochloride 582 Antiparkinson Agents Rotigotine Antiparkinson Agents Dopamine Precursors/ L-Amino Acid 583 Decarboxylase Inhibitors 584 Antiparkinson Agents Carbidopa 585 Antiparkinson Agents Carbidopa/Levodopa Antiparkinson Agents Monoamine Oxidase B (MAO-B) Inhibitors 586 587 Antiparkinson Agents Rasagiline Mesylate 588 Antiparkinson Agents Selegiline Hydrochloride 589 Antiparkinson Agents Antiparkinson Agents, Other 590 Antiparkinson Agents 591 Antiparkinson Agents Entacapone 592 Antiparkinson Agents Tolcapone 593 Antiparkinson Agents 594 Antiparkinson Agents Hydrochloride 595 Antipsychotics 596 Antipsychotics 1st Generation/Typical 597 Antipsychotics Chlorpromazine Hydrochloride 598 Antipsychotics Fluphenazine Hydrochloride 599 Antipsychotics Lactate 600 Antipsychotics Loxapine Succinate 601 Antipsychotics Perphenazine 602 Antipsychotics 603 Antipsychotics Prochlorperazine Edisylate 604 Antipsychotics Prochlorperazine Maleate 605 Antipsychotics Hydrochloride 606 Antipsychotics Thiothixene Hydrochloride 607 Antipsychotics Hydrochloride 608 Antipsychotics 2nd Generation/Atypical 609 Antipsychotics Aripiprazole 610 Antipsychotics Asenapine 611 Antipsychotics Brexipiprazole New FDA Approved Drug, 7/10/15 612 Antipsychotics Cariprazine New FDA Approved Drug, 9/17/15 613 Antipsychotics Iloperidone 614 Antipsychotics Lurasidone

* 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 13 of 38

A B D E F Example Part D Eligible 1 USP Category USP Class Drugs* Salt/Ester Change Language 6152 Antipsychotics Olanzapine 616 Antipsychotics Pimavanserin New FDA Approved Drug, 4/29/16 617 Antipsychotics Quetiapine Fumarate 618 Antipsychotics Paliperidone 619 Antipsychotics Risperidone 620 Antipsychotics Ziprasidone Hydrochloride 621 Antipsychotics Ziprasidone Mesylate 622 Antipsychotics Treatment-Resistant 623 Antipsychotics 624 Antispasticity Agents 625 Antispasticity Agents 626 Antispasticity Agents Dantrolene Sodium 627 Antispasticity Agents Tizanidine Hydrochloride 628 Antivirals 629 Antivirals Anti-cytomegalovirus (CMV) Agents 630 Antivirals 631 Antivirals Sodium 632 Antivirals Sodium 633 Antivirals Hydrochloride 634 Antivirals Anti- (HBV) Agents 635 Antivirals Dipivoxil 636 Antivirals 637 Antivirals 638 Antivirals 639 Antivirals Antivirals 640 Fumarate 641 Antivirals Antivirals Alfa-2b, 642 Recombinant 643 Antivirals Interferon Alfa-2b/Ribavirin 644 Antivirals Interferon Alfa-n3 645 Antivirals Peginterferon Alfa-2a 646 Antivirals Peginterferon Alfa-2b Anti- (HCV) Agents, Direct New class to reflect therapeutics 647 Acting 648 Antivirals 649 Antivirals Discontinued by manufacturer 650 Antivirals 651 Antivirals Discontinued by manufacturer 652 Antivirals 653 Antivirals New FDA Approved Drug, 7/24/15 654 Antivirals 655 Antivirals 656 Antivirals Elbasvir/ New FDA Approved Drug, 1/28/16 657 Antivirals /Sofosbuvir New FDA Approved Drug, 10/10/14 Antivirals // New FDA Approved Drug, 12/19/14 658 / 659 Antivirals Sofosbuvir/ New FDA Approved Drug, 6/28/16 Anti-hepatitis C (HCV) Agents Anti- Nomenclature change; Renamed class to 660 hepatitis C (HCV) Agents, Other reflect therapeutics 661 Ribavirin 662

* 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 14 of 38

A B D E F Example Part D Eligible 1 USP Category USP Class Drugs* Salt/Ester Change Language 2 Interferon Alfa-2b, 663 Recombinant 664 Interferon Alfa-2b/Ribavirin 665 Interferon Alfa-n3 666 Interferon Alfacon-1 667 Peginterferon Alfa-2a 668 Peginterferon Alfa-2b 669 Antivirals Antiherpetic Agents 670 Antivirals Acyclovir 671 Antivirals 672 Antivirals Foscarnet Sodium 673 Antivirals Idoxuridine 674 Antivirals Trifluridine 675 Antivirals Sodium 676 Antivirals Valacyclovir Hydrochloride Antivirals Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI) 677 678 Antivirals Delavirdine Mesylate 679 Antivirals 680 Antivirals Etravirine 681 Antivirals Nevirapine 682 Antivirals Rilpivirine Antivirals Efavirenz/ Emtricitabine/ Tenofovir disoproxil fumarate 683 Antivirals Emtricitabine/ Rilpivirine / Tenofovir disoproxil fumerate 684 Antivirals Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI) 685 686 Antivirals Abacavir Sulfate 687 Antivirals Abacavir/Lamivudine Antivirals Abacavir/ Lamivudine/ 688 Zidovudine 689 Antivirals Didanosine 690 Antivirals 691 Antivirals Emtricitabine Antivirals Emtricitabine/Tenofovir Disoproxil 692 Fumarate 693 Antivirals Lamivudine 694 Antivirals Lamivudine/Zidovudine 695 Antivirals Stavudine Antivirals Tenofovir Disoproxil 696 Fumarate 697 Antivirals Zidovudine 698 Antivirals Anti-HIV Agents, Protease Inhibitors 699 Antivirals Atazanavir Sulfate 700 Antivirals Atazanavir/ Cobicistat New FDA Approved Drug, 1/29/15 701 Antivirals Darunavir Ethanolate 702 Antivirals Darunavir/Cobicistat New FDA Approved Drug, 1/29/15 703 Antivirals Fosamprenavir Calcium 704 Antivirals Indinavir Sulfate

* 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 15 of 38

A B D E F Example Part D Eligible 1 USP Category USP Class Drugs* Salt/Ester Change Language 7052 Antivirals Lopinavir/Ritonavir 706 Antivirals Nelfinavir Mesylate 707 Antivirals Ritonavir 708 Antivirals Saquinavir Mesylate 709 Antivirals Tipranavir Antivirals Anti-HIV Agents, Integrase Inhibitors 710 (INSTI) 711 Antivirals Dolutegravir Sodium Antivirals Elvitegravir/ Cobicistat/ Emtricitabine/ Tenofovir 712 disoproxil fumarate Antivirals Elvitegravir/ Cobicistat/ New FDA Approved Drug, 11/5/15 Emtricitabine/ Tenofovir 713 alafenamide 714 Antivirals Raltegravir 715 Antivirals Anti-HIV Agents, Other 716 Antivirals Enfuvirtide 717 Antivirals Maraviroc 718 Antivirals Anti- Agents 719 Antivirals Amantadine Hydrochloride 720 Antivirals Phosphate 721 Antivirals New FDA Approved Drug, 12/19/14 722 Antivirals Hydrochloride 723 Antivirals 724 Anxiolytics Anxiolytics SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/ Serotonin and Norepinephrine Reuptake Inhibitors) 725 726 Anxiolytics Duloxetine Hydrochloride 727 Anxiolytics Escitalopram Oxalate 728 Anxiolytics Paroxetine Hydrochloride 729 Anxiolytics Sertraline Hydrochloride 730 Anxiolytics Venlafaxine Hydrochloride 731 Anxiolytics 732 Anxiolytics Alprazolam 733 Anxiolytics Chlordiazepoxide 734 Anxiolytics Clonazepam 735 Anxiolytics Clorazepate Dipotassium 736 Anxiolytics Diazepam 737 Anxiolytics Lorazepam 738 Anxiolytics Oxazepam 739 Anxiolytics Anxiolytics, Other 740 Anxiolytics Buspirone Hydrochloride 741 Anxiolytics Doxepin Hydrochloride 742 Anxiolytics Hydroxyzine Hydrochloride 743 Anxiolytics 744 Bipolar Agents 745 Bipolar Agents Mood Stabilizers 746 Bipolar Agents Carbamazepine 747 Bipolar Agents Divalproex Sodium 748 Bipolar Agents Lamotrigine 749 Bipolar Agents Lithium Carbonate 750 Bipolar Agents Valproic Acid

* 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 16 of 38

A B D E F Example Part D Eligible 1 USP Category USP Class Drugs* Salt/Ester Change Language 7512 Bipolar Agents Bipolar Agents, Other 752 Bipolar Agents Aripiprazole 753 Bipolar Agents Asenapine 754 Bipolar Agents Olanzapine 755 Bipolar Agents Quetiapine Fumarate 756 Bipolar Agents Risperidone 757 Bipolar Agents Ziprasidone Hydrochloride 758 Bipolar Agents Ziprasidone Mesylate 759 Blood Glucose Regulators 760 Blood Glucose Regulators Antidiabetic Agents 761 Blood Glucose Regulators 762 Blood Glucose Regulators 763 Blood Glucose Regulators 764 Blood Glucose Regulators 765 Blood Glucose Regulators Acetate 766 Blood Glucose Regulators 767 Blood Glucose Regulators Hydrochloride 768 Blood Glucose Regulators 769 Blood Glucose Regulators Colesevelam Hydrochloride 770 Blood Glucose Regulators 771 Blood Glucose Regulators 772 Blood Glucose Regulators 773 Blood Glucose Regulators 774 Blood Glucose Regulators Phosphate 775 Blood Glucose Regulators 776 Blood Glucose Regulators Bromocriptine Mesylate 777 Blood Glucose Regulators 778 Blood Glucose Regulators New FDA Approved Drug, 4/15/14 779 New FDA Approved Drug, 9/18/14 780 Blood Glucose Regulators 781 Blood Glucose Regulators 782 Blood Glucose Regulators New FDA Approved Drug, 7/27/16 783 Blood Glucose Regulators 784 Blood Glucose Regulators 785 Blood Glucose Regulators 786 Blood Glucose Regulators 787 Blood Glucose Regulators 788 Blood Glucose Regulators New FDA Approved Drug, 1/8/14 789 Blood Glucose Regulators New FDA Approved Drug, 8/1/14 790 Blood Glucose Regulators 791 Blood Glucose Regulators 792 Blood Glucose Regulators 793 Blood Glucose Regulators 794 Blood Glucose Regulators Glyburide 795 Blood Glucose Regulators 796 Blood Glucose Regulators 797 Blood Glucose Regulators 798 Blood Glucose Regulators Hydrochloride 799 Blood Glucose Regulators Maleate 800 Blood Glucose Regulators Glycemic Agents 801 Blood Glucose Regulators 802 Blood Glucose Regulators Diazoxide 803 Blood Glucose Regulators Glucagon 804 Blood Glucose Regulators

* 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 17 of 38

A B D E F Example Part D Eligible 1 USP Category USP Class Drugs* Salt/Ester Change Language 8052 Blood Glucose Regulators 806 Blood Glucose Regulators Aspart 807 Blood Glucose Regulators 808 Blood Glucose Regulators 809 Blood Glucose Regulators 810 Blood Glucose Regulators Insulin Human (Regular) 811 Blood Glucose Regulators 812 Blood Glucose Regulators Isophane Insulin (Human) 813 Blood Glucose Regulators 814 Blood Glucose Regulators New FDA Approved Drug, 9/25/15 815 Blood Glucose Regulators 816 Blood Glucose Regulators 817 Blood Glucose Regulators Blood Glucose Regulators Rapid-acting/ Insulin Aspart Protamine 818 Blood Glucose Regulators Insulin Lispro Rapid-acting/ Insulin Lispro Protamine 819 820 Blood Glucose Regulators Blood Glucose Regulators Insulin Human Regular/ 821 Isophane Insulin Blood Products/Modifiers/ Volume 822 Expanders 823 Blood Products Anticoagulants 824 Blood Products 825 Blood Products Dabigatran 826 Blood Products 827 Blood Products Apixaban 828 Blood Products Rivaroxaban 829 Blood Products Edoxaban New FDA Approved Drug, 1/8/15 830 Blood Products 831 Blood Products Fondaparinux Sodium 832 Blood Products 833 Blood Products 834 Blood Products Dalteparin Sodium 835 Blood Products Enoxaparin Sodium 836 Blood Products 837 Blood Products Vorapaxar New FDA Approved Drug, 5/8/14 838 Blood Products 839 Blood Products Sodium 840 Blood Products Blood Formation Modifiers 841 Blood Products 842 Blood Products Azacitidine New FDA Approved Drug, 4/29/16 843 Blood Products 844 Blood Products Filgrastim 845 Blood Products Pegfilgrastim 846 Blood Products Sargramostim 847 Blood Products 848 Blood Products Darbepoetin Alfa 849 Blood Products Epoetin Alfa 850 Blood Products 851 Blood Products Anagrelide 852 Blood Products 853 Blood Products Eltrombopag Olamine

* 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 18 of 38

A B D E F Example Part D Eligible 1 USP Category USP Class Drugs* Salt/Ester Change Language 8542 Blood Products Romiplostim 855 Blood Products 856 Blood Products Plerixafor Blood Products Coagulants Nomenclature change; Renamed class to 857 Hemostasis Agents reflect therapeutics 858 Blood Products 859 Blood Products Tranexamic Acid 860 Blood Products Platelet Modifying Agents 861 Blood Products 862 Blood Products Clopidogrel Bisulfate 863 Blood Products Prasugrel 864 Blood Products Ticlopidine Hydrochloride 865 Blood Products Ticagrelor 866 Blood Products 867 Blood Products Dipyridamole 868 Blood Products Dipyridamole/ 869 Blood Products 870 Blood Products Cilostazol 871 Cardiovascular Agents 872 Cardiovascular Agents Alpha-adrenergic Agonists 873 Cardiovascular Agents Clonidine Hydrochloride 874 Cardiovascular Agents Droxidopa New FDA Approved Drug, 2/18/14 875 Cardiovascular Agents Guanfacine Hydrochloride 876 Cardiovascular Agents Methyldopa 877 Cardiovascular Agents Methyldopate Hydrochloride 878 Cardiovascular Agents Midodrine Hydrochloride 879 Cardiovascular Agents Phenylephrine Hydrochloride 880 Cardiovascular Agents Alpha-adrenergic Blocking Agents 881 Cardiovascular Agents Doxazosin Mesylate 882 Cardiovascular Agents Phenoxybenzamine Hydrochloride 883 Cardiovascular Agents Prazosin Hydrochloride 884 Cardiovascular Agents Terazosin Hydrochloride Cardiovascular Agents Angiotensin-converting Enzyme (ACE) 885 Inhibitors 886 Cardiovascular Agents Benazepril Hydrochloride 887 Cardiovascular Agents 888 Cardiovascular Agents Enalapril Maleate 889 Cardiovascular Agents Sodium 890 Cardiovascular Agents Lisinopril 891 Cardiovascular Agents Moexipril Hydrochloride 892 Cardiovascular Agents Perindopril Erbumine 893 Cardiovascular Agents Quinapril Hydrochloride 894 Cardiovascular Agents Ramipril 895 Cardiovascular Agents Trandolapril 896 Cardiovascular Agents Angiotensin II Receptor Antagonists 897 Cardiovascular Agents Azilsartan Medoxomil 898 Cardiovascular Agents Candesartan Cilexetil 899 Cardiovascular Agents Eprosartan Mesylate 900 Cardiovascular Agents Irbesartan 901 Cardiovascular Agents Losartan Potassium 902 Cardiovascular Agents Olmesartan Medoxomil 903 Cardiovascular Agents Telmisartan 904 Cardiovascular Agents Valsartan

* 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 19 of 38

A B D E F Example Part D Eligible 1 USP Category USP Class Drugs* Salt/Ester Change Language 9052 Cardiovascular Agents Antiarrhythmics 906 Cardiovascular Agents Hydrochloride 907 Cardiovascular Agents Phosphate 908 Cardiovascular Agents 909 Cardiovascular Agents 910 Cardiovascular Agents Acetate 911 Cardiovascular Agents Hydrochloride 912 Cardiovascular Agents Hydrochloride 913 Cardiovascular Agents Hydrochloride 914 Cardiovascular Agents Hydrochloride 915 Cardiovascular Agents Hydrochloride 916 Cardiovascular Agents Beta-adrenergic Blocking Agents 917 Cardiovascular Agents Acebutolol Hydrochloride 918 Cardiovascular Agents Atenolol 919 Cardiovascular Agents Betaxolol Hydrochloride 920 Cardiovascular Agents Bisoprolol Fumarate 921 Cardiovascular Agents Carvedilol Phosphate 922 Cardiovascular Agents Labetalol Hydrochloride 923 Cardiovascular Agents Metoprolol Succinate 924 Cardiovascular Agents Tartrate 925 Cardiovascular Agents Nadolol 926 Cardiovascular Agents Nebivolol 927 Cardiovascular Agents Penbutolol Sulfate Discontinued by manufacturer 928 Cardiovascular Agents Pindolol 929 Cardiovascular Agents Hydrochloride 930 Cardiovascular Agents Timolol Maleate 931 Cardiovascular Agents Calcium Channel Blocking Agents 932 Cardiovascular Agents 933 Cardiovascular Agents 934 Cardiovascular Agents 935 Cardiovascular Agents 936 Cardiovascular Agents Hydrochloride 937 Cardiovascular Agents 938 Cardiovascular Agents 939 Cardiovascular Agents 940 Cardiovascular Agents 941 Cardiovascular Agents Hydrochloride 942 Cardiovascular Agents Hydrochloride 943 Cardiovascular Agents Cardiovascular Agents , Carbonic Anhydrase Inhibitors 944 945 Cardiovascular Agents Sodium 946 Cardiovascular Agents Methazolamide 947 Cardiovascular Agents Diuretics, Loop 948 Cardiovascular Agents 949 Cardiovascular Agents Ethacrynate Sodium 950 Cardiovascular Agents Ethacrynic Acid 951 Cardiovascular Agents 952 Cardiovascular Agents Torsemide 953 Cardiovascular Agents Diuretics, Potassium-sparing 954 Cardiovascular Agents Hydrochloride 955 Cardiovascular Agents Eplerenone 956 Cardiovascular Agents Spironolactone

* 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 20 of 38

A B D E F Example Part D Eligible 1 USP Category USP Class Drugs* Salt/Ester Change Language 9572 Cardiovascular Agents 958 Cardiovascular Agents Diuretics, 959 Cardiovascular Agents Bendroflumethiazide 960 Cardiovascular Agents Chlorothiazide Sodium 961 Cardiovascular Agents Chlorthalidone 962 Cardiovascular Agents 963 Cardiovascular Agents Indapamide 964 Cardiovascular Agents Methyclothiazide 965 Cardiovascular Agents Metolazone Cardiovascular Agents Dyslipidemics, Fibric Acid Derivatives 966 967 Cardiovascular Agents Choline Fenofibrate 968 Cardiovascular Agents Fenofibrate 969 Cardiovascular Agents Fenofibric Acid 970 Cardiovascular Agents Cardiovascular Agents Dyslipidemics, HMG CoA Reductase 971 Inhibitors 972 Cardiovascular Agents Atorvastatin Calcium 973 Cardiovascular Agents Fluvastatin Sodium 974 Cardiovascular Agents Lovastatin 975 Cardiovascular Agents Pitavastatin 976 Cardiovascular Agents Pravastatin Sodium 977 Cardiovascular Agents Rosuvastatin Calcium 978 Cardiovascular Agents Simvastatin 979 Cardiovascular Agents Dyslipidemics, Other 980 Cardiovascular Agents Cholestyramine 981 Cardiovascular Agents Colesevelam Hydrochloride 982 Cardiovascular Agents Colestipol Hydrochloride 983 Cardiovascular Agents Ezetimibe 984 Cardiovascular Agents Icosapent ethyl 985 Cardiovascular Agents Lomitapide Mesylate 986 Cardiovascular Agents Mipomersen Sodium 987 Cardiovascular Agents Niacin 988 Cardiovascular Agents Omega-3-acid Ethyl Esters 989 Cardiovascular Agents 990 Cardiovascular Agents Alirocumab New FDA Approved Drug, 7/24/15 991 Cardiovascular Agents Evolocumab New FDA Approved Drug, 8/27/15 992 Cardiovascular Agents Vasodilators, Direct-acting Arterial 993 Cardiovascular Agents Hydralazine Hydrochloride 994 Cardiovascular Agents Cardiovascular Agents Vasodilators, Direct-acting Arterial/Venous 995 996 Cardiovascular Agents Isosorbide Dinitrate 997 Cardiovascular Agents Isosorbide Mononitrate 998 Cardiovascular Agents Nitroglycerin 999 Cardiovascular Agents Cardiovascular Agents, Other 1000 Cardiovascular Agents Aliskiren 1001 Cardiovascular Agents 1002 Cardiovascular Agents Ivabradine New FDA Approved Drug, 4/15/15 1003 Cardiovascular Agents Pentoxifylline 1004 Cardiovascular Agents 1005 Cardiovascular Agents Sacubitril/Valsartan New FDA Approved Drug, 7/7/15 1006 Central Nervous System Agents

* 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 21 of 38

A B D E F Example Part D Eligible 1 USP Category USP Class Drugs* Salt/Ester Change Language 2 Central Nervous System Agents Attention Deficit Hyperactivity Disorder 1007 Agents, Amphetamines 1008 Central Nervous System Agents Dextroamphetamine Sulfate Central Nervous System Agents Dextroamphetamine/ Mixed Salts 1009 Amphetamine 1010 Central Nervous System Agents Lisdexamfetamine 1011 Central Nervous System Agents Methamphetamine Hydrochloride Central Nervous System Agents Attention Deficit Hyperactivity Disorder 1012 Agents, Non-amphetamines 1013 Central Nervous System Agents Hydrochloride 1014 Central Nervous System Agents Clonidine Hydrochloride 1015 Central Nervous System Agents Dexmethylphenidate Hydrochloride 1016 Central Nervous System Agents Guanfacine Hydrochloride 1017 Central Nervous System Agents Methylphenidate Hydrochloride 1018 Central Nervous System Agents Fibromyalgia Agents 1019 Central Nervous System Agents Duloxetine Hydrochloride 1020 Central Nervous System Agents 1021 Central Nervous System Agents Pregabalin 1022 Central Nervous System Agents Multiple Sclerosis Agents 1023 Central Nervous System Agents 1024 Central Nervous System Agents Interferon Beta-1a 1025 Central Nervous System Agents Interferon Beta-1b 1026 Central Nervous System Agents 1027 Central Nervous System Agents Dalfampridine 1028 Central Nervous System Agents 1029 Central Nervous System Agents 1030 Central Nervous System Agents 1031 Central Nervous System Agents Fingolimod 1032 Central Nervous System Agents 1033 Central Nervous System Agents Dimethyl fumarate 1034 Central Nervous System Agents Glatiramer Acetate 1035 Central Nervous System Agents Mitoxantrone Hydrochloride 1036 Central Nervous System Agents Peginterferon Beta 1A New FDA Approved Drug, 8/15/14 1037 Central Nervous System Agents 1038 Central Nervous System Agents New FDA Approved Drug, 5/27/16 1039 Central Nervous System Agents Central Nervous System, Other 1040 Central Nervous System Agents 1041 Central Nervous System Agents 1042 Central Nervous System Agents Tetrabenazine 1043 Central Nervous System Agents Central Nervous System Agents / Quinidine 1044 1045 Dental and Oral Agents 1046 Dental and Oral Agents Cevimeline Hydrochloride 1047 Dental and Oral Agents Chlorhexidine Gluconate 1048 Dental and Oral Agents Doxycycline Hyclate 1049 Dental and Oral Agents Minocycline Hydrochloride 1050 Dental and Oral Agents Palifermin 1051 Dental and Oral Agents Pilocarpine Hydrochloride 1052 Dental and Oral Agents Prilocaine Hydrochloride 1053 Dental and Oral Agents Triamcinolone Acetonide 1054 Dermatological Agents 1055 Dermatological Agents

* 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 22 of 38

A B D E F Example Part D Eligible 1 USP Category USP Class Drugs* Salt/Ester Change Language 10562 Dermatological Agents Isotretinoin 1057 Dermatological Agents 1058 Dermatological Agents Adapalene 1059 Dermatological Agents Azelaic Acid 1060 Dermatological Agents Benzoyl Peroxide 1061 Dermatological Agents Dapsone 1062 Dermatological Agents Tazarotene 1063 Dermatological Agents 1064 Dermatological Agents Doxycycline Calcium 1065 Dermatological Agents Hyclate 1066 Dermatological Agents 1067 Dermatological Agents Doxepin Hydrochloride 1068 Dermatological Agents 1069 Dermatological Agents 1070 Dermatological Agents 1071 Dermatological Agents 1072 Dermatological Agents Podofilox 1073 Dermatological Agents 1074 Dermatological Agents Ammonium Lactate 1075 Dermatological Agents 1076 Dermatological Agents 1077 Dermatological Agents Sinecatechins 1078 Dermatological Agents 1079 Dermatological Agents Sulfide 1080 Dermatological Agents 1081 Dermatological Agents Diclofenac Sodium 1082 Dermatological Agents Fluorouracil 1083 Dermatological Agents Imiquimod 1084 Dermatological Agents 1085 Dermatological Agents 1086 Dermatological Agents Methoxsalen 1087 Dermatological Agents 1088 Dermatological Agents Acitretin 1089 Dermatological Agents Calcitriol 1090 Dermatological Agents 1091 Dermatological Agents New FDA Approved Drug, 1/21/15 1092 Dermatological Agents Ixekizumab New FDA Approved Drug, 3/22/16 1093 Dermatological Agents 1094 Dermatological Agents Calcipotriene 1095 Dermatological Agents 1096 Dermatological Agents Becaplermin 1097 Dermatological Agents Collagenase 1098 Dermatological Agents 1099 Dermatological Agents Brimonidine Tartrate Therapeutic Nutrients/ Minerals/ Nomenclature change; Renamed category to Electrolytes Electrolytes/Minerals/ reflect therapeutics. Moved according to Metals/ Vitamins alphabetization.

1100 Electrolytes Electrolyte/Mineral Modifiers Nomenclature change; Renamed class to Electrolyte/Mineral/Metal Modifiers reflect therapeutics 1101 1102 Electrolytes 1103 Electrolytes Deferasirox 1104 Electrolytes Deferiprone 1105 Electrolytes

* 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 23 of 38

A B D E F Example Part D Eligible 1 USP Category USP Class Drugs* Salt/Ester Change Language 11062 Patiromer Sorbitex Calcium New FDA Approved Drug, 10/21/15 1107 Electrolytes Penicillamine Electrolytes Sodium Polystyrene 1108 Sulfonate 1109 Electrolytes Succimer 1110 Electrolytes Tolvaptan 1111 Electrolytes Trientine Hydrochloride 1112 Electrolytes 1113 Electrolytes Electrolyte/Mineral Replacement 1114 Electrolytes Ammonium Chloride 1115 Electrolytes Carglumic Acid 1116 Electrolytes Chromic Chloride Electrolytes Citric Acid/ Potassium Citrate/ Sodium Citrate 1117 1118 Electrolytes Fluoride Sodium 1119 Electrolytes Stannous 1120 Electrolytes Chloride 1121 Electrolytes Sulfate 1122 Electrolytes Manganese Chloride 1123 Electrolytes Potassium Acetate 1124 Electrolytes Bicarbonate 1125 Electrolytes Chloride 1126 Electrolytes Citrate 1127 Electrolytes Gluconate 1128 Electrolytes Phosphates Electrolytes Potassium Bicarbonate/ 1129 Potassium Citrate 1130 Electrolytes Potassium Citrate/ Citric Acid Electrolytes Potassium Citrate/ Sodium 1131 Citrate Electrolytes Potassium Gluconate/ 1132 Potassium Chloride Electrolytes Potassium Gluconate/ 1133 Potassium Citrate Electrolytes Potassium Phosphate/ 1134 Sodium Phosphate 1135 Electrolytes Selenium 1136 Electrolytes Sodium Acetate 1137 Electrolytes Sodium Bicarbonate 1138 Electrolytes Sodium Lactate 1139 Electrolytes Sodium Chloride Electrolytes Sodium Ferric Gluconate Complex 1140 1141 Electrolytes Sodium Phosphates Electrolytes Phosphate Binders Class moved from USP Category 1142 Genitourinary Agents 1143 Electrolytes Calcium Acetate 1144 Electrolytes Ferric Citrate New FDA Approved Drug, 9/5/14 1145 Electrolytes Lanthanum Carbonate 1146 Electrolytes Sevelamer Hydrochloride 1147 Electrolytes Sucroferric Oxyhydroxide 1148 Electrolytes Vitamins 1149 Prenatal Part D eligibile drug (CY16 FRF v09.26.16)

* 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 24 of 38

A B D E F Example Part D Eligible 1 USP Category USP Class Drugs* Salt/Ester Change Language 11502 Gastrointestinal Agents 1151 Gastrointestinal Agents Antispasmodics, Gastrointestinal 1152 Gastrointestinal Agents Atropine Sulfate 1153 Gastrointestinal Agents Dicyclomine Hydrochloride 1154 Gastrointestinal Agents Glycopyrrolate 1155 Gastrointestinal Agents Mepenzolate Bromide 1156 Gastrointestinal Agents Methscopolamine Bromide 1157 Gastrointestinal Agents Scopolamine 1158 Gastrointestinal Agents Histamine2 (H2) Receptor Antagonists 1159 Gastrointestinal Agents Cimetidine Hydrochloride 1160 Gastrointestinal Agents Famotidine 1161 Gastrointestinal Agents Nizatidine 1162 Gastrointestinal Agents Ranitidine Hydrochloride 1163 Gastrointestinal Agents Agents 1164 Gastrointestinal Agents 1165 Gastrointestinal Agents New FDA Approved Drug, 5/27/15 1166 Gastrointestinal Agents Rifaximin New FDA Approved Drug, 3/24/10 1167 Gastrointestinal Agents Alosetron Hydrochloride 1168 Gastrointestinal Agents 1169 Gastrointestinal Agents Linaclotide 1170 Gastrointestinal Agents 1171 Gastrointestinal Agents Laxatives 1172 Gastrointestinal Agents Lactulose Gastrointestinal Agents Polyethylene Glycol 3350 NF 1173 Gastrointestinal Agents Sodium picosulfate/ magnesium oxide/ citric acid 1174 1175 Gastrointestinal Agents Protectants 1176 Gastrointestinal Agents 1177 Gastrointestinal Agents Sucralfate 1178 Gastrointestinal Agents Proton Pump Inhibitors 1179 Gastrointestinal Agents Dexlansoprazole 1180 Gastrointestinal Agents Esomeprazole Magnesium 1181 Gastrointestinal Agents Lansoprazole 1182 Gastrointestinal Agents 1183 Gastrointestinal Agents Pantoprazole Sodium 1184 Gastrointestinal Agents Rabeprazole Sodium 1185 Gastrointestinal Agents Gastrointestinal Agents, Other 1186 Gastrointestinal Agents Alvimopan 1187 Gastrointestinal Agents Gastrointestinal Agents Hydrochloride/ 1188 Atropine Sulfate Gastrointestinal Agents Hydrochloride/ Atropine Sulfate 1189 1190 Gastrointestinal Agents Hydrochloride 1191 Gastrointestinal Agents Methylnaltrexone 1192 Gastrointestinal Agents Metoclopramide 1193 Gastrointestinal Agents Metreleptin New FDA Approved Drug, 2/24/14 1194 Gastrointestinal Agents Rifaximin 1195 Gastrointestinal Agents Ursodiol 1196 Gastrointestinal Agents Naloxegol New FDA Approved Drug, 9/16/14

* 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 25 of 38

A B D E F Example Part D Eligible 1 USP Category USP Class Drugs* Salt/Ester Change Language 11972 Gastrointestinal Agents 1198 Gastrointestinal Agents 1199 Gastrointestinal Agents Somatropin Enzyme Replacement/Modifiers Nomenclature change; Renamed to reflect Genetic or Enzyme Disorder: therapeutics. Moved according to Replacement, Modifiers, Treatment alphabetization.

1200 Genetic or Enzyme Alpha-1 Protinease Inhibitor, Reclassification; drug moved from the class, Human "Respiratory Tract Agents, Other," due to therapeutics. 1201 1202 Genetic or Enzyme 1203 Genetic or Enzyme Cholic Acid New FDA Approved drug, 3/17/15 1204 Genetic or Enzyme 1205 Genetic or Enzyme 1206 Genetic or Enzyme Cysteamine Bitartrate 1207 Genetic or Enzyme 1208 Genetic or Enzyme Eteplirsen New FDA Approved Drug, 9/19/16 1209 Genetic or Enzyme 1210 Genetic or Enzyme Agalsidase Beta 1211 Genetic or Enzyme 1212 Genetic or Enzyme Alglucerase 1213 Genetic or Enzyme Imiglucerase 1214 Genetic or Enzyme Taliglucerase alfa 1215 Genetic or Enzyme Velaglucerase alfa 1216 Genetic or Enzyme 1217 Genetic or Enzyme Eliglustat New FDA Approved Drug, 8/19/14 1218 Genetic or Enzyme Miglustat 1219 Genetic or Enzyme 1220 Genetic or Enzyme Nitisinone 1221 Genetic or Enzyme 1222 Genetic or Enzyme Betaine Anhydrous 1223 Genetic or Enzyme 1224 Genetic or Enzyme Idursulfase 1225 Genetic or Enzyme 1226 Genetic or Enzyme Asfotase Alfa New FDA Approved Drug,10/23/15 1227 Genetic or Enzyme 1228 Genetic or Enzyme Sebelipase Alfa New FDA Approved Drug, 12/8/15 1229 Genetic or Enzyme 1230 Genetic or Enzyme Galsulfase 1231 Genetic or Enzyme Laronidase 1232 Genetic or Enzyme Elosulfase Alfa New FDA Approved Drug, 2/14/14 1233 Genetic or Enzyme 1234 Genetic or Enzyme Pancrelipase 1235 Genetic or Enzyme 1236 Genetic or Enzyme Sapropterin 1237 Genetic or Enzyme 1238 Genetic or Enzyme Pegademase Bovine 1239 Genetic or Enzyme 1240 Genetic or Enzyme Sacrosidase 1241 Genetic or Enzyme 1242 Genetic or Enzyme Sodium Phenylbutyrate 1243 Genetic or Enzyme Glycerol Phenylbutyrate 1244 Genetic or Enzyme Obeticholic Acid New FDA Approved Drug, 5/27/16 1245 Genitourinary Agents

* 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 26 of 38

A B D E F Example Part D Eligible 1 USP Category USP Class Drugs* Salt/Ester Change Language 12462 Genitourinary Agents Antispasmodics, Urinary 1247 Genitourinary Agents 1248 Genitourinary Agents Mirabegron 1249 Genitourinary Agents 1250 Genitourinary Agents Hydrobromide 1251 Genitourinary Agents Fesoterodine Fumarate 1252 Genitourinary Agents Flavoxate Hydrochloride 1253 Genitourinary Agents Oxybutynin Chloride 1254 Genitourinary Agents Succinate 1255 Genitourinary Agents Tartrate 1256 Genitourinary Agents Trospium Chloride 1257 Genitourinary Agents Benign Prostatic Hypertrophy Agents 1258 Genitourinary Agents 1259 Genitourinary Agents Alfuzosin Hydrochloride 1260 Genitourinary Agents Doxazosin Mesylate 1261 Genitourinary Agents Prazosin Hydrochloride 1262 Genitourinary Agents Silodosin 1263 Genitourinary Agents Tamsulosin Hydrochloride 1264 Genitourinary Agents Terazosin Hydrochloride 1265 Genitourinary Agents 1266 Genitourinary Agents Dutasteride 1267 Genitourinary Agents Finasteride 1268 Genitourinary Agents 1269 Genitourinary Agents Genitourinary Agents Phosphate Binders Reclassification; class moved to the category, Electrolytes/Minerals/Heavy Metals/ 1270 Vitamins." 1271 Genitourinary Agents Calcium Acetate 1272 Genitourinary Agents Lanthanum Carbonate 1273 Genitourinary Agents Sevelamer Hydrochloride 1274 Genitourinary Agents Sucroferric Oxyhydroxide 1275 Genitourinary Agents Genitourinary Agents, Other 1276 Genitourinary Agents Bethanechol 1277 Genitourinary Agents Pencillamine 1278 Genitourinary Agents Pentosan Polysulfate Hormonal Agents, Stimulant/ 1279 Replacement/ Modifying (Adrenal) 1280 Hormonal Agents 1281 Hormonal Agents Corticotropin 1282 Hormonal Agents Hormonal Agents Sodium 1283 Phosphate 1284 Hormonal Agents 1285 Hormonal Agents Cortisone Acetate 1286 Hormonal Agents Dexamethasone Acetate Hormonal Agents Dexamethasone Sodium 1287 Phosphate 1288 Hormonal Agents Hydrocortisone Acetate Hormonal Agents Hydrocortisone Sodium Succinate 1289 1290 Hormonal Agents Methylprednisolone Acetate Hormonal Agents Methylprednisolone Sodium Succinate 1291 1292 Hormonal Agents Acetate

* 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 27 of 38

A B D E F Example Part D Eligible 1 USP Category USP Class Drugs* Salt/Ester Change Language 2 Hormonal Agents Prednisolone Sodium 1293 Phosphate 1294 Hormonal Agents 1295 Hormonal Agents Triamcinolone Acetonide 1296 Hormonal Agents Triamcinolone Diacetate 1297 Hormonal Agents Triamcinolone Hexacetonide 1298 Hormonal Agents 1299 Hormonal Agents Alclometasone Dipropionate 1300 Hormonal Agents Clocortolone Pivalate 1301 Hormonal Agents Desonide Hormonal Agents Dexamethasone Sodium 1302 Phosphate 1303 Hormonal Agents Hydrocortisone 1304 Hormonal Agents 1305 Hormonal Agents Betamethasone Valerate 1306 Hormonal Agents Desoximetasone 1307 Hormonal Agents Fluocinolone Acetonide 1308 Hormonal Agents Flurandrenolide 1309 Hormonal Agents Fluticasone Propionate 1310 Hormonal Agents Hydrocortisone Butyrate 1311 Hormonal Agents Probutate 1312 Hormonal Agents Valerate 1313 Hormonal Agents Mometasone Furoate 1314 Hormonal Agents Prednicarbate 1315 Hormonal Agents Triamcinolone Acetonide 1316 Hormonal Agents 1317 Hormonal Agents Amcinonide 1318 Hormonal Agents Betamethasone Dipropionate 1319 Hormonal Agents Desoximetasone 1320 Hormonal Agents Diflorasone Diacetate 1321 Hormonal Agents Fluocinolone Acetonide 1322 Hormonal Agents Fluocinonide 1323 Hormonal Agents Halcinonide 1324 Hormonal Agents Triamcinolone Acetonide 1325 Hormonal Agents 1326 Hormonal Agents Betamethasone Dipropionate 1327 Hormonal Agents Clobetasol Propionate 1328 Hormonal Agents Diflorasone Diacetate 1329 Hormonal Agents Halobetasol Propionate 1330 Hormonal Agents 1331 Hormonal Agents Fludrocortisone Acetate Hormonal Agents, Stimulant/Replacement/ Modifying (Pituitary) 1332 1333 Hormonal Agents 1334 Hormonal Agents Chorionic Gonadotropin 1335 Hormonal Agents 1336 Hormonal Agents Somatropin, Recombinant 1337 Hormonal Agents Tesamorelin 1338 Hormonal Agents 1339 Hormonal Agents Mecasermin Rinfabate 1340 Hormonal Agents 1341 Hormonal Agents Desmopressin Acetate

* 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 28 of 38

A B D E F Example Part D Eligible 1 USP Category USP Class Drugs* Salt/Ester Change Language 2 Hormonal Agents, Stimulant/ Replacement/ Modifying () 1342 1343 Hormonal Agents Alprostadil 1344 Hormonal Agents Tromethamine 1345 Hormonal Agents Misoprostol Hormonal Agents, Stimulant/ Replacement/ Modifying (Sex Hormones/ Modifiers) 1346 1347 Hormonal Agents Anabolic Steroids 1348 Hormonal Agents Oxandrolone 1349 Hormonal Agents Androgens 1350 Hormonal Agents Danazol 1351 Hormonal Agents Fluoxymesterone 1352 Hormonal Agents Methyltestosterone 1353 Hormonal Agents Testosterone Cypionate 1354 Hormonal Agents Testosterone Enanthate 1355 Hormonal Agents Testosterone Propionate 1356 Hormonal Agents Estrogens 1357 Hormonal Agents Estradiol Acetate 1358 Hormonal Agents Estradiol Cypionate 1359 Hormonal Agents Estradiol Hemihydrate 1360 Hormonal Agents Estradiol Valerate 1361 Hormonal Agents Estrogens, Conjugated Hormonal Agents Estrogens, Conjugated 1362 Synthetic 1363 Hormonal Agents Estrogens, Esterified 1364 Hormonal Agents Estrone Discontinued by manufacturer 1365 Hormonal Agents Estropipate 1366 Hormonal Agents Ethinyl Estradiol 1367 Hormonal Agents Progesterone Agonists/Antagonists 1368 Hormonal Agents Ulipristal 1369 Hormonal Agents Progestins 1370 Hormonal Agents Levonorgestrel 1371 Hormonal Agents Medroxyprogesterone Acetate 1372 Hormonal Agents Megestrol Acetate 1373 Hormonal Agents Norethindrone Acetate 1374 Hormonal Agents Norgestrel 1375 Hormonal Agents Progesterone Hormonal Agents Selective Estrogen Receptor Modifying 1376 Agents 1377 Hormonal Agents Raloxifene Hydrochloride 1378 Hormonal Agents Ospemifene Hormonal Agents Bazedoxifene/ conjugated 1379 estrogens Hormonal Agents, Stimulant/Replacement/ Modifying (Thyroid) 1380 1381 Hormonal Agents Levothyroxine Sodium 1382 Hormonal Agents Liothyronine Sodium 1383 Hormonal Agents Liotrix Hormonal Agents, Suppressant 1384 (Adrenal)

* 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 29 of 38

A B D E F Example Part D Eligible 1 USP Category USP Class Drugs* Salt/Ester Change Language 13852 Hormonal Agents Mitotane Hormonal Agents, Suppressant Category removed to reflect therapeutics 1386 (Parathyroid) Hormonal Agents Cinacalcet Hydrochloride Reclassification; drug moved to USP Category, "Metabolic Bone Disease Agents." 1387 Hormonal Agents, Suppressant 1388 (Pituitary) 1389 Hormonal Agents 1390 Hormonal Agents Bromocriptine Mesylate 1391 Hormonal Agents Cabergoline 1392 Hormonal Agents 1393 Hormonal Agents Leuprolide Acetate 1394 Hormonal Agents Nafarelin Acetate 1395 Hormonal Agents Triptorelin Pamoate 1396 Hormonal Agents 1397 Hormonal Agents Degarelix 1398 Hormonal Agents 1399 Hormonal Agents Pegvisomant 1400 Hormonal Agents 1401 Hormonal Agents Lanreotide 1402 Hormonal Agents 1403 Hormonal Agents Pasireotide Hormonal Agents, Suppressant 1404 (Thyroid) 1405 Hormonal Agents Antithyroid Agents 1406 Hormonal Agents Methimazole 1407 Hormonal Agents Propylthiouracil 1408 Immunological Agents Immunological Agents Angioedema (HAE) Agents Angioedema Nomenclature Change; removed parenthetical 1409 Agents 1410 Immunological Agents 1411 Immunological Agents Icatibant Acetate 1412 Immunological Agents Immunological Agents C1 esterase inhibitor 1413 (human) 1414 Immunological Agents Immune Suppressants 1415 Immunological Agents 1416 Immunological Agents 1417 Immunological Agents 1418 Immunological Agents Tacrolimus 1419 Immunological Agents Cyclosporine 1420 Immunological Agents 1421 Immunological Agents Tofacitinib 1422 Immunological Agents 1423 Immunological Agents 1424 Immunological Agents 1425 Immunological Agents 6- Mercaptopurine 1426 Immunological Agents 1427 Immunological Agents 1428 Immunological Agents Everolimus 1429 Immunological Agents Sodium 1430 Immunological Agents Penicillamine 1431 Immunological Agents Pimecrolimus

* 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 30 of 38

A B D E F Example Part D Eligible 1 USP Category USP Class Drugs* Salt/Ester Change Language 14322 Immunological Agents 1433 Immunological Agents 1434 Immunological Agents 1435 Immunological Agents 1436 Immunological Agents 1437 Immunological Agents 1438 Immunological Agents 1439 Immunological Agents 1440 Immunological Agents 1441 Immunological Agents Immunizing Agents, Passive 1442 Immunological Agents 1443 Immunological Agents Anti-thymocyte Globulin Immunological Agents Immune Globulin 1444 Intramuscular (Human) Immunological Agents Immune Globulin Intravenous 1445 (Human) 1446 Immunological Agents Immunomodulators 1447 Immunological Agents 1448 Immunological Agents 1449 Immunological Agents Immunological Agents -1b, 1450 Recombinant 1451 Immunological Agents 1452 Immunological Agents Canakinumab 1453 Immunological Agents 1454 Immunological Agents Siltuximab New FDA Approved Drug, 4/23/14 1455 Immunological Agents 1456 Immunological Agents 1457 Immunological Agents Auranofin 1458 Immunological Agents New FDA Approved Drug, 9/23/14 1459 Immunological Agents 1460 Immunological Agents Natalizumab 1461 Immunological Agents Part D eligible drug (CY16 FRF v09.26.16) 1462 Immunological Agents New FDA Approved Drug, 5/20/14 1463 Immunological Agents Vaccines 1464 Immunological Agents Immunological Agents Diphtheria and Tetanus 1465 Toxoids Adsorbed (DT) Immunological Agents Diphtheria and Tetanus Toxoids and Acellular Pertussis Vaccine Adsorbed (DTaP) 1466 Immunological Agents Diphtheria and Tetanus Toxoids and Acellular Pertussis Vaccine Adsorbed, Hepatitis B (Recombinant) and Inactivated Poliovirus Vaccine

1467 Immunological Agents Diphtheria and Tetanus Toxoids and Acellular Pertussis Absorbed and Inactivated Poliovirus (DTaP- IPV) Vaccine 1468

* 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 31 of 38

A B D E F Example Part D Eligible 1 USP Category USP Class Drugs* Salt/Ester Change Language 2 Immunological Agents Tetanus and Diphtheria Toxoids Adsorbed for Adult 1469 Use (Td) Immunological Agents Tetanus Toxoid, Reduced Diphtheria Toxoid and Acellular Pertussis Vaccine, Adsorbed (Tdap) 1470 1471 Immunological Agents Immunological Agents Haemophilus B Conjugate 1472 Vaccine Immunological Agents Haemophilus B Conjugate Vaccine and Hepatitis B 1473 Vaccine (Recombinant) 1474 Immunological Agents Immunological Agents Hepatitis A Vaccine 1475 Inactivated Immunological Agents Hepatitis A Virus Vaccine Inactivated and Hepatitis B Virus Vaccine Recombinant

1476 1477 Immunological Agents Immunological Agents Diphtheria and Tetanus Toxoids and Acellular Pertussis Vaccine Adsorbed, Hepatitis B (Recombinant) and Inactivated Poliovirus Vaccine

1478 Immunological Agents Haemophilus B Conjugate Vaccine and Hepatitis B 1479 Vaccine (Recombinant) Immunological Agents Hepatitis B Virus Vaccine 1480 Recombinant 1481 Immunological Agents Immunological Agents Japanese Encephalitis Virus 1482 Vaccine Inactivated 1483 Immunological Agents Immunological Agents Measles Virus Vaccine Live 1484 Immunological Agents Measles, Mumps, and 1485 Rubella Virus Vaccine Live Immunological Agents Measles, Mumps, Rubella, and Varicella Virus Vaccine 1486 Live 1487 Immunological Agents Immunological Agents Meningococcal Oligosaccharide Diphtheria CRM197 Conjugate Vaccine

1488 Immunological Agents Meningococcal 1489 Polysaccharide Vaccine

* 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 32 of 38

A B D E F Example Part D Eligible 1 USP Category USP Class Drugs* Salt/Ester Change Language 2 Immunological Agents Meningococcal Polysaccharide Diphtheria Toxoid Conjugate Vaccine

1490 1491 Immunological Agents Immunological Agents Measles, Mumps, and 1492 Rubella Virus Vaccine Live Immunological Agents Measles, Mumps, Rubella, and Varicella Virus Vaccine 1493 Live 1494 Immunological Agents Immunological Agents Human Papillomavirus Bivalent (type 16 and 18) 1495 Vaccine Recombinant Immunological Agents Human Papillomavirus Quadrivalent (types 6, 11, 16 and 18) Vaccine Recombinant 1496 1497 Immunological Agents Immunological Agents Diphtheria and Tetanus Toxoids and Acellular Pertussis Vaccine Adsorbed (DTaP) 1498 Immunological Agents Diphtheria and Tetanus Toxoids and Acellular Pertussis Vaccine Adsorbed, Hepatitis B (Recombinant) and Inactivated Poliovirus

1499 Immunological Agents Diphtheria and Tetanus Toxoids and Acellular Pertussis Absorbed and Inactivated Poliovirus (DTaP- IPV) Vaccine 1500 Immunological Agents Tetanus Toxoid, Reduced Diphtheria Toxoid, and Acellular Pertussis Vaccine, Adsorbed (Tdap) 1501 1502 Immunological Agents Immunological Agents Diphtheria and Tetanus Toxoids and Acellular Pertussis Absorbed and Inactivated Poliovirus (DTaP- IPV) Vaccine 1503 Immunological Agents Diphtheria and Tetanus Toxoids and Acellular Pertussis Vaccine Adsorbed, Hepatitis B (Recombinant) and Inactivated Poliovirus

1504 Immunological Agents Poliovirus Vaccine 1505 Inactivated 1506 Immunological Agents 1507 Immunological Agents Rabies Vaccine

* 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 33 of 38

A B D E F Example Part D Eligible 1 USP Category USP Class Drugs* Salt/Ester Change Language 15082 Immunological Agents 1509 Immunological Agents Rotavirus Vaccine Live 1510 Immunological Agents Immunological Agents Measles, Mumps, and 1511 Rubella Virus Vaccine Live Immunological Agents Measles, Mumps, Rubella, and Varicella Virus Vaccine 1512 Live 1513 Immunological Agents Rubella Virus Vaccine 1514 Immunological Agents Immunological Agents Diphtheria and Tetanus 1515 Toxoids Adsorbed (DT) Immunological Agents Diphtheria and Tetanus Toxoids and Acellular Pertussis Vaccine Adsorbed (DTaP) 1516 Immunological Agents Diphtheria and Tetanus Toxoids and Acellular Pertussis Vaccine Adsorbed, Hepatitis B (Recombinant) and Inactivated Poliovirus Vaccine

1517 Immunological Agents Diphtheria and Tetanus Toxoids and Acellular Pertussis Absorbed and Inactivated Poliovirus (DTaP- IPV) Vaccine 1518 Immunological Agents Tetanus and Diphtheria Toxoids Adsorbed for Adult 1519 Use (Td) 1520 Immunological Agents Tetanus Toxoid 1521 Immunological Agents Tetanus Toxoid Adsorbed Immunological Agents Tetanus Toxoid, Reduced Diphtheria Toxoid, and Acellular Pertussis Vaccine, Adsorbed (Tdap) 1522 1523 Immunological Agents 1524 Immunological Agents Typhoid Vaccine Live Oral Immunological Agents Typhoid Vi Polysaccharide 1525 Vaccine 1526 Immunological Agents Immunological Agents Measles, Mumps, Rubella, and Varicella Virus Vaccine 1527 Live Immunological Agents Meningococcal Group B New FDA Approved Drug, 2/19/10 1528 Vaccine 1529 Immunological Agents Varicella Virus Vaccine 1530 Immunological Agents 1531 Immunological Agents Yellow Fever Vaccine 1532 Immunological Agents 1533 Immunological Agents Zoster Virus Vaccine Live

1534 Inflammatory Bowel Disease Agents 1535 Glucocorticoids

* 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 34 of 38

A B D E F Example Part D Eligible 1 USP Category USP Class Drugs* Salt/Ester Change Language 15362 Betamethasone 1537 Budesonide 1538 Cortisone Acetate 1539 Dexamethasone Acetate Dexamethasone Sodium 1540 Phosphate Hydrocortisone Sodium Succinate 1541 1542 Methylprednisolone Acetate Methylprednisolone Sodium Succinate 1543 1544 Prednisolone Acetate Prednisolone Sodium Succinate 1545 1546 Prednisone 1547 Triamcinolone Acetonide 1548 Triamcinolone Diacetate 1549 1550 Disodium 1551 Mesalamine 1552 Sodium 1553 Sulfonamides 1554 1555 Metabolic Bone Disease Agents 1556 Metabolic Bone Disease Agents 1557 Metabolic Bone Disease Agents Alendronate Sodium 1558 Metabolic Bone Disease Agents Etidronate Disodium 1559 Metabolic Bone Disease Agents Ibandronate Sodium 1560 Metabolic Bone Disease Agents Risedronate Sodium 1561 Metabolic Bone Disease Agents Tiludronate Disodium Discontinued by manufacturer 1562 Metabolic Bone Disease Agents 1563 Metabolic Bone Disease Agents Ibandronate Sodium 1564 Metabolic Bone Disease Agents Pamidronate Disodium 1565 Metabolic Bone Disease Agents Zoledronic Acid 1566 Metabolic Bone Disease Agents 1567 Metabolic Bone Disease Agents Calcitonin, Salmon 1568 Metabolic Bone Disease Agents 1569 Metabolic Bone Disease Agents Teriparatide 1570 Metabolic Bone Disease Agents 1571 Metabolic Bone Disease Agents Denosumab 1572 Metabolic Bone Disease Agents 1573 Metabolic Bone Disease Agents Calcifediol New FDA Approved Drug, 6/17/16 1574 Metabolic Bone Disease Agents Calcitriol Metabolic Bone Disease Agents Cinacalcet Reclassification; drug moved from Hormonal Agents, Parathyroid category due to 1575 therapeutics 1576 Metabolic Bone Disease Agents Doxercalciferol 1577 Parathyroid Hormone New FDA Approved Drug, 1/23/15 1578 Metabolic Bone Disease Agents Paricalcitol 1579 Ophthalmic Agents 1580 Ophthalmic Agents Ophthalmic Anti-allergy Agents 1581 Ophthalmic Agents Hydrochloride 1582 Ophthalmic Agents Bepotastine 1583 Ophthalmic Agents Cromolyn Sodium

* 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 35 of 38

A B D E F Example Part D Eligible 1 USP Category USP Class Drugs* Salt/Ester Change Language 15842 Ophthalmic Agents Emedastine Difumarate 1585 Ophthalmic Agents Epinastine Hydrochloride 1586 Ophthalmic Agents Lodoxamide Tromethamine 1587 Ophthalmic Agents Nedocromil Sodium 1588 Ophthalmic Agents Olopatadine Hydrochloride 1589 Ophthalmic Agents Ophthalmic Antiglaucoma Agents 1590 Ophthalmic Agents 1591 Ophthalmic Agents Apraclonidine Hydrochloride 1592 Ophthalmic Agents Brimonidine Tartrate 1593 Ophthalmic Agents 1594 Ophthalmic Agents Betaxolol Hydrochloride 1595 Ophthalmic Agents Carteolol Hydrochloride 1596 Ophthalmic Agents Levobunolol Hydrochloride 1597 Ophthalmic Agents Metipranolol Hydrochloride 1598 Ophthalmic Agents Timolol Hemihydrate 1599 Ophthalmic Agents Timolol Maleate 1600 Ophthalmic Agents 1601 Ophthalmic Agents Acetazolamide 1602 Ophthalmic Agents Brinzolamide 1603 Ophthalmic Agents Dorzolamide Hydrochloride 1604 Ophthalmic Agents Methazolamide 1605 Ophthalmic Agents 1606 Ophthalmic Agents Echothiophate Iodide 1607 Ophthalmic Agents Pilocarpine Hydrochloride 1608 Ophthalmic Agents Nitrate 1609 Ophthalmic Agents Ophthalmic Anti-inflammatories 1610 Ophthalmic Agents 1611 Ophthalmic Agents Dexamethasone 1612 Ophthalmic Agents Difluprednate 1613 Ophthalmic Agents Fluorometholone Acetate 1614 Ophthalmic Agents Loteprednol Etabonate 1615 Ophthalmic Agents Prednisolone Acetate Ophthalmic Agents Sodium 1616 Phosphate 1617 Ophthalmic Agents Rimexolone 1618 Ophthalmic Agents 1619 Ophthalmic Agents Sodium 1620 Ophthalmic Agents Diclofenac Sodium 1621 Ophthalmic Agents Flurbiprofen Sodium 1622 Ophthalmic Agents Ketorolac Tromethamine 1623 Ophthalmic Agents Nepafenac Ophthalmic Agents Ophthalmic and Prostamide 1624 Analogs 1625 Ophthalmic Agents 1626 Ophthalmic Agents 1627 Ophthalmic Agents 1628 Ophthalmic Agents 1629 Ophthalmic Agents Ophthalmic Agents, Other 1630 Ophthalmic Agents Hydroxypropyl Cellulose 1631 Ophthalmic Agents Naphazoline Hydrochloride Removed due to OTC status 1632 Ophthalmic Agents Lifitegrast New FDA Approved Drug, 7/11/16 1633 Ophthalmic Agents 1634 Ophthalmic Agents Cyclosporine 1635 Otic Agents

* 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 36 of 38

A B D E F Example Part D Eligible 1 USP Category USP Class Drugs* Salt/Ester Change Language 16362 Otic Agents 1637 Otic Agents Fluocinolone Acetonide Respiratory Tract/ Pulmonary Agents 1638 1639 Antihistamines 1640 1641 Azelastine Hydrochloride 1642 Cetirizine Hydrochloride 1643 Desloratadine 1644 Levocetirizine 1645 Olopatadine Hydrochloride 1646 1647 Carbinoxamine 1648 Clemastine Fumarate 1649 Hydrochloride 1650 Diphenhydramine Hydrochloride 1651 Hydroxyzine Hydrochloride 1652 Hydroxyzine Pamoate 1653 Promethazine Hydrochloride Anti-inflammatories, Inhaled 1654 1655 Beclomethasone Dipropionate Dipropionate 1656 Monohydrate 1657 Budesonide 1658 Ciclesonide 1659 Flunisolide 1660 Fluticasone Propionate Mometasone Furoate 1661 Monohydrate 1662 Triamcinolone Acetonide 1663 1664 Sodium 1665 1666 1667 Bronchodilators, Anticholinergic 1668 Aclidinium Bromide 1669 Ipratropium Bromide Tiotropium Bromide 1670 Monohydrate 1671 Umeclidinium New FDA Approved Drug, 4/30/14 1672 Bronchodilators, Sympathomimetic 1673 Albuterol Sulfate 1674 Arformoterol Tartrate 1675 Epinephrine Bitartrate Formoterol Fumarate 1676 Dihydrate Indacaterol inhalation powder Maleate 1677 1678 Levalbuterol Hydrochloride 1679 Metaproterenol Sulfate 1680 Salmeterol Xinafoate 1681 Terbutaline Sulfate

* 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 37 of 38

A B D E F Example Part D Eligible 1 USP Category USP Class Drugs* Salt/Ester Change Language 16822 Olodaterol New FDA Approved Drug, 7/31/14 1683 Cystic Agents 1684 1685 1686 Ivacaftor/Lumacaftor New FDA Approved Drug, 7/2/15 1687 Tobramycin dry-powder 1688 inhaler Aztreonam inhalant solution 1689 1690 Mast Cell Stabilizers 1691 Cromolyn Sodium Phosphodiesterase Inhibitors, Airways 1692 Disease 1693 Aminophylline Dihydrate 1694 Dyphylline Discontinued by manufacturer 1695 Theophylline 1696 1697 Roflumilast 1698 Pulmonary Antihypertensives 1699 1700 1701 1702 1703 1704 Citrate 1705 Tadalafil 1706 1707 Epoprostenol 1708 1709 1710 1711 1712 1713 Selexipag New FDA Approved Drug, 12/21/15 1714 Respiratory Tract Agents, Other 1715 Alpha-1 Proteinase Inhibitor, Reclassification; drug moved to newly Human renamed category, "Genetic or Enzyme Disorder: Replacement, Modifiers, Treatment

1716 Budesonide/ Formoterol 1717 fumarate Fluticasone furoate/ 1718 Vilanterol trifenatate Fluticasone propionate/ 1719 Salmeterol Mometasone furoate/ Formoterol fumerate 1720 dihydrate 1721 1722 Tetrahydrozoline Hydrochloride Umeclidinum/ Vilanterol New FDA Approved Drug, 12/16/13 1723 Trifenate

* 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 38 of 38

A B D E F Example Part D Eligible 1 USP Category USP Class Drugs* Salt/Ester Change Language 17242 Indacaterol/Glycopyrrolate New FDA Approved Drug, 10/29/15 1725 1726 New FDA Approved Drug, 11/4/15 Agents Nomenclature Change, New class to reflect 1727 therapeutics 1728 Nintedanib New FDA Approved Drug, 10/15/14 1729 Pirfenidone New FDA Approved Drug, 10/15/14 1730 Skeletal Muscle Relaxants 1731 Skeletal Muscle Relaxants Cyclobenzaprine Hydrochloride 1732 Skeletal Muscle Relaxants Metaxalone 1733 Skeletal Muscle Relaxants Methocarbamol 1734 Skeletal Muscle Relaxants Citrate 1735 Skeletal Muscle Relaxants 1736 Skeletal Muscle Relaxants 1737 Skeletal Muscle Relaxants Orphenadrine Hydrochloride 1738 Sleep Disorder Agents 1739 Sleep Disorder Agents GABA Receptor Modulators 1740 Sleep Disorder Agents 1741 Sleep Disorder Agents Flurazepam 1742 Sleep Disorder Agents 1743 Sleep Disorder Agents Quazepam* 1744 Sleep Disorder Agents 1745 Sleep Disorder Agents Eszopiclone 1746 Sleep Disorder Agents Zaleplon 1747 Sleep Disorder Agents Zolpidem Tartrate 1748 Sleep Disorder Agents Sleep Disorders, Other 1749 Sleep Disorder Agents Armodafinil 1750 Sleep Disorder Agents Doxepin Hydrochloride 1751 Sleep Disorder Agents Modafinil 1752 Sleep Disorder Agents Sodium Oxybate 1753 Sleep Disorder Agents Suvorexant 1754 Sleep Disorder Agents Tasimelteon New FDA Approved Drug, 1/31/14 1755 Sleep Disorder Agents Ramelteon

* 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