Example Part D USP Class Salt/Ester Eligible Drugs*

1 USP Medicare Model Guidelines 1 of 30* This list is illustrative of Part D Eligible drugs only, and does not infer CMS coverageUSP CategoryUSP ClassExample Part D Eligible Drugs* Salt/EsterAnalgesicsNonsteroidal Anti-inflammatory DrugsCelecoxibDiclofenacPotassiumDifluni salEtodolacFenoprofenCalciumFlurbiprofen IbuprofenIndomethacinKetoprofenKetorolac TromethamineMeclofenamateMefenamic AcidMeloxicamNabumetoneNaproxenOxaprozin PiroxicamSulindacTolmetinOpioid Analgesics, Long-actingHydromorphoneFentanylLevorpha nolTartrateMethadoneHydrochlorideMorphin eSulfateOxycodoneHydrochlorideOxymorphon eHydrochlorideTramadolHydrochlorideOpioi d Analgesics, Short-actingButorphanolTartrateCodeinePh osphateFentanylCitrateHydromorphoneHydro chlorideMeperidineHydrochlorideNalbuphin eHydrochlorideOxycodoneHydrochlorideOxym orphoneHydrochloridePentazocineLactateTa pentadolTramadolHydrochlorideAnesthetics Local AnestheticsLidocaineHydrochlorideLidocai ne and PrilocaineAnti-Addiction/ Substance Abuse Treatment AgentsAlcohol Deterrents/Anti-cravingAcamprosateCalciu mDisulfiramNaltrexoneHydrochlorideOpioid Dependence TreatmentsBuprenorphineBuprenorphine/Nal oxoneNaltrexoneHydrochlorideOpioid Reversal Agents USP Medicare Model Guidelines 2 of 30* This list is illustrative of Part D Eligible drugs only.

2 And does not infer CMS coverageUSP CategoryUSP ClassExample Part D Eligible Drugs* Salt/EsterNaloxoneHydrochlorideSmoking Cessation AgentsBupropionHydrochlorideNicotineVare niclineTartrateAntibacterialsAminoglycos idesAmikacinSulfateGentamicinSulfateKana mycinSulfateNeomycinSulfateParomomycinSu lfateStreptomycinSulfateTobramycinSulfat eTobramycin and DexamethasoneBeta-lactam, CephalosporinsCefadroxilCefazolinCephale xinCefaclorCefoxitinCefprozilCefuroximeA xetilCefdinirCefditorenPivoxilCefiximeCe fotaximeCefpodoximeProxetilCeftazidimeCe ftibutenDihydrateCeftriaxoneSodiumCefepi meHydrochlorideCeftarolineFosamilBeta-la ctam, PenicillinsAmoxicillinAmoxicillin and Clavulanate PotassiumAmpicillinAmpicillin Sodium and Sulbactam SodiumPiperacillinSodiumPiperacillin Sodium and Tazobactam SodiumTicarcillin Disodium and Clavulanate PotassiumPenicillin GBenzathinePotassiumProcaineSodiumPenici llin VPotassiumDicloxacillinSodiumNafcillinSo diumUSP Medicare Model Guidelines 3 of 30* This list is illustrative of Part D Eligible drugs only, and does not infer CMS coverageUSP CategoryUSP ClassExample Part D Eligible Drugs* Salt/EsterOxacillinSodiumBeta-lactam.

3 OtherAztreonamDoripenemErtapenemSodiumIm ipenem and Cilastatin SodiumMeropenemMacrolidesAzithromycinCla rithromycinErythromycinEstolate Ethylsuccinate Lactobionate StearateFidaxomicinTelithromycinQuinolon esBesifloxacinCiprofloxacinGatifloxacinG emifloxacinMesylateLevofloxacinMoxifloxa cinHydrochlorideNorfloxacinOfloxacinSulf onamidesSulfacetamideSodiumSulfadiazineS ulfamethoxazole and TrimethoprimTetracyclinesDemeclocyclineH ydrochlorideDoxycyclineCalciumHyclateMin ocyclineHydrochlorideTetracyclineHydroch lorideAntibacterials, OtherTrimethoprimVancomycinHydrochloride ClindamycinHydrochloridePalmitateLincomy cinHydrochlorideNitrofurantoinLinezolidA cetic AcidBacitracinChloramphenicolSodium SuccinateDaptomycinFosfomycinTromethamin eGramicidinMafenideAcetateMethenamineHip purateMandelateMetronidazoleHydrochlorid eMupirocinCalciumUSP Medicare Model Guidelines 4 of 30* This list is illustrative of Part D Eligible drugs only.

4 And does not infer CMS coverageUSP CategoryUSP ClassExample Part D Eligible Drugs* Salt/EsterPolymyxin BSulfateRetapamulinRifaximinTelavancinTi nidazole TigecyclineAnticonvulsants Calcium Channel Modifying AgentsEthosuximideMethsuximidePregabalin ZonisamideGamma-aminobutyric Acid (GABA) Augmenting AgentsClobazamClonazepamClorazepateDipot assiumDiazepamLorazepamMephobarbitalPhen obarbitalPrimidoneDivalproexSodiumGabape ntinTiagabineHydrochlorideValproateSodiu mVigabatrinGlutamate Reducing Agents FelbamateLamotriginePerampanelTopiramate Sodium Channel AgentsCarbamazepineEslicarbazepine Acetate EthotoinFosphenytoinSodiumOxcarbazepineP henytoinSodiumRufinamideLacosamideAntico nvulsants, OtherLevetiracetamEzogabineAntidementia AgentsCholinesterase InhibitorsDonepezilHydrochlorideGalantam ineHydrochlorideRivastigmineTartrateN-me thyl-D-aspartate (NMDA)

5 Receptor AntagonistMemantineHydrochlorideAntideme ntia Agents, OtherUSP Medicare Model Guidelines 5 of 30* This list is illustrative of Part D Eligible drugs only, and does not infer CMS coverageUSP CategoryUSP ClassExample Part D Eligible Drugs* Salt/EsterErgoloid MesylatesAntidepressantsMonoamine Oxidase InhibitorsPhenelzineSulfateSelegilineTra nylcypromineSulfateSSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/ Serotonin and Norepinephrine Reuptake Inhibitors)CitalopramHydrobromideDesvenl afaxineDuloxetineHydrochlorideEscitalopr amOxalateFluoxetineHydrochlorideFluvoxam ineMaleateLevomilnacipran HydrochlorideMaprotilineHydrochlorideNef azodoneHydrochlorideParoxetineHydrochlor ideSertralineHydrochlorideTrazodoneHydro chlorideVenlafaxineHydrochlorideVilazodo neHydrochlorideVortioxetineTricyclicsAmi triptylineHydrochlorideAmoxapineClomipra mineHydrochlorideDesipramineHydrochlorid eDoxepinHydrochlorideImipramineHydrochlo ridePamoateNortriptylineHydrochloridePro triptylineHydrochlorideTrimipramineMalea teAntidepressants.

6 OtherBupropionHydrochlorideMirtazapineAr ipiprazoleQuetiapineFumarateAntiemeticsE metogenic Therapy AdjunctsDolasetronMesylateGranisetronHyd rochlorideOndansetronHydrochloridePalono setronHydrochlorideAprepitantDronabinolN abiloneAntiemetics, OtherChlorpromazineHydrochlorideDiphenhy dramineHydrochlorideDoxylamine Succinate/ Pyridoxine HydrochlorideHydroxyzinePamoateUSP Medicare Model Guidelines 6 of 30* This list is illustrative of Part D Eligible drugs only, and does not infer CMS coverageUSP CategoryUSP ClassExample Part D Eligible Drugs* Salt/EsterMeclizineHydrochlorideMetoclop ramidePerphenazineProchlorperazineEdisyl ateMaleatePromethazineHydrochlorideScopo lamineTrimethobenzamideHydrochlorideAnti fungalsNaftifineHydrochlorideTerbinafine HydrochlorideButoconazoleNitrateClotrima zoleEconazoleNitrateFluconazoleItraconaz oleKetoconazoleLuliconazoleMiconazoleNit rateOxiconazoleNitratePosaconazoleSertac onazoleNitrateSulconazoleNitrateTerconaz oleVoriconazoleAnidulafunginCaspofunginA cetateMicafunginSodiumNatamycinNystatinB utenafineHydrochlorideCiclopiroxFlucytos ineGriseofulvinAntigout

7 AgentsProbenecidAllopurinolFebuxostatCol chicineAnti-inflammatory AgentsGlucocorticoidsNonsteroidal Anti-inflammatory DrugsCelecoxibDiclofenacPotassiumDifluni salEtodolacFenoprofenCalciumFlurbiprofen IbuprofenIndomethacinUSP Medicare Model Guidelines 7 of 30* This list is illustrative of Part D Eligible drugs only, and does not infer CMS coverageUSP CategoryUSP ClassExample Part D Eligible Drugs* Salt/EsterKetoprofenKetorolacTromethamin eMeclofenamateSodiumMefenamic AcidMeloxicamNabumetoneNaproxenSodiumOxa prozinPiroxicamSulindacTolmetinSodiumAnt imigraine AgentsErgot AlkaloidsDihydroergotamineMesylateErgota mineTartrateSerotonin (5-HT) 1b/1d Receptor AgonistsAlmotriptanMalateEletriptanFrova triptanSuccinateNaratriptanHydrochloride RizatriptanBenzoateSumatriptanZolmitript anProphylacticTimololMaleateDivalproexSo diumTopiramateValproic AcidAntimyasthenic AgentsParasympathomimeticsAmbenoniumChlo rideGuanidineHydrochloridePyridostigmine BromideAntimycobacterialsAntituberculars BedaquilineFumarateCapreomycinSulfateCyc loserineEthambutolHydrochlorideEthionami deIsoniazidPyrazinamideRifampinRifampin and IsoniazidRifampin, Isoniazid, and PyrazinamideRifapentineAntimycobacterial s.

8 OtherDapsoneRifabutinAntineoplasticsAlky lating AgentsAltretamineChlorambucilMechloretha mine HydrochlorideUSP Medicare Model Guidelines 8 of 30* This list is illustrative of Part D Eligible drugs only, and does not infer CMS coverageUSP CategoryUSP ClassExample Part D Eligible Drugs* Salt/EsterMelphalanLomustineBusulfanCycl ophosphamideProcarbazineHydrochlorideAnt iandrogens EnzalutamideBicalutamideFlutamideNilutam ideAbiraterone AcetateAntiangiogenic AgentsLenalidomidePomalidomideThalidomid eAntiestrogens/ModifiersEstramustinePhos phate SodiumTamoxifenCitrateToremifeneCitrateA ntimetabolites MercaptopurineThioguanineHydroxyureaArom atase Inhibitors.

9 3rd GenerationAnastrozoleExemestaneLetrozole Enzyme InhibitorsEtoposideTopotecanMolecular Target InhibitorsVemurafenibDabrafenibTrametini bIbrutinib Afatinib DimaleateErlotinibHydrochlorideVismodegi bRuxolitinibEverolimusCrizotinibUSP Medicare Model Guidelines 9 of 30* This list is illustrative of Part D Eligible drugs only, and does not infer CMS coverageUSP CategoryUSP ClassExample Part D Eligible Drugs* Salt/EsterBosutinibDasatinibImatinibMesy lateNilotinibPonatinibHydrochlorideLapat inib AxitinibCabozantinib PazopanibRegorafenibSorafenibTosylateSun itinibMalateVandetanibMonoclonal Antibodies RituximabOfatumumabRetinoidsAlitretinoin BexaroteneTretinoinAntineoplastics.

10 OtherFludarabineLeucovorinMitoxantroneHy drochlorideVorinostatAntiparasiticsAnthe lminticsAlbendazoleIvermectinMebendazole PraziquantelAntiprotozoalsArtemether and LumefantrineAtovaquone and Proguanil HydrochlorideChloroquinePhosphateHydroxy chloroquineSulfateMefloquineHydrochlorid ePrimaquinePhosphatePyrimethamineQuinine SulfateAtovaquoneNitazoxanidePentamidine IsethionatePediculicides/ScabicidesBenzy l alcoholCrotamitonLindaneMalathionPermeth rinSpinosadAntiparkinson AgentsAnticholinergicsBenztropineMesylat eDiphenhydramineHydrochlorideUSP Medicare Model Guidelines 10 of 30* This list is illustrative of Part D Eligible drugs only, and does not infer CMS coverageUSP CategoryUSP ClassExample Part D Eligible Drugs* Salt/EsterTrihexyphenidylHydrochlorideDo pamine AgonistsApomorphineHydrochlorideBromocri ptineMesylatePramipexoleDihydrochloride MonohydrateRopiniroleHydrochlorideRotigo tineDopamine P