Medicare Model Guidelines Draft v8.0 1 of 97
USP Category USP Class Example Drugs Combination Drug Product
Track Changes
Analgesics CatNonsteroidal Anti-inflammatory Drugs
Class
Celecoxib noDiclofenac Potassium noDiclofenac Epolamine noDiflunisal noEtodolac noFenoprofen Calcium noFlurbiprofen noIbuprofen noIndomethacin noKetoprofen noKetorolac Tromethamine noMeclofenamate Sodium noMefenamic Acid noMeloxicam noNabumetone noNaproxen noOxaprozin noPiroxicam noSulindac noTolmetin Sodium no
Opioid Analgesics, Long-acting Class
Buprenorphine noFentanyl noFentanyl Citrate noFentanyl Hydrochloride no Manufacturer Discontinued
* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage.
Medicare Model Guidelines Draft v8.0 2 of 97
Hydrocodone Bitartrate noHydromorphone Hydrochloride no
Levorphanol Tartrate noMethadone Hydrochloride noMorphine Sulfate noOxycodone Hydrochloride noOxymorphone Hydrochloride noTapentadol Hydrochloride noTramadol Hydrochloride no
Opioid Analgesics, Short-acting Class
Butorphanol Tartrate noCodeine Phosphate noFentanyl Citrate noHydromorphone Hydrochloride no
Meperidine Hydrochloride noMorphine Sulfate no Additional Placement Nalbuphine Hydrochloride noOxycodone Hydrochloride noOxymorphone Hydrochloride noPentazocine Lactate no Manufacturer DiscontinuedTapentadol Hydrochloride noTramadol Hydrochloride no
Analgesics Combinations Class New class to include analgesic combination drug products
Acetaminophen/ Codeine Phosphate
yes
Benzhydrocodone/ A t i h
yes
* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage.
Medicare Model Guidelines Draft v8.0 3 of 97
Hydrocodone Bitartrate/ Acetaminophen
yes
Hydrocodone Bitartrate/ Ibuprofen yes
Morphine Sulfate/ Naltrexone Hydrochloride
yes
Oxycodone Hydrochloride/ Acetaminophen
yes
Oxycodone Hydrochloride/ Aspirin yes
Oxycodone Hydrochloride/ Ibuprofen
yes
Tramadol Hydrochloride/ Acetaminophen
yes
Butalbital/ Acetaminophen yesButalbital/ Acetaminophen/ Caffeine
yes
Butalbital/ Acetaminophen/ Caffeine/ Codeine Phosphate
yes
Butalbital/ Aspirin/ Caffeine yesButalbital/ Aspirin/ Caffeine/ Codeine
yes
Anesthetics CatLocal Anesthetics Class
Lidocaine Hydrochloride noLidocaine/ Epinephrine yesLidocaine/ Prilocaine yesLidocaine/ Tetracaine yes
* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage.
Medicare Model Guidelines Draft v8.0 4 of 97
Anti-Addiction/ Substance Abuse Treatment Agents
Cat
Alcohol Deterrents/Anti-craving Class
Acamprosate Calcium noDisulfiram noNaltrexone Hydrochloride no
Opioid Dependence Treatments Opioid Dependence
Class Renamed class to "Opioid Dependence" to avoid redundancy in category name, since the concept of "treatment agents" is already included
Buprenorphine noBuprenorphine/ Naloxone Hydrochloride
yes
Lofexidine noNaltrexone Hydrochloride no
Opioid Reversal Agents ClassNaloxone Hydrochloride no
Smoking Cessation Agents ClassBupropion Hydrochloride noNicotine Polacrilex noVarenicline Tartrate no
Antibacterials CatAntibacterials Aminoglycosides ClassAntibacterials Amikacin Sulfate noAntibacterials Gentamicin Sulfate noAntibacterials Neomycin Sulfate noAntibacterials Paromomycin Sulfate noAntibacterials Plazomicin noAntibacterials Streptomycin Sulfate noAntibacterials Tobramycin Sulfate no
* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage.
Medicare Model Guidelines Draft v8.0 5 of 97
Antibacterials Beta-lactam, Cephalosporins ClassAntibacterials Antibacterials Cefadroxil noAntibacterials Cefazolin noAntibacterials Cephalexin noAntibacterials Antibacterials Cefaclor noAntibacterials Cefoxitin Sodium noAntibacterials Cefprozil noAntibacterials Cefuroxime Axetil noAntibacterials Sodium noAntibacterials Antibacterials Cefdinir noAntibacterials Cefixime noAntibacterials Cefotaxime Sodium noAntibacterials Cefpodoxime Proxetil noAntibacterials Ceftazidime noAntibacterials Ceftazidime/ Avibactam yesAntibacterials Ceftibuten Dihydrate no Manufacturer DiscontinuedAntibacterials Ceftriaxone Sodium noAntibacterials Antibacterials Cefepime Hydrochloride noAntibacterials Antibacterials Ceftaroline Fosamil noAntibacterials Ceftolozane Sulfate/ Tazobactam yes
Antibacterials Beta-lactam, Penicillins ClassAntibacterials Antibacterials Amoxicillin noAntibacterials Amoxicillin/ Clavulanate yesAntibacterials Ampicillin no
* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage.
Medicare Model Guidelines Draft v8.0 6 of 97
Antibacterials Ampicillin Sodium/ Sulbactam S di
yesAntibacterials Antibacterials Piperacillin Sodium/ Tazobactam
Sodium yes
Antibacterials Antibacterials Penicillin G Benzathine noAntibacterials Penicillin G Potassium noAntibacterials Penicillin G Procaine noAntibacterials Penicillin G Sodium noAntibacterials Penicillin G Benzathine/ Penicillin
G Procaine yes
Antibacterials Penicillin V Potassium noAntibacterials Antibacterials Dicloxacillin Sodium noAntibacterials Nafcillin Sodium noAntibacterials Oxacillin Sodium noAntibacterials Beta-lactam, Other Carbapenems Class Renamed class to add specification
Antibacterials Aztreonam no Moved example drug to USP Class, "Antibacterials, Other"
Antibacterials Doripenem no Manufacturer DiscontinuedAntibacterials Ertapenem Sodium noAntibacterials Imipenem/ Cilastatin Sodium yes
Imipenem/ Cilastatin/ Relebactam yes New FDA approved drug, 7/16/19
Antibacterials Meropenem noAntibacterials Meropenem/ Vaborbactam yesAntibacterials Macrolides ClassAntibacterials Azithromycin noAntibacterials Clarithromycin noAntibacterials Erythromycin no
* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage.
Medicare Model Guidelines Draft v8.0 7 of 97
Antibacterials Erythromycin Ethylsuccinate noAntibacterials Erythromycin Lactobionate noAntibacterials Erythromycin Stearate noAntibacterials Fidaxomicin noAntibacterials Quinolones ClassAntibacterials Besifloxacin Hydrochloride noAntibacterials Ciprofloxacin noAntibacterials Delafloxacin Meglumine noAntibacterials Finafloxacin no Manufacturer DiscontinuedAntibacterials Gatifloxacin noAntibacterials Gemifloxacin Mesylate noAntibacterials Levofloxacin noAntibacterials Moxifloxacin Hydrochloride noAntibacterials Ofloxacin noAntibacterials Sulfonamides ClassAntibacterials Sulfacetamide Sodium noAntibacterials Sulfadiazine noAntibacterials Sulfamethoxazole/ Trimethoprim yes
Antibacterials Tetracyclines ClassAntibacterials Demeclocycline Hydrochloride no
Antibacterials Doxycycline Calcium noAntibacterials Doxycycline Hyclate no
Eravacycline noAntibacterials Minocycline Hydrochloride noAntibacterials Omadacycline noAntibacterials Sarecycline noAntibacterials Tetracycline Hydrochloride noAntibacterials Antibacterials, Other ClassAntibacterials
* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage.
Medicare Model Guidelines Draft v8.0 8 of 97
Antibacterials Silver Sulfadiazine noAntibacterials Antibacterials Trimethoprim noAntibacterials
Dalbavancin noAntibacterials Vancomycin Hydrochloride noAntibacterials Antibacterials Clindamycin Hydrochloride noAntibacterials Clindamycin Palmitate
Hydrochlorideno
Antibacterials Lincomycin Hydrochloride noAntibacterials Antibacterials Nitrofurantoin noAntibacterials Antibacterials Linezolid noAntibacterials Tedizolid Phosphate noAntibacterials Antibacterials Acetic Acid no
Aztreonam no Moved example drug from USP Class, "Beta-lactam, Other"
Antibacterials Bacitracin noAntibacterials Chloramphenicol Sodium
S i tno
Antibacterials Daptomycin noAntibacterials Fosfomycin Tromethamine noAntibacterials Mafenide Acetate noAntibacterials Methenamine Hippurate noAntibacterials Metronidazole noAntibacterials Mupirocin Calcium noAntibacterials Polymyxin B Sulfate noAntibacterials Retapamulin noAntibacterials Rifaximin no
* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage.
Medicare Model Guidelines Draft v8.0 9 of 97
Antibacterials Secnidazole noAntibacterials Tinidazole noAntibacterials Tigecycline noAnticonvulsants CatAnticonvulsants Calcium Channel Modifying Agents Class
Anticonvulsants Ethosuximide noAnticonvulsants Methsuximide noAnticonvulsants Gamma-aminobutyric Acid (GABA)
Augmenting Agents Class
Anticonvulsants Anticonvulsants Clobazam noAnticonvulsants Clonazepam noAnticonvulsants Clorazepate Dipotassium noAnticonvulsants Diazepam noAnticonvulsants Lorazepam noAnticonvulsants Anticonvulsants Phenobarbital noAnticonvulsants Primidone noAnticonvulsants Anticonvulsants Gabapentin noAnticonvulsants Pregabalin noAnticonvulsants Tiagabine noAnticonvulsants Vigabatrin no
Glutamate Reducing Agents Class Removed class due to multiple mechanism of actions of example drugs. Example drugs with multiple mechanism of actions moved to USP Class, "Anticonvulsants, Other.“ Examples drugs moved to USP Class, "Anticonvulsants, Other."
Anticonvulsants Sodium Channel Agents ClassAnticonvulsants Carbamazepine no
* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage.
Medicare Model Guidelines Draft v8.0 10 of 97
Anticonvulsants Eslicarbazepine noEthotoin no
Anticonvulsants Fosphenytoin noAnticonvulsants Lacosamide noAnticonvulsants Oxcarbazepine noAnticonvulsants Phenytoin noAnticonvulsants Rufinamide noAnticonvulsants Zonisamide noAnticonvulsants Anticonvulsants, Other ClassAnticonvulsants Cannabidiol noAnticonvulsants Anticonvulsants Brivaracetam noAnticonvulsants Levetiracetam noAnticonvulsants Anticonvulsants Divalproex noAnticonvulsants Felbamate noAnticonvulsants Lamotrigine noAnticonvulsants Perampanel noAnticonvulsants Stiripentol noAnticonvulsants Topiramate noAnticonvulsants Valproic Acid noAntidementia Agents CatAntidementia Agents Cholinesterase Inhibitors ClassAntidementia Agents Donepezil Hydrochloride noAntidementia Agents Galantamine Hydrobromide noAntidementia Agents Rivastigmine no
Rivastigmine Tartrate noAntidementia Agents N-methyl-D-aspartate (NMDA)
Receptor Antagonist Class
Antidementia Agents Memantine Hydrochloride noAntidementia Agents Antidementia Agents, Other Class
* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage.
Medicare Model Guidelines Draft v8.0 11 of 97
Antidementia Agents Memantine/ Donepezil H d hl id
yesAntidementia Agents Ergoloid Mesylates noAntidepressants CatAntidepressants Monoamine Oxidase Inhibitors ClassAntidepressants Isocarboxazid no Gap drug found on FRFAntidepressants Phenelzine Sulfate noAntidepressants Selegiline noAntidepressants Tranylcypromine Sulfate noAntidepressants SSRIs/SNRIs (Selective Serotonin
Reuptake Inhibitors/ Serotonin and Norepinephrine Reuptake Inhibitors)
Class
Antidepressants Citalopram Hydrobromide noAntidepressants Desvenlafaxine noAntidepressants Desvenlafaxine Succinate noAntidepressants Duloxetine Hydrochloride noAntidepressants Escitalopram Oxalate noAntidepressants Fluoxetine Hydrochloride noAntidepressants Fluvoxamine Maleate noAntidepressants Levomilnacipran Hydrochloride no
Antidepressants Maprotiline Hydrochloride no Example drug moved to USP Class, "Antidepressants, Other."
Antidepressants Nefazodone Hydrochloride noAntidepressants Paroxetine Hydrochloride noAntidepressants Sertraline Hydrochloride noAntidepressants Trazodone Hydrochloride noAntidepressants Venlafaxine Hydrochloride noAntidepressants Vilazodone Hydrochloride noAntidepressants Vortioxetine Hydrobromide noAntidepressants Tricyclics Class
* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage.
Medicare Model Guidelines Draft v8.0 12 of 97
Antidepressants Amitriptyline Hydrochloride noAntidepressants Amoxapine noAntidepressants Clomipramine Hydrochloride noAntidepressants Desipramine Hydrochloride noAntidepressants Doxepin Hydrochloride noAntidepressants Imipramine Hydrochloride noAntidepressants Imipramine Pamoate noAntidepressants Nortriptyline Hydrochloride noAntidepressants Protriptyline Hydrochloride noAntidepressants Trimipramine Maleate noAntidepressants Antidepressants, Other ClassAntidepressants Bupropion Hydrochloride noAntidepressants Mirtazapine noAntidepressants Antidepressants Aripiprazole noAntidepressants Quetiapine Fumarate no
Esketamine Hydrochloride no New FDA approved drug, 3/5/19
Antidepressants Antidepressants Chlordiazepoxide/ Amitriptyline
Hydrochloride yes
Antidepressants Olanzapine/ Fluoxetine yesAntidepressants Perphenazine/ Amitriptyline
Hydrochloride yes
Antiemetics CatAntiemetics Emetogenic Therapy Adjuncts ClassAntiemetics Antiemetics Rolapitant noAntiemetics Antiemetics Dolasetron Mesylate no Manufacturer DiscontinuedAntiemetics Granisetron Hydrochloride no
* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage.
Medicare Model Guidelines Draft v8.0 13 of 97
Antiemetics Ondansetron noAntiemetics Ondansetron Hydrochloride noAntiemetics Palonosetron Hydrochloride noAntiemetics Antiemetics Aprepitant no
Fosnetupitant/ Palonosetron no New FDA approved drug 4/19/18Antiemetics Netupitant/ Palonosetron yesAntiemetics Antiemetics Dronabinol noAntiemetics Nabilone noAntiemetics Antiemetics, Other ClassAntiemetics Chlorpromazine Hydrochloride no
Antiemetics Diphenhydramine Hydrochloride no
Antiemetics Doxylamine Succinate/ Pyridoxine Hydrochloride
yes
Antiemetics Hydroxyzine Hydrochloride noAntiemetics Meclizine Hydrochloride noAntiemetics Metoclopramide noAntiemetics Perphenazine noAntiemetics Prochlorperazine Edisylate noAntiemetics Prochlorperazine Maleate noAntiemetics Promethazine Hydrochloride noAntiemetics Scopolamine noAntiemetics Trimethobenzamide Hydrochloride no
Antifungals CatAntifungals Antifungals Naftifine Hydrochloride noAntifungals Terbinafine Hydrochloride no
* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage.
Medicare Model Guidelines Draft v8.0 14 of 97
Antifungals Antifungals Butoconazole Nitrate noAntifungals Clotrimazole noAntifungals Econazole Nitrate noAntifungals Efinaconazole noAntifungals Fluconazole noAntifungals Isavuconazonium Sulfate noAntifungals Itraconazole noAntifungals Ketoconazole noAntifungals Luliconazole noAntifungals Miconazole Nitrate noAntifungals Oxiconazole Nitrate noAntifungals Posaconazole noAntifungals Sertaconazole Nitrate noAntifungals Sulconazole Nitrate noAntifungals Terconazole noAntifungals Voriconazole noAntifungals Antifungals Anidulafungin noAntifungals Caspofungin Acetate noAntifungals Micafungin Sodium noAntifungals Antifungals Amphotericin B noAntifungals Natamycin no Removed placement. Placement exists under USP Class,
"Ophthalmic Anti-Infectives."Antifungals Nystatin noAntifungals Antifungals Butenafine Hydrochloride noAntifungals Ciclopirox Olamine noAntifungals Flucytosine noAntifungals Griseofulvin no
* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage.
Medicare Model Guidelines Draft v8.0 15 of 97
Antifungals Tavaborole noAntigout Agents CatAntigout Agents Antigout Agents Probenecid noAntigout Agents Antigout Agents Allopurinol noAntigout Agents Febuxostat noAntigout Agents Antigout Agents Colchicine noAntigout Agents Lesinurad no Manufacturer DiscontinuedAntigout Agents Pegloticase noAntigout Agents Antigout Agents Lesinurad/ Allopurinol yes Manufacturer DiscontinuedAntigout Agents Probenecid/ Colchicine yesAnti-inflammatory Agents Cat
Anti-inflammatory Agents Glucocorticoids Class
Anti-inflammatory Agents Nonsteroidal Anti-inflammatory Drugs
Class
Anti-inflammatory Agents Celecoxib no
Anti-inflammatory Agents Diclofenac Potassium no
Anti-inflammatory Agents Diclofenac Epolamine no
Anti-inflammatory Agents Diclofenac Sodium/ Misoprostol yes
Anti-inflammatory Agents Diflunisal no
* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage.
Medicare Model Guidelines Draft v8.0 16 of 97
Anti-inflammatory Agents Etodolac no
Anti-inflammatory Agents Fenoprofen Calcium no
Anti-inflammatory Agents Flurbiprofen no
Anti-inflammatory Agents Ibuprofen no
Anti-inflammatory Agents Ibuprofen/ Famotidine yes
Anti-inflammatory Agents Indomethacin no
Anti-inflammatory Agents Ketoprofen no
Anti-inflammatory Agents Ketorolac Tromethamine no
Anti-inflammatory Agents Meclofenamate Sodium no
Anti-inflammatory Agents Mefenamic Acid no
Anti-inflammatory Agents Meloxicam no
Anti-inflammatory Agents Nabumetone no
Anti-inflammatory Agents Naproxen Sodium no
Anti-inflammatory Agents Naproxen/ Esomeprazole Magnesium
yes
Anti-inflammatory Agents Oxaprozin no
* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage.
Medicare Model Guidelines Draft v8.0 17 of 97
Anti-inflammatory Agents Piroxicam no
Anti-inflammatory Agents Sulindac no
Anti-inflammatory Agents Tolmetin Sodium no
Antimigraine Agents CatAntimigraine Agents Ergot Alkaloids ClassAntimigraine Agents Dihydroergotamine Mesylate noAntimigraine Agents Ergotamine Tartrate noAntimigraine Agents Serotonin (5-HT) 1b/1d Receptor
Agonists Class
Antimigraine Agents Almotriptan Malate noAntimigraine Agents Eletriptan Hydrobromide noAntimigraine Agents Frovatriptan Succinate noAntimigraine Agents Naratriptan Hydrochloride noAntimigraine Agents Rizatriptan Benzoate noAntimigraine Agents Sumatriptan noAntimigraine Agents Sumatriptan/ Naproxen Sodium yes
Antimigraine Agents Zolmitriptan noAntimigraine Agents Prophylactic ClassAntimigraine Agents Antimigraine Agents Erenumab noAntimigraine Agents Fremanezumab noAntimigraine Agents Galcanezumab noAntimigraine Agents Antimigraine Agents Timolol Maleate noAntimigraine Agents Antimigraine Agents Divalproex Sodium noAntimigraine Agents Topiramate no
* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage.
Medicare Model Guidelines Draft v8.0 18 of 97
Antimigraine Agents Valproic Acid noAntimyasthenic Agents CatAntimyasthenic Agents Parasympathomimetics ClassAntimyasthenic Agents Guanidine Hydrochloride noAntimyasthenic Agents Pyridostigmine Bromide noAntimycobacterials CatAntimycobacterials Antituberculars ClassAntimycobacterials Aminosalicylic Acid noAntimycobacterials Bedaquiline Fumarate noAntimycobacterials Capreomycin Sulfate noAntimycobacterials Cycloserine noAntimycobacterials Ethambutol Hydrochloride noAntimycobacterials Ethionamide noAntimycobacterials Isoniazid noAntimycobacterials Pyrazinamide noAntimycobacterials Rifampin noAntimycobacterials Rifapentine noAntimycobacterials Rifampin/ Isoniazid yesAntimycobacterials Rifampin/ Isoniazid/ Pyrazinamide yes
Antimycobacterials Antimycobacterials, Other ClassAntimycobacterials Dapsone noAntimycobacterials Rifabutin noAntineoplastics CatAntineoplastics Alkylating Agents ClassAntineoplastics Antineoplastics Altretamine no Manufacturer DiscontinuedAntineoplastics Antineoplastics Chlorambucil noAntineoplastics Mechlorethamine Hydrochloride no
* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage.
Medicare Model Guidelines Draft v8.0 19 of 97
Antineoplastics Melphalan noAntineoplastics Antineoplastics Lomustine noAntineoplastics Antineoplastics Busulfan noAntineoplastics Cyclophosphamide noAntineoplastics Procarbazine Hydrochloride noAntineoplastics Temozolomide noAntineoplastics Trabectedin noAntineoplastics Antiandrogens ClassAntineoplastics Antineoplastics Apalutamide no
Daroflutamide New FDA approved, 7/30/19Antineoplastics Enzalutamide noAntineoplastics Bicalutamide noAntineoplastics Flutamide noAntineoplastics Nilutamide noAntineoplastics Antineoplastics Abiraterone Acetate noAntineoplastics Antiangiogenic Agents ClassAntineoplastics Lenalidomide noAntineoplastics Pomalidomide noAntineoplastics Thalidomide noAntineoplastics Antiestrogens/Modifiers ClassAntineoplastics Antineoplastics Estramustine Phosphate Sodium no
Antineoplastics Fulvestrant noAntineoplastics Antineoplastics Tamoxifen Citrate noAntineoplastics Toremifene Citrate no
* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage.
Medicare Model Guidelines Draft v8.0 20 of 97
Antineoplastics Antimetabolites ClassAntineoplastics Antineoplastics Capecitabine noAntineoplastics Mercaptopurine noAntineoplastics Thioguanine noAntineoplastics Antineoplastics Hydroxyurea noAntineoplastics Aromatase Inhibitors, 3rd
Generation Class
Antineoplastics Anastrozole noAntineoplastics Exemestane noAntineoplastics Letrozole noAntineoplastics Enzyme Inhibitors ClassAntineoplastics Etoposide noAntineoplastics Topotecan noAntineoplastics Molecular Target Inhibitors Class
Antineoplastics Gefitinib noAntineoplastics Antineoplastics Binimetinib noAntineoplastics Cobimetinib Fumarate noAntineoplastics Antineoplastics Alectinib noAntineoplastics Brigatinib noAntineoplastics Ceritinib noAntineoplastics Crizotinib no
Lorlatinib no New FDA approved drug, 11/2/18Antineoplastics Antineoplastics Dabrafenib Mesylate noAntineoplastics Encorafenib noAntineoplastics Trametinib Dimethyl Sulfoxide no
* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage.
Medicare Model Guidelines Draft v8.0 21 of 97
Antineoplastics Vemurafenib noAntineoplastics Antineoplastics Acalabrutinib no New FDA approved drug,10/31/17 Antineoplastics Ibrutinib noAntineoplastics Antineoplastics Abemaciclib no New FDA approved drug, 09/28/17Antineoplastics Palbociclib noAntineoplastics Ribociclib no New FDA approved drug, 3/13/17Antineoplastics Antineoplastics Ramucirumab noAntineoplastics Antineoplastics Afatinib Dimaleate noAntineoplastics Dacomitinib noAntineoplastics Erlotinib Hydrochloride no
Neratinib no New FDA approved drug, 7/17/17Antineoplastics Osimertinib Mesylate no
Erdafitinib no New FDA approved drug, 4/12/19
Antineoplastics Glasdegib no New FDA approved drug, 11/21/18
Antineoplastics Sonidegib Phosphate noAntineoplastics Vismodegib noAntineoplastics Antineoplastics Ivosidenib no New FDA approved drug, 7/20/18Antineoplastics Antineoplastics Ruxolitinib Phosphate no New FDA approved drug, 05/24/19Antineoplastics
Cabazitaxel noAntineoplastics
Antineoplastics Everolimus no
* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage.
Medicare Model Guidelines Draft v8.0 22 of 97
Antineoplastics Antineoplastics Bosutinib Monohydrate noAntineoplastics Dasatinib noAntineoplastics Imatinib Mesylate noAntineoplastics Nilotinib Hydrochloride
Monohydrateno
Antineoplastics Ponatinib Hydrochloride noAntineoplastics Antineoplastics Lapatinib Ditosylate noAntineoplastics Axitinib noAntineoplastics Cabozantinib S-Malate no
EntrectinibAntineoplastics Lenvatinib Mesylate no
Pexidartinib New FDA approved drug 8/2/19Antineoplastics Pazopanib Hydrochloride noAntineoplastics Regorafenib noAntineoplastics Sorafenib Tosylate noAntineoplastics Sunitinib Malate noAntineoplastics Vandetanib noAntineoplastics
Gilteritinib no New FDA approved drug, 11/28/18Antineoplastics Midostaurin no
Larotrectinib no New FDA approved drug, 11/26/18
Antineoplastics Alpelisib no New FDA approved drug, 05/24/19
Antineoplastics Copanlisib no New FDA approved drug, 09/14/17Antineoplastics Duvelisib no New FDA approved drug, 09/24/18Antineoplastics Idelalisib noAntineoplastics Antineoplastics Niraparib no New FDA approved drug, 03/27/17
* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage.
Medicare Model Guidelines Draft v8.0 23 of 97
Antineoplastics Olaparib noAntineoplastics Rucaparib no New FDA approved drug, 12/19/16Antineoplastics Talazoparib no New FDA approved drug, 10/16/18Antineoplastics Antineoplastics Venetoclax noAntineoplastics Antineoplastics Belinostat noAntineoplastics Panobinostat Lactate noAntineoplastics Monoclonal Antibody/Antibody-
D C j t Class
Antineoplastics Moxetumomab Pasudotox no New FDA approved drug, 9/13/18Antineoplastics Antineoplastics Bevacizumab no
Mogamulizumab no New FDA approved drug 8/8/19
Antineoplastics Antineoplastics Blinatumomab noAntineoplastics Antineoplastics Daratumumab noAntineoplastics Antineoplastics Dinutuximab noAntineoplastics Antineoplastics Elotuzumab noAntineoplastics Antineoplastics Ipilimumab noAntineoplastics Antineoplastics Pertuzumab no
Trastuzumab/ Hyaluronidase no New FDA approved drug, 02/28/19Antineoplastics Antineoplastics Cetuximab noAntineoplastics
* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage.
Medicare Model Guidelines Draft v8.0 24 of 97
Antineoplastics Olaratumab noAntineoplastics Antineoplastics Atezolizumab noAntineoplastics Avelumab noAntineoplastics Cemiplimab noAntineoplastics Durvalumab noAntineoplastics Nivolumab noAntineoplastics Pembrolizumab noAntineoplastics Antineoplastics Obinutuzumab noAntineoplastics Ofatumumab noAntineoplastics Rituximab noAntineoplastics Rituximab/ Hyaluronidase yesAntineoplastics Antineoplastics Ado-Trastuzumab Emtansine noAntineoplastics Brentuximab Vedotin no
Gemtuzumab Ozogamicin no New FDA approved drug, 09/01/17 Antineoplastics Inotuzumab Ozogamicin no
Polatuzumab Vedotin no New FDA approved drug, 06/10/19Antineoplastics Retinoids ClassAntineoplastics Alitretinoin noAntineoplastics Bexarotene noAntineoplastics Tretinoin noAntineoplastics Treatment Adjuncts ClassAntineoplastics Allopurinol noAntineoplastics Mesna noAntineoplastics Rasburicase noAntineoplastics Antineoplastics, Other Class
Methotrexate no Additional placementPemetrexed Disodium no New FDA approved drug, 5/23/19
* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage.
Medicare Model Guidelines Draft v8.0 25 of 97
Antineoplastics Aldesleukin noAntineoplastics Asparaginase-erwinia no
Calaspargase Pegol no New FDA approved drug, 12/20/18Antineoplastics Denileukin Diftitox noAntineoplastics Enasidenib no New FDA approved drug, 08/01/17Antineoplastics Fludarabine Phosphate noAntineoplastics Ixazomib Citrate noAntineoplastics Letrozole/ Ribociclib yes New FDA approved drug, 05/04/17Antineoplastics Leucovorin no
Levoleucovorin Calcium no New FDA approved drug 10/19/18Antineoplastics Mitoxantrone Hydrochloride no
Permetrexed Disodium new FDA approved drug, 5/23/19Antineoplastics Pegaspargase no
Selinexor no New FDA approved drug, 7/3/19Tagraxofusp no New FDA approved drug, 12/21/18
Antineoplastics Trifluridine/ Tipiracil yes New FDA approved drug, 02/22/19Antineoplastics Vorinostat noAntiparasitics CatAntiparasitics Anthelmintics ClassAntiparasitics Albendazole noAntiparasitics Ivermectin noAntiparasitics Mebendazole noAntiparasitics Moxidectin noAntiparasitics Praziquantel no
Triclabendazole no New FDA approved drug 11/9/18Antiparasitics Antiprotozoals ClassAntiparasitics Antiparasitics Miltefosine noAntiparasitics
* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage.
Medicare Model Guidelines Draft v8.0 26 of 97
Antiparasitics Artemether/ Lumefantrine yesAntiparasitics Atovaquone/ Proguanil
Hydrochloride yes
Antiparasitics Chloroquine Phosphate noAntiparasitics Hydroxychloroquine Sulfate noAntiparasitics Mefloquine Hydrochloride noAntiparasitics Primaquine Phosphate noAntiparasitics Quinine Sulfate noAntiparasitics Tafenoquine Succinate no New FDA approved drug, 7/20/2018Antiparasitics Antiparasitics Atovaquone noAntiparasitics Benznidazole noAntiparasitics Nitazoxanide noAntiparasitics Pentamidine Isethionate noAntiparasitics Pyrimethamine noAntiparkinson Agents CatAntiparkinson Agents Anticholinergics ClassAntiparkinson Agents Benztropine Mesylate noAntiparkinson Agents Diphenhydramine Hydrochloride no
Antiparkinson Agents Trihexyphenidyl Hydrochloride noAntiparkinson Agents Dopamine Agonists ClassAntiparkinson Agents Apomorphine Hydrochloride noAntiparkinson Agents Bromocriptine Mesylate noAntiparkinson Agents Pramipexole Dihydrochloride noAntiparkinson Agents Ropinirole Hydrochloride noAntiparkinson Agents Rotigotine no
* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage.
Medicare Model Guidelines Draft v8.0 27 of 97
Antiparkinson Agents Dopamine Precursors/ L-Amino Acid Decarboxylase Inhibitors Dopamine Precursors and/or L-Amino Acid Decarboxylase Inhibitors
Class Renamed class to add specification
Antiparkinson Agents Carbidopa noAntiparkinson Agents Carbidopa/ Levodopa yes
Levodopa no New FDA approved drug, 12/21/18Antiparkinson Agents Monoamine Oxidase B (MAO-B)
Inhibitors Class
Antiparkinson Agents Rasagiline Mesylate noAntiparkinson Agents Safinamide no New FDA approved drug, 3/21/17Antiparkinson Agents Selegiline Hydrochloride noAntiparkinson Agents Antiparkinson Agents, Other ClassAntiparkinson Agents Carbidopa/ Levodopa/
E t yes
Antiparkinson Agents Carbidopa/ Levodopa/ Entacapone
Gap drug to include combination
Antiparkinson Agents Entacapone noAntiparkinson Agents Tolcapone noAntiparkinson Agents Antiparkinson Agents Amantadine Hydrochloride noAntipsychotics CatAntipsychotics 1st Generation/Typical ClassAntipsychotics Chlorpromazine Hydrochloride no
Antipsychotics Fluphenazine Hydrochloride noAntipsychotics Fluphenazine Decanoate noAntipsychotics Haloperidol noAntipsychotics Haloperidol Decanoate noAntipsychotics Loxapine Succinate noAntipsychotics Perphenazine no
* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage.
Medicare Model Guidelines Draft v8.0 28 of 97
Antipsychotics Pimozide noAntipsychotics Prochlorperazine Edisylate noAntipsychotics Prochlorperazine Maleate noAntipsychotics Thioridazine Hydrochloride noAntipsychotics Thiothixene Hydrochloride noAntipsychotics Trifluoperazine Hydrochloride noAntipsychotics 2nd Generation/Atypical ClassAntipsychotics Aripiprazole noAntipsychotics Asenapine noAntipsychotics Brexpiprazole noAntipsychotics Cariprazine Hydrochloride noAntipsychotics Iloperidone noAntipsychotics Lurasidone Hydrochloride noAntipsychotics Olanzapine noAntipsychotics Olanzapine Pamoate noAntipsychotics Pimavanserin Tartrate noAntipsychotics Quetiapine Fumarate noAntipsychotics Paliperidone noAntipsychotics Paliperidone Palmitate noAntipsychotics Risperidone noAntipsychotics Ziprasidone Hydrochloride noAntipsychotics Ziprasidone Mesylate noAntipsychotics Treatment-Resistant ClassAntipsychotics Clozapine noAntispasticity Agents CatAntispasticity Agents Baclofen noAntispasticity Agents Dantrolene Sodium noAntispasticity Agents Tizanidine Hydrochloride noAntivirals CatAntivirals Anti-cytomegalovirus (CMV) Agents Class
* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage.
Medicare Model Guidelines Draft v8.0 29 of 97
Antivirals Cidofovir noAntivirals Foscarnet Sodium noAntivirals Ganciclovir Sodium no
Letermovir no New FDA approved drug,11/08/17Antivirals Valganciclovir Hydrochloride noAntivirals Anti-hepatitis B (HBV) Agents ClassAntivirals Adefovir Dipivoxil noAntivirals Entecavir noAntivirals Lamivudine noAntivirals Ribavirin noAntivirals Tenofovir Alafenamide no New FDA approved drug, 11/10/16Antivirals Tenofovir Disoproxil Fumarate no
Interferon Alfa-2b, Recombinant no
Interferon Alfa-n3 noPeginterferon Alfa-2a noPeginterferon Alfa-2b no
Antivirals Anti-hepatitis C (HCV) Agents, Other
Class
Ribavirin no
Interferon Alfa-2b, Recombinant no
Interferon Alfa-n3 noPeginterferon Alfa-2a noPeginterferon Alfa-2b no
Anti-hepatitis C (HCV) Agents Direct Acting Agents
Class
Ribavirin no
Antivirals Daclatasvir no
* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage.
Medicare Model Guidelines Draft v8.0 30 of 97
Antivirals Sofosbuvir noAntivirals Antivirals Dasabuvir/ Ombitasvir/
Paritaprevir/ Ritonavir yes
Antivirals Elbasvir/ Grazoprevir yesAntivirals Glecaprevir/ Pibrentasvir yes New FDA approved drug, 08/03/17Antivirals Ledipasvir/ Sofosbuvir yesAntivirals Ombitasvir/ Paritaprevir/ Ritonavir yes
Antivirals Sofosbuvir/ Velpatasvir/ V il i
yesAntivirals Velpatasvir/ Sofosbuvir yesAntivirals Antiherpetic Agents ClassAntivirals Acyclovir noAntivirals Famciclovir noAntivirals Foscarnet Sodium noAntivirals Idoxuridine no Manufacturer DiscontinuedAntivirals Penciclovir Sodium noAntivirals Valacyclovir Hydrochloride noAntivirals Anti-HIV Agents, Non-nucleoside
Reverse Transcriptase Inhibitors (NNRTI)
Class
Antivirals Delavirdine Mesylate noAntivirals Doravirine noAntivirals Efavirenz noAntivirals Etravirine noAntivirals Nevirapine noAntivirals Rilpivirine Hydrochloride noAntivirals Anti-HIV Agents, Nucleoside and
Nucleotide Reverse Transcriptase Inhibitors (NRTI)
Class
* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage.
Medicare Model Guidelines Draft v8.0 31 of 97
Antivirals Abacavir Sulfate noAntivirals Didanosine noAntivirals Emtricitabine noAntivirals Lamivudine noAntivirals Stavudine noAntivirals Tenofovir Disoproxil Fumarate noAntivirals Zidovudine noAntivirals Anti-HIV Agents, Protease Inhibitors
(PI) Class
Antivirals Atazanavir Sulfate noAntivirals Darunavir noAntivirals Fosamprenavir Calcium noAntivirals Indinavir Sulfate noAntivirals Nelfinavir Mesylate noAntivirals Ritonavir noAntivirals Saquinavir Mesylate noAntivirals Tipranavir noAntivirals Anti-HIV Agents, Integrase
Inhibitors (INSTI) Class
Antivirals Dolutegravir Sodium noAntivirals Raltegravir Potassium noAntivirals Anti-HIV Agents, Other ClassAntivirals Ibalizumab noAntivirals Antivirals Cobicistat noAntivirals Enfuvirtide noAntivirals Maraviroc noAntivirals Anti-HIV Combinations Class New class to add Anti-HIV combination drug productsAntivirals Abacavir Sulfate/ Lamivudine yesAntivirals Abacavir Sulfate/ Lamivudine/
Zidovudine yes
* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage.
Medicare Model Guidelines Draft v8.0 32 of 97
Antivirals Abacavir/ Dolutegravir/ L i di
yesAntivirals Atazanavir/ Cobicistat yesAntivirals Bictegravir/ Emtricitabine/
Tenofovir Alafenamide yes
Antivirals Darunavir/ Cobicistat yesAntivirals Darunavir/ Cobicistat/
Emtricitabine/ Tenofovir Alafenamide Fumarate
yes
Dolutegravir/ Lamivudine yes New FDA approved drug, 4/8/19
Antivirals Dolutegravir/ Rilpivirine yesAntivirals Doravirine/ Lamivudine/ Tenofovir
Disproxil Fumarate yes
Antivirals Efavirenz/ Emtricitabine/ Tenofovir Disoproxil Fumarate
yes
Antivirals Efavirenz/ Lamivudine/ Tenofovir Disoproxil Fumarate
yes
Antivirals Elvitegravir/ Cobicistat/ Emtricitabine/ Tenofovir Alafenamide Fumarate
yes
Antivirals Elvitegravir/ Cobicistat/ Emtricitabine/ Tenofovir Disoproxil Fumarate
yes
Antivirals Emtricitabine/ Rilpivirine / Tenofovir Disoproxil Fumarate
yes
Antivirals Emtricitabine/ Rilpivirine/ Tenofovir Alafenamide Fumarate
yes
Antivirals Emtricitabine/ Tenofovir Alafenamide Fumarate
yes
Antivirals Emtricitabine/ Tenofovir Disoproxil Fumarate
yes
* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage.
Medicare Model Guidelines Draft v8.0 33 of 97
Antivirals Lamivudine/ Tenofovir Disoproxil Fumarate
yes
Antivirals Lamivudine/ Zidovudine yesAntivirals Lopinavir/ Ritonavir yesAntivirals Anti-influenza Agents ClassAntivirals Amantadine Hydrochloride noAntivirals Baloxavir Marboxil noAntivirals Oseltamivir Phosphate noAntivirals Peramivir noAntivirals Rimantadine Hydrochloride noAntivirals Zanamivir noAnxiolytics CatAnxiolytics SSRIs/SNRIs (Selective Serotonin
Reuptake Inhibitors/ Serotonin and Norepinephrine Reuptake Inhibitors)
Class
Anxiolytics Duloxetine Hydrochloride noAnxiolytics Escitalopram Oxalate noAnxiolytics Paroxetine Hydrochloride noAnxiolytics Sertraline Hydrochloride noAnxiolytics Venlafaxine Hydrochloride noAnxiolytics Benzodiazepines ClassAnxiolytics Alprazolam noAnxiolytics Chlordiazepoxide noAnxiolytics Clonazepam noAnxiolytics Clorazepate Dipotassium noAnxiolytics Diazepam noAnxiolytics Lorazepam noAnxiolytics Oxazepam noAnxiolytics Anxiolytics, Other Class
* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage.
Medicare Model Guidelines Draft v8.0 34 of 97
Anxiolytics Buspirone Hydrochloride noAnxiolytics Doxepin Hydrochloride noAnxiolytics Hydroxyzine Hydrochloride noAnxiolytics Hydroxyzine Pamoate noAnxiolytics Meprobamate noBipolar Agents CatBipolar Agents Mood Stabilizers ClassBipolar Agents Carbamazepine noBipolar Agents Divalproex Sodium noBipolar Agents Lamotrigine noBipolar Agents Lithium Carbonate noBipolar Agents Valproic Acid noBipolar Agents Bipolar Agents, Other ClassBipolar Agents Aripiprazole noBipolar Agents Asenapine noBipolar Agents Olanzapine noBipolar Agents Olanzapine Pamoate noBipolar Agents Quetiapine Fumarate noBipolar Agents Risperidone noBipolar Agents Ziprasidone Hydrochloride noBipolar Agents Ziprasidone Mesylate noBlood Glucose Regulators Cat
Blood Glucose Regulators Antidiabetic Agents Class
Blood Glucose Regulators
Blood Glucose Regulators Metformin Hydrochloride no
Blood Glucose Regulators
* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage.
Medicare Model Guidelines Draft v8.0 35 of 97
Blood Glucose Regulators Alogliptin no
Blood Glucose Regulators Linagliptin no
Blood Glucose Regulators Saxagliptin no
Blood Glucose Regulators Sitagliptin Phosphate no
Blood Glucose Regulators Blood Glucose Regulators Albiglutide no
Blood Glucose Regulators Dulaglutide no
Blood Glucose Regulators Exenatide no
Blood Glucose Regulators Liraglutide no
Blood Glucose Regulators Lixisenatide no
Blood Glucose Regulators Semaglutide no
Blood Glucose Regulators
Blood Glucose Regulators Canagliflozin no
Blood Glucose Regulators Dapagliflozin no
Blood Glucose Regulators Ertugliflozin no New FDA approved drug 12/19/17
Blood Glucose Regulators Empagliflozin no
* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage.
Medicare Model Guidelines Draft v8.0 36 of 97
Blood Glucose Regulators
Blood Glucose Regulators Chlorpropamide no Manufacturer Discontinued
Blood Glucose Regulators Glimepiride no
Blood Glucose Regulators Glipizide no
Blood Glucose Regulators Glyburide no
Blood Glucose Regulators Tolazamide no
Blood Glucose Regulators Tolbutamide no
Blood Glucose Regulators
Blood Glucose Regulators Pioglitazone Hydrochloride no
Blood Glucose Regulators Rosiglitazone Maleate no
Blood Glucose Regulators
Blood Glucose Regulators Acarbose no
Blood Glucose Regulators Miglitol no
Blood Glucose Regulators
Blood Glucose Regulators Nateglinide no
* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage.
Medicare Model Guidelines Draft v8.0 37 of 97
Blood Glucose Regulators Repaglinide no
Blood Glucose Regulators Pramlintide Acetate no
Blood Glucose Regulators Colesevelam Hydrochloride no
Blood Glucose Regulators Bromocriptine Mesylate no
Blood Glucose Regulators Antidiabetic Combinations Class New class to add antidiabetic combination drug products
Blood Glucose Regulators Alogliptin Benzoate/ Pioglitazone Hydrochloride
yes
Blood Glucose Regulators Alogliptin/ Metformin H d hl id
yesBlood Glucose Regulators Canagliflozin/ Metformin
Hydrochloride yes
Blood Glucose Regulators Dapagliflozin/ Metformin Hydrochloride
yes
Blood Glucose Regulators Dapagliflozin/ Saxagliptin yesDapagliflozin/ Saxagliptin/ Metformin Hydrochloride
yes New FDA approved drug, 5/2/19
Blood Glucose Regulators Empagliflozin/ Linagliptin yesBlood Glucose Regulators Empagliflozin/ Metformin
Hydrochloride yes New FDA approved drug,12/9/16
Blood Glucose Regulators Ertugliflozin/ Metformin H d hl id
yes New FDA approved drug,12/19/17Blood Glucose Regulators Ertugliflozin/ Sitagliptin yes New FDA approved drug, 12/19/17Blood Glucose Regulators Glipizide/ Metformin Hydrochloride yesBlood Glucose Regulators Glyburide/ Metformin
H d hl id yes
Blood Glucose Regulators Insulin Degludec/ Liraglutide yesBlood Glucose Regulators Insulin Glargine/ Lixisenatide yes
* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage.
Medicare Model Guidelines Draft v8.0 38 of 97
Blood Glucose Regulators Linagliptin/ Metformin H d hl id
yesBlood Glucose Regulators Pioglitazone Hydrochloride/
Glimepiride yes
Blood Glucose Regulators Pioglitazone Hydrochloride/ Metformin Hydrochloride
yes
Blood Glucose Regulators Repaglinide/ Metformin Hydrochloride
yes
Blood Glucose Regulators Saxagliptin/ Metformin H d hl id
yesBlood Glucose Regulators Sitagliptin/ Metformin
H d hl id yes
Blood Glucose Regulators Glycemic Agents Class
Blood Glucose Regulators Diazoxide no
Blood Glucose Regulators Glucagon no
Blood Glucose Regulators Insulins Class
Blood Glucose Regulators
Blood Glucose Regulators Insulin Aspart no
Blood Glucose Regulators Insulin Glulisine no
Blood Glucose Regulators Insulin Lispro no
Blood Glucose Regulators
Blood Glucose Regulators Insulin Human (Regular) no
* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage.
Medicare Model Guidelines Draft v8.0 39 of 97
Blood Glucose Regulators
Blood Glucose Regulators Isophane Insulin (Human) no
Blood Glucose Regulators
Blood Glucose Regulators Insulin Degludec no
Blood Glucose Regulators Insulin Detemir no
Blood Glucose Regulators Insulin Glargine no
Blood Glucose Regulators
Blood Glucose Regulators Insulin Aspart/ Insulin Degludec yes
Blood Glucose Regulators Insulin Aspart Rapid-acting/ Insulin Aspart Protamine
yes
Blood Glucose Regulators Insulin Lispro Rapid-acting/ Insulin Lispro Protamine
yes
Blood Glucose Regulators Insulin Human Regular/ Isophane Insulin
yes
Blood Products/ Modifiers/ Volume Expanders Blood Products and Modifiers
Cat Renamed category to remove, "Volume Expanders" since drugs that are volume expanders also modify blood products.
Blood Products and Modifiers
Anticoagulants Class
Blood Products and Modifiers
Blood Products and M difi
Dabigatran Etexilate Mesylate no
* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage.
Medicare Model Guidelines Draft v8.0 40 of 97
Blood Products and Modifiers
Desirudin no Manufacturer Discontinued
Blood Products and Modifiers
Blood Products and Modifiers
Apixaban no
Blood Products and Modifiers
Betrixaban no N
Blood Products and Modifiers
Rivaroxaban no
Blood Products and Modifiers
Edoxaban Tosylate no
Blood Products and Modifiers
Blood Products and Modifiers
Fondaparinux Sodium no
Blood Products and Modifiers
Blood Products and Modifiers
Heparin, porcine no
Blood Products and Modifiers
Blood Products and Modifiers
Dalteparin Sodium no
Blood Products and Modifiers
Enoxaparin Sodium no
Blood Products and Modifiers
Blood Products and Modifiers
Vorapaxar Sulfate no
* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage.
Medicare Model Guidelines Draft v8.0 41 of 97
Blood Products and Modifiers
Blood Products and Modifiers
Warfarin Sodium no
Blood Products and Modifiers
Hemostasis Agents Class
Blood Products and Modifiers
Blood Products and Modifiers
Tranexamic Acid no
Blood Products and Modifiers
Blood Products and Modifiers
6-Aminocaproic Acid no
Blood Products and Modifiers
Platelet Modifying Agents Class
Blood Products and Modifiers
Blood Products and Modifiers
Clopidogrel Bisulfate no
Blood Products and Modifiers
Prasugrel Hydrochloride no
Blood Products and Modifiers
Ticlopidine Hydrochloride no
Blood Products and Modifiers
Ticagrelor no
Aspirin noAvatrombopag no New FDA approve drug, 05/21/18Caplacizumab no New FDA approved drug, 02/06/19Cilostazol no
* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage.
Medicare Model Guidelines Draft v8.0 42 of 97
Dipyridamole noAspirin/ Dipyridamole yesFostamatinib no New FDA approved drug, 04/17/2018
Blood Formation Modifiers Blood Products and Modifiers, Other
Class Renamed class to "Blood Products and Modifiers, Other" to encompass additional drugs
Filgrastim noPegfilgrastim noSargramostim no Darbepoetin Alfa noEpoetin Alfa noMethoxy polyethylene glycol-epoetin beta
no
Anagrelide no Eltrombopag Olamine noLusutrombopag no New FDA approved drug, 07/31/2018Romiplostim no Plerixafor no
Cardiovascular Agents CatAlpha-adrenergic Agonists Class
Clonidine Hydrochloride noDroxidopa noGuanfacine Hydrochloride noMethyldopa noMethyldopate Hydrochloride no Manufacturer DiscontinuedMidodrine Hydrochloride no
* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage.
Medicare Model Guidelines Draft v8.0 43 of 97
Phenylephrine Hydrochloride noAlpha-adrenergic Blocking Agents Class
Doxazosin Mesylate noPhenoxybenzamine Hydrochloride no
Prazosin Hydrochloride noTerazosin Hydrochloride no
Angiotensin-converting Enzyme (ACE) Inhibitors
Class
Benazepril Hydrochloride noCaptopril noEnalapril Maleate noFosinopril Sodium noLisinopril noMoexipril Hydrochloride noPerindopril Erbumine noQuinapril Hydrochloride noRamipril noTrandolapril no
Angiotensin II Receptor Antagonists class
Azilsartan Medoxomil noCandesartan Cilexetil noEprosartan Mesylate noIrbesartan noLosartan Potassium noOlmesartan Medoxomil noTelmisartan noValsartan no
Antiarrhythmics class
* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage.
Medicare Model Guidelines Draft v8.0 44 of 97
Disopyramide Phosphate noFlecainide Acetate noMexiletine Hydrochloride noPropafenone Hydrochloride noQuinidine Sulfate no Acebutolol no Added example drug due to antiarrhythmic indicationPropranolol no Added example drug due to antiarrhythmic indication Amiodarone Hydrochloride noDofetilide noDronedarone noSotalol Hydrochloride no Diltiazem no Added example drug due to antiarrhythmic indicationVerapamil no Added example drug due to antiarrhythmic indication Digoxin no Added example drug due to antiarrhythmic indication
Beta-adrenergic Blocking Agents class
Atenolol noBetaxolol Hydrochloride noBisoprolol Fumarate noMetoprolol Succinate noMetoprolol Tartrate noNebivolol Hydrochloride no Nadolol noPropranolol Hydrochloride no
* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage.
Medicare Model Guidelines Draft v8.0 45 of 97
Timolol Maleate no Acebutolol Hydrochloride noCarteolol no Removed example drug due to dosage form, ophthalmic
solution. Additional placement in USP Category, "Ophthalmic Agents"
Pindolol noCarvedilol Phosphate noLabetalol Hydrochloride no
Calcium Channel Blocking Agents class Removed class and replaced with 2 new USP Classes, "Calcium Channel-Blocking Agents, Dihydropyridines," and "Calcium Channel Blocking Agents, Nondihydropyridines"
Amlodipine Besylate noFelodipine noIsradipine noNicardipine Hydrochloride noNifedipine noNimodipine noNisoldipine no
Diltiazem Hydrochloride noVerapamil Hydrochloride no
Calcium Channel Blocking Agents, Dihydropyridines
class New Class to provide therapeutic distinction
Amlodipine Besylate noFelodipine noIsradipine noNicardipine Hydrochloride noNifedipine no
* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage.
Medicare Model Guidelines Draft v8.0 46 of 97
Nimodipine noNisoldipine no
Calcium Channel Blocking Agents, Nondihydropyridines
class New Class to provide therapeutic distinction
Diltiazem Hydrochloride noVerapamil Hydrochloride no
Diuretics, Carbonic Anhydrase Inhibitors
class Removed class due to limited relevance to cardiovascular agents.
Acetazolamide Sodium no Moved example drug to USP Class, "Cardiovascular Agents, Other". Additional placment in USP Category, "Ophthalmic Agents"
Methazolamide no Removed example drug due to indication. Additional placement in USP Category, "Ophthalmic Agents"
Diuretics, Loop classBumetanide noEthacrynate Sodium noEthacrynic Acid noFurosemide noTorsemide no
Diuretics, Potassium-sparing classAmiloride Hydrochloride noEplerenone noSpironolactone noTriamterene no
Diuretics, Thiazide classBendroflumethiazide no Manufacturer DiscontinuedChlorothiazide Sodium noChlorthalidone noHydrochlorothiazide noIndapamide noMethyclothiazide no
* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage.
Medicare Model Guidelines Draft v8.0 47 of 97
Metolazone noDyslipidemics, Fibric Acid Derivatives
class
Choline Fenofibrate noFenofibrate noFenofibric Acid noGemfibrozil no
Dyslipidemics, HMG CoA Reductase Inhibitors
class
Atorvastatin Calcium noFluvastatin Sodium noLovastatin noPitavastatin noPravastatin Sodium noRosuvastatin Calcium noSimvastatin no
Dyslipidemics, Other classCholestyramine noColesevelam Hydrochloride noColestipol Hydrochloride noEzetimibe noIcosapent Ethyl noLomitapide Mesylate noMipomersen Sodium no Manufacturer DiscontinuedNiacin noOmega-3-acid Ethyl Esters noOmega-3 Carboxylic Acids no Manufacturer Discontinued Ezetimibe/ Simvastatin yes Removed PG
* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage.
Medicare Model Guidelines Draft v8.0 48 of 97
Alirocumab no Example drug moved to new USP Class, "Dyslipidemics, PCSK9 Inhibitor."
Evolocumab no Example drug moved to new USP Class, "Dyslipidemics, PCSK9 Inhibitor."
Dyslipidemics, PCSK9 Inhibitor class New Class to provide therapeutic distinctionAlirocumab noEvolocumab no
Vasodilators, Direct-acting Arterial class Removed class, replaced with new USP Class, "Vasodilators"
Hydralazine Hydrochloride noMinoxidil no
Vasodilators, Direct-acting Arterial/Venous
class Removed class, replaced with new USP Class, "Vasodilators"
Isosorbide Dinitrate noIsosorbide Mononitrate noNitroglycerin no
Vasodilators class New USP class to consolidate two removed USP classes," Vasodilators, Direct-acting Arterial," and "Vasodilators, Direct-acting Arterial/Venous"
Hydralazine Hydrochloride noMinoxidil no Isosorbide Dinitrate noIsosorbide Mononitrate noNitroglycerin no
Cardiovascular Agents, Other Class Acetazolamide no Moved from deleted USP Class, "Diuretics, Carbonic
Anhydrase Inhibitors."Aliskiren Fumarate no
* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage.
Medicare Model Guidelines Draft v8.0 49 of 97
Digoxin noIvabradine Hydrochloride noMecamylamine Hydrochloride noPentoxifylline noRanolazine no
Cardiovascular Combinations Class New Class to add specificationAliskiren Hemifumarate/ Hydrochlorothiazide
yes
Amiloride Hydrochloride/ Hydrochlorothiazide
yes
Amlodipine Besylate/ Atorvastatin Calcium
yes
Amlodipine/ Benazepril Hydrochloride
yes
Amlodipine Besylate/ Celecoxib yes New FDA approved drug, 05/31/18
Amlodipine/ Olmesartan Medoxomil
yes
Amlodipine/ Valsartan yesAmlodipine/ Valsartan/ Hydrochlorothiazide
yes
Atenolol/ Chlorthalidone yesAzilsartan Kamedoxomil/ Chlorthalidone
yes
Benazepril Hydrochloride/ Hydrochlorothiazide
yes
Bisoprolol Fumarate/ Hydrochlorothiazide
yes
Candesartan Cilexetil/ Hydrochlorothiazide
yes
Captopril/ Hydrochlorothiazide yes
* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage.
Medicare Model Guidelines Draft v8.0 50 of 97
Enalapril Maleate/ Hydrochlorothiazide
yes
Ezetimibe/ Simvastatin yes Placed in Dyslipedmics, OtherFosinopril Sodium/ Hydrochlorothiazide
yes
Hydralazine Hydrochloride/ Isosorbide Dinitrate
yes
Irbesartan/ Hydrochlorothiazide yes
Lisinopril/ Hydrochlorothiazide yesLosartan Potassium/ Hydrochlorothiazide
yes
Methyldopa/ Hydrochlorothiazide yes
Metoprolol Succinate/ Hydrochlorothiazide
yes
Metoprolol Tartrate/ Hydrochlorothiazide
yes
Moexipril Hydrochloride/ Hydrochlorothiazide
yes
Nadolol/ Bendroflumethiazide yesNebivolol Hydrochloride/ Valsartan yes
Olmesartan Medoxmil/ Hydrochlorothiazide
yes
Olmesartan Medoxomil/ Amlodipine Besylate/ Hydrochlorothiazide
yes
Perindopril Arginine/ Amlodipine Besylate
yes
* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage.
Medicare Model Guidelines Draft v8.0 51 of 97
Propranolol Hydrochloride/ Hydrochlorothiazide
yes
Quinapril Hydrochloride/ Hydrochlorothiazide
yes
Sacubitril/ Valsartan yesSpironolactone/ Hydrochlorothiazide
yes
Telmisartan/ Amlodipine yesTelmisartan/ Hydrochlorothiazide yes
Trandolapril/ Verapamil Hydrochloride
yes
Triamterene/ Hydrochlorothiazide yes
Valsartan/ Hydrochlorothiazide yesCentral Nervous System Agents
Cat
Central Nervous System Agents
Attention Deficit Hyperactivity Disorder Agents, Amphetamines
Class
Central Nervous System Agents
Amphetamine no
Central Nervous System Agents
Dextroamphetamine Sulfate no
Central Nervous System Agents
Dextroamphetamine Saccharate/ Amphetamine Aspartate/ Dextroamphetamine Sulfate/ Amphetamine Sulfate
yes
Central Nervous System Agents
* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage.
Medicare Model Guidelines Draft v8.0 52 of 97
Central Nervous System Agents
Lisdexamfetamine Dimesylate no
Central Nervous System Agents
Methamphetamine Hydrochloride no
Central Nervous System Agents
Attention Deficit Hyperactivity Disorder Agents, Non-amphetamines
Class
Central Nervous System Agents
Atomoxetine Hydrochloride no
Central Nervous System Agents
Clonidine Hydrochloride no
Central Nervous System Agents
Dexmethylphenidate Hydrochloride
no
Central Nervous System Agents
Guanfacine Hydrochloride no
Central Nervous System Agents
Methylphenidate Hydrochloride no
Central Nervous System Agents
Fibromyalgia Agents Class
Central Nervous System Agents
Duloxetine Hydrochloride no
Central Nervous System Agents
Milnacipran Hydrochloride no
Central Nervous System Agents
Pregabalin no
Multiple Sclerosis Agents Class Interferon Beta-1a noInterferon Beta-1b noPeginterferon Beta-1a no
* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage.
Medicare Model Guidelines Draft v8.0 53 of 97
Dalfampridine no Teriflunomide no Fingolimod Hydrochloride noSiponimod no New FDA approved drug, 3/26/19 Alemtuzumab noCladribine no New FDA approved drug, 3/29/19Dimethyl fumarate noGlatiramer Acetate noMitoxantrone Hydrochloride noNatalizumab noOcrelizumab noDaclizumab no Manufacturer Discontinued
Central Nervous System, Other ClassAmifampridine Phosphate no New FDA approved drug, 11/28/18Carbamazepine noDeutetrabenazine no New FDA approved drug, 04/03/17Dextromethorphan Hydrobromide/ Quinidine Sulfate
yes
Central Nervous System Agents
Edaravone no
Central Nervous System Agents
Gabapentin no
Central Nervous System Agents
Gabapentin Enacarbil no
Central Nervous System Agents
Tetrabenazine no
* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage.
Medicare Model Guidelines Draft v8.0 54 of 97
Central Nervous System Agents
Riluzole no
Central Nervous System Agents
Valbenazine no
Dental and Oral Agents CatDental and Oral Agents Cevimeline Hydrochloride noDental and Oral Agents Chlorhexidine Gluconate noDental and Oral Agents Doxycycline Hyclate noDental and Oral Agents Minocycline Hydrochloride noDental and Oral Agents Palifermin noDental and Oral Agents Pilocarpine Hydrochloride noDental and Oral Agents Prilocaine Hydrochloride noDental and Oral Agents Triamcinolone Acetonide noDermatological Agents CatDermatological Agents Acne and Rosacea Agents Class New class to add acne and rosacea agentsDermatological Agents Dermatological Agents Acitretin noDermatological Agents Adapalene noDermatological Agents Isotretinoin noDermatological Agents Tazarotene noDermatological Agents Tretinoin noDermatological Agents Dermatological Agents Azelaic Acid noDermatological Agents Brimonidine Tartrate noDermatological Agents Oxymetazoline noDermatological Agents Dermatological Agents Adapalene/ Benzoyl Peroxide yesDermatological Agents Clindamycin/ Benzoyl Peroxide yes
Dermatological Agents Clindamycin/ Tretinoin yes
* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage.
Medicare Model Guidelines Draft v8.0 55 of 97
Dermatological Agents Erythromycin/ Benzoyl Peroxide yes
Dermatological Agents Dermatitis and Pruritus Agents Class New class to add dermatitis and pruritus agentsDermatological Agents Dermatological Agents Alclometasone Dipropionate noDermatological Agents Clocortolone Pivalate noDermatological Agents Desonide noDermatological Agents Hydrocortisone noDermatological Agents Dermatological Agents Betamethasone Valerate noDermatological Agents Desoximetasone noDermatological Agents Fluocinolone Acetonide noDermatological Agents Flurandrenolide noDermatological Agents Fluticasone Propionate noDermatological Agents Hydrocortisone Butyrate noDermatological Agents Hydrocortisone Probutate noDermatological Agents Hydrocortisone Valerate noDermatological Agents Mometasone Furoate noDermatological Agents Triamcinolone Acetonide noDermatological Agents Dermatological Agents Amcinonide noDermatological Agents Betamethasone Dipropionate noDermatological Agents Desoximetasone noDermatological Agents Diflorasone Diacetate noDermatological Agents Fluocinolone Acetonide noDermatological Agents Fluocinonide noDermatological Agents Halcinonide noDermatological Agents Triamcinolone Acetonide noDermatological Agents Dermatological Agents Betamethasone Dipropionate noDermatological Agents Clobetasol Propionate no
* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage.
Medicare Model Guidelines Draft v8.0 56 of 97
Dermatological Agents Diflorasone Diacetate noDermatological Agents Halobetasol Propionate noDermatological Agents Dermatological Agents Ammonium Lactate noDermatological Agents Crisaborole no New FDA approved drug, 12/14/16Dermatological Agents Doxepin Hydrochloride noDermatological Agents Pimecrolimus noDermatological Agents Selenium Sulfide no
Tacrolimus noDermatological Agents Topical Anti-infectives Class New class to add topical anti-infectivesDermatological Agents Dermatological Agents Clindamycin Phosphate noDermatological Agents Erythromycin noDermatological Agents Benzoyl Peroxide noDermatological Agents Dapsone noDermatological Agents Ozenoxacin no New FDA approved drug, 12/11/17Dermatological Agents Dermatological Agents Butenafine Hydrochloride noDermatological Agents Ciclopirox Olamine noDermatological Agents Efinaconazole noDermatological Agents Ketoconazole noDermatological Agents Tavaborole noDermatological Agents Terbinafine Hydrochloride noDermatological Agents Dermatological Agents Acyclovir noDermatological Agents Penciclovir noDermatological Agents Pediculicides/Scabicides Class USP Class moved from USP Category, "Antiparasitics." Dermatological Agents Crotamiton noDermatological Agents Ivermectin noDermatological Agents Lindane noDermatological Agents Malathion no
* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage.
Medicare Model Guidelines Draft v8.0 57 of 97
Dermatological Agents Spinosad noDermatological Agents Dermatological Agents, Other Class New class to add miscellaneous dermatological agentsDermatological Agents Dermatological Agents AbobotulinumyoxinA noDermatological Agents Bimatoprost noDermatological Agents Deoxycholic Acid noDermatological Agents Eflornithine noDermatological Agents Finasteride noDermatological Agents Glycopyrronium noDermatological Agents OnabotulinumtoxinA no
PrabotulinumtoxinA no New FDA approved drug, 02/01/19Dermatological Agents Dermatological Agents Anthralin noDermatological Agents Apremilast noDermatological Agents Calcipotriene noDermatological Agents Calcitriol noDermatological Agents Methoxsalen noDermatological Agents Dermatological Agents Diclofenac Sodium noDermatological Agents Fluorouracil noDermatological Agents Imiquimod noDermatological Agents Ingenol mebutate noDermatological Agents Podofilox noDermatological Agents Sinecatechins noDermatological Agents Dermatological Agents Becaplermin noDermatological Agents Collagenase noDermatological Agents Silver Sulfadiazine noDermatological Agents Dermatological Agents Acyclovir/ Hydrocortisone yes
* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage.
Medicare Model Guidelines Draft v8.0 58 of 97
Dermatological Agents Calcipotriene/ Betamethasone Dipropionate
yes
Dermatological Agents Clotrimazole/ Betamethasone Dipropionate
yes
Dermatological Agents Fluocinolone Acetonide/ Hydroquinone/ Tretinoin
yes
Dermatological Agents Hydrocortisone Acetate/ Pramoxine Hydrochloride
yes
Dermatological Agents Neomycin/ Polymyxin B Sulfates/ Bacitracin Zinc/ Hydrocortisone
yes
Dermatological Agents Neomycin Sulfate/ Fluocinolone Acetonide
yes
Dermatological Agents Nystatin/ Triamcinolone Acetonide yes
Electrolytes/Minerals/Metals/ Vitamins
Cat
Electrolytes/Minerals/Metals/
Electrolyte/Mineral/Metal Modifiers Class
Electrolytes/Minerals/Metals/
Electrolytes/Minerals/Metals/
Deferasirox no
Electrolytes/Minerals/Metals/
Deferiprone no
Electrolytes/Minerals/Metals/
Electrolytes/Minerals/Metals/
Penicillamine no
Electrolytes/Minerals/Metals/
Succimer no
* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage.
Medicare Model Guidelines Draft v8.0 59 of 97
Electrolytes/Minerals/Metals/
Tolvaptan no
Electrolytes/Minerals/Metals/
Trientine Hydrochloride no
Electrolytes/Minerals/Metals/
Electrolytes/Minerals/Metals/
Prussian Blue no
Electrolytes/Minerals/Metals/
Zinc Acetate no
Electrolytes/Minerals/Metals/
Electrolyte/Mineral Replacement Class
Electrolytes/Minerals/Metals/
Ammonium Chloride no
Electrolytes/Minerals/Metals/
Carglumic Acid no
Electrolytes/Minerals/Metals/
Chromic Chloride no
Electrolytes/Minerals/Metals/
Citric Acid/ Potassium Citrate/ Sodium Citrate
yes
Electrolytes/Minerals/Metals/
Fluoride Sodium no
Electrolytes/Minerals/Metals/
Fluoride Stannous no
Electrolytes/Minerals/Metals/
Magnesium Chloride no
Electrolytes/Minerals/Metals/
Magnesium Sulfate no
Electrolytes/Minerals/Metals/
Manganese Chloride no
* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage.
Medicare Model Guidelines Draft v8.0 60 of 97
Electrolytes/Minerals/Metals/
Potassium Acetate no
Electrolytes/Minerals/Metals/
Potassium Bicarbonate no
Electrolytes/Minerals/Metals/
Potassium Chloride no
Electrolytes/Minerals/Metals/
Potassium Citrate no
Electrolytes/Minerals/Metals/
Potassium Gluconate no
Electrolytes/Minerals/Metals/
Potassium Phosphates no
Electrolytes/Minerals/Metal/
Potassium Citrate/ Citric Acid yesElectrolytes/Minerals/Metal
/Potassium Citrate/ Sodium Citrate yes
Electrolytes/Minerals/Metals/
Potassium Phosphate/ Sodium Phosphate
yes
Electrolytes/Minerals/Metals/
Sodium Acetate no
Electrolytes/Minerals/Metals/
Sodium Bicarbonate no
Electrolytes/Minerals/Metals/
Sodium Lactate no
Electrolytes/Minerals/Metals/
Sodium Chloride no
Electrolytes/Minerals/Metals/
Sodium Ferric Gluconate Complex no
Electrolytes/Minerals/Metals/
Phosphate Binders Class
Electrolytes/Minerals/Metals/
Calcium Acetate no
* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage.
Medicare Model Guidelines Draft v8.0 61 of 97
Electrolytes/Minerals/Metals/
Ferric Citrate no
Electrolytes/Minerals/Metals/
Lanthanum Carbonate no
Electrolytes/Minerals/Metals/
Sevelamer Hydrochloride no
Electrolytes/Minerals/Metals/
Sodium Zirconium Cyclosilicate no
Electrolytes/Minerals/Metals/
Sucroferric Oxyhydroxide no
Electrolytes/Minerals/Metals/
Potassium Binders Class
Electrolytes/Minerals/Metals/
Patiromer Sorbitex Calcium no
Electrolytes/Minerals/Metals/
Sodium Polystyrene Sulfonate no
Electrolytes/Minerals/Metals/
Vitamins Class
Electrolytes/Minerals/Metals/
Prenatal no
Gastrointestinal Agents Cat
Gastrointestinal Agents Anti-Diarrheal Agents Class New class to add anti-diarrheal agents
Gastrointestinal Agents Alosetron Hydrochloride no
Gastrointestinal Agents Crofelemer no
Gastrointestinal Agents Eluxadoline no
* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage.
Medicare Model Guidelines Draft v8.0 62 of 97
Gastrointestinal Agents Loperamide Hydrochloride no
Rifamycin no New FDA approved drug, 11/16/18Gastrointestinal Agents Rifaximin no
Gastrointestinal Agents Telotristat Ethyl no New FDA approved drug, 02/28/17
Gastrointestinal Agents
Gastrointestinal Agents Difenoxin/ Atropine Sulfate yes
Gastrointestinal Agents Diphenoxylate Hydrochloride/ Atropine Sulfate
yes
Gastrointestinal Agents Antispasmodics, Gastrointestinal Class
Gastrointestinal Agents Dicyclomine Hydrochloride no
Gastrointestinal Agents Glycopyrrolate no
Gastrointestinal Agents Mepenzolate Bromide no Manufacturer Discontinued
Gastrointestinal Agents Methscopolamine Bromide no
Gastrointestinal Agents Scopolamine no
Gastrointestinal Agents Anti-Constipation Agents Class New class to add anti-constipation agents
Gastrointestinal Agents
Gastrointestinal Agents Lactulose no
* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage.
Medicare Model Guidelines Draft v8.0 63 of 97
Gastrointestinal Agents Polyethylene Glycol 3350 NF no
Te Tenaparor New FDA approved drug, 09/12/19Gastrointestinal Agents
Gastrointestinal Agents Lubiprostone no
Gastrointestinal Agents Methylnaltrexone no
Gastrointestinal Agents Naloxegol Oxalate no
Gastrointestinal Agents Naldemedine no
Gastrointestinal Agents
Gastrointestinal Agents Linaclotide no
Gastrointestinal Agents Plecanatide no New FDA approved drug,1/19/17
Prucalopride no New FDA approved drug, 12/14/18Gastrointestinal Agents Histamine2 (H2) Receptor
Antagonists Class
Gastrointestinal Agents Cimetidine Hydrochloride no
Gastrointestinal Agents Famotidine no
Gastrointestinal Agents Nizatidine no
Gastrointestinal Agents Ranitidine Hydrochloride no
* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage.
Medicare Model Guidelines Draft v8.0 64 of 97
Irritable Bowel Syndrome Agents Class Removed class due to broaden class name to effect rather than disease state. Example drugs moved to new classes, Anti-Diarrheal agents and Anti-Constipation Agents.
Laxatives Class Removed class to broaden class name to Anti-Constipation Agents.
Gastrointestinal Agents Protectants Class
Gastrointestinal Agents Misoprostol no
Gastrointestinal Agents Sucralfate no
Gastrointestinal Agents Proton Pump Inhibitors Class
Gastrointestinal Agents Dexlansoprazole no
Gastrointestinal Agents Esomeprazole Magnesium no
Strontium noGastrointestinal Agents Lansoprazole no
Gastrointestinal Agents Omeprazole no
Gastrointestinal Agents Omeprazole/ Sodium Bicarbonate yes
Gastrointestinal Agents Pantoprazole Sodium no
Gastrointestinal Agents Rabeprazole Sodium no
Gastrointestinal Agents Gastrointestinal Agents, Other Class
* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage.
Medicare Model Guidelines Draft v8.0 65 of 97
Gastrointestinal Agents Alvimopan no
Gastrointestinal Agents Bezlotoxumab no
Gastrointestinal Agents Chenodiol no
Gastrointestinal Agents Metoclopramide no
Gastrointestinal Agents Metreleptin no
Gastrointestinal Agents Rifaximin no
Gastrointestinal Agents Ursodiol no
Moved PGBismuth Subcitrate Potassium/ Metronidazole/ Tetracycline Hydrochloride
yes Example drug incorporated to account for combinations
Lansoprazole/ Amoxicillin/ Clarithromycin
yes Example drug incorporated to account for combinations
Omeprazole/ Clarithromycin/ Amoxicillin
yes Example drug incorporated to account for combinations
Gastrointestinal Agents
Gastrointestinal Agents Glutamine no
Gastrointestinal Agents Somatropin no
Gastrointestinal Agents Teduglutide no
* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage.
Medicare Model Guidelines Draft v8.0 66 of 97
Gastrointestinal Agents
Gastrointestinal Agents Polyethylene Glycol 3350/ Sodium Chloride/ Potassium Chloride/ Sodium Bicarbonate/ Sodium Sulfate
yes
Gastrointestinal Agents Polyethylene Glycol 3350/ Sodium Chloride/ Sodium Bicarbonate/ Potassium Chloride
yes
Gastrointestinal Agents Polyethylene Glycol 3350/ Sodium Chloride/ Sodium Bicarbonate/ Potassium Chloride/ Bisacodyl
yes
Gastrointestinal Agents Polyethylene Glycol 3350/ Sodium Sulfate/ Sodium Chloride/ Potassium Chloride/ Ascorbic Acid/ Sodium Ascorbate
yes
Gastrointestinal Agents Sodium Picosulfate/ Magnesium Oxide/ Anhydrous Citric Acid
yes
Genetic or Enzyme Disorder: Replacement, Modifiers, Treatment
Cat
Genetic or Enzyme Disorder
Genetic or Enzyme Disorder
Inotersen no
Genetic or Enzyme Disorder
Patisiran no
* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage.
Medicare Model Guidelines Draft v8.0 67 of 97
Tafamidis no New FDA approved drug, 5/3/19Tafamidis Meglumine no New FDA approved drug, 5/3/19
Genetic or Enzyme Disorder
Genetic or Enzyme Disorder
Burosumab no
Genetic or Enzyme Disorder
Genetic or Enzyme Di d
Alpha-1 Proteinase Inhibitor, H
noGenetic or Enzyme Disorder
Genetic or Enzyme Disorder
Cerliponase alfa no
Genetic or Enzyme Disorder
Genetic or Enzyme Disorder
Cholic Acid no
Genetic or Enzyme Disorder
Genetic or Enzyme Disorder
Cysteamine Bitartrate no
Genetic or Enzyme Disorder
Genetic or Enzyme Disorder
Eteplirsen no
Genetic or Enzyme Disorder
Genetic or Enzyme Disorder
Agalsidase Beta no
* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage.
Medicare Model Guidelines Draft v8.0 68 of 97
Genetic or Enzyme Disorder
Migalastat Hydrochloride no
Genetic or Enzyme Disorder
Genetic or Enzyme Disorder
Imiglucerase no
Genetic or Enzyme Disorder
Taliglucerase Alfa no
Genetic or Enzyme Disorder
Velaglucerase Alfa no
Genetic or Enzyme Disorder
Genetic or Enzyme Disorder
Eliglustat no
Genetic or Enzyme Disorder
Miglustat no
Genetic or Enzyme Disorder
Genetic or Enzyme Disorder
Genetic or Enzyme Disorder
Nitisinone no
Genetic or Enzyme Disorder
Genetic or Enzyme Disorder
Betaine Hydrochloride no
Genetic or Enzyme Disorder
Genetic or Enzyme Disorder
Idursulfase no
* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage.
Medicare Model Guidelines Draft v8.0 69 of 97
Genetic or Enzyme Disorder
Genetic or Enzyme Disorder
Dichlorphenamide no
Genetic or Enzyme Disorder
Genetic or Enzyme Disorder
Asfotase Alfa no
Genetic or Enzyme Disorder
Genetic or Enzyme Disorder
Sebelipase Alfa no
Genetic or Enzyme Disorder
Genetic or Enzyme Disorder
Genetic or Enzyme Disorder
Galsulfase no
Genetic or Enzyme Disorder
Laronidase no
Genetic or Enzyme Disorder
Elosulfase Alfa no
Genetic or Enzyme Disorder
Genetic or Enzyme Disorder
Pancrelipase no
Genetic or Enzyme Disorder
Genetic or Enzyme Disorder
Pegvaliase no New FDA approved drug, 05/24/18
* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage.
Medicare Model Guidelines Draft v8.0 70 of 97
Genetic or Enzyme Disorder
Sapropterin Dihydrochloride no
Genetic or Enzyme Disorder
Genetic or Enzyme Disorder
Elapegademase no New FDA approved drug, 10/05/18
Genetic or Enzyme Disorder
Pegademase Bovine no
Genetic or Enzyme Disorder
Genetic or Enzyme Disorder
Glutamine no
Genetic or Enzyme Disorder
Genetic or Enzyme Disorder
Sacrosidase no
Genetic or Enzyme Disorder
Genetic or Enzyme Disorder
Sodium Phenylbutyrate no
Genetic or Enzyme Disorder
Glycerol Phenylbutyrate no
Genetic or Enzyme Disorder
Obeticholic Acid no
Genitourinary Agents CatGenitourinary Agents Antispasmodics, Urinary ClassGenitourinary Agents Genitourinary Agents Mirabegron no New FDA approved drug, 10/12/18Genitourinary Agents Genitourinary Agents Darifenacin Hydrobromide no
* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage.
Medicare Model Guidelines Draft v8.0 71 of 97
Genitourinary Agents Fesoterodine Fumarate noGenitourinary Agents Flavoxate Hydrochloride noGenitourinary Agents Oxybutynin Chloride noGenitourinary Agents Solifenacin Succinate noGenitourinary Agents Tolterodine Tartrate noGenitourinary Agents Trospium Chloride noGenitourinary Agents Benign Prostatic Hypertrophy
Agents Class
Genitourinary Agents Genitourinary Agents Alfuzosin Hydrochloride noGenitourinary Agents Doxazosin Mesylate noGenitourinary Agents Prazosin Hydrochloride noGenitourinary Agents Silodosin noGenitourinary Agents Tamsulosin Hydrochloride noGenitourinary Agents Terazosin Hydrochloride noGenitourinary Agents Genitourinary Agents Dutasteride noGenitourinary Agents Dutasteride/ Tamsulosin
Hydrochloride yes
Genitourinary Agents Finasteride noGenitourinary Agents Genitourinary Agents Tadalafil noGenitourinary Agents Genitourinary Agents, Other ClassGenitourinary Agents Bethanechol noGenitourinary Agents Penicillamine noGenitourinary Agents Pentosan Polysulfate Sodium noHormonal Agents, Stimulant/ Replacement/ Modifying (Adrenal)
Cat
Hormonal
* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage.
Medicare Model Guidelines Draft v8.0 72 of 97
Hormonal Corticotropin noHormonal Hormonal Betamethasone Acetate/
Betamethasone Sodium Phosphate
yes
Hormonal Budesonide noHormonal Cortisone Acetate noHormonal Deflazacort no New FDA approved drug, 2/9/17Hormonal Dexamethasone Acetate noHormonal Dexamethasone Sodium
Phosphateno
Hormonal Hydrocortisone Acetate noHormonal Hydrocortisone Sodium Succinate noHormonal Methylprednisolone Acetate noHormonal Methylprednisolone Sodium
S i tno
Hormonal Prednisolone Acetate noHormonal Prednisolone Sodium Phosphate no
Hormonal Prednisone noHormonal Triamcinolone Acetonide noHormonal Triamcinolone Diacetate no Manufacturer DiscontinuedHormonal Triamcinolone Hexacetonide noHormonal Hormonal Fludrocortisone Acetate noHormonal Agents, Stimulant/Replacement/ Modifying (Pituitary)
Cat
Hormonal Hormonal Chorionic Gonadotropin noHormonal Choriogonadotropin Alfa noHormonal
* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage.
Medicare Model Guidelines Draft v8.0 73 of 97
Hormonal Somatropin, Recombinant noHormonal Tesamorelin Acetate noHormonal Hormonal Mecasermin Rinfabate noHormonal Hormonal Desmopressin Acetate noHormonal noHormonal Agents, Stimulant/ Replacement/ Modifying (Prostaglandins)
Cat
Hormonal Alprostadil noHormonal Carboprost Tromethamine noHormonal Misoprostol noHormonal Agents, Stimulant/ Replacement/ Modifying (Sex Hormones/ Modifiers)
Cat
Hormonal Anabolic Steroids ClassHormonal Oxandrolone noHormonal Oxymetholone noHormonal Androgens ClassHormonal Danazol noHormonal Fluoxymesterone noHormonal Methyltestosterone noHormonal Testosterone Cypionate noHormonal Testosterone Enanthate noHormonal Estrogens ClassHormonal Estradiol Acetate no
* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage.
Medicare Model Guidelines Draft v8.0 74 of 97
Hormonal Estradiol Cypionate noHormonal Estradiol Valerate noHormonal Conjugated Estrogens noHormonal Esterified Estrogens noHormonal Estropipate noHormonal Ethinyl Estradiol no
Progesterone Agonists/Antagonists Class Removed class, example drug not FRF eligible
UlipristalHormonal Progestins ClassHormonal Hydroxyprogesterone Caproate no
Hormonal Levonorgestrel noHormonal Medroxyprogesterone Acetate noHormonal Megestrol Acetate noHormonal Norethindrone Acetate noHormonal Progesterone noHormonal Selective Estrogen Receptor
M dif i A t Class
Hormonal Conjugated Estrogens/ B d if
yesHormonal noHormonal Raloxifene Hydrochloride noHormonal Ospemifene noHormonal Hormonal Agents, Stimulant/
Replacement/ Modifying (Sex Hormones/ Modifiers), Other
Class New class to add combination drug products
Hormonal Estradiol/ Norgestimate yesHormonal Estradiol/ Levonorgestrel yesHormonal Estradiol/ Norethindrone Acetate yes
Estradiol/ Progesterone no New FDA approved drug, 10/28/18
* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage.
Medicare Model Guidelines Draft v8.0 75 of 97
Hormonal Agents, Stimulant/Replacement/ Modifying (Thyroid)
Cat
Hormonal Levothyroxine Sodium noHormonal Liothyronine Sodium noHormonal Liotrix no Manufacturer DiscontinuedHormonal Agents, Suppressant (Adrenal)
Cat
Hormonal Mitotane noHormonal Agents, Suppressant (Pituitary)
Cat
Hormonal Hormonal Bromocriptine Mesylate noHormonal Cabergoline noHormonal Hormonal Goserelin Acetate noHormonal Leuprolide Acetate noHormonal Nafarelin Acetate noHormonal Triptorelin Pamoate noHormonal Hormonal Degarelix Acetate noHormonal Elagolix noHormonal Hormonal Pegvisomant noHormonal Hormonal Lanreotide Acetate noHormonal Octreotide Acetate noHormonal Pasireotide Diaspartate noHormonal Pamoate noHormonal Agents, Suppressant (Thyroid)
Cat
* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage.
Medicare Model Guidelines Draft v8.0 76 of 97
Hormonal Antithyroid Agents ClassHormonal Methimazole noHormonal Propylthiouracil noImmunological Agents CatImmunological Agents Angioedema Agents ClassImmunological Agents Immunological Agents Icatibant Acetate noImmunological Agents Immunological Agents C1 esterase inhibitor (human) noImmunological Agents C1 esterase inhibitor
( bi t) no
Immunological Agents Immunological Agents Lanadelumab noImmunological Agents Immune Suppressants ClassImmunological AgentsImmunological Agents Mycophenolic Acid noImmunological AgentsImmunological Agents Tacrolimus noImmunological Agents Cyclosporine noImmunological AgentsImmunological Agents Baricitinib no New FDA approved drug, 05/31/18Immunological Agents Tofacitinib Citrate noImmunological AgentsImmunological Agents Sirolimus noImmunological AgentsImmunological Agents Mercaptopurine noImmunological Agents Abatacept noImmunological Agents Anakinra noImmunological Agents Belatacept noImmunological Agents Everolimus noImmunological Agents Methotrexate Sodium noImmunological Agents Pimecrolimus no
* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage.
Medicare Model Guidelines Draft v8.0 77 of 97
Immunological AgentsImmunological Agents Azathioprine noImmunological AgentsImmunological Agents Adalimumab noImmunological Agents Certolizumab Pegol noImmunological Agents Etanercept noImmunological Agents Golimumab noImmunological Agents Infliximab no
Class
Anti-thymocyte Globulin noImmune Globulin Intramuscular (Human)
no
Immune Globulin Intravenous (Human)
no
ClassImmunological AgentsImmunological Agents Belimumab noImmunological AgentsImmunological Agents Interferon Gamma-1b,
Recombinantno
Immunological AgentsImmunological Agents Brodalumab no New FDA approved drug, 02/15/19Immunological Agents Canakinumab noImmunological Agents Dupilumab noImmunological Agents Guselkumab noImmunological Agents Ixekizumab noImmunological Agents Rilonacept noImmunological Agents Risankizumab no New FDA approved drug, 04/23/19Immunological Agents Sarilumab noImmunological Agents Secukinumab no
* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage.
Medicare Model Guidelines Draft v8.0 78 of 97
Immunological Agents Siltuximab noTildrakizumab no New FDA approved drug, 03/20/18Tocilizumab no
Auranofin noApremilast noEculizumab no
Immunological Agents Emapalumab no New FDA approved drug, 11/20/18Immunological Agents Leflunomide noImmunological Agents Natalizumab noImmunological Agents Omalizumab noImmunological Agents Ravulizumab no New FDA approved drug, 12/21/18Immunological Agents Vedolizumab noImmunological AgentsImmunological Agents Sweet Vernal/ Orchard/ Perennial
Rye/ Timothy/ Kentucky Blue Grass Mixed Pollens Allergen Extract
yes
Immunological Agents Vaccines ClassImmunological Agents Immunological Agents Adenovirus Type 4 and Type 7
Vaccine Live Oral yes
Immunological Agents Anthrax Vaccine Adsorbed noImmunological Agents Immunological Agents Cholera Vaccine Live Oral noImmunological Agents Immunological Agents Diphtheria and Tetanus Toxoids
and Acellular Pertussis Vaccine Adsorbed (DTaP)
yes
* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage.
Medicare Model Guidelines Draft v8.0 79 of 97
Immunological Agents Tetanus and Diphtheria Toxoids Adsorbed (Td)
yes
Immunological Agents Diphtheria and Tetanus Toxoids Adsorbed (DT)
yes
Immunological Agents Tetanus Toxoid, Reduced Diphtheria Toxoid and Acellular Pertussis Vaccine, Adsorbed (Tdap)
yes
Diphtheria and Tetanus Toxoids and Acellular Pertussis Absorbed and Inactivated Poliovirus (DTaP-IPV) Vaccine
yes
Immunological Agents Diphtheria and Tetanus Toxoids and Acellular Pertussis Vaccine Adsorbed, Hepatitis B (Recombinant) and Inactivated Poliovirus Vaccine (DTaP-HepB-IPV)
yes
Immunological Agents Diphtheria and Tetanus Toxoids and Acellular Pertussis Vaccine Adsorbed, Inactivated Poliovirus and Haemophilus B Conjugate (Tetanus Toxoid Conjugate) (DTaP-IPV/Hib)
yes
Immunological Agents Haemophilus B Conjugate Vaccine (Tetanus Toxoid Conjugate)
no
* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage.
Medicare Model Guidelines Draft v8.0 80 of 97
Immunological Agents Diphtheria and Tetanus Toxoids and Acellular Pertussis Vaccine Adsorbed, Inactivated Poliovirus and Haemophilus B Conjugate (Tetanus Toxoid Conjugate) (DTaP-IPV/Hib)
yes
Immunological Agents Immunological Agents Hepatitis A Vaccine noImmunological Agents Hepatitis A and Hepatitis B
(Recombinant) Vaccine yes
Immunological Agents Immunological Agents Hepatitis B Virus Vaccine
Recombinant no
Immunological Agents Diphtheria and Tetanus Toxoids and Acellular Pertussis Vaccine Adsorbed, Hepatitis B (Recombinant) and Inactivated Poliovirus Vaccine (DTaP-HepB-IPV)
yes
Immunological Agents Hepatitis A and Hepatitis B (Recombinant) Vaccine
yes
Immunological Agents Immunological Agents Human Papillomavirus
Quadrivalent (types 6, 11, 16 and 18) Vaccine Recombinant
yes
Immunological Agents Immunological Agents Influenza Vaccine no
Influenza Vaccine Live noImmunological Agents
* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage.
Medicare Model Guidelines Draft v8.0 81 of 97
Immunological Agents Japanese Encephalitis Virus, Inactivated, Adsorbed
no
Immunological Agents Immunological Agents Measles, Mumps, and Rubella
Virus Vaccine Live yes
Immunological Agents Measles, Mumps, Rubella, and Varicella Virus Vaccine Live
yes
Immunological Agents Immunological Agents Meningococcal Groups (A, C, Y,
and W-135) Polysaccharide Diphtheria Toxoid Conjugate Vaccine
yes
Immunological Agents Meningococcal Group B Vaccine no
Immunological Agents Immunological Agents Measles, Mumps, and Rubella
Virus Vaccine Live yes
Immunological Agents Measles, Mumps, Rubella, and Varicella Virus Vaccine Live
yes
Immunological Agents Immunological Agents Diphtheria and Tetanus Toxoids
and Acellular Pertussis Vaccine Adsorbed (DTaP)
yes
Tetanus Toxoid, Reduced Diphtheria Toxoid and Acellular Pertussis Vaccine, Adsorbed (Tdap)
yes
* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage.
Medicare Model Guidelines Draft v8.0 82 of 97
Immunological Agents Diphtheria and Tetanus Toxoids and Acellular Pertussis Absorbed and Inactivated Poliovirus (DTaP-IPV) Vaccine
yes
Immunological Agents Diphtheria and Tetanus Toxoids and Acellular Pertussis Vaccine Adsorbed, Hepatitis B (Recombinant) and Inactivated Poliovirus Vaccine (DTaP-HepB-IPV)
yes
Immunological Agents Diphtheria and Tetanus Toxoids and Acellular Pertussis Vaccine Adsorbed, Inactivated Poliovirus and Haemophilus B Conjugate (Tetanus Toxoid Conjugate) (DTaP-IPV/Hib)
yes
Immunological Agents Pneumococcal 13-Valent
Conjugate Vaccine no
Immunological Agents Pneumococcal Vaccine Polyvalent no
Immunological Agents Immunological Agents Poliovirus Vaccine Inactivated noImmunological Agents Diphtheria and Tetanus Toxoids
and Acellular Pertussis Absorbed and Inactivated Poliovirus (DTaP-IPV) Vaccine
yes
* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage.
Medicare Model Guidelines Draft v8.0 83 of 97
Immunological Agents Diphtheria and Tetanus Toxoids and Acellular Pertussis Vaccine Adsorbed, Hepatitis B (Recombinant) and Inactivated Poliovirus Vaccine (DTaP-HepB-IPV)
yes
Diphtheria and Tetanus Toxoids and Acellular Pertussis Vaccine Adsorbed, Inactivated Poliovirus and Haemophilus B Conjugate (Tetanus Toxoid Conjugate) (DTaP-IPV/Hib)
yes
Immunological Agents Immunological Agents Rabies Vaccine noImmunological Agents Immunological Agents Rotavirus Vaccine Live noImmunological Agents Immunological Agents Measles, Mumps, and Rubella
Virus Vaccine Live yes
Immunological Agents Measles, Mumps, Rubella, and Varicella Virus Vaccine Live
yes
Immunological Agents Immunological Agents Zoster Vaccine Live noImmunological Agents Zoster Vaccine Recombinant,
Adjuvanted no
Immunological Agents Varicella Virus Vaccine Live noImmunological Agents
* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage.
Medicare Model Guidelines Draft v8.0 84 of 97
Immunological Agents Diphtheria and Tetanus Toxoids and Acellular Pertussis Vaccine Adsorbed (DTaP)
yes
Tetanus and Diphtheria Toxoids Adsorbed (Td)
yes
Immunological Agents Diphtheria and Tetanus Toxoids Adsorbed (DT)
yes
Immunological Agents Tetanus Toxoid, Reduced Diphtheria Toxoid and Acellular Pertussis Vaccine, Adsorbed (Tdap)
yes
Immunological Agents Diphtheria and Tetanus Toxoids and Acellular Pertussis Absorbed and Inactivated Poliovirus (DTaP-IPV) Vaccine
yes
Immunological Agents Diphtheria and Tetanus Toxoids and Acellular Pertussis Vaccine Adsorbed, Hepatitis B (Recombinant) and Inactivated Poliovirus Vaccine (DTaP-HepB-IPV)
yes
Immunological Agents Diphtheria and Tetanus Toxoids and Acellular Pertussis Vaccine Adsorbed, Inactivated Poliovirus and Haemophilus B Conjugate (Tetanus Toxoid Conjugate) (DTaP-IPV/Hib)
yes
* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage.
Medicare Model Guidelines Draft v8.0 85 of 97
BCG vaccine no Typhoid Vaccine Live Oral noTyphoid Vi Polysaccharide Vaccine
no
Varicella Virus Vaccine Live noMeasles, Mumps, Rubella, and Varicella Virus Vaccine Live
yes
Immunological Agents Yellow Fever Vaccine noInflammatory Bowel Disease Agents
Cat
Inflammatory Bowel Glucocorticoids ClassInflammatory Bowel Budesonide noInflammatory Bowel Cortisone Acetate noInflammatory Bowel Dexamethasone Acetate noInflammatory Bowel Dexamethasone Sodium
Phosphateno
Inflammatory Bowel Hydrocortisone Sodium Succinate noInflammatory Bowel Methylprednisolone Acetate noInflammatory Bowel Methylprednisolone Sodium
S i tno
Inflammatory Bowel Prednisolone Acetate noInflammatory Bowel Prednisolone Sodium Succinate noInflammatory Bowel Prednisone noInflammatory Bowel Triamcinolone Acetonide noInflammatory Bowel Triamcinolone Diacetate no
* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage.
Medicare Model Guidelines Draft v8.0 86 of 97
Inflammatory Bowel Aminosalicylates Aminosalicylates and/ or Prodrugs
Class Renamed Class to add specification
Inflammatory Bowel Balsalazide Disodium noInflammatory Bowel Mesalamine noInflammatory Bowel Olsalazine Sodium no
Sulfasalazine no Added example drug from removed USP Class, "Sulfonamides."
Inflammatory Bowel Sulfonamides Class Removed USP Class, example drug moved to renamed USP Class, "Aminosalicylates and/or Prodrugs."
Inflammatory Bowel Sulfasalazine no Example drug moved to renamed USP Class, "Aminosalicylates and/or Prodrugs"
Metabolic Bone Disease A t
CatMetabolic Bone Disease
Metabolic Bone Disease Alendronate Sodium no
Metabolic Bone Disease Alendronate Sodium/ Cholecalciferol
yes Gap drug incoporated to include combination
Metabolic Bone Disease Etidronate Disodium no
Metabolic Bone Disease Ibandronate Sodium no
Metabolic Bone Disease Pamidronate Disodium no
Metabolic Bone Disease Risedronate Sodium no
Metabolic Bone Disease Zoledronic Acid no
Metabolic Bone Disease
* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage.
Medicare Model Guidelines Draft v8.0 87 of 97
Metabolic Bone Disease Abaloparatide no New FDA approved drug 04/28/17
Metabolic Bone Disease Calcitonin, Salmon no
Metabolic Bone Disease Parathyroid Hormone no
Metabolic Bone Disease Teriparatide no
Metabolic Bone Disease
Metabolic Bone Disease Cinacalcet Hydrochloride no
Metabolic Bone Disease Etelcalcetide no
Metabolic Bone Disease
Metabolic Bone Disease Denosumab no
Metabolic Bone Disease
Metabolic Bone Disease Calcifediol no
Metabolic Bone Disease Calcitriol no
Metabolic Bone Disease Doxercalciferol no
Metabolic Bone Disease Paricalcitol no
Romosozumab no New FDA approved drug, 4/9/19
Ophthalmic Agents Cat
* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage.
Medicare Model Guidelines Draft v8.0 88 of 97
Ophthalmic Agents Ophthalmic Anti-allergy Agents Class
Ophthalmic Agents Ophthalmic Agents Azelastine Hydrochloride noOphthalmic Agents Cetirizine Hydrochloride noOphthalmic Agents Emedastine Difumarate noOphthalmic Agents Epinastine Hydrochloride noOphthalmic Agents Olopatadine Hydrochloride noOphthalmic Agents Ophthalmic Agents Alcaftadine noOphthalmic Agents Bepotastine Besilate noOphthalmic Agents Ophthalmic Agents Cromolyn Sodium noOphthalmic Agents Lodoxamide Tromethamine noOphthalmic Agents Nedocromil Sodium noOphthalmic Agents Ophthalmic Antiglaucoma Agents
Intraocular Pressure Lowering Agents
Class Renamed class to broaden class name to effect rather than disease state.
Ophthalmic Agents Netarsudil noOphthalmic Agents Ophthalmic Agents Apraclonidine Hydrochloride noOphthalmic Agents Brimonidine Tartrate noOphthalmic Agents Ophthalmic Agents Betaxolol Hydrochloride noOphthalmic Agents Carteolol Hydrochloride noOphthalmic Agents Levobunolol Hydrochloride noOphthalmic Agents Metipranolol Hydrochloride noOphthalmic Agents Timolol Maleate noOphthalmic Agents Ophthalmic Agents Acetazolamide noOphthalmic Agents Brinzolamide no
* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage.
Medicare Model Guidelines Draft v8.0 89 of 97
Ophthalmic Agents Dorzolamide Hydrochloride noOphthalmic Agents Methazolamide noOphthalmic Agents Ophthalmic Agents Carbachol noOphthalmic Agents Echothiophate Iodide noOphthalmic Agents Pilocarpine Hydrochloride noOphthalmic Agents Pilocarpine Nitrate noOphthalmic Agents Ophthalmic Agents Bimatoprost noOphthalmic Agents Latanoprost noOphthalmic Agents Latanoprostene Bunod no New FDA approved drug, 11/02/17Ophthalmic Agents Tafluprost noOphthalmic Agents Travoprost noOphthalmic Agents Ophthalmic Agents Ophthalmic Anti-Infectives Class New class to add ophthalmic anti-infectivesOphthalmic Agents Ophthalmic Agents Azithromycin noOphthalmic Agents Bacitracin noOphthalmic Agents Besifloxacin Hydrochloride noOphthalmic Agents Ciprofloxacin noOphthalmic Agents Erythromycin noOphthalmic Agents Gatifloxacin noOphthalmic Agents Gentamicin Sulfate noOphthalmic Agents Levofloxacin noOphthalmic Agents Moxifloxacin Hydrochloride noOphthalmic Agents Ofloxacin noOphthalmic Agents Sulfacetamide Sodium noOphthalmic Agents Tobramycin noOphthalmic Agents Ophthalmic Agents Ophthalmic Agents Natamycin no
* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage.
Medicare Model Guidelines Draft v8.0 90 of 97
Ophthalmic Agents Ophthalmic Agents Ganciclovir Sodium noOphthalmic Agents Trifluridine noOphthalmic Agents Ophthalmic Anti-inflammatories Class
Ophthalmic Agents Ophthalmic Agents Dexamethasone noOphthalmic Agents Difluprednate noOphthalmic Agents Fluorometholone Acetate noOphthalmic Agents Loteprednol Etabonate noOphthalmic Agents Prednisolone Acetate noOphthalmic Agents Sodium Phosphate noOphthalmic Agents Rimexolone noOphthalmic Agents Triamcinolone noOphthalmic Agents Ophthalmic Agents Bromfenac Sodium noOphthalmic Agents Diclofenac Sodium noOphthalmic Agents Flurbiprofen Sodium noOphthalmic Agents Ketorolac Tromethamine noOphthalmic Agents Nepafenac no
Ophthalmic Prostaglandin and Prostamide Analogs
Class Removed class. Example drugs moved to new USP Class, "Intraocular Pressure Lowering Agents."
Ophthalmic Agents Ophthalmic Agents, Other ClassOphthalmic Agents Cenegermin no New FDA approved drug, 08/22/19Ophthalmic Agents Ophthalmic Agents Cyclopentolate Hydrochloride noOphthalmic Agents Ophthalmic Agents Hydroxypropyl Cellulose noOphthalmic Agents Ophthalmic Agents Lifitegrast noOphthalmic Agents
* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage.
Medicare Model Guidelines Draft v8.0 91 of 97
Cyclosporine no
Ophthalmic Agents Ophthalmic Combinations Class New class to add ophthalmic combination drug products
Ophthalmic Agents Cyclopentolate Hydrochloride/ Phenylephrine Hydrochloride
yes
Ophthalmic Agents Gentamicin Sulfate/ Prednisolone Acetate
yes
Ophthalmic Agents Hydroxyamphetamine Hydrobromide/ Tropicamide
yes
Ophthalmic Agents Loteprednol Etabonate/ T b i
yesOphthalmic Agents Neomycin/ Polymyxin B Sulfates/
Bacitracin Zinc/ Hydrocortisone Acetate
yes
Ophthalmic Agents Neomycin/ Polymyxin B Sulfates/ Dexamethasone
yes
Ophthalmic Agents Neomycin/ Polymyxin B Sulfates/ Hydrocortisone
yes
Ophthalmic Agents Phenylephrine/ Ketorolac yesOphthalmic Agents Sulfacetamide Sodium/
Prednisolone Acetate yes
Ophthalmic Agents Tobramycin/ Dexamethasone yes
Netarsudil Mesylate/ Latanoprost yes New FDA approved drug, 03/12/19
Otic Agents CatOtic Agents Class New class to add otic anti-infectivesOtic Agents Ciprofloxacin noOtic Agents Ofloxacin no
* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage.
Medicare Model Guidelines Draft v8.0 92 of 97
Otic Agents Class New class to add otic glucocorticoidsOtic Agents Fluocinolone Acetonide noOtic Agents Otic Combinations Class New class to add otic combination drug productsOtic Agents Ciprofloxacin/ Dexamethasone yes
Otic Agents Ciprofloxacin/ Fluocinolone Acetonide
yes
Otic Agents Ciprofloxacin Hydrochloride/ Hydrocortisone
yes
Otic Agents Hydrocortisone/ Acetic Acid yesOtic Agents Neomycin/ Polymyxin B Sulfates/
Hydrocortisone yes
Respiratory Tract/ Pulmonary Agents
Cat
Respiratory Tract Antihistamines ClassRespiratory Tract Respiratory Tract Azelastine Hydrochloride noRespiratory Tract Levocetirizine Dihydrochloride noRespiratory Tract Olopatadine Hydrochloride noRespiratory Tract Respiratory Tract Carbinoxamine Maleate noRespiratory Tract Clemastine Fumarate noRespiratory Tract Cyproheptadine Hydrochloride noRespiratory Tract Diphenhydramine Hydrochloride no
Respiratory Tract Hydroxyzine Hydrochloride noRespiratory Tract Hydroxyzine Pamoate noRespiratory Tract Promethazine Hydrochloride noRespiratory Tract Respiratory Tract Azelastine Hydrochloride/
Fluticasone Propionate yes
* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage.
Medicare Model Guidelines Draft v8.0 93 of 97
Respiratory Tract Anti-inflammatories, Inhaled Corticosteroids
Class
Respiratory Tract Beclomethasone Dipropionate no
Respiratory Tract Budesonide noRespiratory Tract Ciclesonide noRespiratory Tract Flunisolide noRespiratory Tract Fluticasone Propionate noRespiratory Tract Fluticasone Furoate noRespiratory Tract Mometasone Furoate noRespiratory Tract Triamcinolone Acetonide noRespiratory Tract Antileukotrienes ClassRespiratory Tract Montelukast Sodium noRespiratory Tract Zafirlukast noRespiratory Tract Zileuton noRespiratory Tract Bronchodilators, Anticholinergic Class
Respiratory Tract Aclidinium Bromide noRespiratory Tract Glycopyrrolate noRespiratory Tract Ipratropium Bromide no
Revefenacin no New FDA approved drug, 11/9/18Respiratory Tract Tiotropium Bromide noRespiratory Tract Umeclidinium noRespiratory Tract Bronchodilators, Sympathomimetic Class
Respiratory Tract Albuterol Sulfate noRespiratory Tract Arformoterol Tartrate no
Epinephrine no outpatient drug to reflect auto injection useRespiratory Tract Epinephrine Bitartrate no Removed due to OTC statusRespiratory Tract Formoterol Fumarate Dihydrate no
* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage.
Medicare Model Guidelines Draft v8.0 94 of 97
Respiratory Tract Indacaterol Maleate noRespiratory Tract Levalbuterol Hydrochloride noRespiratory Tract Tartrate noRespiratory Tract Metaproterenol Sulfate noRespiratory Tract Salmeterol Xinafoate noRespiratory Tract Terbutaline Sulfate noRespiratory Tract Olodaterol noRespiratory Tract Bronchodilator Combinations Class New class to add combination bronchodilator drug products
Aclidinium Bromide/ Formoterol Fumarate
yes
Respiratory Tract Budesonide/ Formoterol Fumarate Dihydrate
yes
Respiratory Tract Fluticasone Furoate/ Vilanterol Trifenatate
yes
Respiratory Tract Fluticasone Propionate/ S l t l
yesRespiratory Tract Mometasone Furoate/ Formoterol
Fumarate Dihydrate yes
Respiratory Tract Indacaterol/ Glycopyrrolate yesRespiratory Tract Umeclidinium Bromide/ Vilanterol
Trifenatate yes
Respiratory Tract Fluticasone Furoate/ Umeclidinium Bromide/ Vilanterol Trifenatate
yes
Respiratory Tract Glycopyrrolate/ Formoterol F t
yesRespiratory Tract Ipratropium Bromide/ Albuterol
Sulfate yes
Respiratory Tract Tiotropium Bromide/ Olodaterol yesRespiratory Tract Cystic Fibrosis Agents ClassRespiratory Tract Respiratory Tract Ivacaftor no
* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage.
Medicare Model Guidelines Draft v8.0 95 of 97
Respiratory Tract Lumacaftor/ Ivacaftor yesRespiratory Tract Tezacaftor/ Ivacaftor yesRespiratory Tract Respiratory Tract Tobramycin noRespiratory Tract Aztreonam noRespiratory Tract Respiratory Tract Dornase Alfa noRespiratory Tract Mast Cell Stabilizers ClassRespiratory Tract Cromolyn Sodium noRespiratory Tract Phosphodiesterase Inhibitors,
Airways Disease Class
Respiratory Tract Aminophylline noRespiratory Tract Theophylline noRespiratory Tract Respiratory Tract Roflumilast noRespiratory Tract Pulmonary Antihypertensives ClassRespiratory Tract Respiratory Tract Ambrisentan noRespiratory Tract Bosentan noRespiratory Tract Macitentan noRespiratory Tract Respiratory Tract Sildenafil Citrate noRespiratory Tract Tadalafil noRespiratory Tract Respiratory Tract Epoprostenol noRespiratory Tract Iloprost noRespiratory Tract Treprostinil noRespiratory Tract Respiratory Tract Riociguat noRespiratory Tract Respiratory Tract Selexipag no
* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage.
Medicare Model Guidelines Draft v8.0 96 of 97
Respiratory Tract Respiratory Tract Agents, Other Class
Respiratory Tract Acetylcysteine noRespiratory Tract Respiratory Tract Benralizumab no New FDA approved drug, 11/14/17Respiratory Tract Mepolizumab noRespiratory Tract Pulmonary Fibrosis Agents ClassRespiratory Tract Nintedanib noRespiratory Tract Pirfenidone noSkeletal Muscle Relaxants Cat
Skeletal Muscle Relaxants Cyclobenzaprine Hydrochloride no
Skeletal Muscle Relaxants Metaxalone no
Skeletal Muscle Relaxants Methocarbamol no
Skeletal Muscle Relaxants Orphenadrine Citrate no
Skeletal Muscle Relaxants Carisoprodol no
Skeletal Muscle Relaxants Carisoprodol/ Aspirin yes
Skeletal Muscle Relaxants Carisoprodol/ Aspirin/ Codeine Phosphate
yes
Skeletal Muscle Relaxants Chlorzoxazone no
Skeletal Muscle Relaxants Orphenadrine Hydrochloride no
Skeletal Muscle Relaxants Orphenadrine Citrate/ Aspirin/ Caffeine
yes
* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage.
Medicare Model Guidelines Draft v8.0 97 of 97
Skeletal Muscle Relaxants
Skeletal Muscle Relaxants Abobotulinum Toxin A no
Skeletal Muscle Relaxants Incobotulinum Toxin A no
Skeletal Muscle Relaxants Rimabotulinum Toxin B no
Sleep Disorder Agents CatSleep Disorder Agents GABA Receptor Modulators ClassSleep Disorder Agents Sleep Disorder Agents Estazolam noSleep Disorder Agents Flurazepam noSleep Disorder Agents Temazepam noSleep Disorder Agents Quazepam noSleep Disorder Agents Sleep Disorder Agents Eszopiclone noSleep Disorder Agents Zaleplon noSleep Disorder Agents Zolpidem Tartrate noSleep Disorder Agents Sleep Disorders, Other ClassSleep Disorder Agents Armodafinil noSleep Disorder Agents Doxepin Hydrochloride noSleep Disorder Agents Modafinil no
PitolisantSleep Disorder Agents Sodium Oxybate no
Solriamfetol no New FDA approved drug, 03/20/19Sleep Disorder Agents Sleep Disorder Agents Suvorexant noSleep Disorder Agents Sleep Disorder Agents Tasimelteon noSleep Disorder Agents Ramelteon no
* This list is illustrative of Part D eligible drugs only, and does not infer CMS coverage.
Top Related