mtus drug list v.3 8 ccr §9792.27.15) · 10/1/2018 · mtus drug list v.3 (8 ccr § 9792.27.15)...

MTUS Drug List v.3 (8 CCR § 9792.27.15)

DrugIngredient ReferenceBrandNameExempt/Non‐Exempt* SpecialFill** Peri‐Op*** DrugClass ReferenceinACOEMGuidelines* DosageForm Strength

UniquePharmaceuticalIdentifier(s)

Acetaminophen Tylenol Exempt Analgesics‐NonNarcotic

✓AnkleandFootDisorders✓CervicalandThoracicSpineDisorders✓ChronicPain✓✕ElbowDisorders✓✕Hand,Wrist,andForearmDisorders✓HipandGroinDisorders✓KneeDisorders✓LowBackDisorders✓Shoulder

AcetylL‐Carnitine Non‐ExemptPsychotherapeuticandNeurologicalAgents‐

Misc✕ChronicPain

Acyclovir Zovirax Non‐Exempt Antivirals ⦸ChronicPain

Adalimumab Humira Non‐ExemptAnalgesics‐Anti‐

Inflammatory(TNF‐alphablocker)

✕HipandGroinDisorders✕KneeDisorders✕LowBackDisorders

AlbuterolSulfate Proventil Exempt AntiasthmaticandBronchodilatorAgents ✓WorkRelatedAsthma

Alcaftadine Lastacaft Exempt Antihistamineand/ormastcellstabilization ✓Eye

AlclometasoneDipropionate Aclovate Non‐Exempt Dermatologicals ✓AnkleandFootDisorders

MTUSDrugListv.3(8CCR§9792.27.15)EFFECTIVEDATE:October1,2018

TheMTUSDrugListmustbeusedinconjunctionwith1)theMTUSGuidelines,whichcontainspecifictreatmentrecommendationsbasedonconditionandphaseoftreatmentand2)thedrugformularyrules.(See8CCR§9792.20‐§9792.27.23.)"ReferenceinACOEMGuidelines"indicatesguidelinetopic(s)whichdiscussthedrug.IneachguidelinetheremaybeconditionsforwhichthedrugisRecommended(✓),NotRecommended(✕),orNoRecommendation(⦸).Consultguidelinetodeterminetherecommendationfortheconditiontobetreatedandtoassureproperphaseofcareuse.*Exempt/Non‐Exempt"Exempt"indicatesdrugmaybeprescribed/dispensedwithoutseekingauthorizationthroughProspectiveReviewifinaccordancewithMTUS.1)Physiciandispensed"Exempt"drugslimitedtoone7‐daysupplyatinitialvisitwithinsevendaysofthedateofinjurywithoutProspectiveReview.2)Prescription/dispensingofBrandname"Exempt"drugwheregenericisavailablerequiresauthorizationthroughProspectiveReview."Non‐Exempt"or“Unlisted”drugrequiresauthorizationthroughProspectiveReviewpriortoprescribingordispensing.(See8CCR§9792.27.1through§9792.27.23forcompleterules.)**SpecialFill‐IndicatestheNon‐Exemptdrugmaybeprescribed/dispensedwithoutProspectiveReview:1)Rxatinitialvisitwithin7daysofinjury,and2)Supplynottoexceed#daysindicated,and3)isagenericorsinglesourcebrand,orbrandwherephysiciansubstantiatesmedicalnecessity,and4)ifinaccordwithMTUS.(See8CCR§9792.27.12.)***PerioperativeFill–IndicatestheNon‐Exemptdrugmaybeprescribed/dispensedwithoutProspectiveReview:1)Rxissuedduringtheperioperativeperiod(4daysbeforethrough4daysaftersurgery),and2)Supplynottoexceed#daysindicated,and3)isagenericorsinglesourcebrand,orbrandwherephysiciansubstantiatesmedicalnecessity,and4)isinaccordwithMTUS.(See8CCR§9792.27.13.)

*ACOEM Guidelines Copyright Reed Group Ltd.

Effective October 1, 2018 1 of 26




AlendronateSodium Fosamax Non‐Exempt

EndocrineandMetabolicAgents‐

Misc.(Bisphosphonate)

✓ChronicPain✓⦸HipandGroinDisorders⦸KneeDisorders✕LowBackDisorders✓Shoulder

AmantadineHCL Symmetrel Non‐ExemptAntiparkinsonAgents(NMDAreceptorantagonist)

✕ChronicPain✕LowBackDisorders

Amcinonide Cyclocort Non‐Exempt Dermatologicals ✓AnkleandFootDisorders

AmitriptylineHCL Elavil Non‐Exempt Antidepressants(TCAs)

✓✕CervicalandThoracicSpineDisorders✓✕ChronicPain✕⦸HipandGroinDisorders✓✕⦸KneeDisorders✓⦸LowBackDisorders✓✕Shoulder

AmlodipineBesylate Norvasc Non‐Exempt CalciumChannelBlockers ✓Hand,Wrist,andForearmDisorders

Amoxicillin/ClavulanateP Augmentin Exempt Antibiotics(Penicillins)

✓⦸AnkleandFootDisorders✓Hand,Wrist,andForearmDisorders✓LowBackDisorders

Anakinra Kineret Non‐Exempt Analgesics‐Anti‐inflammatory ✕KneeDisorders

Apixaban Eliquis Non‐Exempt 14Days Anticoagulants⦸AnkleandFootDisorders✓HipandGroinDisorders✓KneeDisorders

ArtificialTearOintments RefreshPM Exempt OphthalmicAgents(ArtificialTears) ✓Eye

AscorbicAcid VitaminC Non‐Exempt Vitamins

✕⦸AnkleandFootDisorders✕CervicalandThoracicSpineDisorders⦸ChronicPain✕LowBackDisorders

Aspirin Bayer Exempt Analgesics‐NonNarcotic

✓AnkleandFootDisorders✓CervicalandThoracicSpineDisorders✕ChronicPain✓ElbowDisorders✓✕⦸Hand,Wrist,andForearmDisorders✓HipandGroinDisorders✓KneeDisorders✓LowBackDisorders✓Shoulder

Aspirin/Caffeine/DihydrocodeineBitartrate Synalgos‐DC Non‐Exempt Analgesics‐Opioid

✕AnkleandFootDisorders✕CervicalandThoracicSpineDisorders✕ChronicPain✕ElbowDisorders✕Hand,Wrist,andForearmDisorders✕HipandGroinDisorders✕KneeDisorders✕LowBackDisorders✕Shoulder

AzelastineOphth Optivar Exempt Antihistamineand/ormastcellstabilization ✓Eye

AzithromycinOphth Azasite Exempt Antibiotics(Macrolides) ✓✕⦸Eye

Azithromycin Zithromax Non‐Exempt Antibiotics(Macrolides) ✕Hand,Wrist,andForearmDisorders

Bacitracin Exempt Anti‐InfectiveAgents‐Misc.

✓AnkleandFootDisorders⦸Hand,Wrist,andForearmDisorders






Baclofen Lioresal Non‐Exempt 4Days 4DaysMusculoskeletalTherapyAgents

(MuscleRelaxants)

✓✕CervicalandThoracicSpineDisorders✓✕⦸ChronicPain✓✕HipandGroinDisorders✕⦸KneeDisorders✓✕LowBackDisorders✓✕Shoulder

Becaplermin Regranex Non‐Exempt Dermatologicals ✓AnkleandFootDisorders

BeclomethasoneDipropionate Qvar Non‐Exempt AntiasthmaticandBronchodilatorAgents ✓WorkRelatedAsthma

BepotastineOphth Bepreve Exempt Antihistamineand/ormastcellstabilization ✓Eye

BesifloxacinOphth Besivance Exempt Topicalantibiotic ✓✕⦸Eye

Betamethasone Celestone Non‐Exempt 4Days Corticosteroids

✓✕⦸ AnkleandFootDisorders✓✕CervicalandThoracicSpineDisorders✓ChronicPain✓⦸ElbowDisorders✓✕⦸Hand,Wrist,andForearmDisorders✓✕HipandGroinDisorders✓⦸KneeDisorders✓✕⦸LowBackDisorders✓✕⦸ Shoulder

BetamethasoneDipropionat Diprosone Non‐Exempt Dermatologicals ✓AnkleandFootDisorders

BetamethasoneValerate Valisone Non‐Exempt Dermatologicals ✓AnkleandFootDisorders

Bromfenac Prolensa Exempt OphthalmicAgents(NSAID) ✓✕Eye

Budesonide Pulmicort Non‐Exempt AntiasthmaticandBronchodilatorAgents ✓WorkRelatedAsthma

Budesonide/Formoterol Symbicort Non‐Exempt AntiasthmaticandBronchodilatorAgents ✓WorkRelatedAsthma

Buprenorphine(HCL) Butrans Non‐Exempt Analgesics‐Opioid

✕AnkleandFootDisorders✕CervicalandThoracicSpineDisorders✕ChronicPain✕ElbowDisorders✕Hand,Wrist,andForearmDisorders✕HipandGroinDisorders✕KneeDisorders✕LowBackDisorders✓Opioid✕Shoulder

BuprenorphineHCL/Naloxone Suboxone Non‐Exempt Analgesics‐Opioid







BupropionHCL Wellbutrin,WellbutrinXL,WellbutrinSR Non‐ExemptAntidepressants

(SSRI)

✕CervicalandThoracicSpineDisorders✓✕⦸ChronicPain✕HipandGroinDisorders✕KneeDisorders✕LowBackDisorders✕Shoulder

Butalbital/Apap/Caffeine Non‐Exempt Analgesics‐NonNarcotic ✕Hand,Wrist,andForearmDisorders

Butalbital/Asa/Caffeine Non‐Exempt Analgesics‐NonNarcotic ✕Hand,Wrist,andForearmDisorders

ButenafineHCl LotriminUltra Non‐Exempt Dermatologicals ✓AnkleandFootDisorders

ButorphanolTartrate Stadol Non‐Exempt Analgesics‐Opioid


Calcitonin‐Salmon Fortical,Miacalcin Non‐Exempt



✕AnkleandFootDisorders✓✕ChronicPain✓⦸HipandGroinDisorders⦸KneeDisorders✕LowBackDisorders

CalciumPhosphateTribasic Non‐Exempt Minerals&Electrolytes ⦸AnkleandFootDisorders

Camphor BengayUltra Non‐Exempt Dermatologicals

⦸CervicalandThoracicSpineDisorders⦸ChronicPain✓Hand,Wrist,andForearmDisorders✕⦸HipandGroinDisorders⦸LowBackDisorders⦸Shoulder

Capsaicin Zostrix ExemptDermatologicals

(Topicalcreamsandointments)

✓CervicalandThoracicSpineDisorders✓⦸ChronicPain✓Hand,Wrist,andForearmDisorders✓HipandGroinDisorders✓LowBackDisorders✓⦸Shoulder

Carbamazepine Tegretol Non‐Exempt Anticonvulsants

✓CervicalandThoracicSpineDisorders✓ChronicPain⦸LowBackDisorders✓✕Shoulder

CarboxymethylcelluloseSodiumOphthalmic RefreshPlus Exempt OphthalmicAgents(ArtificialTears) ✓Eye

Carisoprodol Soma Non‐ExemptMusculoskeletalTherapyAgents

(MuscleRelaxants)

✕CervicalandThoracicSpineDisorders✕ChronicPain✕HipandGroinDisorders✕KneeDisorders✕LowBackDisorders✕Shoulder

CefuroximeAxetil Ceftin Exempt Antibiotics(Cephalosporins) ✓Hand,Wrist,andForearmDisorders






Celecoxib Celebrex Exempt Analgesics‐Anti‐Inflammatory(NSAID)

✓AnkleandFootDisorders✓CervicalandThoracicSpineDisorders✓ChronicPain✓✕⦸ElbowDisorders✓✕⦸Hand,Wrist,andForearmDisorders✓⦸HipandGroinDisorders✓⦸KneeDisorders✓LowBackDisorders✓Shoulder

Cephalexin Keflex Exempt Antibiotics(Cephalosporins)

✓⦸AnkleandFootDisorders✕Hand,Wrist,andForearmDisorders

CertolizumabPegol Cimzia Non‐Exempt GastrointestinalAgents(TNFBlocker)


Chlorzoxazone Lorzone,ParafonForte Non‐ExemptMusculoskeletalTherapyAgents

(MuscleRelaxants)


CholineMagnesiumTrisalicylate Trilisate Exempt Analgesics‐NonNarcotic(NSAID)


ChondroitinSulfate Non‐Exempt AlternativeMedicines(OTCnutraceutical)

⦸Hand,Wrist,andForearmDisorders⦸HipandGroinDisorders⦸KneeDisorders⦸Shoulder

Ciclesonide Alvesco Non‐Exempt AntiasthmaticandBronchodilatorAgents ✓WorkRelatedAsthma

CiclopiroxOlamine Loprox Non‐Exempt Dermatologicals ✓AnkleandFootDisorders

Cimetidine Tagamet Exempt UlcerDrugs(H2receptorblocker)

✓CervicalandThoracicSpineDisorders✓ElbowDisorders✓Hand,Wrist,andForearmDisorders✓HipandGroinDisorders✓KneeDisorders✓LowBackDisorders✓Shoulder

Ciprofloxacin Cipro Exempt Antibiotics(Fluoroquinolones)

✓AnkleandFootDisorders✓Hand,Wrist,andForearmDisorders

CiprofloxacinHCLOphthalmic Ciloxan Exempt OphthalmicAgents(Antibiotics) ✓✕⦸Eye

CitalopramHydrobromide Celexa Non‐Exempt Antidepressants(SSRI)

✕CervicalandThoracicSpineDisorders✓✕ChronicPain✕HipandGroinDisorders✓✕KneeDisorders✕LowBackDisorders✕Shoulder

Clarithromycin Biaxin Non‐Exempt Antibiotics(Macrolides) ✕Hand,Wrist,andForearmDisorders






ClindamycinHCL Cleocin Exempt Anti‐InfectiveAgents‐Misc.

✓⦸AnkleandFootDisorders✓✕⦸Hand,Wrist,andForearmDisorders✓HipandGroinDisorders✓KneeDisorders

ClomipramineHCL Anafranil Non‐Exempt Antidepressants(TCAs)

✕CervicalandThoracicSpineDisorders✓ChronicPain✕⦸HipandGroinDisorders✕⦸KneeDisorders✕LowBackDisorders✕Shoulder

Clonazepam Klonopin Non‐Exempt Anticonvulsants ⦸LowBackDisorders✕Shoulder

ClonidineHCL Catapres Non‐Exempt Analgesics‐NonNarcotic✓⦸ChronicPain✕⦸LowBackDisorders

ClotrimazoleAntifungal LotriminAF Non‐Exempt Dermatologicals ✓AnkleandFootDisorders

CodeinePhosphate Non‐Exempt Analgesics‐Opioid


CodeineSulfate Non‐Exempt Analgesics‐Opioid


Codeine/Acetaminophen Tylenol#3,Tylenol#4 Non‐Exempt Analgesics‐Opioid


CoenzymeQ10 CoQ10 Non‐Exempt AlternativeMedicines ⦸ChronicPain

Colchicine Non‐Exempt GoutAgents ✕CervicalandThoracicSpineDisorders✕LowBackDisorders






Cortisone Cortone Non‐Exempt 4Days Corticosteroids

✓✕⦸AnkleandFootDisorders✓✕CervicalandThoracicSpineDisorders✓✕ChronicPain⦸ElbowDisorders✓⦸Hand,Wrist,andForearmDisorders✕HipandGroinDisorders✓✕⦸LowBackDisorders✓✕⦸ Shoulder

CreatineMonohydrate Non‐Exempt Chemicals ⦸ChronicPain

CromolynSodium Intal Non‐Exempt AntiasthmaticandBronchodilatorAgents ✓WorkRelatedAsthma

CromolynSodium(Opthalmic) Opticrom Exempt Antihistamineand/ormastcellstabilization ✓Eye

CyclobenzaprineHCL Flexeril Non‐Exempt 4DaysMusculoskeletalTherapyAgents

(MuscleRelaxants)

✓✕CervicalandThoracicSpineDisorders✓✕⦸ChronicPain✕HipandGroinDisorders✕⦸KneeDisorders✓✕LowBackDisorders✓✕Shoulder

CyclopentolateHCL Cyclogyl Non‐Exempt OphthalmicAgents(Anticholinergics) ✕Eye

Dalteparin Fragmin Non‐Exempt Anticoagulants ⦸AnkleandFootDisorders

DantroleneSodium Dantrium Non‐ExemptMusculoskeletalTherapyAgents

(MuscleRelaxants)


Dehydroepiandrosterone(DHEA) Non‐Exempt Chemicals ⦸ChronicPain

DesipramineHCL Norpramin Non‐Exempt Antidepressants(TCAs)

✓✕CervicalandThoracicSpineDisorders✓ChronicPain⦸HipandGroinDisorders✓✕⦸KneeDisorders✓⦸LowBackDisorders✓✕Shoulder

Desloratadine Clarinex Exempt Antihistamineand/ormastcellstabilization ✓Eye

Desonide Desowen Non‐Exempt Dermatologicals ✓AnkleandFootDisorders

Desoximetasone Topicort Non‐Exempt Dermatologicals ✓AnkleandFootDisorders






DesvenlafaxineER Pristiq Non‐Exempt Antidepressants(SNRI)

✕CervicalandThoracicSpineDisorders✕ChronicPain✕HipandGroinDisorders✕KneeDisorders✕⦸LowBackDisorders✕Shoulder

Dexamethasone Decadron Non‐Exempt 4Days Corticosteroids

✓✕⦸ AnkleandFootDisorders✓✕CervicalandThoracicSpineDisorders✓✕ChronicPain✓⦸ElbowDisorders✓✕⦸Hand,Wrist,andForearmDisorders✕HipandGroinDisorders✓⦸KneeDisorders✓✕⦸LowBackDisorders✓✕⦸ Shoulder

DexamethasoneSodiumPhosphateOphthalmic Maxidex Non‐Exempt 4Days OphthalmicAgents(Steroid) ✓✕⦸Eye

Dexlansoprazole Dexilant Exempt UlcerDrugs(Protonpumpinhibitor)

✓CervicalandThoracicSpineDisorders✓ElbowDisorders✓Hand,Wrist,andForearmDisorders✓KneeDisorders✓Shoulder

Dextromethorphan Delsym Non‐ExemptCough/Cold/Allergy(NMDAReceptorAntagonist)

✓✕⦸ ChronicPain✕LowBackDisorders✓Shoulder

Diazepam Valium Non‐Exempt AntianxietyAgents(Musclerelaxant) ✕ChronicPain

DiclofenacPotassium Cataflam Exempt Analgesics‐Anti‐Inflammatory(NSAID)

✓AnkleandFootDisorders✓CervicalandThoracicSpineDisorders⦸ChronicPain✓✕⦸ElbowDisorders✓✕⦸Hand,Wrist,andForearmDisorders✓⦸HipandGroinDisorders✓⦸KneeDisorders✓LowBackDisorders✓Shoulder

DiclofenacSodium Voltaren Non‐Exempt Analgesics‐Antiinflammatory ⦸ChronicPain

DiclofenacSodium(Topical) Voltaren1%gel Exempt Dermatologicals

✓✕⦸ AnkleandFootDisorders⦸CervicalandThoracicSpineDisorders✓ChronicPain✓⦸ElbowDisorders✓Hand,Wrist,andForearmDisorders✕⦸HipandGroinDisorders⦸LowBackDisorders⦸Shoulder

DiclofenacSodiumOphthalmic Voltaren Exempt OphthalmicAgents(NSAID) ✓✕Eye






DiclofenacSodium/Misoprostol Arthrotec ExemptAnalgesics‐Anti‐

Inflammatory(NSAID/Ulcerdrug)

✓⦸AnkleandFootDisorders✓CervicalandThoracicSpineDisorders✕ChronicPain✓ElbowDisorders✓Hand,Wrist,andForearmDisorders✓HipandGroinDisorders✓KneeDisorders✓LowBackDisorders✓Shoulder

DicloxacillinSodium Dynapen Exempt Antibiotics(Penicillins) ✓⦸AnkleandFootDisorders

Diflunisal Dolobid Exempt Analgesics‐Anti‐Inflammatory(NSAID)


DimethylSulfoxide DMSO Non‐ExemptGenitourinary‐Misc.(Ointmentsandtopical

agents)

✕CervicalandThoracicSpineDisorders✓ChronicPain✕⦸HipandGroinDisorders✕LowBackDisorders

DolasetronMesylate Anzemet Non‐Exempt Antiemetics ⦸ChronicPain

DoxepinHCL Sinequan Non‐Exempt Antidepressants(TCAs)

✓✕CervicalandThoracicSpineDisorders✕ChronicPain⦸HipandGroinDisorders✕⦸KneeDisorders✓⦸LowBackDisorders✕Shoulder

Doxycycline Vibramycin Exempt Antibiotics(Tetracyclines)

✓⦸AnkleandFootDisorders✓Hand,Wrist,andForearmDisorders✓HipandGroinDisorders

DuloxetineHCL Cymbalta Non‐Exempt Antidepressants(SNRI)

✓✕CervicalandThoracicSpineDisorders✓ChronicPain⦸HipandGroinDisorders✓✕⦸KneeDisorders✓⦸LowBackDisorders✓✕⦸ Shoulder

EconazoleNitrate Spectazole Non‐Exempt Dermatologicals ✓AnkleandFootDisorders

EmedastineOphth Emadine Exempt Antihistamineand/ormastcellstabilization ✓Eye

EnoxaparinSodium Lovenox Non‐Exempt 14Days Anticoagulants⦸AnkleandFootDisorders✓HipandGroinDisorders✓KneeDisorders

EpinastineHCL Elestat Exempt Antihistamineand/ormastcellstabilization ✓Eye

Erythromycin Ery‐Tab Non‐Exempt Antibiotics(Macrolides) ✕Hand,Wrist,andForearmDisorders

ErythromycinOphthalmicOintment Ilotycin Exempt OphthalmicAgents(Antibiotics) ✓✕⦸Eye

EscitalopramOxalate Lexapro Non‐Exempt Antidepressants(SSRI)

✕CervicalandThoracicSpineDisorders✓✕ChronicPain✕HipandGroinDisorders






EsomeprazoleMagnesium Nexium Exempt UlcerDrugs(Protonpumpinhibitor)


Esomeprazole/Naproxen Vimovo Non‐Exempt

Analgesics‐Anti‐Inflammatory(Proton

PumpInhibitor/NSAID)


Estradiol Climara,Estraderm Non‐Exempt Estrogens ✕ChronicPain

Etanercept Enbrel Non‐ExemptAnalgesics‐Anti‐



EtidronateDisodium Didronel Non‐Exempt



✓⦸HipandGroinDisorders⦸KneeDisorders✕LowBackDisorders✓Shoulder

Etodolac Lodine Exempt Analgesics‐Anti‐Inflammatory(NSAID)


Famciclovir Famvir Non‐Exempt Antivirals ⦸ChronicPain

Famotidine Pepcid Exempt UlcerDrugs(H2receptorblocker)







Famotidine/Ibuprofen Duexis Non‐Exempt

Analgesics‐Anti‐Inflammatory(H2ReceptorBlocker

/NSAID)


FenoprofenCalcium Nalfon Exempt Analgesics‐Anti‐Inflammatory(NSAID)


Fentanyl Duragesic Non‐Exempt Analgesics‐Opioid


FentanylCitrateOralTransmucosal Actiq,Fentora Non‐Exempt Analgesics‐Opioid


Fluconazole Diflucan Non‐Exempt Antifungals ✓AnkleandFootDisorders

Flunisolide AerospanHFA Non‐Exempt AntiasthmaticandBronchodilatorAgents ✓WorkRelatedAsthma

FluocinoloneAcetonide Synalar Non‐Exempt Dermatologicals ✓AnkleandFootDisorders

Fluocinonide Non‐Exempt Dermatologicals ✕⦸ElbowDisorders

Fluorometholone FML Non‐Exempt 4Days OphthalmicAgents ✓✕⦸Eye

FluoxetineHCL Prozac Non‐Exempt Antidepressants(SSRI)







Flurbiprofen Ansaid Exempt Analgesics‐Anti‐Inflammatory(NSAID)


FlurbiprofenSodium Ocufen ExemptAnti‐Inflammatory(NSAID)Ophthalmic

Drops✓✕Eye

FluticasonePropionate Flovent Non‐Exempt AntiasthmaticandBronchodilatorAgents ✓WorkRelatedAsthma

FluticasoneProp(Topical) Cutivate Non‐Exempt Dermatologicals ✓AnkleandFootDisorders

Fluticasone‐Salmeterol Advair Non‐Exempt AntiasthmaticandBronchodilatorAgents ✓WorkRelatedAsthma

FluvoxamineMaleate Luvox Non‐Exempt Antidepressants(SSRI)

✕CervicalandThoracicSpineDisorders✓✕ChronicPain✕HipandGroinDisorders✕KneeDisorders✕LowBackDisorders✕Shoulder

FolicAcid Non‐Exempt HematopoieticAgents ✕CervicalandThoracicSpineDisorders

FondaparinuxSodium Arixtra Non‐Exempt 14Days Anticoagulants⦸AnkleandFootDisorders✓HipandGroinDisorders✓KneeDisorders

FormoterolFumarate Foradil Non‐Exempt AntiasthmaticandBronchodilatorAgents ✓WorkRelatedAsthma

Formoterol/Mometasone Dulera Non‐Exempt AntiasthmaticandBronchodilatorAgents ✓WorkRelatedAsthma

Gabapentin Neurontin Non‐Exempt 4Days Anticonvulsants

✓✕⦸ CervicalandThoracicSpineDisorders✓ChronicPain✓✕⦸HipandGroinDisorders✓✕⦸KneeDisorders✓⦸LowBackDisorders✓✕⦸ Shoulder

Gabapentin(Once‐daily) Gralise Non‐ExemptPsychotherapeuticandNeurologicalAgents‐

Misc✕ChronicPain

GabapentinEnacarbil Horizant Non‐ExemptPsychotherapeuticandNeurologicalAgents‐

Misc✓✕ChronicPain

Gatifloxacin Zymaxid Exempt OphthalmicAgents(Anti‐bacterial) ✓✕Eye

Gentamicin(Topical) Exempt Dermatologicals ✓AnkleandFootDisorders






GentamicinSulfateOphthalmic Gentak Exempt OphthalmicAgents(Anti‐bacterial) ✓✕⦸Eye

GlucosamineSulfate Non‐Exempt AlternativeMedicines(OTCnutraceutical)

⦸Hand,Wrist,andForearmDisorders⦸HipandGroinDisorders✕KneeDisorders⦸Shoulder

Golimumab Simponi Non‐ExemptAnalgesics‐Anti‐



HeparinSodium Non‐Exempt 14Days Anticoagulants✕⦸AnkleandFootDisorders✓HipandGroinDisorders✓KneeDisorders

HomatropineHBrOphthalmic IsoptoHomatropine Exempt OphthalmicAgents(Anticholinergics) ✕Eye

Hydrochlorothiazide Microzide Non‐Exempt Diuretics ✕AnkleandFootDisorders✕Hand,Wrist,andForearmDisorders

HydrocodoneBitartrate ZohydroER,HysinglaER Non‐Exempt Analgesics‐Opioid


Hydrocodone/Acetaminophen Norco,Vicodin,Xodol Non‐Exempt 4Days 4Days Analgesics‐Opioid

✓✕AnkleandFootDisorders✓✕CervicalandThoracicSpineDisorders✓✕ChronicPain✓✕ElbowDisorders✓✕Hand,Wrist,andForearmDisorders✓HipandGroinDisorders✓KneeDisorders✓✕LowBackDisorders✓✕Shoulder

Hydrocodone/Ibuprofen Vicoprofen Non‐Exempt Analgesics‐Opioid


Hydrocortisone Cortef Non‐Exempt 4Days Corticosteroids

✓✕AnkleandFootDisorders✓✕CervicalandThoracicSpineDisorders✓✕ChronicPain⦸ElbowDisorders✓✕⦸Hand,Wrist,andForearmDisorders✕HipandGroinDisorders⦸KneeDisorders✓✕⦸LowBackDisorders✓✕⦸ Shoulder

Hydrocortisone(Topical) Non‐Exempt Dermatologicals ✓AnkleandFootDisorders

HydrocortisoneValerate Westcort Non‐Exempt Dermatologicals ✓AnkleandFootDisorders






HydromorphoneHCL Dilaudid Non‐Exempt Analgesics‐Opioid


IbandronateSodium Boniva Non‐Exempt




Ibuprofen Motrin Exempt Analgesics‐Anti‐Inflammatory(NSAID)

✓AnkleandFootDisorders✓CervicalandThoracicSpineDisorders✓ChronicPain✓✕⦸ElbowDisorders✓✕⦸Hand,Wrist,andForearmDisorders✓⦸HipandGroinDisorders✓✕⦸KneeDisorders✓LowBackDisorders✓Shoulder

ImipramineHCL Tofranil Non‐Exempt Antidepressants(TCAs)

✓✕CervicalandThoracicSpineDisorders✕ChronicPain⦸HipandGroinDisorders✕KneeDisorders✓⦸LowBackDisorders✕Shoulder

Indomethacin Indocin Exempt Analgesics‐Anti‐Inflammatory(NSAID)


IrrigatingEyewash Exempt OphthalmicAgents ✓Eye

Itraconazole Sporanox Non‐Exempt Antifungals ✓AnkleandFootDisorders

Ketoconazole Nizoral Non‐Exempt Dermatologicals ✓AnkleandFootDisorders

Ketoprofen Oruvail Exempt Analgesics‐Anti‐Inflammatory(NSAID)







KetorolacTromethamine Non‐Exempt Analgesics‐Anti‐Inflammatory(NSAID)


KetorolacTromethamineOphthalmic Acular Exempt OphthalmicAgents(NSAID) ✓✕Eye

KetotifenFumarate Zaditor Exempt OphthalmicAgents ✓Eye

Lamotrigine Lamictal Non‐Exempt Anticonvulsants

✓CervicalandThoracicSpineDisorders✓ChronicPain⦸LowBackDisorders✕Shoulder

Lansoprazole Prevacid Exempt UlcerDrugs(Protonpumpinhibitor)


Lenalidomide Revlimid Non‐Exempt MiscellaneousTherapeuticClasses ✕ChronicPain

Levalbuterol Xopenex Exempt AntiasthmaticandBronchodilatorAgents ✓WorkRelatedAsthma

Levetiracetam Keppra Non‐Exempt Anticonvulsants✕ChronicPain⦸LowBackDisorders✕Shoulder

Levofloxacin Levaquin Exempt Antibiotics(Fluoroquinolones)

✓AnkleandFootDisorders✓✕Hand,Wrist,andForearmDisorders✓HipandGroinDisorders

LevofloxacinOphthalmicSolution Quixin Exempt OphthalmicAgents(Anti‐bacterial) ✓✕⦸Eye

Levomilnacipran Fetzima Non‐Exempt Antidepressants(SNRI)


LevorphanolTartrate Levo‐Dromoran Non‐Exempt Analgesics‐Opioid







Lidocaine Lidoderm Non‐Exempt Dermatologicals

✓⦸AnkleandFootDisorders✕CervicalandThoracicSpineDisorders✓⦸ChronicPain⦸ElbowDisorders✓Hand,Wrist,andForearmDisorders✕⦸HipandGroinDisorders✕⦸LowBackDisorders

LidocaineHCl Non‐Exempt Dermatologicals ✕CervicalandThoracicSpineDisorders

LidocaineHClOphth Akten Exempt OpthalmicAgents ✓Eye

Lidocaine/Prilocaine Emla Non‐Exempt Dermatologicals

✕CervicalandThoracicSpineDisorders⦸ChronicPain✓Hand,Wrist,andForearmDisorders✕⦸HipandGroinDisorders✕LowBackDisorders⦸Shoulder

LodoxamideOphth Alomide Exempt Antihistamineand/ormastcellstabilization ✓Eye

Loratadine Claritin Exempt Antihistamineand/ormastcellstabilization ✓Eye

Lorazepam Ativan Non‐Exempt AntianxietyAgents ✓AnkleandFootDisorders

LoteprednolEtabonateOphthalmic Alrex Non‐Exempt 4Days OphthalmicAgents(Steroid) ✓✕⦸Eye

Magnesium Non‐Exempt Minerals&Electrolytes ✕ChronicPain

MaprotilineHCL Ludiomil Non‐Exempt Antidepressants(TCAs)

✕CervicalandThoracicSpineDisorders✕ChronicPain✕⦸HipandGroinDisorders✕⦸KneeDisorders✕LowBackDisorders✕Shoulder

MeclofenamateSodium Meclomen Exempt Analgesics‐Anti‐Inflammatory(NSAID)


MefenamicAcid Ponstel Exempt Analgesics‐Anti‐Inflammatory(NSAID)







Melatonin Non‐Exempt ✓ChronicPain

Meloxicam Mobic Exempt Analgesics‐Anti‐Inflammatory(NSAID)


MemantineHCL Namenda Non‐Exempt

PsychotherapeuticandNeurologicalAgents‐

Misc.(NDMAReceptorAntagonist)

✕⦸ChronicPain✕LowBackDisorders

Menthol BengayUltra,Biofreeze Non‐Exempt Dermatologicals

⦸AnkleandFootDisorders⦸CervicalandThoracicSpineDisorders⦸ChronicPain✓Hand,Wrist,andForearmDisorders✕⦸HipandGroinDisorders⦸LowBackDisorders⦸Shoulder

MeperidineHCL Demerol Non‐Exempt Analgesics‐Opioid


Metaxalone Skelaxin Non‐ExemptMusculoskeletalTherapyAgents

(MuscleRelaxants)


MethadoneHCL Dolophine Non‐Exempt Analgesics‐Opioid


Methocarbamol Robaxin Non‐ExemptMusculoskeletalTherapyAgents

(MuscleRelaxants)







MethylSalicylate BengayUltra Non‐Exempt Dermatologicals

⦸CervicalandThoracicSpineDisorders⦸ChronicPain✓Hand,Wrist,andForearmDisorders✕⦸HipandGroinDisorders⦸LowBackDisorders⦸Shoulder

Methylprednisolone Medrol Non‐Exempt 4Days Corticosteroids

✓✕AnkleandFootDisorders✓✕CervicalandThoracicSpineDisorders✓✕ChronicPain⦸ElbowDisorders✓⦸Hand,Wrist,andForearmDisorders✕HipandGroinDisorders✓✕⦸LowBackDisorders✓✕⦸Shoulder✓WorkRelatedAsthma

Methylsulfonylmethane Non‐Exempt Chemicals(OTCnutraceuticals)

⦸HipandGroinDisorders⦸KneeDisorders⦸Shoulder

Metronidazole Exempt Dermatologicals ✓AnkleandFootDisorders

MetronidazoleOral Flagyl Exempt Anti‐InfectiveAgents‐Misc. ✓Hand,Wrist,andForearmDisorders

MiconazoleNitrate Micatin Non‐Exempt Dermatologicals ✓AnkleandFootDisorders

Milnacipran Savella Non‐Exempt

PsychotherapeuticandNeurologicalAgents‐

Misc.(Anti‐depressant)

✕CervicalandThoracicSpineDisorders✓✕ChronicPain✕HipandGroinDisorders✕KneeDisorders✕LowBackDisorders✕Shoulder

MinocyclineHCl Minocin Non‐Exempt Antibiotics(Tetracyclines) ✓⦸AnkleandFootDisorders

Mirtazapine Remeron Non‐Exempt Antidepressants ✓ChronicPain

Misoprostol Cytotec Exempt UlcerDrugs


MometasoneFuroate(Topical) Elocon Non‐Exempt Dermatologicals ✓AnkleandFootDisorders

MometasoneFuroate Asmanex Non‐Exempt AntiasthmaticandBronchodilatorAgents ✓WorkRelatedAsthma

MontelukastSodium Singluair Non‐Exempt AntiasthmaticandBronchodilatorAgents ✓WorkRelatedAsthma

MorphineSulfate Non‐Exempt 4Days 4Days Analgesics‐Opioid







MorphineSulfateExtendedRelease MSContin,Kadian,Avinza Non‐Exempt Analgesics‐Opioid

✕AnkleandFootDisorders✕CervicalandThoracicSpineDisorders✓✕ChronicPain✕ElbowDisorders✓✕Hand,Wrist,andForearmDisorders✕HipandGroinDisorders✕KneeDisorders✕LowBackDisorders✕Shoulder

Morphine/Naltrexone Embeda Non‐Exempt Analgesics‐Opioid


MoxifloxacinHCL Avelox Exempt Antibiotics(Fluoroquinolones)

✓AnkleandFootDisorders✓Hand,Wrist,andForearmDisorders

MoxifloxacinHCLOphthalmic Vigamox Exempt OphthalmicAgents(Antibiotics) ✓✕⦸Eye

Mupirocin Bactroban Exempt Dermatologicals ✓AnkleandFootDisorders

Nabumetone Relafen Exempt Analgesics‐Anti‐Inflammatory(NSAID)


N‐Acetyl‐L‐Cysteine NAC Non‐Exempt Nutrients

✕CervicalandThoracicSpineDisorders✓✕ChronicPain✕⦸HipandGroinDisorders✕LowBackDisorders

NaloxoneHCL Evzio,Narcan Exempt AntidotesandSpecificAntagonists ✓Opioid

Naproxen Aleve,Naprosyn Exempt Analgesics‐Anti‐Inflammatory(NSAID)

✓⦸AnkleandFootDisorders✓✕CervicalandThoracicSpineDisorders✓ChronicPain✓✕⦸ElbowDisorders✓✕⦸Hand,Wrist,andForearmDisorders✓⦸HipandGroinDisorders✓⦸KneeDisorders✓⦸LowBackDisorders✓⦸Shoulder

NatamycinOphth Natacyn Exempt Antifungals ✓✕Eye

Nedocromil Alocril Exempt OphtalmicAgents ✓Eye

NeomycinSulfate Non‐Exempt Dermatologicals ⦸Hand,Wrist,andForearmDisorders

Neomycin/PolymyxinB/Bacitracin Neosporin Exempt Dermatologicals ✓AnkleandFootDisorders






Nifedipine Procardia Non‐Exempt CalciumChannelBlockers ✓Hand,Wrist,andForearmDisorders

NitroglycerinTransdermal Nitro‐Dur Non‐ExemptAntianginalAgents(Glyceriltrinitrate

patches)

✓⦸AnkleandFootDisorders⦸Shoulder

Nizatidine Axid Exempt UlcerDrugs(H2receptorblocker)


NortriptylineHCL Pamelor Non‐Exempt Antidepressants(TCAs)


Nystatin/Triamcinolone MycologII Non‐Exempt Dermatologicals ✓AnkleandFootDisorders

OfloxacinOphthalmicSolution Ocuflox Exempt OphthalmicAgents(Anti‐bacterial) ✓✕⦸Eye

OlopatadineHCL Pataday,Patanol Exempt Antihistamineand/ormastcellstabilization ✓Eye

Omeprazole Prilosec Exempt UlcerDrugs(Protonpumpinhibitor)


Ondansetron Zofran Non‐Exempt Antiemetics ⦸ChronicPain

OrphenadrineCitrate Norflex Non‐ExemptMusculoskeletalTherapyAgents

(MuscleRelaxants)


Oxaprozin Daypro Exempt Analgesics‐Anti‐Inflammatory(NSAID)


Oxcarbazepine Trileptal Non‐Exempt Anticonvulsants

✓CervicalandThoracicSpineDisorders✓ChronicPain⦸LowBackDisorders✕Shoulder






OxycodoneHCL OxyContin,Roxicodone Non‐Exempt 4Days 4Days Analgesics‐Opioid


Oxycodone/Acetaminophen Percocet Non‐Exempt 4days 4days Analgesics‐Opioid


Oxycodone/Aspirin Percodan Non‐Exempt Analgesics‐Opioid


Oxycodone/Ibuprofen Combunox Non‐Exempt Analgesics‐Opioid


OxymorphoneHCL Opana,OpanaER Non‐Exempt Analgesics‐Opioid


Oxytocin Pitocin Non‐Exempt Oxytocics ✕ChronicPain

PantoprazoleSodium Protonix Exempt UlcerDrugs(Protonpumpinhibitor)







ParoxetineHCL Paxil Non‐Exempt Antidepressants(SSRI)


PenicillinVPotassium Non‐Exempt Antibiotics(Penicillins) ✕Hand,Wrist,andForearmDisorders

Pentazocine/NaloxoneHCL TalwinNX Non‐Exempt Analgesics‐Opioid


Phenytoin Dilantin Non‐Exempt Anticonvulsants✕ChronicPain⦸LowBackDisorders✕Shoulder

Piroxicam Feldene Non‐Exempt Analgesics‐Anti‐Inflammatory(NSAID)


PramipexoleDihydrochloride Mirapex Non‐ExemptAntiparkinsonandRelatedTherapy

Agents⦸ChronicPain

Prednicarbate Dermatop Non‐Exempt Dermatologicals ✓AnkleandFootDisorders

Prednisolone Orapred Non‐Exempt 4Days Corticosteroids


PrednisoloneAcetate PredForte,PredMild Non‐Exempt OphthalmicAgents(Steroid) ✓✕⦸Eye

PrednisoloneSodiumOphth Omnipred Non‐Exempt 4Days OphthalmicAgents(Steroid) ✓✕⦸Eye

Prednisone Sterapred Non‐Exempt 4Days Corticosteroids







Pregabalin Lyrica Non‐Exempt Anticonvulsants

⦸CervicalandThoracicSpineDisorders✓ChronicPain✓⦸LowBackDisorders✓✕⦸ Shoulder

Pregabalin(Once‐daily) LyricaCR Non‐ExemptPsychotherapeuticandNeurologicalAgents‐

Misc✕ChronicPain

ProparacaineHCL Alcaine Exempt OphthalmicAgents(Anesthetic) ✓Eye

ProtriptylineHCL Non‐Exempt Antidepressants(TCAs)✕ChronicPain✕KneeDisorders

PyridostigmineBromide Mestinon Non‐Exempt Antimyasthenic/CholinergicAgents ✕ChronicPain

QuetiapineFumarate Seroquel Non‐Exempt Antipsychotics/AntimanicAgents ⦸ChronicPain

RabeprazoleSodium Aciphex Exempt UlcerDrugs(Protonpumpinhibitor)


RaloxifeneHydrochloride Evista Non‐ExemptEndocrineand

MetabolicAgents‐Misc.

✕ChronicPain

RanitidineHCL Zantac Exempt UlcerDrugs(H2receptorblocker)


RegularInsulin HumulinR Non‐Exempt Antidiabetics ✕AnkleandFootDisorders✕Hand,Wrist,andForearmDisorders

RisedronateSodium Actonel Non‐Exempt




Rivaroxaban Xarelto Non‐Exempt 14Days Anticoagulants⦸AnkleandFootDisorders✓HipandGroinDisorders✓KneeDisorders

S‐Adenosylmethionine SAME Non‐Exempt AlternativeMedicines ✕ChronicPain

Salmeterol Serevent Non‐Exempt AntiasthmaticandBronchodilatorAgents ✓WorkRelatedAsthma

Salsalate Disalcid Exempt Analgesics‐NonNarcotic(NSAID)







SertralineHCL Zoloft Non‐Exempt Antidepressants(SSRI)


SilverSulfadiazine Silvadene Non‐Exempt Dermatologicals ⦸Hand,Wrist,andForearmDisorders

SodiumChlorideOphthalmic Exempt OphthalmicAgents ✓Eye

SodiumOxybate Xyrem Non‐ExemptPsychotherapeuticandNeurologicalAgents‐

Misc.✓ChronicPain

Sucralfate Carafate Exempt UlcerDrugs

✓CervicalandThoracicSpineDisorders✓ElbowDisorders✓HipandGroinDisorders✓KneeDisorders✓LowBackDisorders✓Shoulder

Sulfamethoxazole/Trimethoprim Bactrim Exempt Anti‐InfectiveAgents‐Misc.

✓⦸AnkleandFootDisorders✓✕⦸Hand,Wrist,andForearmDisorders

Sulindac Clinoril Exempt Analgesics‐Anti‐Inflammatory(NSAID)


Tacrolimus Protopic Non‐Exempt Dermatologicals ✓AnkleandFootDisorders

Tapentadol Nucynta Non‐Exempt Analgesics‐Opioid


TerbinafineHCl Lamisil Non‐Exempt Antifungals ✓AnkleandFootDisorders

TerbinafineHCl(Topical) Lamisil Non‐Exempt Dermatologicals ✓AnkleandFootDisorders

TetracaineHCL Tetcaine Exempt OphthalmicAgents(Anesthetic) ✓Eye

TetracyclineHCL Exempt Tetracyclines ✓Eye

Thalidomide Thalomid Non‐Exempt AssortedClasses ✕ChronicPain✕LowBackDisorders

Theophylline Theo‐24,Theo‐Dur Non‐Exempt AntiasthmaticandBronchodilatorAgents ✓WorkRelatedAsthma

TiagabineHCL Gabitril Non‐Exempt Anticonvulsants✕ChronicPain⦸LowBackDisorders✕Shoulder






TizanidineHCL Zanaflex Non‐Exempt 4daysMusculoskeletalTherapyAgents

(MuscleRelaxants)

✓✕CervicalandThoracicSpineDisorders✓✕⦸ChronicPain✓✕HipandGroinDisorders✕⦸KneeDisorders✓✕LowBackDisorders✓✕Shoulder

TobramycinOphthalmic Tobrex Exempt OphthalmicAgents(Anti‐bacterial) ✓✕⦸Eye

Tolnaftate Tinactin Non‐Exempt Dermatologicals ✓AnkleandFootDisorders

TolmetinSodium Tolectin Exempt Analgesics‐Anti‐Inflammatory(NSAID)


Topiramate Topamax Non‐Exempt Anticonvulsants

✓✕CervicalandThoracicSpineDisorders✓ChronicPain✕⦸HipandGroinDisorders✕⦸KneeDisorders✓⦸LowBackDisorders✕⦸Shoulder

TramadolHCL Ultram,UltramER Non‐Exempt 4Days 4Days Analgesics‐Opioid


TramadolHCL/AC Ultracet Non‐Exempt 4Days 4Days Analgesics‐Opioid


TranexamicAcid Lysteda Exempt Hemostatics ✓Eye

TrazodoneHCL Desyrel,Oleptro Non‐Exempt Antidepressants(SSRI)

✕CervicalandThoracicSpineDisorders✓✕⦸ChronicPain✕HipandGroinDisorders✕KneeDisorders✕LowBackDisorders✕Shoulder

TriamcinoloneAcetonideI Non‐Exempt Dermatologicals ✓AnkleandFootDisorders

TrolamineSalicylate Arthricream Non‐Exempt Dermatologicals ✓Hand,Wrist,andForearmDisorders

TropicamideOphthalmic Mydriacyl Exempt OphthalmicAgents(Anticholinergics) ✕Eye

Trypsin Non‐Exempt Chemicals(Proteolyticenzyme) ✕AnkleandFootDisorders






ValacyclovirHCL Valtrex Non‐Exempt Antivirals ✕⦸ChronicPain

ValproicAcid Depakote,Depakene,Depacon Non‐Exempt Anticonvulsants✕ChronicPain⦸LowBackDisorders✕Shoulder

VenlafaxineHCL Effexor Non‐Exempt Antidepressants(SNRI)


Vilazodone Viibryd Non‐Exempt Antidepressants(SSRI)


VitaminA Non‐Exempt Vitamins ✕CervicalandThoracicSpineDisorders

VitaminB‐12 Cyanocobalamin,Methylcobalamin Non‐ExemptHematopoieticAgents

(Vitamins)

✕CervicalandThoracicSpineDisorders⦸ElbowDisorders✕LowBackDisorders

VitaminB‐6 Pyridoxine Non‐Exempt Vitamins

✕⦸AnkleandFootDisorders✕CervicalandThoracicSpineDisorders✕ElbowDisorders✕Hand,Wrist,andForearmDisorders

VitaminD3 Non‐Exempt Vitamins ✓ChronicPain

VitaminE Non‐Exempt Vitamins✕⦸AnkleandFootDisorders✕CervicalandThoracicSpineDisorders✕LowBackDisorders

WarfarinSodium Coumadin Non‐Exempt 14Days Anticoagulants⦸AnkleandFootDisorders✓HipandGroinDisorders✓KneeDisorders

Zafirlukast Accolate Non‐Exempt AntiasthmaticandBronchodilatorAgents ✓WorkRelatedAsthma

Zileuton Zyflo Non‐Exempt AntiasthmaticandBronchodilatorAgents ✓WorkRelatedAsthma

ZolpidemTartrate Ambien Non‐ExemptHypnotics/Sedatives/SleepDisorder

Agents✕ChronicPain

Zonisamide Zonegran Non‐Exempt Anticonvulsants✕ChronicPain⦸LowBackDisorders✕Shoulder



mtus drug list v.3 8 ccr §9792.27.15) · 10/1/2018 · mtus drug list v.3 (8 ccr § 9792.27.15)...

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