MTUS Drug List V.5 ( 8 CCR §9792.27.15) EFFECTIVE DATE: August 1, 2019

MTUS Drug List v.5 (8 CCR § 9792.27.15)

MTUS Drug List v.5 ( 8 CCR §9792.27.15) EFFECTIVE DATE: August 1, 2019

The MTUS Drug List must be used in conjunction with 1) the MTUS Guidelines, which contain specific treatment recommendations based on condition and phase of treatment and 2) the drug formulary rules. (See 8 CCR §9792.20 - §9792.27.23.) "Reference in ACOEM Guidelines" indicates guideline topic(s) which discuss the drug. In each guideline there may be conditions for which the drug is Recommended (✓), Not Recommended (✕), or No Recommendation (⦸). Consult guideline to determine the recommendation for the condition to be treated and to assure proper phase of care use. * Exempt/Non-Exempt "Exempt" indicates drug may be prescribed/dispensed without seeking authorization through Prospective Review if in accordance with MTUS. 1) Physician dispensed "Exempt" drugs limited to one 7-day supply at initial visit within seven days of the date of injury without Prospective Review. 2) Prescription/dispensing of Brand name "Exempt"drug where generic is available requires authorization through Prospective Review. "Non-Exempt" or “Unlisted” drug requires authorization through Prospective Review prior to prescribing or dispensing. (See 8 CCR §9792.27.1 through §9792.27.23 for complete rules.) ** Special Fill - Indicates the Non-Exempt drug may be prescribed/dispensed without Prospective Review: 1) Rx at initial visit within 7 days of injury, and 2) Supply not to exceed #days indicated, and 3) is a generic or single source brand, or brand where physician substantiates medical necessity, and 4) if in accord with MTUS. (See 8 CCR § 9792.27.12.) ***Perioperative Fill – Indicates the Non-Exempt drug may be prescribed/dispensed without Prospective Review: 1) Rx issued during the perioperative period (4 days before through 4 days after surgery), and 2) Supply not to exceed #days indicated, and 3) is a generic or single source brand, or brand where physician substantiates medical necessity, and 4) is in accord with MTUS. (See 8 CCR § 9792.27.13.)

Analgesics - Anti- ✕ Hip and Groin Disorders adalimumab Humira Non-Exempt Inflammatory (TNF- ✕ Knee Disorders alpha blocker) ✕ Low Back Disorders

Antiasthmatic and albuterol sulfate Proventil Exempt ✓ Work Related Asthma Bronchodilator Agents

Antihistamine and/or alcaftadine Lastacaft Exempt ✓ Eye mast cell stabilization

alclometasone dipropionate Aclovate Non-Exempt Dermatologicals ✓ Ankle and Foot Disorders ✓ Chronic Pain Endocrine and ✓⦸ Hip and Groin Disorders Metabolic Agents- alendronate sodium Fosamax Non-Exempt ⦸ Knee Disorders Misc. ✕ Low Back Disorders (Bisphosphonate) ✓ Shoulder almotriptan malate Axert Exempt Migraine Products ✓ Traumatic Brain Injury

alprazolam Xanax Non-Exempt Antianxiety Agents ✕ Post-Traumatic Stress Disorder

Antiparkinson Agents ✕ Chronic Pain amantadine hcl Symmetrel Non-Exempt (NMDA receptor ✕ Low Back Disorders antagonist) ✓⦸ Traumatic Brain Injury

amcinonide Cyclocort Non-Exempt Dermatologicals ✓ Ankle and Foot Disorders

*ACOEM Guidelines Copyright Reed Group Ltd.

Effective August 1, 2019 1 of 29

MTUS Drug List v.5 (8 CCR § 9792.27.15)

Exempt/Non- Unique Drug Ingredient Brand Example Special Fill** Peri-Op*** Drug Class Reference in ACOEM Guidelines * Dosage Form Strength Pharmaceutical Exempt* Identifier(s) ✓✕ Cervical and Thoracic Spine Disorders ✓✕ Chronic Pain ✕⦸ Hip and Groin Disorders Antidepressants amitriptyline hcl Elavil Non-Exempt ✓✕⦸ Knee Disorders (TCAs) ✓⦸ Low Back Disorders ⦸ Post-Traumatic Stress Disorder ✓✕ Shoulder Calcium Channel amlodipine besylate Norvasc Non-Exempt ✓ Hand, Wrist, and Forearm Disorders Blockers ✓⦸ Ankle and Foot Disorders Antibiotics amoxicillin/clavulanate p Augmentin Exempt ✓ Hand, Wrist, and Forearm Disorders (Penicillins) ✓ Low Back Disorders Analgesics - Anti- anakinra Kineret Non-Exempt ✕ Knee Disorders inflammatory ⦸ Ankle and Foot Disorders apixaban Eliquis Non-Exempt 14 Days Anticoagulants ✓ Hip and Groin Disorders ✓ Knee Disorders

Antipsychotic/ aripiprazole Abilify Non-Exempt ⦸ Post-Traumatic Stress Disorder Antimanic Agents

Ophthalmic Agents artificial tear ointments Refresh PM Exempt ✓ Eye (Artificial Tears) ✕⦸ Ankle and Foot Disorders ✕ Cervical and Thoracic Spine Disorders ascorbic acid Vitamin C Non-Exempt Vitamins ⦸ Chronic Pain ✕ Low Back Disorders ✓ Ankle and Foot Disorders ✓ Cervical and Thoracic Spine Disorders ✕ Chronic Pain ✓ Elbow Disorders Analgesics - aspirin Bayer Exempt ✓✕⦸ Hand, Wrist, and Forearm Disorders NonNarcotic ✓ Hip and Groin Disorders ✓ Knee Disorders ✓ Low Back Disorders ✓ Shoulder ✕ Ankle and Foot Disorders ✕ Cervical and Thoracic Spine Disorders ✕ Chronic Pain ✕ Elbow Disorders aspirin/caffeine/dihydrocodeine bitartrate Synalgos-DC Non-Exempt Analgesics - Opioid ✕ Hand, Wrist, and Forearm Disorders ✕ Hip and Groin Disorders ✕ Knee Disorders ✕ Low Back Disorders ✕ Shoulder atenolol Tenormin Exempt Beta Blockers ✓ Traumatic Brain Injury

Antihistamine and/or azelastine ophth Optivar Exempt ✓ Eye mast cell stabilization Antibiotics azithromycin ophth Azasite Exempt ✓✕⦸ Eye (Macrolides) Antibiotics azithromycin Zithromax Non-Exempt ✕ Hand, Wrist, and Forearm Disorders (Macrolides)

Anti-Infective Agents - ✓ Ankle and Foot Disorders bacitracin Exempt Misc. ⦸ Hand, Wrist, and Forearm Disorders

*ACOEM Guidelines Copyright Reed Group Ltd.

Effective August 1, 2019 2 of 29

MTUS Drug List v.5 (8 CCR § 9792.27.15)

Exempt/Non- Unique Drug Ingredient Brand Example Special Fill** Peri-Op*** Drug Class Reference in ACOEM Guidelines * Dosage Form Strength Pharmaceutical Exempt* Identifier(s) ✓✕ Cervical and Thoracic Spine Disorders ✓✕⦸ Chronic Pain Musculoskeletal ✓✕ Hip and Groin Disorders baclofen Lioresal Non-Exempt 4 Days 4 Days Therapy Agents ✕⦸ Knee Disorders (Muscle Relaxants) ✓✕ Low Back Disorders ✓✕ Shoulder ✓ Traumatic Brain Injury becaplermin Regranex Non-Exempt Dermatologicals ✓Ankle and Foot Disorders

Antiasthmatic and beclomethasone dipropionate Qvar Non-Exempt ✓ Work Related Asthma Bronchodilator Agents

Antihistamine and/or bepotastine ophth Bepreve Exempt ✓ Eye mast cell stabilization

besifloxacin ophth Besivance Exempt Topical antibiotic ✓✕⦸ Eye ✓✕⦸ Ankle and Foot Disorders ✓✕ Cervical and Thoracic Spine Disorders ✓ Chronic Pain ✓⦸ Elbow Disorders betamethasone Celestone Non-Exempt 4 Days Corticosteroids ✓✕⦸ Hand, Wrist, and Forearm Disorders ✓✕ Hip and Groin Disorders ✓⦸ Knee Disorders ✓✕⦸ Low Back Disorders ✓✕⦸ Shoulder betamethasone dipropionat Diprosone Non-Exempt Dermatologicals ✓ Ankle and Foot Disorders

betamethasone valerate Valisone Non-Exempt Dermatologicals ✓ Ankle and Foot Disorders

boswellia serrata extract Non-Exempt Chemicals ⦸ Traumatic Brain Injury

Ophthalmic Agents bromfenac Prolensa Exempt ✓✕ Eye (NSAID) Antiparkinson and bromocriptine mesylate Parlodel Non-Exempt Related Therapy ⦸ Traumatic Brain Injury Agents

Antiasthmatic and budesonide Pulmicort Non-Exempt ✓ Work Related Asthma Bronchodilator Agents

Antiasthmatic and budesonide/formoterol Symbicort Non-Exempt ✓ Work Related Asthma Bronchodilator Agents ✕ Ankle and Foot Disorders ✕ Cervical and Thoracic Spine Disorders ✕ Chronic Pain ✕ Elbow Disorders ✕ Hand, Wrist, and Forearm Disorders buprenorphine (hcl) Butrans Non-Exempt Analgesics - Opioid ✕ Hip and Groin Disorders ✕ Knee Disorders ✕ Low Back Disorders ✓ Opioid ✕ Shoulder

*ACOEM Guidelines Copyright Reed Group Ltd.

Effective August 1, 2019 3 of 29

MTUS Drug List v.5 (8 CCR § 9792.27.15)

butenafine hcl Lotrimin Ultra Non-Exempt Dermatologicals ✓ Ankle and Foot Disorders

✕ Ankle and Foot Disorders ✕ Cervical and Thoracic Spine Disorders ✕ Chronic Pain ✕ Elbow Disorders butorphanol tartrate Stadol Non-Exempt Analgesics - Opioid ✕ Hand, Wrist, and Forearm Disorders ✕ Hip and Groin Disorders ✕ Knee Disorders ✕ Low Back Disorders ✕ Shoulder Endocrine and cabergoline Non-Exempt Metabolic Agents - ⦸ Traumatic Brain Injury Misc. ✕ Ankle and Foot Disorders Endocrine and ✓✕ Chronic Pain Metabolic Agents- calcitonin-salmon Fortical, Miacalcin Non-Exempt ✓⦸ Hip and Groin Disorders Misc. ⦸ Knee Disorders (Bisphosphonate) ✕ Low Back Disorders Minerals & calcium phosphate tribasic Non-Exempt ⦸ Ankle and Foot Disorders Electrolytes ⦸ Cervical and Thoracic Spine Disorders ⦸ Chronic Pain ✓ Hand, Wrist, and Forearm Disorders camphor Bengay Ultra Non-Exempt Dermatologicals ✕⦸ Hip and Groin Disorders ⦸ Low Back Disorders ⦸ Shoulder ✓ Cervical and Thoracic Spine Disorders ✓⦸ Chronic Pain Dermatologicals ✓ Hand, Wrist, and Forearm Disorders capsaicin Zostrix Exempt (Topical creams and ✓ Hip and Groin Disorders ointments) ✓ Low Back Disorders ✓⦸ Shoulder ✓ Cervical and Thoracic Spine Disorders ✓ Chronic Pain carbamazepine Tegretol Non-Exempt Anticonvulsants ⦸ Low Back Disorders ✓✕ Shoulder

*ACOEM Guidelines Copyright Reed Group Ltd.

Effective August 1, 2019 4 of 29

MTUS Drug List v.5 (8 CCR § 9792.27.15)

Exempt/Non- Unique Drug Ingredient Brand Example Special Fill** Peri-Op*** Drug Class Reference in ACOEM Guidelines * Dosage Form Strength Pharmaceutical Exempt* Identifier(s) Ophthalmic Agents carboxymethylcellulose sodium ophthalmic Refresh Plus Exempt ✓ Eye (Artificial Tears) ✕ Cervical and Thoracic Spine Disorders ✕ Chronic Pain Musculoskeletal ✕ Hip and Groin Disorders carisoprodol Soma Non-Exempt Therapy Agents ✕ Knee Disorders (Muscle Relaxants) ✕ Low Back Disorders ✕ Shoulder Antibiotics cefuroxime axetil Ceftin Exempt ✓ Hand, Wrist, and Forearm Disorders (Cephalosporins) ✓ Ankle and Foot Disorders ✓ Cervical and Thoracic Spine Disorders ✓ Chronic Pain ✓✕⦸ Elbow Disorders Analgesics - Anti- ✓✕⦸ Hand, Wrist, and Forearm Disorders celecoxib Celebrex Exempt Inflammatory (NSAID) ✓⦸ Hip and Groin Disorders ✓⦸ Knee Disorders ✓ Low Back Disorders ✓ Shoulder ⦸ Traumatic Brain Injury

Antibiotics ✓⦸ Ankle and Foot Disorders cephalexin Keflex Exempt (Cephalosporins) ✕ Hand, Wrist, and Forearm Disorders

✕ Hip and Groin Disorders Gastrointestinal certolizumab pegol Cimzia Non-Exempt ✕ Knee Disorders Agents (TNF Blocker) ✕ Low Back Disorders ✕ Cervical and Thoracic Spine Disorders ✕ Chronic Pain Musculoskeletal ✕ Hip and Groin Disorders chlorzoxazone Lorzone, Parafon Forte Non-Exempt Therapy Agents ✕ Knee Disorders (Muscle Relaxants) ✕ Low Back Disorders ✕ Shoulder ✓ Ankle and Foot Disorders ✓ Cervical and Thoracic Spine Disorders ✓ Chronic Pain ✓✕⦸ Elbow Disorders Analgesics - ✓✕⦸ Hand, Wrist, and Forearm Disorders choline magnesium trisalicylate Trilisate Exempt NonNarcotic (NSAID) ✓⦸ Hip and Groin Disorders ✓⦸ Knee Disorders ✓ Low Back Disorders ✓ Shoulder ⦸ Traumatic Brain Injury ⦸ Hand, Wrist, and Forearm Disorders Alternative Medicines ⦸ Hip and Groin Disorders chondroitin sulfate Non-Exempt (OTC nutraceutical) ⦸ Knee Disorders ⦸ Shoulder

Antiasthmatic and ciclesonide Alvesco Non-Exempt ✓ Work Related Asthma Bronchodilator Agents

ciclopirox olamine Loprox Non-Exempt Dermatologicals ✓ Ankle and Foot Disorders

*ACOEM Guidelines Copyright Reed Group Ltd.

Effective August 1, 2019 5 of 29

MTUS Drug List v.5 (8 CCR § 9792.27.15)

Exempt/Non- Unique Drug Ingredient Brand Example Special Fill** Peri-Op*** Drug Class Reference in ACOEM Guidelines * Dosage Form Strength Pharmaceutical Exempt* Identifier(s) ✓ Cervical and Thoracic Spine Disorders ✓ Elbow Disorders ✓ Hand, Wrist, and Forearm Disorders Ulcer Drugs (H2 ✓ Hip and Groin Disorders cimetidine Tagamet Exempt receptor blocker) ✓ Knee Disorders ✓ Low Back Disorders ✓ Shoulder ✓ Traumatic Brain Injury

Antibiotics ✓ Ankle and Foot Disorders ciprofloxacin Cipro Exempt (Fluoroquinolones) ✓ Hand, Wrist, and Forearm Disorders

Ophthalmic Agents ciprofloxacin hcl ophthalmic Ciloxan Exempt ✓✕⦸ Eye (Antibiotics) ✕ Cervical and Thoracic Spine Disorders ✓✕ Chronic Pain ✕ Hip and Groin Disorders Antidepressants citalopram hydrobromide Celexa Exempt ✓✕ Knee Disorders (SSRI) ✕ Low Back Disorders ✓ Post-Traumatic Stress Disorder ✕ Shoulder citicoline Ceraxon Non-Exempt Alternative Medicines ⦸ Traumatic Brain Injury

Antibiotics clarithromycin Biaxin Non-Exempt ✕ Hand, Wrist, and Forearm Disorders (Macrolides) ✓⦸ Ankle and Foot Disorders Anti-Infective Agents - ✓✕⦸ Hand, Wrist, and Forearm Disorders clindamycin hcl Cleocin Exempt Misc. ✓ Hip and Groin Disorders ✓ Knee Disorders ✕ Cervical and Thoracic Spine Disorders ✓ Chronic Pain Antidepressants ✕⦸ Hip and Groin Disorders clomipramine hcl Anafranil Non-Exempt (TCAs) ✕⦸ Knee Disorders ✕ Low Back Disorders ✕ Shoulder ⦸ Low Back Disorders clonazepam Klonopin Non-Exempt Anticonvulsants ✕ Post-Traumatic Stress Disorder ✕ Shoulder

clonidine Catapres TTS Non-Exempt Antihypertensives ⦸ Post-Traumatic Stress Disorder

Analgesics - ✓⦸ Chronic Pain clonidine hcl Catapres Non-Exempt NonNarcotic ✕⦸ Low Back Disorders

clotrimazole antifungal Lotrimin AF Non-Exempt Dermatologicals ✓ Ankle and Foot Disorders ✕ Ankle and Foot Disorders ✕ Cervical and Thoracic Spine Disorders ✕ Chronic Pain ✕ Elbow Disorders codeine sulfate Non-Exempt Analgesics - Opioid ✕ Hand, Wrist, and Forearm Disorders ✕ Hip and Groin Disorders ✕ Knee Disorders ✕ Low Back Disorders ✕ Shoulder

*ACOEM Guidelines Copyright Reed Group Ltd.

Effective August 1, 2019 6 of 29

MTUS Drug List v.5 (8 CCR § 9792.27.15)

✕ Cervical and Thoracic Spine Disorders colchicine Non-Exempt Gout Agents ✕ Low Back Disorders ✓✕⦸ Ankle and Foot Disorders ✓✕ Cervical and Thoracic Spine Disorders ✓✕ Chronic Pain ⦸ Elbow Disorders cortisone Cortone Non-Exempt 4 Days Corticosteroids ✓⦸ Hand, Wrist, and Forearm Disorders ✕ Hip and Groin Disorders ✓✕⦸ Low Back Disorders ✓✕⦸ Shoulder

creatine monohydrate Non-Exempt Chemicals ⦸ Chronic Pain

Antiasthmatic and cromolyn sodium Intal Non-Exempt ✓ Work Related Asthma Bronchodilator Agents

Antihistamine and/or cromolyn sodium (opthalmic) Opticrom Exempt ✓ Eye mast cell stabilization ✓✕ Cervical and Thoracic Spine Disorders ✓✕⦸ Chronic Pain Musculoskeletal ✕ Hip and Groin Disorders cyclobenzaprine hcl Flexeril Non-Exempt 4 Days Therapy Agents ✕⦸ Knee Disorders (Muscle Relaxants) ✓✕ Low Back Disorders ✓✕ Shoulder Ophthalmic Agents cyclopentolate hcl Cyclogyl Non-Exempt ✕ Eye (Anticholinergics) Miscellaneous cyclosporine Sandimmune Non-Exempt ⦸ Traumatic Brain Injury Therapeutic Classes

dalteparin Fragmin Non-Exempt Anticoagulants ⦸ Ankle and Foot Disorders ✕ Cervical and Thoracic Spine Disorders ✕ Chronic Pain Musculoskeletal ✕ Hip and Groin Disorders dantrolene sodium Dantrium Non-Exempt 4 Days Therapy Agents ✕ Knee Disorders (Muscle Relaxants) ✕ Low Back Disorders ✕ Shoulder ✓ Traumatic Brain Injury dehydroepiandrosterone (dhea) Non-Exempt Chemicals ⦸ Chronic Pain

✓✕ Cervical and Thoracic Spine Disorders ✓ Chronic Pain ⦸ Hip and Groin Disorders Antidepressants ✓✕⦸ Knee Disorders desipramine hcl Norpramin Exempt (TCAs) ✓⦸ Low Back Disorders ⦸ Post-Traumatic Stress Disorder ✓✕ Shoulder ✓ Traumatic Brain Injury

*ACOEM Guidelines Copyright Reed Group Ltd.

Effective August 1, 2019 7 of 29

MTUS Drug List v.5 (8 CCR § 9792.27.15)

Exempt/Non- Unique Drug Ingredient Brand Example Special Fill** Peri-Op*** Drug Class Reference in ACOEM Guidelines * Dosage Form Strength Pharmaceutical Exempt* Identifier(s) Antihistamine and/or desloratadine Clarinex Exempt ✓ Eye mast cell stabilization Endocrine and desmopressin acetate DDAVP Exempt Metabolic Agents - ✓ Traumatic Brain Injury Misc.

desonide Desowen Non-Exempt Dermatologicals ✓ Ankle and Foot Disorders

desoximetasone Topicort Non-Exempt Dermatologicals ✓ Ankle and Foot Disorders

✕ Cervical and Thoracic Spine Disorders ✕ Chronic Pain Antidepressants ✕ Hip and Groin Disorders desvenlafaxine er Pristiq Non-Exempt (SNRI) ✕ Knee Disorders ✕⦸ Low Back Disorders ✕ Shoulder ✓✕⦸ Ankle and Foot Disorders ✓✕ Cervical and Thoracic Spine Disorders ✓✕ Chronic Pain ✓⦸ Elbow Disorders ✓✕⦸ Hand, Wrist, and Forearm Disorders dexamethasone Decadron Non-Exempt 4 Days Corticosteroids ✕ Hip and Groin Disorders ✓⦸ Knee Disorders ✓✕⦸ Low Back Disorders ✓✕⦸ Shoulder ✕ Traumatic Brain Injury Ophthalmic Agents dexamethasone sodium phosphate ophthalmic Maxidex Non-Exempt 4 Days ✓✕⦸ Eye (Steroid) ✓ Cervical and Thoracic Spine Disorders ✓ Elbow Disorders Ulcer Drugs (Proton dexlansoprazole Dexilant Exempt ✓ Hand, Wrist, and Forearm Disorders pump inhibitor) ✓ Knee Disorders ✓ Shoulder Cough/Cold/Allergy ✓✕⦸ Chronic Pain dextromethorphan Delsym Non-Exempt (NMDA Receptor ✕ Low Back Disorders Antagonist) ✓ Shoulder Psychotherapeutic and dextromethorphan-quinidine sulfate Nuedexta Non-Exempt Neurological Agents- ⦸ Traumatic Brain Injury Misc. Antianxiety Agents diazepam Valium Non-Exempt ✕ Chronic Pain (Muscle relaxant) ✓ Ankle and Foot Disorders ✓ Cervical and Thoracic Spine Disorders ⦸ Chronic Pain ✓✕⦸ Elbow Disorders Analgesics - Anti- ✓✕⦸ Hand, Wrist, and Forearm Disorders diclofenac potassium Cataflam Exempt Inflammatory (NSAID) ✓⦸ Hip and Groin Disorders ✓⦸ Knee Disorders ✓ Low Back Disorders ✓ Shoulder ⦸ Traumatic Brain Injury

*ACOEM Guidelines Copyright Reed Group Ltd.

Effective August 1, 2019 8 of 29

MTUS Drug List v.5 (8 CCR § 9792.27.15)

Exempt/Non- Unique Drug Ingredient Brand Example Special Fill** Peri-Op*** Drug Class Reference in ACOEM Guidelines * Dosage Form Strength Pharmaceutical Exempt* Identifier(s) ✓ Ankle and Foot Disorders ✓ Cervical and Thoracic Spine Disorders ⦸ Chronic Pain ✓✕⦸ Elbow Disorders Analgesics - ✓✕⦸ Hand, Wrist, and Forearm Disorders diclofenac sodium Voltaren Non-Exempt Antiinflammatory ✓⦸ Hip and Groin Disorders ✓⦸ Knee Disorders ✓ Low Back Disorders ✓ Shoulder ⦸ Traumatic Brain Injury ✓✕⦸ Ankle and Foot Disorders ⦸ Cervical and Thoracic Spine Disorders ✓ Chronic Pain ✓⦸ Elbow Disorders diclofenac sodium (topical) Voltaren 1% gel Exempt Dermatologicals ✓ Hand, Wrist, and Forearm Disorders ✕⦸ Hip and Groin Disorders ⦸ Low Back Disorders ⦸ Shoulder Ophthalmic Agents diclofenac sodium ophthalmic Voltaren Exempt ✓✕ Eye (NSAID) ✓⦸ Ankle and Foot Disorders ✓ Cervical and Thoracic Spine Disorders ✕ Chronic Pain ✓ Elbow Disorders Analgesics - Anti- ✓ Hand, Wrist, and Forearm Disorders diclofenac sodium/misoprostol Arthrotec Exempt Inflammatory (NSAID/ ✓ Hip and Groin Disorders Ulcer drug) ✓ Knee Disorders ✓ Low Back Disorders ✓ Shoulder ✕ Traumatic Brain Injury Antibiotics dicloxacillin sodium Dynapen Exempt ✓⦸ Ankle and Foot Disorders (Penicillins) ✓ Ankle and Foot Disorders ✓ Cervical and Thoracic Spine Disorders ✓ Chronic Pain ✓✕⦸ Elbow Disorders Analgesics - Anti- ✓✕⦸ Hand, Wrist, and Forearm Disorders diflunisal Dolobid Exempt Inflammatory (NSAID) ✓⦸ Hip and Groin Disorders ✓⦸ Knee Disorders ✓ Low Back Disorders ✓ Shoulder ⦸ Traumatic Brain Injury dihydroergotamine mesylat Migranal Exempt Migraine Products ✓ Traumatic Brain Injury ✕ Cervical and Thoracic Spine Disorders Genitourinary - Misc. ✓ Chronic Pain dimethyl sulfoxide DMSO Non-Exempt (Ointments and topical ✕⦸ Hip and Groin Disorders agents) ✕ Low Back Disorders ✕ Chronic Pain ⦸ Low Back Disorders divalproex sodium Depakote Non-Exempt Anticonvulsants ✕ Post-Traumatic Stress Disorder ✕ Shoulder ✕⦸ Traumatic Brain Injury dolasetron mesylate Anzemet Non-Exempt Antiemetics ⦸ Chronic Pain Psychotherapeutic and donepezil hcl Aricept Exempt Neurological Agents- ✓ Traumatic Brain Injury Misc.

*ACOEM Guidelines Copyright Reed Group Ltd.

Effective August 1, 2019 9 of 29

MTUS Drug List v.5 (8 CCR § 9792.27.15)

✓✕ Cervical and Thoracic Spine Disorders ✕ Chronic Pain Antidepressants ⦸ Hip and Groin Disorders doxepin hcl Sinequan Non-Exempt (TCAs) ✕⦸ Knee Disorders ✓⦸ Low Back Disorders ✕ Shoulder ✓⦸ Ankle and Foot Disorders Antibiotics doxycycline Vibramycin Exempt ✓ Hand, Wrist, and Forearm Disorders (Tetracyclines) ✓ Hip and Groin Disorders ✓✕ Cervical and Thoracic Spine Disorders ✓ Chronic Pain Antidepressants ⦸ Hip and Groin Disorders duloxetine hcl Cymbalta Non-Exempt (SNRI) ✓✕⦸ Knee Disorders ✓⦸ Low Back Disorders ✓✕⦸ Shoulder

econazole nitrate Spectazole Non-Exempt Dermatologicals ✓ Ankle and Foot Disorders

eletriptan hydrobromide Relpax Exempt Migraine Products ✓ Traumatic Brain Injury

Antihistamine and/or emedastine ophth Emadine Exempt ✓ Eye mast cell stabilization ⦸ Ankle and Foot Disorders enoxaparin sodium Lovenox Non-Exempt 14 Days Anticoagulants ✓ Hip and Groin Disorders ✓ Knee Disorders

Antihistamine and/or epinastine hcl Elestat Exempt ✓ Eye mast cell stabilization

Antibiotics erythromycin Ery-Tab Non-Exempt ✕ Hand, Wrist, and Forearm Disorders (Macrolides)

Ophthalmic Agents erythromycin ophthalmic ointment Ilotycin Exempt ✓✕⦸ Eye (Antibiotics) ✕ Cervical and Thoracic Spine Disorders ✓✕ Chronic Pain ✕ Hip and Groin Disorders Antidepressants escitalopram oxalate Lexapro Exempt ✓✕ Knee Disorders (SSRI) ✕ Low Back Disorders ✓ Post-Traumatic Stress Disorder ✕ Shoulder ✓ Cervical and Thoracic Spine Disorders ✓ Elbow Disorders ✓ Hand, Wrist, and Forearm Disorders Ulcer Drugs (Proton esomeprazole magnesium Nexium Exempt ✓ Hip and Groin Disorders pump inhibitor) ✓ Knee Disorders ✓ Low Back Disorders ✓ Shoulder ✕ Ankle and Foot Disorders ✕ Cervical and Thoracic Spine Disorders ✕ Chronic Pain Analgesics - Anti- ✕ Elbow Disorders Inflammatory (Proton ✕ Hand, Wrist, and Forearm Disorders esomeprazole/naproxen Vimovo Non-Exempt Pump Inhibitor ✕ Hip and Groin Disorders /NSAID) ✕ Knee Disorders ✕ Low Back Disorders ✕ Shoulder ✕ Traumatic Brain Injury

*ACOEM Guidelines Copyright Reed Group Ltd.

Effective August 1, 2019 10 of 29

MTUS Drug List v.5 (8 CCR § 9792.27.15)

Analgesics - Anti- ✕ Hip and Groin Disorders etanercept Enbrel Non-Exempt Inflammatory (TNF- ✕ Knee Disorders alpha blocker) ✕ Low Back Disorders Endocrine and ✓⦸ Hip and Groin Disorders Metabolic Agents- ⦸ Knee Disorders etidronate disodium Didronel Non-Exempt Misc. ✕ Low Back Disorders (Bisphosphonate) ✓ Shoulder ✓ Ankle and Foot Disorders ✓ Cervical and Thoracic Spine Disorders ✓ Chronic Pain ✓✕⦸ Elbow Disorders Analgesics - Anti- ✓✕⦸ Hand, Wrist, and Forearm Disorders etodolac Lodine Exempt Inflammatory (NSAID) ✓⦸ Hip and Groin Disorders ✓⦸ Knee Disorders ✓ Low Back Disorders ✓ Shoulder ⦸ Traumatic Brain Injury famciclovir Famvir Non-Exempt Antivirals ⦸ Chronic Pain ✓ Cervical and Thoracic Spine Disorders ✓ Elbow Disorders ✓ Hand, Wrist, and Forearm Disorders Ulcer Drugs (H2 ✓ Hip and Groin Disorders famotidine Pepcid Exempt receptor blocker) ✓ Knee Disorders ✓ Low Back Disorders ✓ Shoulder ✓ Traumatic Brain Injury ✕ Ankle and Foot Disorders ✕ Cervical and Thoracic Spine Disorders ✕ Chronic Pain Analgesics - Anti- ✕ Elbow Disorders Inflammatory (H2 ✕ Hand, Wrist, and Forearm Disorders famotidine/ibuprofen Duexis Non-Exempt Receptor Blocker ✕ Hip and Groin Disorders /NSAID) ✕ Knee Disorders ✕ Low Back Disorders ✕ Shoulder ✕ Traumatic Brain Injury ✓ Ankle and Foot Disorders ✓ Cervical and Thoracic Spine Disorders ✓ Chronic Pain ✓✕⦸ Elbow Disorders Analgesics - Anti- ✓✕⦸ Hand, Wrist, and Forearm Disorders fenoprofen calcium Nalfon Exempt Inflammatory (NSAID) ✓⦸ Hip and Groin Disorders ✓⦸ Knee Disorders ✓ Low Back Disorders ✓ Shoulder ⦸ Traumatic Brain Injury ✕ Ankle and Foot Disorders ✕ Cervical and Thoracic Spine Disorders ✕ Chronic Pain ✕ Elbow Disorders fentanyl Duragesic Non-Exempt Analgesics - Opioid ✕ Hand, Wrist, and Forearm Disorders ✕ Hip and Groin Disorders ✕ Knee Disorders ✕ Low Back Disorders ✕ Shoulder

*ACOEM Guidelines Copyright Reed Group Ltd.

Effective August 1, 2019 11 of 29

MTUS Drug List v.5 (8 CCR § 9792.27.15)

Antiasthmatic and flunisolide Aerospan HFA Non-Exempt ✓ Work Related Asthma Bronchodilator Agents

fluocinolone acetonide Synalar Non-Exempt Dermatologicals ✓Ankle and Foot Disorders

fluocinonide Non-Exempt Dermatologicals ✕⦸ Elbow Disorders

fluorometholone FML Non-Exempt 4 Days Ophthalmic Agents ✓✕⦸ Eye

✕ Cervical and Thoracic Spine Disorders ✓✕ Chronic Pain ✕ Hip and Groin Disorders Antidepressants fluoxetine hcl Prozac Exempt ✓✕ Knee Disorders (SSRI) ✕ Low Back Disorders ✓ Post-Traumatic Stress Disorder ✕ Shoulder ✓ Ankle and Foot Disorders ✓ Cervical and Thoracic Spine Disorders ✓ Chronic Pain ✓✕⦸ Elbow Disorders Analgesics - Anti- ✓✕⦸ Hand, Wrist, and Forearm Disorders flurbiprofen Ansaid Exempt Inflammatory (NSAID) ✓⦸ Hip and Groin Disorders ✓⦸ Knee Disorders ✓ Low Back Disorders ✓ Shoulder ⦸ Traumatic Brain Injury Anti-Inflammatory flurbiprofen sodium Ocufen Exempt (NSAID) Ophthalmic ✓✕ Eye Drops

Antiasthmatic and fluticasone propionate Flovent Non-Exempt ✓ Work Related Asthma Bronchodilator Agents

fluticasone prop (topical) Cutivate Non-Exempt Dermatologicals ✓ Ankle and Foot Disorders

Antiasthmatic and fluticasone-salmeterol Advair Non-Exempt ✓ Work Related Asthma Bronchodilator Agents ✕ Cervical and Thoracic Spine Disorders ✓✕ Chronic Pain ✕ Hip and Groin Disorders Antidepressants fluvoxamine maleate Luvox Non-Exempt ✕ Knee Disorders (SSRI) ✕ Low Back Disorders ⦸ Post-Traumatic Stress Disorder ✕ Shoulder folic acid Non-Exempt Hematopoietic Agents ✕ Cervical and Thoracic Spine Disorders

*ACOEM Guidelines Copyright Reed Group Ltd.

Effective August 1, 2019 12 of 29

MTUS Drug List v.5 (8 CCR § 9792.27.15)

Antiasthmatic and formoterol fumarate Foradil Non-Exempt ✓ Work Related Asthma Bronchodilator Agents

Antiasthmatic and formoterol/mometasone Dulera Non-Exempt ✓ Work Related Asthma Bronchodilator Agents

frovatriptan succinate Frova Exempt Migraine Products ✓ Traumatic Brain Injury

✓✕⦸ Cervical and Thoracic Spine Disorders ✓ Chronic Pain ✓✕⦸ Hip and Groin Disorders gabapentin Neurontin Non-Exempt 4 Days Anticonvulsants ✓✕⦸ Knee Disorders ✓⦸Low Back Disorders ✕ Post-Traumatic Stress Disorder ✓✕⦸ Shoulder

Psychotherapeutic and ✕ Chronic Pain gabapentin (once-daily) Gralise Non-Exempt Neurological Agents - ✕ Post-Traumatic Stress Disorder Misc Psychotherapeutic and ✓✕ Chronic Pain gabapentin enacarbil Horizant Non-Exempt Neurological Agents - ✕ Post-Traumatic Stress Disorder Misc Ophthalmic Agents gatifloxacin Zymaxid Exempt ✓✕ Eye (Anti-bacterial)

gentamicin (topical) Exempt Dermatologicals ✓Ankle and Foot Disorders

Ophthalmic Agents gentamicin sulfate ophthalmic Gentak Exempt ✓✕⦸ Eye (Anti-bacterial) ⦸ Hand, Wrist, and Forearm Disorders Alternative Medicines ⦸ Hip and Groin Disorders glucosamine sulfate Non-Exempt (OTC nutraceutical) ✕ Knee Disorders ⦸ Shoulder Analgesics - Anti- ✕ Hip and Groin Disorders golimumab Simponi Non-Exempt Inflammatory (TNF- ✕ Knee Disorders alpha blocker) ✕ Low Back Disorders

ADHD/Anti- guanfacine er Intuniv Non-Exempt Narcolepsy/Anti- ✕ Post-Traumatic Stress Disorder Obesity/Anorexiants

guanfacine hcl Tenex Non-Exempt Antihypertensives ✕ Post-Traumatic Stress Disorder

✕⦸ Ankle and Foot Disorders heparin sodium Non-Exempt 14 Days Anticoagulants ✓ Hip and Groin Disorders ✓ Knee Disorders Ophthalmic Agents homatropine hbr ophthalmic Isopto Homatropine Exempt ✕ Eye (Anticholinergics) ✕ Ankle and Foot Disorders hydrochlorothiazide Microzide Non-Exempt Diuretics ✕ Hand, Wrist, and Forearm Disorders

*ACOEM Guidelines Copyright Reed Group Ltd.

Effective August 1, 2019 13 of 29

MTUS Drug List v.5 (8 CCR § 9792.27.15)

hydrocortisone (topical) Non-Exempt Dermatologicals ✓ Ankle and Foot Disorders

hydrocortisone valerate Westcort Non-Exempt Dermatologicals ✓ Ankle and Foot Disorders

✕ Ankle and Foot Disorders ✕ Cervical and Thoracic Spine Disorders ✕ Chronic Pain ✕ Elbow Disorders hydromorphone hcl Dilaudid Non-Exempt Analgesics - Opioid ✕ Hand, Wrist, and Forearm Disorders ✕ Hip and Groin Disorders ✕ Knee Disorders ✕ Low Back Disorders ✕ Shoulder Endocrine and ✓⦸ Hip and Groin Disorders Metabolic Agents- ⦸ Knee Disorders ibandronate sodium Boniva Non-Exempt Misc. ✕ Low Back Disorders (Bisphosphonate) ✓ Shoulder

*ACOEM Guidelines Copyright Reed Group Ltd.

Effective August 1, 2019 14 of 29

MTUS Drug List v.5 (8 CCR § 9792.27.15)

inositol Non-Exempt Nutrients ⦸ Post-Traumatic Stress Disorder

irrigating eyewash Exempt Ophthalmic Agents ✓ Eye

itraconazole Sporanox Non-Exempt Antifungals ✓Ankle and Foot Disorders

ketoconazole Nizoral Non-Exempt Dermatologicals ✓Ankle and Foot Disorders ✓ Ankle and Foot Disorders ✓ Cervical and Thoracic Spine Disorders ✓ Chronic Pain ✓✕⦸ Elbow Disorders Analgesics - Anti- ✓✕⦸ Hand, Wrist, and Forearm Disorders ketoprofen Oruvail Exempt Inflammatory (NSAID) ✓⦸ Hip and Groin Disorders ✓⦸ Knee Disorders ✓ Low Back Disorders ✓ Shoulder ⦸ Traumatic Brain Injury ✕ Ankle and Foot Disorders ✕ Cervical and Thoracic Spine Disorders ✕ Chronic Pain ✕ Elbow Disorders Analgesics - Anti- ✕ Hand, Wrist, and Forearm Disorders ketorolac tromethamine Non-Exempt Inflammatory (NSAID) ✕ Hip and Groin Disorders ✕ Knee Disorders ✕ Low Back Disorders ✕ Shoulder ✕ Traumatic Brain Injury Ophthalmic Agents ketorolac tromethamine ophthalmic Acular Exempt ✓✕ Eye (NSAID)

*ACOEM Guidelines Copyright Reed Group Ltd.

Effective August 1, 2019 15 of 29

MTUS Drug List v.5 (8 CCR § 9792.27.15)

✓ Cervical and Thoracic Spine Disorders ✓ Chronic Pain lamotrigine Lamictal Non-Exempt Anticonvulsants ⦸ Low Back Disorders ⦸ Post-Traumatic Stress Disorder ✕ Shoulder ✓ Cervical and Thoracic Spine Disorders ✓ Elbow Disorders ✓ Hand, Wrist, and Forearm Disorders Ulcer Drugs (Proton ✓ Hip and Groin Disorders lansoprazole Prevacid Exempt pump inhibitor) ✓ Knee Disorders ✓ Low Back Disorders ✓ Shoulder ✓ Traumatic Brain Injury Miscellaneous lenalidomide Revlimid Non-Exempt ✕ Chronic Pain Therapeutic Classes

Antiasthmatic and levalbuterol Xopenex Exempt ✓ Work Related Asthma Bronchodilator Agents

✕ Chronic Pain levetiracetam Keppra Non-Exempt Anticonvulsants ⦸ Low Back Disorders ✕ Shoulder ✓ Ankle and Foot Disorders Antibiotics levofloxacin Levaquin Exempt ✓✕ Hand, Wrist, and Forearm Disorders (Fluoroquinolones) ✓ Hip and Groin Disorders Ophthalmic Agents levofloxacin ophthalmic solution Quixin Exempt ✓✕⦸ Eye (Anti-bacterial) ✕ Cervical and Thoracic Spine Disorders ✕ Chronic Pain Antidepressants ✕ Hip and Groin Disorders levomilnacipran Fetzima Non-Exempt (SNRI) ✕ Knee Disorders ✕ Low Back Disorders ✕ Shoulder ✕ Ankle and Foot Disorders ✕ Cervical and Thoracic Spine Disorders ✕ Chronic Pain ✕ Elbow Disorders levorphanol tartrate Levo-Dromoran Non-Exempt Analgesics - Opioid ✕ Hand, Wrist, and Forearm Disorders ✕ Hip and Groin Disorders ✕ Knee Disorders ✕ Low Back Disorders ✕ Shoulder ✓⦸ Ankle and Foot Disorders ✕ Cervical and Thoracic Spine Disorders ✓⦸ Chronic Pain lidocaine Lidoderm Non-Exempt Dermatologicals ⦸ Elbow Disorders ✓ Hand, Wrist, and Forearm Disorders ✕⦸ Hip and Groin Disorders ✕⦸ Low Back Disorders

lidocaine hcl Non-Exempt Dermatologicals ✕ Cervical and Thoracic Spine Disorders

lidocaine hcl ophth Akten Exempt Opthalmic Agents ✓ Eye

*ACOEM Guidelines Copyright Reed Group Ltd.

Effective August 1, 2019 16 of 29

MTUS Drug List v.5 (8 CCR § 9792.27.15)

Exempt/Non- Unique Drug Ingredient Brand Example Special Fill** Peri-Op*** Drug Class Reference in ACOEM Guidelines * Dosage Form Strength Pharmaceutical Exempt* Identifier(s) ✕ Cervical and Thoracic Spine Disorders ⦸ Chronic Pain ✓ Hand, Wrist, and Forearm Disorders lidocaine/prilocaine Emla Non-Exempt Dermatologicals ✕⦸ Hip and Groin Disorders ✕ Low Back Disorders ⦸ Shoulder Antipsychotics / lithium carbonate Lithobid Non-Exempt ⦸ Traumatic Brain Injury Antimanic Agents Antihistamine and/or lodoxamide ophth Alomide Exempt ✓ Eye mast cell stabilization

Antihistamine and/or loratadine Claritin Exempt ✓ Eye mast cell stabilization

lorazepam Ativan Non-Exempt Antianxiety Agents ✓ Ankle and Foot Disorders

Ophthalmic Agents loteprednol etabonate ophthalmic Alrex Non-Exempt 4 Days ✓✕⦸ Eye (Steroid) Minerals & magnesium Non-Exempt ✕ Chronic Pain Electrolytes ✕ Cervical and Thoracic Spine Disorders ✕ Chronic Pain Antidepressants ✕⦸ Hip and Groin Disorders maprotiline hcl Ludiomil Non-Exempt (TCAs) ✕⦸ Knee Disorders ✕ Low Back Disorders ✕ Shoulder ✓ Ankle and Foot Disorders ✓ Cervical and Thoracic Spine Disorders ✓ Chronic Pain ✓✕⦸ Elbow Disorders Analgesics - Anti- ✓✕⦸ Hand, Wrist, and Forearm Disorders meclofenamate sodium Meclomen Exempt Inflammatory (NSAID) ✓⦸ Hip and Groin Disorders ✓⦸ Knee Disorders ✓ Low Back Disorders ✓ Shoulder ⦸ Traumatic Brain Injury medroxyprogesterone Provera Non-Exempt Progestins ✕ Traumatic Brain Injury ✓ Ankle and Foot Disorders ✓ Cervical and Thoracic Spine Disorders ✓ Chronic Pain ✓✕⦸ Elbow Disorders Analgesics - Anti- ✓✕⦸ Hand, Wrist, and Forearm Disorders mefenamic acid Ponstel Exempt Inflammatory (NSAID) ✓⦸ Hip and Groin Disorders ✓⦸ Knee Disorders ✓ Low Back Disorders ✓ Shoulder ⦸ Traumatic Brain Injury

melatonin Non-Exempt Alternative Medicines ✓ Chronic Pain

*ACOEM Guidelines Copyright Reed Group Ltd.

Effective August 1, 2019 17 of 29

MTUS Drug List v.5 (8 CCR § 9792.27.15)

Exempt/Non- Unique Drug Ingredient Brand Example Special Fill** Peri-Op*** Drug Class Reference in ACOEM Guidelines * Dosage Form Strength Pharmaceutical Exempt* Identifier(s) ✓ Ankle and Foot Disorders ✓ Cervical and Thoracic Spine Disorders ✓ Chronic Pain ✓✕⦸ Elbow Disorders Analgesics - Anti- ✓✕⦸ Hand, Wrist, and Forearm Disorders meloxicam Mobic Exempt Inflammatory (NSAID) ✓⦸ Hip and Groin Disorders ✓⦸ Knee Disorders ✓ Low Back Disorders ✓ Shoulder ⦸ Traumatic Brain Injury Psychotherapeutic and Neurological Agents - ✕⦸ Chronic Pain memantine hcl Namenda Non-Exempt Misc. ✕ Low Back Disorders (NDMA Receptor ⦸ Traumatic Brain Injury Antagonist) ⦸ Ankle and Foot Disorders ⦸ Cervical and Thoracic Spine Disorders ⦸ Chronic Pain menthol Bengay Ultra, Biofreeze Non-Exempt Dermatologicals ✓ Hand, Wrist, and Forearm Disorders ✕⦸ Hip and Groin Disorders ⦸ Low Back Disorders ⦸ Shoulder ✕ Ankle and Foot Disorders ✕ Cervical and Thoracic Spine Disorders ✕ Chronic Pain ✕ Elbow Disorders meperidine hcl Demerol Non-Exempt Analgesics - Opioid ✕ Hand, Wrist, and Forearm Disorders ✕ Hip and Groin Disorders ✕ Knee Disorders ✕ Low Back Disorders ✕ Shoulder ✕ Cervical and Thoracic Spine Disorders ✕ Chronic Pain Musculoskeletal ✕ Hip and Groin Disorders metaxalone Skelaxin Non-Exempt Therapy Agents ✕ Knee Disorders (Muscle Relaxants) ✕ Low Back Disorders ✕ Shoulder ✕ Ankle and Foot Disorders ✕ Cervical and Thoracic Spine Disorders ✕ Chronic Pain ✕ Elbow Disorders ✕ Hand, Wrist, and Forearm Disorders methadone hcl Dolophine Non-Exempt Analgesics - Opioid ✕ Hip and Groin Disorders ✕ Knee Disorders ✕ Low Back Disorders ✓ Opioid ✕ Shoulder ✕ Cervical and Thoracic Spine Disorders ✕ Chronic Pain Musculoskeletal ✕ Hip and Groin Disorders methocarbamol Robaxin Non-Exempt Therapy Agents ✕ Knee Disorders (Muscle Relaxants) ✕ Low Back Disorders ✕ Shoulder ⦸ Cervical and Thoracic Spine Disorders ⦸ Chronic Pain ✓ Hand, Wrist, and Forearm Disorders methyl salicylate Bengay Ultra Non-Exempt Dermatologicals ✕⦸ Hip and Groin Disorders ⦸ Low Back Disorders ⦸ Shoulder

*ACOEM Guidelines Copyright Reed Group Ltd.

Effective August 1, 2019 18 of 29

MTUS Drug List v.5 (8 CCR § 9792.27.15)

Exempt/Non- Unique Drug Ingredient Brand Example Special Fill** Peri-Op*** Drug Class Reference in ACOEM Guidelines * Dosage Form Strength Pharmaceutical Exempt* Identifier(s) ADHD / Anti- methylphenidate hydrochloride Ritalin, Concerta Non-Exempt 4 Days narcolepsy / Anti- ✓ Traumatic Brain Injury Obesity / Anorexiants ✓✕ Ankle and Foot Disorders ✓✕ Cervical and Thoracic Spine Disorders ✓✕ Chronic Pain ⦸ Elbow Disorders ✓⦸ Hand, Wrist, and Forearm Disorders methylprednisolone Medrol Non-Exempt 4 Days Corticosteroids ✕ Hip and Groin Disorders ✓✕⦸ Low Back Disorders ✓✕⦸ Shoulder ✓ Work Related Asthma ✕ Traumatic Brain Injury ⦸ Hip and Groin Disorders Chemicals (OTC methylsulfonylmethane Non-Exempt ⦸ Knee Disorders nutraceuticals) ⦸ Shoulder

metronidazole Exempt Dermatologicals ✓ Ankle and Foot Disorders

Anti-Infective Agents - metronidazole oral Flagyl Exempt ✓Hand, Wrist, and Forearm Disorders Misc.

miconazole nitrate Micatin Non-Exempt Dermatologicals ✓ Ankle and Foot Disorders

Hypnotics / Sedatives midazolam hcl Versed Non-Exempt 4 Days / Sleep Disorder ✓ Traumatic Brain Injury Agents ✕ Cervical and Thoracic Spine Disorders Psychotherapeutic and ✓✕ Chronic Pain Neurological Agents - ✕ Hip and Groin Disorders milnacipran Savella Non-Exempt Misc. (Anti- ✕ Knee Disorders depressant) ✕ Low Back Disorders ✕ Shoulder Antibiotics minocycline hcl Minocin Non-Exempt ✓⦸ Ankle and Foot Disorders (Tetracyclines)

✓ Chronic Pain mirtazapine Remeron Exempt Antidepressants ✓ Post-Traumatic Stress Disorder ✓ Cervical and Thoracic Spine Disorders ✓ Elbow Disorders ✓ Hand, Wrist, and Forearm Disorders ✓ Hip and Groin Disorders misoprostol Cytotec Exempt Ulcer Drugs ✓ Knee Disorders ✓ Low Back Disorders ✓ Shoulder ✓ Traumatic Brain Injury ADHD / Anti- modafinil Provigil Non-Exempt narcolepsy / Anti- ⦸ Traumatic Brain Injury Obesity / Anorexiants

mometasone furoate (topical) Elocon Non-Exempt Dermatologicals ✓ Ankle and Foot Disorders

Antiasthmatic and mometasone furoate Asmanex Non-Exempt ✓ Work Related Asthma Bronchodilator Agents

Antiasthmatic and montelukast sodium Singluair Non-Exempt ✓ Work Related Asthma Bronchodilator Agents

*ACOEM Guidelines Copyright Reed Group Ltd.

Effective August 1, 2019 19 of 29

MTUS Drug List v.5 (8 CCR § 9792.27.15)

Ophthalmic Agents moxifloxacin hcl ophthalmic Vigamox Exempt ✓✕⦸ Eye (Antibiotics)

mupirocin Bactroban Exempt Dermatologicals ✓Ankle and Foot Disorders

nabilone Cesamet Non-Exempt Antiemetics ⦸ Post-Traumatic Stress Disorder

✓ Ankle and Foot Disorders ✓ Cervical and Thoracic Spine Disorders ✓ Chronic Pain ✓✕⦸ Elbow Disorders Analgesics - Anti- ✓✕⦸ Hand, Wrist, and Forearm Disorders nabumetone Relafen Exempt Inflammatory (NSAID) ✓⦸ Hip and Groin Disorders ✓⦸ Knee Disorders ✓ Low Back Disorders ✓ Shoulder ⦸ Traumatic Brain Injury ✕ Cervical and Thoracic Spine Disorders ✓✕ Chronic Pain n-acetyl-l-cysteine NAC Non-Exempt Nutrients ✕⦸ Hip and Groin Disorders ✕ Low Back Disorders Antidotes and Specific naloxone hcl Evzio, Narcan Exempt ✓ Opioid Antagonists

*ACOEM Guidelines Copyright Reed Group Ltd.

Effective August 1, 2019 20 of 29

MTUS Drug List v.5 (8 CCR § 9792.27.15)

natamycin ophth Natacyn Exempt Antifungals ✓✕ Eye

nedocromil Alocril Exempt Ophtalmic Agents ✓ Eye

nefazodone hcl Serzone Exempt Antidepressants ✓ Post-Traumatic Stress Disorder

neomycin sulfate Non-Exempt Dermatologicals ⦸ Hand, Wrist, and Forearm Disorders

neomycin/polymyxin b/bacitracin Neosporin Exempt Dermatologicals ✓ Ankle and Foot Disorders

Calcium Channel nifedipine Procardia Non-Exempt ✓ Hand, Wrist, and Forearm Disorders Blockers Antianginal Agents ✓⦸ Ankle and Foot Disorders nitroglycerin transdermal Nitro-Dur Non-Exempt (Glyceril trinitrate ⦸ Shoulder patches) ✓ Cervical and Thoracic Spine Disorders ✓ Elbow Disorders ✓ Hand, Wrist, and Forearm Disorders Ulcer Drugs (H2 nizatidine Axid Exempt ✓ Hip and Groin Disorders receptor blocker) ✓ Knee Disorders ✓ Low Back Disorders ✓ Shoulder ✓✕ Cervical and Thoracic Spine Disorders ✓ Chronic Pain ⦸ Hip and Groin Disorders Antidepressants nortriptyline hcl Pamelor Non-Exempt ✓✕⦸ Knee Disorders (TCAs) ✓⦸ Low Back Disorders ⦸ Post-Traumatic Stress Disorder ✓✕ Shoulder nystatin/triamcinolone Mycolog II Non-Exempt Dermatologicals ✓Ankle and Foot Disorders

Antipsychotics / ✓ Traumatic Brain Injury olanzapine Zyprexa Non-Exempt 4 Days Antimanic Agents ✓ Post-Traumatic Stress Disorder Ophthalmic Agents ofloxacin ophthalmic solution Ocuflox Exempt ✓✕⦸ Eye (Anti-bacterial) Antihistamine and/or olopatadine hcl Pataday, Patanol Exempt ✓ Eye mast cell stabilization

omega-3 Omega-3 Fatty Acids Non-Exempt Nutrients ⦸ Post-Traumatic Stress Disorder

✓ Cervical and Thoracic Spine Disorders ✓ Elbow Disorders ✓ Hand, Wrist, and Forearm Disorders Ulcer Drugs (Proton ✓ Hip and Groin Disorders omeprazole Prilosec Exempt pump inhibitor) ✓ Knee Disorders ✓ Low Back Disorders ✓ Shoulder ✓ Traumatic Brain Injury

*ACOEM Guidelines Copyright Reed Group Ltd.

Effective August 1, 2019 21 of 29

MTUS Drug List v.5 (8 CCR § 9792.27.15)

✕ Cervical and Thoracic Spine Disorders ✕ Chronic Pain Musculoskeletal ✕ Hip and Groin Disorders orphenadrine citrate Norflex Non-Exempt Therapy Agents ✕ Knee Disorders (Muscle Relaxants) ✕ Low Back Disorders ✕ Shoulder ✓ Ankle and Foot Disorders ✓ Cervical and Thoracic Spine Disorders ✓ Chronic Pain ✓✕⦸ Elbow Disorders Analgesics - Anti- ✓✕⦸ Hand, Wrist, and Forearm Disorders oxaprozin Daypro Exempt Inflammatory (NSAID) ✓⦸ Hip and Groin Disorders ✓⦸ Knee Disorders ✓ Low Back Disorders ✓ Shoulder ⦸ Traumatic Brain Injury ✓ Cervical and Thoracic Spine Disorders ✓ Chronic Pain oxcarbazepine Trileptal Non-Exempt Anticonvulsants ⦸ Low Back Disorders ✕ Shoulder ✓✕ Ankle and Foot Disorders ✓✕ Cervical and Thoracic Spine Disorders ✓✕ Chronic Pain ✓✕ Elbow Disorders oxycodone hcl OxyContin, Roxicodone Non-Exempt 4 Days 4 Days Analgesics - Opioid ✓✕ Hand, Wrist, and Forearm Disorders ✓ Hip and Groin Disorders ✓ Knee Disorders ✓✕ Low Back Disorders ✓✕ Shoulder ✓✕ Ankle and Foot Disorders ✓✕ Cervical and Thoracic Spine Disorders ✓✕ Chronic Pain ✓✕ Elbow Disorders oxycodone/acetaminophen Percocet Non-Exempt 4 days 4 days Analgesics - Opioid ✓✕ Hand, Wrist, and Forearm Disorders ✓ Hip and Groin Disorders ✓ Knee Disorders ✓✕ Low Back Disorders ✓✕ Shoulder ✕ Ankle and Foot Disorders ✕ Cervical and Thoracic Spine Disorders ✕ Chronic Pain ✕ Elbow Disorders oxycodone/aspirin Percodan Non-Exempt Analgesics - Opioid ✕ Hand, Wrist, and Forearm Disorders ✕ Hip and Groin Disorders ✕ Knee Disorders ✕ Low Back Disorders ✕ Shoulder ✕ Ankle and Foot Disorders ✕ Cervical and Thoracic Spine Disorders ✕ Chronic Pain ✕ Elbow Disorders oxycodone/ibuprofen Combunox Non-Exempt Analgesics - Opioid ✕ Hand, Wrist, and Forearm Disorders ✕ Hip and Groin Disorders ✕ Knee Disorders ✕ Low Back Disorders ✕ Shoulder

*ACOEM Guidelines Copyright Reed Group Ltd.

Effective August 1, 2019 22 of 29

MTUS Drug List v.5 (8 CCR § 9792.27.15)

Antibiotics penicillin v potassium Non-Exempt ✕ Hand, Wrist, and Forearm Disorders (Penicillins) ✕ Ankle and Foot Disorders ✕ Cervical and Thoracic Spine Disorders ✕ Chronic Pain ✕ Elbow Disorders pentazocine/naloxone hcl Talwin NX Non-Exempt Analgesics - Opioid ✕ Hand, Wrist, and Forearm Disorders ✕ Hip and Groin Disorders ✕ Knee Disorders ✕ Low Back Disorders ✕ Shoulder

phenelzine sulfate Nardil Exempt Antidepressants ✓ Post-Traumatic Stress Disorder

Hypnotics / Sedatives phenobarbital Non-Exempt / Sleep Disorder ✕⦸ Traumatic Brain Injury Agents ✕ Chronic Pain ⦸ Low Back Disorders phenytoin Dilantin Non-Exempt Anticonvulsants ✕ Shoulder ✕⦸ Traumatic Brain Injury ✕ Ankle and Foot Disorders ✕ Cervical and Thoracic Spine Disorders ✕ Chronic Pain ✕ Elbow Disorders Analgesics - Anti- ✕ Hand, Wrist, and Forearm Disorders piroxicam Feldene Non-Exempt Inflammatory (NSAID) ✕ Hip and Groin Disorders ✕ Knee Disorders ✕ Low Back Disorders ✕ Shoulder ✕ Traumatic Brain Injury

*ACOEM Guidelines Copyright Reed Group Ltd.

Effective August 1, 2019 23 of 29

MTUS Drug List v.5 (8 CCR § 9792.27.15)

prazosin hcl Minpress Exempt Antihypertensives ✓ Post-Traumatic Stress Disorder

prednicarbate Dermatop Non-Exempt Dermatologicals ✓ Ankle and Foot Disorders

✓✕ Ankle and Foot Disorders ✓✕ Cervical and Thoracic Spine Disorders ✓✕ Chronic Pain ⦸ Elbow Disorders prednisolone Orapred Non-Exempt 4 Days Corticosteroids ✓⦸ Hand, Wrist, and Forearm Disorders ✕ Hip and Groin Disorders ✓✕⦸ Low Back Disorders ✓✕⦸ Shoulder ✓ Work Related Asthma Ophthalmic Agents prednisolone acetate Pred Forte, Pred Mild Non-Exempt ✓✕⦸ Eye (Steroid) Ophthalmic Agents prednisolone sodium ophth Omnipred Non-Exempt 4 Days ✓✕⦸ Eye (Steroid) ✓✕ Ankle and Foot Disorders ✓✕ Cervical and Thoracic Spine Disorders ✓✕ Chronic Pain ⦸ Elbow Disorders prednisone Sterapred Non-Exempt 4 Days Corticosteroids ✓⦸ Hand, Wrist, and Forearm Disorders ✕ Hip and Groin Disorders ✓✕⦸ Low Back Disorders ✓✕⦸ Shoulder ✓ Work Related Asthma ⦸ Cervical and Thoracic Spine Disorders ✓ Chronic Pain pregabalin Lyrica Non-Exempt Anticonvulsants ✓⦸ Low Back Disorders ✓✕⦸ Shoulder Psychotherapeutic and pregabalin (once-daily) Lyrica CR Non-Exempt Neurological Agents - ✕ Chronic Pain Misc

progesterone Non-Exempt Progestins ✕ Traumatic Brain Injury

Ophthalmic Agents proparacaine hcl Alcaine Exempt ✓ Eye (Anesthetic) ✓ Traumatic Brain Injury propranolol hcl Inderal Exempt Beta Blockers ⦸ Post-Traumatic Stress Disorder

Antidepressants ✕ Chronic Pain protriptyline hcl Non-Exempt (TCAs) ✕ Knee Disorders Antimyasthenic / pyridostigmine bromide Mestinon Non-Exempt ✕ Chronic Pain Cholinergic Agents ⦸ Chronic Pain Antipsychotics / quetiapine fumarate Seroquel Non-Exempt 4 Days ✓ Traumatic Brain Injury Antimanic Agents ✓ Post-Traumatic Stress Disorder

*ACOEM Guidelines Copyright Reed Group Ltd.

Effective August 1, 2019 24 of 29

MTUS Drug List v.5 (8 CCR § 9792.27.15)

Exempt/Non- Unique Drug Ingredient Brand Example Special Fill** Peri-Op*** Drug Class Reference in ACOEM Guidelines * Dosage Form Strength Pharmaceutical Exempt* Identifier(s) ✓ Cervical and Thoracic Spine Disorders ✓ Elbow Disorders ✓ Hand, Wrist, and Forearm Disorders Ulcer Drugs (Proton ✓ Hip and Groin Disorders rabeprazole sodium Aciphex Exempt pump inhibitor) ✓ Knee Disorders ✓ Low Back Disorders ✓ Shoulder ✓ Traumatic Brain Injury Endocrine and raloxifene hydrochloride Evista Non-Exempt Metabolic Agents- ✕ Chronic Pain Misc. ✓ Cervical and Thoracic Spine Disorders ✓ Elbow Disorders ✓ Hand, Wrist, and Forearm Disorders Ulcer Drugs (H2 ✓ Hip and Groin Disorders ranitidine hcl Zantac Exempt receptor blocker) ✓ Knee Disorders ✓ Low Back Disorders ✓ Shoulder ✓ Traumatic Brain Injury ✕ Ankle and Foot Disorders regular insulin Humulin R Non-Exempt Antidiabetics ✕ Hand, Wrist, and Forearm Disorders Endocrine and ✓⦸ Hip and Groin Disorders Metabolic Agents- ⦸ Knee Disorders risedronate sodium Actonel Non-Exempt Misc. ✕ Low Back Disorders (Bisphosphonate) ✓ Shoulder Antipsychotics / ⦸ Post-Traumatic Stress Disorder risperidone Risperdal Non-Exempt 4 Days Antimanic Agents ✓ Traumatic Brain Injury ⦸ Ankle and Foot Disorders rivaroxaban Xarelto Non-Exempt 14 Days Anticoagulants ✓ Hip and Groin Disorders ✓ Knee Disorders Psychotherapeutic and rivastigmine tartrate Exelon Exempt Neurological Agents - ✓ Traumatic Brain Injury Misc. rizatriptan benzoate Maxalt Exempt Migraine Products ✓ Traumatic Brain Injury

s-adenosylmethionine SAM E Non-Exempt Alternative Medicines ✕ Chronic Pain

Antiasthmatic and salmeterol Serevent Non-Exempt ✓ Work Related Asthma Bronchodilator Agents

✓ Ankle and Foot Disorders ✓ Cervical and Thoracic Spine Disorders ✓ Chronic Pain ✓✕⦸ Elbow Disorders Analgesics - ✓✕⦸ Hand, Wrist, and Forearm Disorders salsalate Disalcid Exempt NonNarcotic (NSAID) ✓⦸ Hip and Groin Disorders ✓⦸ Knee Disorders ✓ Low Back Disorders ✓ Shoulder ⦸ Traumatic Brain Injury ✕ Cervical and Thoracic Spine Disorders ✓✕ Chronic Pain ✕ Hip and Groin Disorders Antidepressants ✓✕ Knee Disorders sertraline hcl Zoloft Exempt (SSRI) ✕ Low Back Disorders ✓ Post-Traumatic Stress Disorder ✕ Shoulder ✓ Traumatic Brain Injury

*ACOEM Guidelines Copyright Reed Group Ltd.

Effective August 1, 2019 25 of 29

MTUS Drug List v.5 (8 CCR § 9792.27.15)

sodium chloride ophthalmic Exempt Ophthalmic Agents ✓ Eye

Psychotherapeutic and sodium oxybate Xyrem Non-Exempt Neurological Agents - ✓ Chronic Pain Misc. ✓ Cervical and Thoracic Spine Disorders ✓ Elbow Disorders ✓ Hip and Groin Disorders sucralfate Carafate Exempt Ulcer Drugs ✓ Knee Disorders ✓ Low Back Disorders ✓ Shoulder ✓ Traumatic Brain Injury Anti-Infective Agents - ✓⦸ Ankle and Foot Disorders sulfamethoxazole/trimethoprim Bactrim Exempt Misc. ✓✕⦸ Hand, Wrist, and Forearm Disorders ✓ Ankle and Foot Disorders ✓ Cervical and Thoracic Spine Disorders ✓ Chronic Pain ✓✕⦸ Elbow Disorders Analgesics - Anti- ✓✕⦸ Hand, Wrist, and Forearm Disorders sulindac Clinoril Exempt Inflammatory (NSAID) ✓⦸ Hip and Groin Disorders ✓⦸ Knee Disorders ✓ Low Back Disorders ✓ Shoulder ⦸ Traumatic Brain Injury sumatriptan succinate Imitrex Exempt Migraine Products ✓ Traumatic Brain Injury

tacrolimus Protopic Non-Exempt Dermatologicals ✓Ankle and Foot Disorders ✕ Ankle and Foot Disorders ✕ Cervical and Thoracic Spine Disorders ✕ Chronic Pain ✕ Elbow Disorders tapentadol Nucynta Non-Exempt Analgesics - Opioid ✕ Hand, Wrist, and Forearm Disorders ✕ Hip and Groin Disorders ✕ Knee Disorders ✕ Low Back Disorders ✕ Shoulder Hypnotics / Sedatives temazepam Restoril Non-Exempt / Sleep Disorder ✕ Post-Traumatic Stress Disorder Agents terbinafine hcl Lamisil Non-Exempt Antifungals ✓Ankle and Foot Disorders

terbinafine hcl (topical) Lamisil Non-Exempt Dermatologicals ✓ Ankle and Foot Disorders

Ophthalmic Agents tetracaine hcl Tetcaine Exempt ✓ Eye (Anesthetic)

tetracycline hcl Exempt Tetracyclines ✓ Eye

✕ Chronic Pain thalidomide Thalomid Non-Exempt Assorted Classes ✕ Low Back Disorders

Antiasthmatic and theophylline Theo-24, Theo-Dur Non-Exempt ✓ Work Related Asthma Bronchodilator Agents

*ACOEM Guidelines Copyright Reed Group Ltd.

Effective August 1, 2019 26 of 29

MTUS Drug List v.5 (8 CCR § 9792.27.15)

Exempt/Non- Unique Drug Ingredient Brand Example Special Fill** Peri-Op*** Drug Class Reference in ACOEM Guidelines * Dosage Form Strength Pharmaceutical Exempt* Identifier(s) ✕ Chronic Pain ⦸ Low Back Disorders tiagabine hcl Gabitril Non-Exempt Anticonvulsants ✕ Post-Traumatic Stress Disorder ✕ Shoulder ✓✕ Cervical and Thoracic Spine Disorders ✓✕⦸ Chronic Pain Musculoskeletal ✓✕ Hip and Groin Disorders tizanidine hcl Zanaflex Non-Exempt 4 days Therapy Agents ✕⦸ Knee Disorders (Muscle Relaxants) ✓✕ Low Back Disorders ✓✕ Shoulder ✓ Traumatic Brain Injury Ophthalmic Agents tobramycin ophthalmic Tobrex Exempt ✓✕⦸ Eye (Anti-bacterial)

tolnaftate Tinactin Non-Exempt Dermatologicals ✓ Ankle and Foot Disorders ✓ Ankle and Foot Disorders ✓ Cervical and Thoracic Spine Disorders ✓ Chronic Pain ✓✕⦸ Elbow Disorders Analgesics - Anti- ✓✕⦸ Hand, Wrist, and Forearm Disorders tolmetin sodium Tolectin Exempt Inflammatory (NSAID) ✓⦸ Hip and Groin Disorders ✓⦸ Knee Disorders ✓ Low Back Disorders ✓ Shoulder ⦸ Traumatic Brain Injury ✓✕ Cervical and Thoracic Spine Disorders ✓ Chronic Pain ✕⦸ Hip and Groin Disorders topiramate Topamax Non-Exempt Anticonvulsants ✕⦸ Knee Disorders ✓⦸ Low Back Disorders ⦸ Post-Traumatic Stress Disorder ✕⦸ Shoulder ✓✕ Ankle and Foot Disorders ✓✕ Cervical and Thoracic Spine Disorders ✓✕ Chronic Pain ✓✕ Elbow Disorders tramadol hcl Ultram, Ultram ER Non-Exempt 4 Days 4 Days Analgesics - Opioid ✓✕ Hand, Wrist, and Forearm Disorders ✓ Hip and Groin Disorders ✓ Knee Disorders ✓✕ Low Back Disorders ✓✕ Shoulder ✓✕ Ankle and Foot Disorders ✓✕ Cervical and Thoracic Spine Disorders ✓✕ Chronic Pain ✓✕ Elbow Disorders tramadol hcl/ac Ultracet Non-Exempt 4 Days 4 Days Analgesics - Opioid ✓✕ Hand, Wrist, and Forearm Disorders ✓ Hip and Groin Disorders ✓ Knee Disorders ✓✕ Low Back Disorders ✓✕ Shoulder ✓ Eye tranexamic acid Lysteda Exempt Hemostatics ✓ Traumatic Brain Injury

*ACOEM Guidelines Copyright Reed Group Ltd.

Effective August 1, 2019 27 of 29

MTUS Drug List v.5 (8 CCR § 9792.27.15)

Exempt/Non- Unique Drug Ingredient Brand Example Special Fill** Peri-Op*** Drug Class Reference in ACOEM Guidelines * Dosage Form Strength Pharmaceutical Exempt* Identifier(s) ✕ Cervical and Thoracic Spine Disorders ✓✕⦸ Chronic Pain ✕ Hip and Groin Disorders Antidepressants trazodone hcl Desyrel, Oleptro Non-Exempt ✕ Knee Disorders (SSRI) ✕ Low Back Disorders ⦸ Post-Traumatic Stress Disorder ✕ Shoulder

triamcinolone acetonide i Non-Exempt Dermatologicals ✓ Ankle and Foot Disorders

trolamine salicylate Arthricream Non-Exempt Dermatologicals ✓ Hand, Wrist, and Forearm Disorders

Ophthalmic Agents tropicamide ophthalmic Mydriacyl Exempt ✕ Eye (Anticholinergics) Chemicals (Proteolytic trypsin Non-Exempt ✕ Ankle and Foot Disorders enzyme) valacyclovir hcl Valtrex Non-Exempt Antivirals ✕⦸ Chronic Pain

✕ Chronic Pain ⦸ Low Back Disorders Depakote, Depakene, valproic acid Non-Exempt Anticonvulsants ✕ Post-Traumatic Stress Disorder Depacon ✕ Shoulder ✕⦸ Traumatic Brain Injury ✓✕ Cervical and Thoracic Spine Disorders ✓ Chronic Pain ⦸ Hip and Groin Disorders Antidepressants venlafaxine hcl Effexor Exempt ✓✕⦸ Knee Disorders (SNRI) ✓⦸ Low Back Disorders ✓ Post-Traumatic Stress Disorder ✓✕ Shoulder ✕ Cervical and Thoracic Spine Disorders ✕ Chronic Pain ✕ Hip and Groin Disorders Antidepressants vilazodone Viibryd Non-Exempt ✕ Knee Disorders (SSRI) ✕ Low Back Disorders ✕ Post-Traumatic Stress Disorder ✕ Shoulder vitamin a Non-Exempt Vitamins ✕ Cervical and Thoracic Spine Disorders ✕ Cervical and Thoracic Spine Disorders Cyanocobalamin, Hematopoietic Agents vitamin b-12 Non-Exempt ⦸ Elbow Disorders Methylcobalamin (Vitamins) ✕ Low Back Disorders ✕⦸ Ankle and Foot Disorders ✕ Cervical and Thoracic Spine Disorders vitamin b-6 Pyridoxine Non-Exempt Vitamins ✕ Elbow Disorders ✕ Hand, Wrist, and Forearm Disorders

vitamin d3 Non-Exempt Vitamins ✓ Chronic Pain

✕⦸ Ankle and Foot Disorders vitamin e Non-Exempt Vitamins ✕ Cervical and Thoracic Spine Disorders ✕ Low Back Disorders ⦸ Ankle and Foot Disorders warfarin sodium Coumadin Non-Exempt 14 Days Anticoagulants ✓ Hip and Groin Disorders ✓ Knee Disorders

Antiasthmatic and zafirlukast Accolate Non-Exempt ✓ Work Related Asthma Bronchodilator Agents

*ACOEM Guidelines Copyright Reed Group Ltd.

Effective August 1, 2019 28 of 29

MTUS Drug List v.5 (8 CCR § 9792.27.15)

Antipsychotics / ziprasidone hcl Geodon Non-Exempt 4 Days ✓ Traumatic Brain Injury Antimanic Agents

zolmitriptan Zomig Exempt Migraine Products ✓ Traumatic Brain Injury

Hypnotics / Sedatives zolpidem tartrate Ambien Non-Exempt / Sleep Disorder ✕ Chronic Pain Agents ✕ Chronic Pain zonisamide Zonegran Non-Exempt Anticonvulsants ⦸ Low Back Disorders ✕ Shoulder

*ACOEM Guidelines Copyright Reed Group Ltd.

Effective August 1, 2019 29 of 29