New York Workers’ Compensation Formulary Change Tracker: Updates since the previous version (Aug. 2019) are highlighted in red

Carpal Pain Non Ankle / Back Mid / Hip / Knee Neck Shoulder Tunnel CRPS Elbow Eye Acute Therapeutic Category Generic Name Foot Low (MTG) Groin (MTG) (MTG) (MTG) Special Special Phase A Phase B (MTG) (MTG) Perioperative Considerations Analgesics - Narcotic** Codeine-Acetaminophen 1,3 x x Analgesics - Narcotic** Hydrocodone-Acetaminophen 1,3 x x Analgesics - Narcotic** Hydrocodone-Ibuprofen 1,3 x x Analgesics - Narcotic** Morphine 1,3 x x Analgesics - Narcotic** Oxycodone HCl 1,3 x x Analgesics - Narcotic** Oxycodone-Acetaminophen 1,3 x x Analgesics - Narcotic** Oxycodone-Aspirin 1,3 x x Analgesics - Narcotic** Tapentadol 1,3 x Analgesics - Narcotic** HCl 1,3 x x Analgesics - Narcotic** Tramadol-Acetaminophen 1,3 x x Analgesics - Nonnarcotic Acetaminophen x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Analgesics - Nonnarcotic Aspirin x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Analgesics - Nonnarcotic - Magnesium Salicylates x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Analgesics - Nonnarcotic Diflunisal x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Analgesics - Topical Capsaicin x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Analgesics - Topical Diclofenac Na (1% only) x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Analgesics - Topical Lidocaine Patch (4% Only) x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Analgesics - Topical Methyl Salicylate x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Antacids Alum Hydrox-Mag Trisil-Alginic Acid-Sod 4 x x Antacids Aluminum - Magnesium Hydroxides 4 x x Aluminum Hydroxide-Magnesium Carbonate Antacids 4 x x Susp Aluminum Hydroxide-Magnesium Trisilicate Antacids 4 x x Chew Tab Antacids Calcium - Magnesium Carbonates 4 x x Antacids Calcium Carbonate 4 x x Antacids Calcium Carbonate - Simethicone 4 x x Antacids Calcium Carbonate-Mag Hydroxide 4 x x Antianxiety Agents Alprazolam 1 x Antianxiety Agents Buspirone 1 x Antiasthmatics Aclidinium Bromide Aerosol Powd x x Antiasthmatics Albuterol Inhal x x Yes Antiasthmatics Albuterol Sulfate x x Yes Antiasthmatics Beclomethasone Inh x x Yes Antiasthmatics x x Yes Antiasthmatics Budesonide Inh x x Yes Antiasthmatics Budesonide- Fumarate Inh x x Yes Antiasthmatics Inh x x Yes Antiasthmatics Cromolyn Na Inhal x x Yes Antiasthmatics Epinephrine Inhal x x Yes Antiasthmatics Inh x x Yes Antiasthmatics Furoate- Inh x x Yes Antiasthmatics Fluticasone Inh x x Yes Antiasthmatics Fluticasone- Inhal x x Yes Antiasthmatics Formoterol Fumarate Soln Nebu x x Yes Antiasthmatics Formoterol/ x x Yes Antiasthmatics Maleate Inhal x x Yes Antiasthmatics Inhal x x Yes Antiasthmatics Ipratropium-Albuterol Inh x x Yes Antiasthmatics Levalbuterol HCl Inhal x x Yes Antiasthmatics Chloride Inhal x x Yes Antiasthmatics Mometasone Furoate Inh x x Yes Mometasone Furoate-Formoterol Fumarate Antiasthmatics x x Yes Rev. November 5, 2019 Inh Antiasthmatics x x Page 1 Yes Antiasthmatics x x Yes

REV: July 31, 2019 Page 1 of 8 Carpal Pain Non Ankle / Back Mid / Hip / Knee Neck Shoulder Asthma Tunnel CRPS Elbow Eye Acute Therapeutic Category Generic Name Foot Low (MTG) Groin (MTG) (MTG) (MTG) Special Special Phase A Phase B (MTG) (MTG) Perioperative Considerations Analgesics - Narcotic** Codeine-Acetaminophen 1,3 x x Analgesics - Narcotic** Hydrocodone-Acetaminophen 1,3 x x Analgesics - Narcotic** Hydrocodone-Ibuprofen 1,3 x x Analgesics - Narcotic** Morphine 1,3 x x Analgesics - Narcotic** Oxycodone HCl 1,3 x x Analgesics - Narcotic** Oxycodone-Acetaminophen 1,3 x x Analgesics - Narcotic** Oxycodone-Aspirin 1,3 x x Analgesics - Narcotic** Tapentadol 1,3 x Analgesics - Narcotic** Tramadol HCl 1,3 x x Analgesics - Narcotic** Tramadol-Acetaminophen 1,3 x x Analgesics - Nonnarcotic Acetaminophen x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Analgesics - Nonnarcotic Aspirin x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Analgesics - Nonnarcotic Choline - Magnesium Salicylates x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Analgesics - Nonnarcotic Diflunisal x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Analgesics - Topical Capsaicin x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Analgesics - Topical Diclofenac Na (1% only) x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Analgesics - Topical Lidocaine Patch (4% Only) x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Analgesics - Topical Methyl Salicylate x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Antacids Alum Hydrox-Mag Trisil-Alginic Acid-Sod 4 x x Antacids Aluminum - Magnesium Hydroxides 4 x x Aluminum Hydroxide-Magnesium Carbonate Antacids 4 x x Susp Aluminum Hydroxide-Magnesium Trisilicate Antacids 4 x x Chew Tab Antacids Calcium - Magnesium Carbonates 4 x x Antacids Calcium Carbonate 4 x x Antacids Calcium Carbonate - Simethicone 4 x x Antacids Calcium Carbonate-Mag Hydroxide 4 x x Antianxiety Agents Alprazolam 1 x Antianxiety Agents Buspirone 1 x Antiasthmatics Aclidinium Bromide Aerosol Powd x x Antiasthmatics Albuterol Inhal x x Yes Antiasthmatics Albuterol Sulfate x x Yes Antiasthmatics Beclomethasone Inh x x Yes Antiasthmatics Budesonide x x Yes Antiasthmatics Budesonide Inh x x Yes Antiasthmatics Budesonide-Formoterol Fumarate Inh x x Yes Antiasthmatics Ciclesonide Inh x x Yes Antiasthmatics Cromolyn Na Inhal x x Yes Antiasthmatics Epinephrine Inhal x x Yes Antiasthmatics Flunisolide Inh x x Yes Antiasthmatics Fluticasone Furoate-Vilanterol Inh x x Yes Antiasthmatics Fluticasone Inh x x Yes Antiasthmatics Fluticasone-Salmeterol Inhal x x Yes Antiasthmatics Formoterol Fumarate Soln Nebu x x Yes NewAntiasthmatics York Workers’ CompensationFormoterol/Mometasone Formulary Change Tracker: Updatesx xsince the previous versionYes (Aug. 2019) are highlighted in red Antiasthmatics Indacaterol Maleate Inhal x x Yes Antiasthmatics Ipratropium Bromide Inhal x x Yes Antiasthmatics Ipratropium-Albuterol Inh x x Yes Carpal Pain Non Ankle / Back Mid / Hip / Knee Neck Shoulder Asthma Tunnel CRPS Elbow Eye Acute AntiasthmaticsTherapeutic Category Levalbuterol GenericHCl Inhal Name x x Foot Yes Low (MTG) Groin (MTG) (MTG) (MTG) Special Special Antiasthmatics Methacholine Chloride Inhal xPhase A xPhase B Yes (MTG) (MTG) Perioperative Antiasthmatics Mometasone Furoate Inh Considerations x x Yes Carpal Pain Non Analgesics - Narcotic** MometasoneCodeine-Acetaminophen Furoate-Formoterol Fumarate 1,3 x x Ankle / Back Mid / Hip / Knee Neck Shoulder Antiasthmatics x x AsthmaYes Tunnel CRPS Elbow Eye Acute AnalgesicsTherapeutic - Narcotic** Category InhHydrocodone-AcetaminophenGeneric Name 1,3 x x Foot Low (MTG) Groin (MTG) (MTG) (MTG) Special Special AntiasthmaticsAnalgesics - Narcotic** MontelukastHydrocodone-Ibuprofen 1,3 x Phase A x Phase B x Yes (MTG) (MTG) Perioperative AntiasthmaticsAnalgesics - Narcotic** RoflumilastMorphine 1,3 Considerations x x x Yes AntiasthmaticsAnalgesics - Narcotic** OxycodoneSalmeterol HCl 1,3 x x x Yes AntiasthmaticsAnalgesics - Narcotic** Oxycodone-AcetaminophenTerbutaline 1,3 x x x Yes AntiasthmaticsAnalgesics - Narcotic** Oxycodone-AspirinTheophylline 1,3 x x x Yes AntiasthmaticsAnalgesics - Narcotic** TapentadolTiotropium Bromide Monohydrate Inhal 1,3 x x Yes REV:AntiasthmaticsAnalgesics July 31, - Narcotic** 2019 TramadolTriamcinolone HCl Acetonide Inh 1,3 x x x Yes Page 1 of 8 AntiasthmaticsAnalgesics - Narcotic** Tramadol-AcetaminophenZafirlukast 1,3 x x x Yes AntiasthmaticsAnalgesics - Nonnarcotic AcetaminophenZileuton x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Analgesics - Nonnarcotic Aspirin x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Anticoagulants Apixaban x x Yes Yes Analgesics - Nonnarcotic Choline - Magnesium Salicylates x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Anticoagulants Dalteparin x x Yes Yes Analgesics - Nonnarcotic Diflunisal x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Anticoagulants Enoxaparin Na x x Yes Yes Analgesics - Topical Capsaicin x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Anticoagulants Fondaparinux Na x x Yes Yes Analgesics - Topical Diclofenac Na (1% only) x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Anticoagulants Rivaroxaban x x Yes Yes Analgesics - Topical Lidocaine Patch (4% Only) x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes AnticoagulantsAnalgesics - Topical MethylWarfarin Salicylate Na x x Yes Yes Yes Yes Yes Yes YesYes Yes Yes Yes AnticonvulsantAntacids AlumCarbamazepine Hydrox-Mag Trisil-Alginic Acid-Sod 4 x x 2nd 2nd 2nd 2nd AnticonvulsantAntacids AluminumClonazepam - Magnesium Hydroxides 4 x x Anticonvulsant AluminumDivalproex Hydroxide-Magnesium Carbonate x x Antacids 4 x x Anticonvulsant SuspGabapentin x x x 2nd 2nd 2nd 2nd Anticonvulsant AluminumLamotrigine Hydroxide-Magnesium Trisilicate x x 2nd 2nd 2nd 2nd Antacids 4 x x Anticonvulsant ChewLevetiracetam Tab x x AnticonvulsantAntacids CalciumOxcarbazepine - Magnesium Carbonates 4 x x 2nd 2nd 2nd 2nd AnticonvulsantAntacids CalciumPhenytoin Carbonate 4 x x AnticonvulsantAntacids CalciumPregabalin Carbonate - Simethicone 4 x x 2nd 2nd 2nd 2nd AnticonvulsantAntacids CalciumTopiramate Carbonate-Mag Hydroxide 4 x x 2nd 2nd 2nd 2nd AnticonvulsantAntianxiety Agents AlprazolamValproic Acid 1 x x AntidepressantsAntianxiety Agents BuspironeAmitriptyline 1 x x Yes Yes Yes Yes AntidepressantsAntiasthmatics AclidiniumBupropion Bromide Aerosol Powd x x 2nd 2nd 2nd 2nd AntidepressantsAntiasthmatics AlbuterolCitalopram Inhal 4 x x Yes AntidepressantsAntiasthmatics AlbuterolClomipramine Sulfate 4 x x Yes AntidepressantsAntiasthmatics BeclomethasoneDesipramine Inh x x Yes Yes Yes Yes Yes AntidepressantsAntiasthmatics BudesonideDesvenlafaxine 4 x x Yes AntidepressantsAntiasthmatics BudesonideDoxepin Inh x x Yes Yes Yes Yes Yes Antiasthmatics Budesonide-Formoterol Fumarate Inh x x Yes Antidepressants Duloxetine x 2nd 2nd 2nd 2nd Antiasthmatics Ciclesonide Inh x x Yes Antidepressants Escitalopram 4 x Antiasthmatics Cromolyn Na Inhal x x Yes Antidepressants Fluoxetine 4 x Antiasthmatics Epinephrine Inhal x x Yes Antidepressants Fluvoxamine 4 x Antiasthmatics Flunisolide Inh x x Yes Antidepressants x x Yes Yes Yes Yes Antiasthmatics Fluticasone Furoate-Vilanterol Inh x x Yes Antidepressants Isocarboxazid 4 x Antiasthmatics Fluticasone Inh x x Yes Antidepressants 4 x Antiasthmatics Fluticasone-Salmeterol Inhal x x Yes Antidepressants Nefazodone 4 x Antiasthmatics Formoterol Fumarate Soln Nebu x x Yes Antidepressants x Yes Yes Yes Yes Antiasthmatics Formoterol/Mometasone x x Yes Antidepressants 4 x Antiasthmatics Indacaterol Maleate Inhal x x Yes Antidepressants Phenelzine 4 x Antiasthmatics Ipratropium Bromide Inhal x x Yes Antidepressants 4 x Antiasthmatics Ipratropium-Albuterol Inh x x Yes Antidepressants Sertraline 4 x Antiasthmatics Levalbuterol HCl Inhal x x Yes Antidepressants Tranylcypromine 4 x Antiasthmatics Methacholine Chloride Inhal x x Yes AntidepressantsAntiasthmatics MometasoneTrazodone Furoate Inh 4 x x Yes Antidepressants MometasoneTrimipramine Furoate-Formoterol Fumarate x Yes Yes Yes Yes Antiasthmatics x x Yes Antidepressants InhVenlafaxine x 2nd 2nd 2nd 2nd AntidepressantsAntiasthmatics MontelukastVilazodone 4 x x Yes Rev.AntidiabeticsAntiasthmatics November 5, 2019 RoflumilastGlipizide x x Yes Antidiabetics Glucose Tablets/Gel x Page 2 Antidiabetics Glyburide x Antidiabetics Insulin x Antidiabetics Metformin HCl x REV: July 31, 2019 Page 1 of 8

REV: July 31, 2019 Page 2 of 8 Carpal Pain Non Ankle / Back Mid / Hip / Knee Neck Shoulder Asthma Tunnel CRPS Elbow Eye Acute Therapeutic Category Generic Name Foot Low (MTG) Groin (MTG) (MTG) (MTG) Special Special Phase A Phase B (MTG) (MTG) Perioperative Considerations Antiasthmatics Salmeterol x x Yes Antiasthmatics x x Yes Antiasthmatics x x Yes Antiasthmatics Monohydrate Inhal x x Yes Antiasthmatics Acetonide Inh x x Yes Antiasthmatics x x Yes Antiasthmatics x x Yes Anticoagulants Apixaban x x Yes Yes Anticoagulants Dalteparin x x Yes Yes Anticoagulants Enoxaparin Na x x Yes Yes Anticoagulants Fondaparinux Na x x Yes Yes Anticoagulants Rivaroxaban x x Yes Yes Anticoagulants Warfarin Na x x Yes Yes Anticonvulsant Carbamazepine x x 2nd 2nd 2nd 2nd Anticonvulsant Clonazepam x x Anticonvulsant Divalproex x x Anticonvulsant Gabapentin x x x 2nd 2nd 2nd 2nd Anticonvulsant Lamotrigine x x 2nd 2nd 2nd 2nd Anticonvulsant Levetiracetam x x Anticonvulsant Oxcarbazepine x x 2nd 2nd 2nd 2nd Anticonvulsant Phenytoin x x Anticonvulsant Pregabalin x x 2nd 2nd 2nd 2nd Anticonvulsant Topiramate x x 2nd 2nd 2nd 2nd Anticonvulsant Valproic Acid x x Antidepressants x x Yes Yes Yes Yes Antidepressants Bupropion x 2nd 2nd 2nd 2nd Antidepressants Citalopram 4 x Antidepressants 4 x Antidepressants x Yes Yes Yes Yes Antidepressants Desvenlafaxine 4 x Antidepressants x Yes Yes Yes Yes Antidepressants Duloxetine x 2nd 2nd 2nd 2nd Antidepressants Escitalopram 4 x Antidepressants Fluoxetine 4 x Antidepressants Fluvoxamine 4 x Antidepressants Imipramine x x Yes Yes Yes Yes Antidepressants Isocarboxazid 4 x Antidepressants Mirtazapine 4 x Antidepressants Nefazodone 4 x Antidepressants Nortriptyline x Yes Yes Yes Yes Antidepressants Paroxetine 4 x NewAntidepressants York Workers’ CompensationPhenelzine Formulary Change Tracker:4 Updates xsince the previous version (Aug. 2019) are highlighted in red Antidepressants Protriptyline 4 x Antidepressants Sertraline 4 x Antidepressants Tranylcypromine 4 x Carpal Pain Non Ankle / Back Mid / Hip / Knee Neck Shoulder Antidepressants Trazodone 4 x Asthma Tunnel CRPS Elbow Eye Acute Therapeutic Category Generic Name Foot Low (MTG) Groin (MTG) (MTG) (MTG) Special Special Antidepressants Phase A xPhase B Yes (MTG) Yes Yes (MTG)Yes Perioperative Antidepressants Venlafaxine Considerations x 2nd 2nd 2nd 2nd AnalgesicsAntidepressants - Narcotic** Codeine-AcetaminophenVilazodone 1,34 x x x AnalgesicsAntidiabetics - Narcotic** Hydrocodone-AcetaminophenGlipizide 1,3 x x Analgesics - Narcotic** Hydrocodone-Ibuprofen 1,3 x x Carpal Pain Non Antidiabetics Glucose Tablets/Gel x Ankle / Back Mid / Hip / Knee Neck Shoulder Analgesics - Narcotic** Morphine 1,3 x x Asthma Tunnel CRPS Elbow Eye Acute AntidiabeticsTherapeutic Category Glyburide Generic Name x Foot Low (MTG) Groin (MTG) (MTG) (MTG) Special Special AnalgesicsAntidiabetics - Narcotic** OxycodoneInsulin HCl 1,3 x Phase A Phase B x (MTG) (MTG) Perioperative AnalgesicsAntidiabetics - Narcotic** Oxycodone-AcetaminophenMetformin HCl 1,3 Considerations x x AnalgesicsAntidiabetics - Narcotic** Oxycodone-AspirinSitagliptin Phosphate 1,3 x x AnalgesicsAntidiarrheals - Narcotic** TapentadolDiphenoxylate w/ 1,34 x x Analgesics - Narcotic** Tramadol HCl 1,3 x x Antidiarrheals Loperamide 4 x x Analgesics - Narcotic** Tramadol-Acetaminophen 1,3 x x Antiemetic - Antivertigo 4 x x Analgesics - Nonnarcotic Acetaminophen x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes REV:Antifungals July 31, 2019 Fluconazole 2 x x Yes Page 2 of 8 Analgesics - Nonnarcotic Aspirin x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes AnalgesicsAntifungals - Nonnarcotic CholineItraconazole - Magnesium Salicylates 2 x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes AnalgesicsAntifungals - Nonnarcotic DiflunisalKetoconazole 2 x x x YesYes Yes Yes Yes Yes Yes Yes Yes Yes Yes AnalgesicsAntifungals - Topical CapsaicinNystatin 2 x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes AnalgesicsAntifungals - Topical DiclofenacTerbinafine Na (1% only) 2 x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes AnalgesicsAntihistamines - Topical LidocaineCetirizine Patch (4% Only) 4 x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes AnalgesicsAntihistamines - Topical MethylCyproheptadine Salicylate 4 x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes AntacidsAntihistamines AlumDesloratadine Hydrox-Mag Trisil-Alginic Acid-Sod 4 x x AntacidsAntihistamines AluminumDiphenhydramine - Magnesium Hydroxides 4 x x Antihistamines AluminumFexofenadine Hydroxide-Magnesium Carbonate 4 x x Antacids 4 x x Antihistamines SuspHydroxyzine 4 x x Antihistamines AluminumLevocetirizine Hydroxide-Magnesium Trisilicate 4 x x Antacids 4 x x Antihistamines ChewLoratadine Tab 4 x x AntacidsAntihistamines CalciumPromethazine - Magnesium Carbonates 4 x x Clonidine HCl AntacidsAntihypertensive Calcium Carbonate 4 x x Antacids Calcium Carbonate - Simethicone 4 x x AntacidsAntihypertensive CalciumLisinopril Carbonate-Mag Hydroxide 4 x x AntianxietyAntihypertensive Agents AlprazolamLosartan 1 x AntianxietyAntihypertensive Agents BuspironePrazosin 1 x AntiasthmaticsAnti-Infectives, Misc. AclidiniumClindamycin Bromide Aerosol Powd 2,4 x x Yes Yes Yes Yes AntiasthmaticsAnti-Infectives, Misc. AlbuterolLinezolid Inhal 2,4 x x Yes AntiasthmaticsAnti-Infectives, Misc. AlbuterolMetronidazole Sulfate 2,4 x x Yes Yes Yes Yes Yes AntiasthmaticsAnti-Infectives, Misc. BeclomethasoneSulfamethoxazole-Trimethoprim Inh 2,4 x x Yes Yes Yes Yes Yes AntiasthmaticsAnti-Infectives, Misc. BudesonideVancomycin 2,4 x x Yes AntiasthmaticsAnti-Inflammatory BudesonideCelecoxib Inh x x 2nd Yes 2nd 2nd 2nd 2nd 2nd 2nd 2nd 2nd 2nd Antiasthmatics Budesonide-Formoterol Fumarate Inh x x Yes Anti-Inflammatory Diclofenac x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Antiasthmatics Ciclesonide Inh x x Yes Anti-Inflammatory Etodolac x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Antiasthmatics Cromolyn Na Inhal x x Yes Anti-Inflammatory Ibuprofen x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Antiasthmatics Epinephrine Inhal x x Yes Anti-Inflammatory Indomethacin x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Antiasthmatics Flunisolide Inh x x Yes Anti-Inflammatory Meloxicam x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Antiasthmatics Fluticasone Furoate-Vilanterol Inh x x Yes Anti-Inflammatory Naproxen x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Antiasthmatics Fluticasone Inh x x Yes Anti-Inflammatory Sulindac x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Antiasthmatics Fluticasone-Salmeterol Inhal x x Yes Antimalarial Hydroxychloroquine 2 x Antiasthmatics Formoterol Fumarate Soln Nebu x x Yes Antineoplastic Cabozantinib 4 x Antiasthmatics Formoterol/Mometasone x x Yes Antineoplastic Dabrafenib 4 x Antiasthmatics Indacaterol Maleate Inhal x x Yes Antineoplastic Doxorubicin 4 x Antiasthmatics Ipratropium Bromide Inhal x x Yes Antineoplastic Interferon Gamma-1B 4 x Antiasthmatics Ipratropium-Albuterol Inh x x Yes Antineoplastic Methotrexate 4 x Antiasthmatics Levalbuterol HCl Inhal x x Yes Antineoplastic Trametinib 4 x Antiasthmatics Methacholine Chloride Inhal x x Yes Antineoplastic Vandetanib 4 x Antiasthmatics Mometasone Furoate Inh x x Yes Antineoplastic Vismodegib 4 x Mometasone Furoate-Formoterol Fumarate AntiasthmaticsAntipsychotics Aripiprazole 4 x x Yes Inh Antipsychotics Asenapine Maleate 4 x Antiasthmatics Montelukast x x Yes Antipsychotics 4 x x Rev.Antiasthmatics November 5, 2019 Roflumilast x x Yes Antipsychotics Haloperidol 4 x x Page 3 Antipsychotics Lithium 4 x x Antipsychotics Lurasidone 4 x Antipsychotics 4 x x REV:Antipsychotics July 31, 2019 Paliperidone 4 x Page 1 of 8 Antipsychotics Perphenazine 4 x

REV: July 31, 2019 Page 3 of 8 Carpal Pain Non Ankle / Back Mid / Hip / Knee Neck Shoulder Asthma Tunnel CRPS Elbow Eye Acute Therapeutic Category Generic Name Foot Low (MTG) Groin (MTG) (MTG) (MTG) Special Special Phase A Phase B (MTG) (MTG) Perioperative Considerations Antidiabetics Sitagliptin Phosphate x Antidiarrheals Diphenoxylate w/ Atropine 4 x x Antidiarrheals Loperamide 4 x x Antiemetic - Antivertigo Meclizine 4 x x Antifungals Fluconazole 2 x x Yes Antifungals Itraconazole 2 x x Yes Antifungals Ketoconazole 2 x x Yes Antifungals Nystatin 2 x x Yes Antifungals Terbinafine 2 x x Yes Antihistamines Cetirizine 4 x x Antihistamines 4 x x Antihistamines Desloratadine 4 x x Antihistamines 4 x x Antihistamines Fexofenadine 4 x x Antihistamines Hydroxyzine 4 x x Antihistamines Levocetirizine 4 x x Antihistamines Loratadine 4 x x Antihistamines 4 x x Clonidine HCl Antihypertensive x Antihypertensive Lisinopril x Antihypertensive Losartan x Antihypertensive Prazosin x Anti-Infectives, Misc. Clindamycin 2,4 x x Yes Yes Yes Yes Anti-Infectives, Misc. Linezolid 2,4 x Anti-Infectives, Misc. Metronidazole 2,4 x x Yes Yes Yes Yes Anti-Infectives, Misc. Sulfamethoxazole-Trimethoprim 2,4 x x Yes Yes Yes Yes Anti-Infectives, Misc. Vancomycin 2,4 x x Anti-Inflammatory Celecoxib x 2nd 2nd 2nd 2nd 2nd 2nd 2nd 2nd 2nd 2nd Anti-Inflammatory Diclofenac x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Anti-Inflammatory Etodolac x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Anti-Inflammatory Ibuprofen x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Anti-Inflammatory Indomethacin x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Anti-Inflammatory Meloxicam x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Anti-Inflammatory Naproxen x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Anti-Inflammatory Sulindac x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Antimalarial Hydroxychloroquine 2 x Antineoplastic Cabozantinib 4 x Antineoplastic Dabrafenib 4 x NewAntineoplastic York Workers’ CompensationDoxorubicin Formulary Change Tracker:4 Updates xsince the previous version (Aug. 2019) are highlighted in red Antineoplastic Interferon Gamma-1B 4 x Antineoplastic Methotrexate 4 x Antineoplastic Trametinib 4 x Carpal Pain Non Ankle / Back Mid / Hip / Knee Neck Shoulder Asthma Tunnel CRPS Elbow Eye Acute AntineoplasticTherapeutic Category Vandetanib Generic Name 4 x Foot Low (MTG) Groin (MTG) (MTG) (MTG) Special Special Antineoplastic Vismodegib 4 Phase A x Phase B (MTG) (MTG) Perioperative Antipsychotics Aripiprazole 4 Considerations x x AntipsychoticsAntiasthmatics AsenapineSalmeterol Maleate 4 x x Yes AntipsychoticsAntiasthmatics ChlorpromazineTerbutaline 4 x x Yes AntipsychoticsAntiasthmatics HaloperidolTheophylline 4 x x Yes AntipsychoticsAntiasthmatics LithiumTiotropium Bromide Monohydrate Inhal 4 x x Yes AntipsychoticsAntiasthmatics LurasidoneTriamcinolone Acetonide Inh 4 x x Yes Carpal Pain Non Ankle / Back Mid / Hip / Knee Neck Shoulder Antiasthmatics Zafirlukast x x AsthmaYes Tunnel CRPS Elbow Eye Acute AntipsychoticsTherapeutic Category Olanzapine Generic Name 4 x x Foot Low (MTG) Groin (MTG) (MTG) (MTG) Special Special AntipsychoticsAntiasthmatics PaliperidoneZileuton 4 xPhase A x Phase B Yes (MTG) (MTG) Perioperative AntipsychoticsAnticoagulants PerphenazineApixaban 4 Considerations x x Yes Yes AntipsychoticsAnticoagulants ProchlorperazineDalteparin 4 x x Yes Yes AntipsychoticsAnticoagulants QuetiapineEnoxaparin Na 4 x x Yes Yes AntipsychoticsAnticoagulants RisperidoneFondaparinux Na 4 x x Yes Yes AntipsychoticsAnticoagulants ZiprasidoneRivaroxaban 4 x x Yes Yes REV:AntiretroviralsAnticoagulants July 31, 2019 AtazanavirWarfarin Na 2 x x Yes Yes Page 3 of 8 AntiretroviralsAnticonvulsant DarunavirCarbamazepine 2 x x 2nd 2nd 2nd 2nd AntiretroviralsAnticonvulsant EmtricitabineClonazepam 2 x x AntiretroviralsAnticonvulsant FosamprenavirDivalproex 2 x x AntiretroviralsAnticonvulsant LamivudineGabapentin 2 x x x 2nd 2nd 2nd 2nd AntiretroviralsAnticonvulsant RaltegravirLamotrigine 2 x x 2nd 2nd 2nd 2nd AntiretroviralsAnticonvulsant RitonavirLevetiracetam 2 x x AntiretroviralsAnticonvulsant StavudineOxcarbazepine 2 x x 2nd 2nd 2nd 2nd AntiretroviralsAnticonvulsant TenofovirPhenytoin 2 x x AntiretroviralsAnticonvulsant ZidovudinePregabalin 2 x x 2nd 2nd 2nd 2nd AntitubercularAnticonvulsant EthambutolTopiramate 2,4 x x 2nd 2nd 2nd 2nd AntitubercularAnticonvulsant IsoniazidValproic Acid 2,4 x x AntitubercularAntidepressants RifabutinAmitriptyline 2,4 x x Yes Yes Yes Yes AntitubercularAntidepressants RifampinBupropion 2,4 x 2nd 2nd 2nd 2nd AntiviralAntidepressants AcyclovirCitalopram 24 x x AntiviralAntidepressants OseltamivirClomipramine 24 x x AntiviralAntidepressants ZanamivirDesipramine 2 x x Yes Yes Yes Yes BetaAntidepressants Blockers CarvedilolDesvenlafaxine 4 x x BetaAntidepressants Blockers MetoprololDoxepin Tartrate x x Yes Yes Yes Yes BetaAntidepressants Blockers NebivololDuloxetine x x 2nd 2nd 2nd 2nd BetaAntidepressants Blockers PropranololEscitalopram HCl 4 x x CalciumAntidepressants Blockers AmlodipineFluoxetine 4 x x CalciumAntidepressants Blockers DiltiazemFluvoxamine 4 x x CalciumAntidepressants Blockers NifedipineImipramine x x Yes Yes Yes Yes CephalosporinsAntidepressants CefaclorIsocarboxazid 24 x x Yes Yes Yes Yes Yes Yes Yes CephalosporinsAntidepressants CefadroxilMirtazapine 24 x x Yes Yes Yes Yes Yes Yes Yes CephalosporinsAntidepressants CefdinirNefazodone 24 x x Yes Yes Yes Yes Yes Yes Yes CephalosporinsAntidepressants CefiximeNortriptyline 2 x x Yes Yes Yes Yes Yes Yes YesYes Yes Yes CephalosporinsAntidepressants CefpodoximeParoxetine 24 x x Yes Yes Yes Yes Yes Yes Yes CephalosporinsAntidepressants CefprozilPhenelzine 24 x x Yes Yes Yes Yes Yes Yes Yes CephalosporinsAntidepressants CephalexinProtriptyline 24 x x Yes Yes Yes Yes Yes Yes Yes CorticosteroidsAntidepressants MethylprednisoloneSertraline 4 x x Yes Yes Yes CorticosteroidsAntidepressants PrednisoloneTranylcypromine 4 x x Yes Yes Yes CorticosteroidsAntidepressants PrednisoneTrazodone 4 x x Yes Yes Yes Cough/ColdAntidepressants AcetylcysteineTrimipramine Inhal x x Yes Yes Yes Yes Cough/ColdAntidepressants BenzonatateVenlafaxine x x 2nd 2nd 2nd 2nd Cough/ColdAntidepressants Cetirizine-PseudoephedrineVilazodone 4 x x Cough/ColdAntidiabetics ChlorpheniramineGlipizide - Phenylephrine x Cough/ColdAntidiabetics Chlorpheniramine-AcetaminophenGlucose Tablets/Gel x Cough/ColdAntidiabetics Chlorpheniramine-DMGlyburide x Cough/ColdAntidiabetics DextromethorphanInsulin x Rev.Antidiabetics November 5, 2019 Metformin HCl x Cough/Cold Dextromethorphan-APAP-Chlorpheniramine x Page 4 Cough/Cold Dextromethorphan-Diphenhyd-APAP x Decongestants Cromolyn Nasal x Decongestants Oxymetazoline x Decongestants Phenylephrine Nasal x REV: July 31, 2019 Page 2 of 8 Decongestants Pseudoephedrine x Decongestants Saline Nasal x Decongestants Tetrahydrozoline Nasal x Decongestants Triamcinolone Acetonide Nasal x

REV: July 31, 2019 Page 4 of 8 Carpal Pain Non Ankle / Back Mid / Hip / Knee Neck Shoulder Asthma Tunnel CRPS Elbow Eye Acute Therapeutic Category Generic Name Foot Low (MTG) Groin (MTG) (MTG) (MTG) Special Special Phase A Phase B (MTG) (MTG) Perioperative Considerations Antipsychotics Prochlorperazine 4 x Antipsychotics 4 x x Antipsychotics Risperidone 4 x Antipsychotics Ziprasidone 4 x Antiretrovirals Atazanavir 2 x Antiretrovirals Darunavir 2 x Antiretrovirals Emtricitabine 2 x Antiretrovirals Fosamprenavir 2 x Antiretrovirals Lamivudine 2 x Antiretrovirals Raltegravir 2 x Antiretrovirals Ritonavir 2 x Antiretrovirals Stavudine 2 x Antiretrovirals Tenofovir 2 x Antiretrovirals Zidovudine 2 x Antitubercular Ethambutol 2,4 x Antitubercular Isoniazid 2,4 x Antitubercular Rifabutin 2,4 x Antitubercular Rifampin 2,4 x Antiviral Acyclovir 2 x Antiviral Oseltamivir 2 x Antiviral Zanamivir 2 x Beta Blockers Carvedilol x x Beta Blockers Metoprolol Tartrate x x Beta Blockers Nebivolol x x Beta Blockers Propranolol HCl x x Calcium Blockers Amlodipine x x Calcium Blockers Diltiazem x x Calcium Blockers Nifedipine x x Cephalosporins Cefaclor 2 x x Yes Yes Yes Yes Yes Yes Yes Cephalosporins Cefadroxil 2 x x Yes Yes Yes Yes Yes Yes Yes Cephalosporins Cefdinir 2 x x Yes Yes Yes Yes Yes Yes Yes Cephalosporins Cefixime 2 x x Yes Yes Yes Yes Yes Yes Yes Cephalosporins Cefpodoxime 2 x x Yes Yes Yes Yes Yes Yes Yes Cephalosporins Cefprozil 2 x x Yes Yes Yes Yes Yes Yes Yes Cephalosporins Cephalexin 2 x x Yes Yes Yes Yes Yes Yes Yes Corticosteroids Methylprednisolone x x Yes Yes Yes Corticosteroids Prednisolone x x Yes Yes Yes NewCorticosteroids York Workers’ CompensationPrednisone Formulary Change Tracker: Updatesx xsince the previous version (Aug.Yes 2019)Yes are highlighted in red Yes Cough/Cold Acetylcysteine Inhal x Cough/Cold Benzonatate x Carpal Pain Non Cough/Cold Cetirizine-Pseudoephedrine x Ankle / Back Mid / Hip / Knee Neck Shoulder Asthma Tunnel CRPS Elbow Eye Acute Cough/ColdTherapeutic Category ChlorpheniramineGeneric - Phenylephrine Name x Foot Low (MTG) Groin (MTG) (MTG) (MTG) Special Special Cough/Cold Chlorpheniramine-Acetaminophen x Phase A Phase B (MTG) (MTG) Perioperative Cough/Cold Chlorpheniramine-DM Considerations x AntidiabeticsCough/Cold SitagliptinDextromethorphan Phosphate x AntidiarrhealsCough/Cold DiphenoxylateDextromethorphan-APAP-Chlorpheniramine w/ Atropine 4 x x AntidiarrhealsCough/Cold LoperamideDextromethorphan-Diphenhyd-APAP 4 x x AntiemeticDecongestants - Antivertigo MeclizineCromolyn Nasal 4 x x AntifungalsDecongestants FluconazoleOxymetazoline 2 x x Yes AntifungalsDecongestants ItraconazolePhenylephrine Nasal 2 x x Yes Carpal Pain Non AntifungalsDecongestants KetoconazolePseudoephedrine 2 x x AnkleYes / Back Mid / Hip / Knee Neck Shoulder Asthma Tunnel CRPS Elbow Eye Acute AntifungalsDecongestantsTherapeutic Category NystatinSaline Nasal Generic Name 2 x x FootYes Low (MTG) Groin (MTG) (MTG) (MTG) Special Special AntifungalsDecongestants TerbinafineTetrahydrozoline Nasal 2 x Phase A x Phase B Yes (MTG) (MTG) Perioperative AntihistaminesDecongestants CetirizineTriamcinolone Acetonide Nasal 4 Considerations x x AntihistaminesDecongestants (Nasal Steroids) CyproheptadineBudesonide Nasal 4 x x AntihistaminesDecongestants (Nasal Steroids) DesloratadineFlunisolide Nasal 4 x x AntihistaminesDecongestants (Nasal Steroids) DiphenhydramineFluticasone Propionate Nasal 4 x x Carpal Pain Non Ankle / Back Mid / Hip / Knee Neck Shoulder AntihistaminesDecongestants (Nasal Steroids) FexofenadineMometasone Furoate Nasal 4 x x Asthma Tunnel CRPS Elbow Eye Acute REV:Therapeutic July 31, 2019 Category Generic Name Foot Low (MTG) Groin (MTG) (MTG) (MTG)Page 4 of 8 Special Special AntihistaminesDermatological HydroxyzineBacitracin 4 x Phase A x Phase B Yes Yes (MTG) Yes Yes Yes Yes (MTG) Yes Perioperative AntihistaminesDermatological LevocetirizineBetamethasone 4 Considerations x x Yes AntihistaminesDermatological LoratadineCapsicum 4 x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes AntihistaminesDermatological PromethazineCiclopirox Olamine 4 x x Yes Clonidine HCl AntihypertensiveDermatological Clobetasol 4 x x Dermatological Clotrimazole 4 x x Yes Antihypertensive Lisinopril x Dermatological Clotrimazole w/ Topical 4 x x Antihypertensive Losartan x Dermatological Desonide 4 x x Yes Antihypertensive Prazosin x Dermatological Desoximetasone 4 x x Yes Anti-Infectives, Misc. Clindamycin 2,4 x x Yes Yes Yes Yes Dermatological Econazole 4 x x Yes Anti-Infectives, Misc. Linezolid 2,4 x Dermatological Fluocinolone Acetonide 4 x x Yes Anti-Infectives, Misc. Metronidazole 2,4 x x Yes Yes Yes Yes Dermatological Fluticasone Prop 4 x x Yes Anti-Infectives, Misc. Sulfamethoxazole-Trimethoprim 2,4 x x Yes Yes Yes Yes Dermatological Gentamicin 4 x x Yes Anti-Infectives, Misc. Vancomycin 2,4 x x Dermatological Hydrocortisone 4 x x Yes Anti-Inflammatory Celecoxib x 2nd 2nd 2nd 2nd 2nd 2nd 2nd 2nd 2nd 2nd Dermatological Ketoconazole 4 x x Yes Anti-Inflammatory Diclofenac x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Dermatological Metronidazole 4 x x Yes Anti-Inflammatory Etodolac x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Dermatological Miconazole Nitrate 4 x x Yes Anti-Inflammatory Ibuprofen x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Dermatological Mupirocin x x Yes Anti-Inflammatory Indomethacin x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Dermatological Neomycin Sulfate 4 x x Yes Yes Yes Yes Yes Yes Yes Anti-Inflammatory Meloxicam x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Dermatological Neomycin-Polymyxin-Bacitracin 4 x x Yes Anti-Inflammatory Naproxen x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Dermatological Nystatin 4 x x Yes Anti-Inflammatory Sulindac x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Dermatological Nystatin-Triamcinolone 4 x x Yes Antimalarial Hydroxychloroquine 2 x Dermatological Silver Sulfadiazine x x Antineoplastic Cabozantinib 4 x Dermatological Tolnaftate 4 x x Yes Antineoplastic Dabrafenib 4 x AntineoplasticDermatological DoxorubicinTriamcinolone 4 x x Yes AntineoplasticDiuretics InterferonBumetanide Gamma-1B 4 x x AntineoplasticDiuretics MethotrexateFurosemide 4 x x AntineoplasticDiuretics TrametinibSpironolactone 4 x x AntineoplasticFluoroquinolones VandetanibCiprofloxacin 42 x x Yes Yes Yes Yes Yes Yes Yes AntineoplasticFluoroquinolones VismodegibLevofloxacin 42 x x Yes Yes Yes Yes Yes Yes Yes AntipsychoticsFluoroquinolones AripiprazoleMoxifloxacin 42 x x Yes Yes Yes Yes Yes Yes Yes AntipsychoticsGI, Misc AsenapineMetoclopramide Maleate 4 x AntipsychoticsGI, Misc ChlorpromazineSimethicone 4 x x AntipsychoticsHematopoetic Agents HaloperidolFolic Acid 4 x x AntipsychoticsHypnotics LithiumDoxepin 4 x x AntipsychoticsHypnotics LurasidoneTemazepam 4 x AntipsychoticsHypnotics OlanzapineZolpidem 4 x x AntipsychoticsLaxatives PaliperidoneBisacodyl 4 x x Rev.AntipsychoticsLaxatives November 5, 2019 PerphenazineDocusate Calcium 4 x x Laxatives Docusate Na 4 x x Page 5 Laxatives Glycerin 4 x x Laxatives Lactulose 4 x x Laxatives Mineral Oil 4 x x REV:Laxatives July 31, 2019 Na Phosphates - Enema 4 x x Page 3 of 8 Laxatives Polyethylene Glycol 3350 4 x x Laxatives Psyllium 4 x x Macrolide Antibiotics Azithromycin 2 x x Yes Yes Yes Yes Yes Yes Yes Macrolide Antibiotics Clarithromycin 2 x x Yes Yes Yes Yes Yes Yes Yes Macrolide Antibiotics Erythromycin 2 x x Yes Yes Yes Yes Yes Yes Yes Migraine Products Butalbital-Acetaminophen-Caffeine 4 x x

REV: July 31, 2019 Page 5 of 8

REV: July 31, 2019 Page 1 of 1 Carpal Pain Non Ankle / Back Mid / Hip / Knee Neck Shoulder Asthma Tunnel CRPS Elbow Eye Acute Therapeutic Category Generic Name Foot Low (MTG) Groin (MTG) (MTG) (MTG) Special Special Phase A Phase B (MTG) (MTG) Perioperative Considerations Decongestants (Nasal Steroids) Budesonide Nasal x x Decongestants (Nasal Steroids) Flunisolide Nasal x x Decongestants (Nasal Steroids) Nasal x x Decongestants (Nasal Steroids) Mometasone Furoate Nasal x x Dermatological Bacitracin 4 x x Yes Yes Yes Yes Yes Yes Yes Dermatological Betamethasone 4 x x Yes Dermatological Capsicum x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Dermatological Ciclopirox Olamine 4 x x Yes Dermatological Clobetasol 4 x x Dermatological Clotrimazole 4 x x Yes Dermatological Clotrimazole w/ Betamethasone Topical 4 x x Dermatological Desonide 4 x x Yes Dermatological Desoximetasone 4 x x Yes Dermatological Econazole 4 x x Yes Dermatological Fluocinolone Acetonide 4 x x Yes Dermatological Fluticasone Prop 4 x x Yes Dermatological Gentamicin 4 x x Yes Dermatological Hydrocortisone 4 x x Yes Dermatological Ketoconazole 4 x x Yes Dermatological Metronidazole 4 x x Yes Dermatological Miconazole Nitrate 4 x x Yes Dermatological Mupirocin x x Yes Dermatological Neomycin Sulfate 4 x x Yes Yes Yes Yes Yes Yes Yes Dermatological Neomycin-Polymyxin-Bacitracin 4 x x Yes Dermatological Nystatin 4 x x Yes Dermatological Nystatin-Triamcinolone 4 x x Yes Dermatological Silver Sulfadiazine x x Dermatological Tolnaftate 4 x x Yes Dermatological Triamcinolone 4 x x Yes Diuretics Bumetanide x Diuretics Furosemide x Diuretics Spironolactone x Fluoroquinolones Ciprofloxacin 2 x x Yes Yes Yes Yes Yes Yes Yes Fluoroquinolones Levofloxacin 2 x x Yes Yes Yes Yes Yes Yes Yes NewFluoroquinolones York Workers’ CompensationMoxifloxacin Formulary Change Tracker:2 Updatesx xsince the previousYes version (Aug.Yes 2019) are highlightedYes in red Yes Yes Yes Yes GI, Misc Metoclopramide 4 x GI, Misc Simethicone 4 x x Hematopoetic Agents Folic Acid 4 x Carpal Pain Non Ankle / Back Mid / Hip / Knee Neck Shoulder Hypnotics Doxepin 4 x Asthma Tunnel CRPS Elbow Eye Acute Therapeutic Category Generic Name Foot Low (MTG) Groin (MTG) (MTG) (MTG) Special Special Hypnotics Temazepam 4 Phase A x Phase B (MTG) (MTG) Perioperative Hypnotics Zolpidem 4 Considerations x AnalgesicsLaxatives - Narcotic** BisacodylCodeine-Acetaminophen 1,34 x x x AnalgesicsLaxatives - Narcotic** DocusateHydrocodone-Acetaminophen Calcium 1,34 x x x AnalgesicsLaxatives - Narcotic** DocusateHydrocodone-Ibuprofen Na 1,34 x x x AnalgesicsLaxatives - Narcotic** GlycerinMorphine 1,34 x x x AnalgesicsLaxatives - Narcotic** LactuloseOxycodone HCl 1,34 x x x AnalgesicsLaxatives - Narcotic** MineralOxycodone-Acetaminophen Oil 1,34 x x x AnalgesicsLaxatives - Narcotic** NaOxycodone-Aspirin Phosphates - Enema 1,34 x x x Analgesics - Narcotic** Tapentadol 1,3 x Laxatives Polyethylene Glycol 3350 4 x x Analgesics - Narcotic** Tramadol HCl 1,3 x x Laxatives Psyllium 4 x x Analgesics - Narcotic** Tramadol-Acetaminophen 1,3 x x Macrolide Antibiotics Azithromycin 2 x x Yes Yes Carpal Yes Yes Yes Yes Pain Non Yes Analgesics - Nonnarcotic Acetaminophen x x x AnkleYes / BackYes Mid / Yes Yes Yes HipYes / KneeYes NeckYes Yes ShoulderYes Asthma Tunnel CRPS Elbow Eye Acute AnalgesicsMacrolideTherapeutic -Antibiotics Nonnarcotic Category ClarithromycinAspirin Generic Name 2 x x x FootYes LowYesYes (MTG) Yes Yes Yes GroinYes (MTG)Yes (MTG)Yes Yes (MTG)Yes Special Special Phase A Phase B (MTG) (MTG) AnalgesicsMacrolide -Antibiotics Nonnarcotic ErythromycinCholine - Magnesium Salicylates 2 x x x Yes YesYes Yes Yes Yes Yes Yes Yes Yes Yes Perioperative AnalgesicsMigraine Products - Nonnarcotic Butalbital-Acetaminophen-CaffeineDiflunisal 4 Considerations x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes MigraineAnalgesics Products - Topical Butalbital-Aspirin-CaffeineCapsaicin 4 x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes MigraineAnalgesics Products - Topical SumatriptanDiclofenac Na (1% only) x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes MouthAnalgesics - Throat - Topical (local) ClotrimazoleLidocaine Patch Troche (4% Only) 4 x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes MouthAnalgesics - Throat - Topical (local) LidocaineMethyl Salicylate Viscous 2% 4 x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes REV: July 31, 2019 Page 5 of 8 MouthAntacids - Throat (local) NystatinAlum Hydrox-Mag Suspension Trisil-Alginic Acid-Sod 4 x x OphthalmicAntacids AlcaftadineAluminum - Magnesium Hydroxides 4 x x Yes Ophthalmic ApraclonidineAluminum Hydroxide-Magnesium HCL Carbonate x x Yes Antacids 4 x x Ophthalmic ArtificialSusp Tear Ophth x x Yes Ophthalmic AtropineAluminum Sulfate Hydroxide-Magnesium Solution Trisilicate x x Yes Antacids 4 x x Ophthalmic AzelastineChew Tab x x Yes OphthalmicAntacids AzithromycinCalcium - Magnesium Carbonates 4 x x Yes OphthalmicAntacids BacitracinCalcium Carbonate Ophth 4 x x Yes OphthalmicAntacids Bacitracin-PolymyxinCalcium Carbonate - Simethicone B 4 x x Yes OphthalmicAntacids Bacitracin-Polymyxin-Neomycin-HCCalcium Carbonate-Mag Hydroxide 4 x x Yes OphthalmicAntianxiety Agents BepotastineAlprazolam 1 x x Yes OphthalmicAntianxiety Agents BesifloxacinBuspirone 1 x x Yes OphthalmicAntiasthmatics BetaxololAclidinium Bromide Aerosol Powd x x Yes OphthalmicAntiasthmatics BevacizumabAlbuterol Inhal x x Yes Yes Antiasthmatics Albuterol Sulfate x x Yes Ophthalmic Bimatoprost Ophth x x Yes Antiasthmatics Beclomethasone Inh x x Yes Ophthalmic Brimonidine Tartrate Ophth x x Yes Antiasthmatics Budesonide x x Yes Ophthalmic Brimonidine Tartrate-Timolol Maleate Ophth x x Yes Antiasthmatics Budesonide Inh x x Yes OphthalmicAntiasthmatics BrinzolamideBudesonide-Formoterol Ophth Fumarate Inh x x Yes Yes OphthalmicAntiasthmatics BromfenacCiclesonide Na Inh Ophth x x Yes Yes Carboxymethylcell-Glycerin-Polysorb 80 OphthalmicAntiasthmatics Cromolyn Na Inhal x x Yes Yes Antiasthmatics OphthEpinephrine Inhal x x Yes OphthalmicAntiasthmatics CarboxymethylcelluloseFlunisolide Inh x x Yes Yes OphthalmicAntiasthmatics CarteololFluticasone Furoate-Vilanterol Inh x x Yes Yes OphthalmicAntiasthmatics CarteololFluticasone HCL Inh x x Yes Yes Ophthalmic Ciprofloxacin x x Yes Antiasthmatics Fluticasone-Salmeterol Inhal x x Yes Ophthalmic Cromolyn x x Yes Antiasthmatics Formoterol Fumarate Soln Nebu x x Yes Ophthalmic x x Yes Antiasthmatics Formoterol/Mometasone x x Yes Ophthalmic Dexamethasone x x Yes Antiasthmatics Indacaterol Maleate Inhal x x Yes Ophthalmic Diclofenac x x Yes Antiasthmatics Ipratropium Bromide Inhal x x Yes Ophthalmic Dorzolamide x x Yes Antiasthmatics Ipratropium-Albuterol Inh x x Yes Ophthalmic Dorzolamide HCL x x Yes Antiasthmatics Levalbuterol HCl Inhal x x Yes Ophthalmic Emedastine x x Yes Antiasthmatics Methacholine Chloride Inhal x x Yes OphthalmicAntiasthmatics EpinastineMometasone Furoate Inh x x Yes Yes Ophthalmic ErythromycinMometasone Furoate-Formoterol Fumarate x x Yes Antiasthmatics x x Yes Ophthalmic FluorometholoneInh x x Yes OphthalmicAntiasthmatics FlurbiprofenMontelukast x x Yes Yes Rev.OphthalmicAntiasthmatics November 5, 2019 GatifloxacinRoflumilast x x Yes Yes Ophthalmic Gentamicin x x Page 6 Yes Ophthalmic Glycerin (Ophth Lubricant) x x Yes Ophthalmic Glycerin-Hypromellose-PEG 400 x x Yes Ophthalmic x x Yes REV:Ophthalmic July 31, 2019 Hypromellose x x Yes Page 1 of 8 Ophthalmic Irrigating Eyewash x x Yes Ophthalmic Ketorolac Trometh x x Yes Ophthalmic Ketotifen x x Yes Ophthalmic Latanoprost Ophth x x Yes Ophthalmic Levobunolol HCL x x Yes Ophthalmic Levofloxacin x x Yes Ophthalmic Lodoxamide x x Yes Ophthalmic Loteprednol x x Yes

REV: July 31, 2019 Page 6 of 8 Carpal Pain Non Ankle / Back Mid / Hip / Knee Neck Shoulder Asthma Tunnel CRPS Elbow Eye Acute Therapeutic Category Generic Name Foot Low (MTG) Groin (MTG) (MTG) (MTG) Special Special Phase A Phase B (MTG) (MTG) Perioperative Considerations Migraine Products Butalbital-Aspirin-Caffeine 4 x x Migraine Products Sumatriptan x Mouth - Throat (local) Clotrimazole Troche 4 x x Mouth - Throat (local) Lidocaine Viscous 2% 4 x x Mouth - Throat (local) Nystatin Suspension 4 x x Ophthalmic Alcaftadine x x Yes Ophthalmic Apraclonidine HCL x x Yes Ophthalmic Artificial Tear Ophth x x Yes Ophthalmic Atropine Sulfate Solution x x Yes Ophthalmic Azelastine x x Yes Ophthalmic Azithromycin x x Yes Ophthalmic Bacitracin Ophth x x Yes Ophthalmic Bacitracin-Polymyxin B x x Yes Ophthalmic Bacitracin-Polymyxin-Neomycin-HC x x Yes Ophthalmic Bepotastine x x Yes Ophthalmic Besifloxacin x x Yes Ophthalmic Betaxolol x x Yes Ophthalmic Bevacizumab x x Yes Ophthalmic Bimatoprost Ophth x x Yes Ophthalmic Brimonidine Tartrate Ophth x x Yes Ophthalmic Brimonidine Tartrate-Timolol Maleate Ophth x x Yes Ophthalmic Brinzolamide Ophth x x Yes Ophthalmic Bromfenac Na Ophth x x Yes Carboxymethylcell-Glycerin-Polysorb 80 Ophthalmic x x Yes Ophth Ophthalmic Carboxymethylcellulose x x Yes Ophthalmic Carteolol x x Yes Ophthalmic Carteolol HCL x x Yes Ophthalmic Ciprofloxacin x x Yes Ophthalmic Cromolyn x x Yes Ophthalmic Cyclopentolate x x Yes Ophthalmic Dexamethasone x x Yes Ophthalmic Diclofenac x x Yes NewOphthalmic York Workers’ CompensationDorzolamide Formulary Change Tracker: Updatesx xsince the previous version (Aug. 2019) are highlighted inYes red Ophthalmic Dorzolamide HCL x x Yes Ophthalmic Emedastine x x Yes Ophthalmic Epinastine x x Carpal Yes Pain Non Ankle / Back Mid / Hip / Knee Neck Shoulder Asthma Tunnel CRPS Elbow Eye Acute OphthalmicTherapeutic Category ErythromycinGeneric Name x x Foot Low (MTG) Yes Groin (MTG) (MTG) (MTG) Special Special Ophthalmic Fluorometholone x Phase A x Phase B (MTG) Yes (MTG) Perioperative Ophthalmic Flurbiprofen Considerations x x Yes MigraineOphthalmic Products Butalbital-Aspirin-CaffeineGatifloxacin 4 x x Yes MigraineOphthalmic Products SumatriptanGentamicin x x Yes MouthOphthalmic - Throat (local) ClotrimazoleGlycerin (Ophth Troche Lubricant) 4 x x Yes MouthOphthalmic - Throat (local) LidocaineGlycerin-Hypromellose-PEG Viscous 2% 400 4 x x Yes MouthOphthalmic - Throat (local) NystatinHomatropine Suspension 4 x x Yes Ophthalmic AlcaftadineHypromellose x x Yes Ophthalmic ApraclonidineIrrigating Eyewash HCL x x Yes Ophthalmic ArtificialKetorolac Tear Trometh Ophth x x Yes Ophthalmic AtropineKetotifen Sulfate Solution x x Yes Ophthalmic AzelastineLatanoprost Ophth x x Yes Ophthalmic Levobunolol HCL x x Carpal Yes Pain Non Ophthalmic Azithromycin x x Ankle / Back Mid / Yes Hip / Knee Neck Shoulder Asthma Tunnel CRPS Elbow Eye Acute OphthalmicTherapeutic Category BacitracinLevofloxacin OphthGeneric Name x x Foot Low (MTG) Yes Groin (MTG) (MTG) (MTG) Special Special Ophthalmic Bacitracin-PolymyxinLodoxamide B xPhase A xPhase B (MTG) Yes (MTG) Perioperative Ophthalmic Bacitracin-Polymyxin-Neomycin-HCLoteprednol Considerations x x Yes Ophthalmic MethylcelluloseBepotastine Ophth x x Yes Ophthalmic MetipranololBesifloxacin x x Yes Ophthalmic MoxifloxacinBetaxolol HCl x x Yes Ophthalmic NaBevacizumab Chloride Hypertonic x x Yes REV: July 31, 2019 Page 6 of 8 Ophthalmic NaphazolineBimatoprost HClOphth x x Yes Ophthalmic NatamycinBrimonidine Tartrate Ophth x x Yes Ophthalmic NedocromilBrimonidine Tartrate-Timolol Maleate Ophth x x Yes Ophthalmic Neomycin-Bacitracin-PolymyxinBrinzolamide Ophth x x Yes Ophthalmic Neomycin-Polymyxin-DexamethasoneBromfenac Na Ophth x x Yes Ophthalmic Neomycin-Polymyxin-GramicidinCarboxymethylcell-Glycerin-Polysorb 80 x x Yes Ophthalmic x x Yes Ophthalmic Neomycin-Polymyxin-HCOphth x x Yes Ophthalmic OfloxacinCarboxymethylcellulose x x Yes Ophthalmic OlopatadineCarteolol x x Yes Ophthalmic PhenylephrineCarteolol HCL HCL x x Yes Ophthalmic PilocarpineCiprofloxacin HCL x x Yes Ophthalmic PolyethyleneCromolyn Glycol 400 x x Yes Ophthalmic PolyethyleneCyclopentolate Glycol-Polyvinyl x x Yes Ophthalmic PolymyxinDexamethasone B-Trimethoprim x x Yes Ophthalmic PolysorbateDiclofenac 80 x x Yes Ophthalmic PolyvinylDorzolamide Alcohol x x Yes Ophthalmic PolyvinylDorzolamide Alcohol-Povidone HCL x x Yes Ophthalmic PrednisoloneEmedastine Acetate x x Yes Ophthalmic PrednisoloneEpinastine Na Phosphate x x Yes Ophthalmic ProparacaineErythromycin HCL x x Yes Ophthalmic Sulfacetamide-PrednisoloneFluorometholone x x Yes Ophthalmic SulfacetamineFlurbiprofen x x Yes Ophthalmic TetracaineGatifloxacin HCL x x Yes Ophthalmic TimololGentamicin Maleate x x Yes Ophthalmic TobramycinGlycerin (Ophth Lubricant) x x Yes Ophthalmic Tobramycin-DexamethasoneGlycerin-Hypromellose-PEG 400 x x Yes Ophthalmic TranexamicHomatropine Acid x x Yes Ophthalmic TravoprostHypromellose x x Yes Ophthalmic TrifluridineIrrigating Eyewash x x Yes Ophthalmic TropicamideKetorolac Trometh x x Yes Ophthalmic WhiteKetotifen Petrolatum-Mineral Oil x x Yes OTICOphthalmic AceticLatanoprost Acid Ophth x x Yes OTICOphthalmic Antipyrine-BenzocaineLevobunolol HCL Otic Soln x x Yes OTICOphthalmic Antipyrine-Benzocaine-Glycerin-ZincLevofloxacin Ace x x Yes OTICOphthalmic Antipyrine-Benzocaine-PolycosanolLodoxamide x x Yes Rev.OTICOphthalmic November 5, 2019 CiprofloxacinLoteprednol x x Yes OTIC Fluocinolone x x Page 7 OTIC Hydrocortisone w/ Acetic Acid x x OTIC Neomycin-Polymyxin-HC x x OTIC Ofloxacin x x REV: July 31, 2019 Page 6 of 8 OTIC Pramoxine-Chloroxylenol x x OTIC Pramoxine-HC-Chloroxylenol x x Penicillins Amoxicillin 2 x x Yes Yes Yes Yes Yes Yes Yes Penicillins Amoxicillin-Clavulanate 2 x x Yes Yes Yes Yes Yes Yes Yes Penicillins Ampicillin 2 x x Yes Yes Yes Yes Yes Yes Yes Penicillins Dicloxacillin 2 x x Yes Yes Yes Yes Yes Yes Yes Penicillins Penicillin 2 x x Yes Yes Yes Yes Yes Yes Yes Pressors Epinephrine x Respiratory, Misc Nintedanib Esylate 4 x Respiratory, Misc Pirfenidone 4 x

REV: July 31, 2019 Page 7 of 8 Carpal Pain Non Ankle / Back Mid / Hip / Knee Neck Shoulder Asthma Tunnel CRPS Elbow Eye Acute Therapeutic Category Generic Name Foot Low (MTG) Groin (MTG) (MTG) (MTG) Special Special Phase A Phase B (MTG) (MTG) Perioperative Considerations Ophthalmic Methylcellulose Ophth x x Yes Ophthalmic Metipranolol x x Yes Ophthalmic Moxifloxacin HCl x x Yes Ophthalmic Na Chloride Hypertonic x x Yes Ophthalmic Naphazoline HCl x x Yes Ophthalmic Natamycin x x Yes Ophthalmic x x Yes Ophthalmic Neomycin-Bacitracin-Polymyxin x x Yes Ophthalmic Neomycin-Polymyxin-Dexamethasone x x Yes Ophthalmic Neomycin-Polymyxin-Gramicidin x x Yes Ophthalmic Neomycin-Polymyxin-HC x x Yes Ophthalmic Ofloxacin x x Yes Ophthalmic x x Yes Ophthalmic Phenylephrine HCL x x Yes Ophthalmic HCL x x Yes Ophthalmic Polyethylene Glycol 400 x x Yes Ophthalmic Polyethylene Glycol-Polyvinyl Alcohol x x Yes Ophthalmic Polymyxin B-Trimethoprim x x Yes Ophthalmic Polysorbate 80 x x Yes Ophthalmic Polyvinyl Alcohol x x Yes Ophthalmic Polyvinyl Alcohol-Povidone x x Yes Ophthalmic Prednisolone Acetate x x Yes Ophthalmic Prednisolone Na Phosphate x x Yes Ophthalmic Proparacaine HCL x x Yes Ophthalmic Sulfacetamide-Prednisolone x x Yes Ophthalmic Sulfacetamine x x Yes Ophthalmic Tetracaine HCL x x Yes Ophthalmic Timolol Maleate x x Yes Ophthalmic Tobramycin x x Yes Ophthalmic Tobramycin-Dexamethasone x x Yes Ophthalmic Tranexamic Acid x x Yes NewOphthalmic York Workers’ CompensationTravoprost Formulary Change Tracker: Updatesx xsince the previous version (Aug. 2019) are highlighted inYes red Ophthalmic Trifluridine x x Yes Ophthalmic x x Yes Ophthalmic White Petrolatum-Mineral Oil x x Carpal Yes Pain Non Ankle / Back Mid / Hip / Knee Neck Shoulder OTIC Acetic Acid x x Asthma Tunnel CRPS Elbow Eye Acute Therapeutic Category Generic Name Foot Low (MTG) Groin (MTG) (MTG) (MTG) Special Special OTIC Antipyrine-Benzocaine Otic Soln xPhase A xPhase B (MTG) (MTG) Perioperative OTIC Antipyrine-Benzocaine-Glycerin-Zinc Ace Considerations x x AntipsychoticsOTIC ProchlorperazineAntipyrine-Benzocaine-Polycosanol 4 x x AntipsychoticsOTIC QuetiapineCiprofloxacin 4 x x AntipsychoticsOTIC RisperidoneFluocinolone 4 x x AntipsychoticsOTIC ZiprasidoneHydrocortisone w/ Acetic Acid 4 x x AntiretroviralsOTIC AtazanavirNeomycin-Polymyxin-HC 2 x x AntiretroviralsOTIC DarunavirOfloxacin 2 x x AntiretroviralsOTIC EmtricitabinePramoxine-Chloroxylenol 2 x x AntiretroviralsOTIC FosamprenavirPramoxine-HC-Chloroxylenol 2 x x AntiretroviralsPenicillins LamivudineAmoxicillin 2 x x Yes Yes Yes Yes Yes Yes Yes AntiretroviralsPenicillins RaltegravirAmoxicillin-Clavulanate 2 x x Yes Yes Yes Yes Yes Yes Yes AntiretroviralsPenicillins RitonavirAmpicillin 2 x x Yes Yes Yes Yes Yes Yes Yes AntiretroviralsPenicillins StavudineDicloxacillin 2 x x Yes Yes Yes Yes Yes Yes Yes Penicillins Penicillin 2 x x Yes Yes Carpal Yes Yes Yes Yes Pain Non Yes Antiretrovirals Tenofovir 2 x Ankle / Back Mid / Hip / Knee Neck Shoulder Asthma Tunnel CRPS Elbow Eye Acute AntiretroviralsPressorsTherapeutic Category ZidovudineEpinephrine Generic Name 2 x Foot Low (MTG) Groin (MTG) (MTG) (MTG) Special Special AntitubercularRespiratory, Misc EthambutolNintedanib Esylate 2,44 Phase A x Phase B (MTG) (MTG) Perioperative AntitubercularRespiratory, Misc IsoniazidPirfenidone 2,44 Considerations x AntitubercularSkeletal Muscle Relaxants RifabutinBaclofen 2,41 x xx 2nd 2nd 2nd 2nd AntitubercularSkeletal Muscle Relaxants RifampinCarisoprodol 2,41 x xx 2nd 2nd 2nd 2nd AntiviralSkeletal Muscle Relaxants AcyclovirCyclobenzaprine 1,2 3 xx x Yes Yes Yes Yes AntiviralSkeletal Muscle Relaxants OseltamivirMetaxalone 21 xx x 2nd 2nd 2nd 2nd REV: July 31, 2019 Page 7 of 8 AntiviralSkeletal Muscle Relaxants ZanamivirMethocarbamol 21 xx x 2nd 2nd 2nd 2nd BetaSkeletal Blockers Muscle Relaxants CarvedilolTizanidine HCl 1 xx xx 2nd 2nd 2nd 2nd BetaTetracyclines Blockers MetoprololDoxycycline Tartrate 2 xx xx Yes Yes Yes Yes Yes Yes Yes BetaTetracyclines Blockers NebivololMinocycline 2 xx xx Yes Yes Yes Yes Yes Yes Yes BetaTetracyclines Blockers PropranololTetracycline HCl 2 xx xx Yes Yes Yes Yes Yes Yes Yes CalciumUlcer Drugs Blockers AmlodipineCimetidine xx xx Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes CalciumUlcer Drugs Blockers DiltiazemDicyclomine HCl xx xx CalciumUlcer Drugs Blockers NifedipineEsomeprazole xx xx Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes CephalosporinsUlcer Drugs CefaclorFamotidine 2 xx xx Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes CephalosporinsUlcer Drugs CefadroxilHyoscyamine 2 xx xx Yes Yes Yes Yes Yes Yes Yes CephalosporinsUlcer Drugs CefdinirLansoprazole 2 xx xx Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes CephalosporinsUlcer Drugs CefiximeMisoprostol 2 xx xx Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes CephalosporinsUlcer Drugs CefpodoximeNizatidine 2 xx xx Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes CephalosporinsUlcer Drugs CefprozilOmeprazole 2 xx xx Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes CephalosporinsUlcer Drugs CephalexinPantoprazole 2 xx xx Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes CorticosteroidsUlcer Drugs MethylprednisoloneRabeprazole xx xx Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes CorticosteroidsUlcer Drugs PrednisoloneRanitidine xx xx Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes CorticosteroidsUlcer Drugs PrednisoneSucralfate xx xx Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Rev.Cough/Cold November 5, 2019 Acetylcysteine Inhal x Cough/Cold Benzonatate x Cough/Cold Cetirizine-Pseudoephedrine x SPECIALCough/Cold CONSIDERATIONS Chlorpheniramine: - Phenylephrine x ** Prescriber should consider appropriateness of naloxone when prescribing opioids. The WCB supports the 1.Cough/Cold Not to exceed a single sevenChlorpheniramine-Acetaminophen (7) day supply. x NYS DOH recommendations. After appropriate claimant assessment, if in the prescriber’s judgement it is 2.Cough/Cold For the prescribed courseChlorpheniramine-DM of therapy. x appropriate for the claimant to obtain naloxone, the provider should submit a prior authorization request. Cough/Cold Dextromethorphan x 3.Cough/Cold Short acting only. Dextromethorphan-APAP-Chlorpheniramine x health.ny.gov/professionals/ems/policy/13-10.htm 4.Cough/Cold As clinically indicated for Dextromethorphan-Diphenhyd-APAPcausally related injuries or x governor.ny.gov/news/governor-cuomo-announces-narcan-now-available-independent-pharmacies Decongestantsconditions utilizing acceptedCromolyn standards Nasal of medical care. x Decongestants Oxymetazoline x Decongestants Phenylephrine Nasal x Decongestants Pseudoephedrine x Decongestants Saline Nasal x Decongestants Tetrahydrozoline Nasal x WCB.NY.GOVDecongestants Triamcinolone Acetonide Nasal x Page 8 WCB-drug-formulary-1-v2 11-19 CHANGES

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