MTUS Drug List v.3 (8 CCR § 9792.27.15)
MTUS Drug List v.3 ( 8 CCR §9792.27.15) EFFECTIVE DATE: October 1, 2018
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.)
Reference Brand Exempt/Non‐ Unique Drug Ingredient Special Fill** Peri‐Op*** Drug Class Reference in ACOEM Guidelines * Dosage Form Strength Pharmaceutical Name Exempt* Identifier(s) ✓ Ankle and Foot Disorders ✓ Cervical and Thoracic Spine Disorders ✓ Chronic Pain ✓✕ Elbow Disorders Analgesics ‐ Acetaminophen Tylenol Exempt ✓✕ Hand, Wrist, and Forearm Disorders NonNarcotic ✓ Hip and Groin Disorders ✓ Knee Disorders ✓ Low Back Disorders ✓ Shoulder
Psychotherapeutic and Acetyl L‐Carnitine Non‐Exempt Neurological Agents ‐ ✕ Chronic Pain Misc
Acyclovir Zovirax Non‐Exempt Antivirals ⦸ Chronic Pain
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
*ACOEM Guidelines Copyright Reed Group Ltd.
Effective October 1, 2018 1 of 26 MTUS Drug List v.3 (8 CCR § 9792.27.15)
Reference Brand Exempt/Non‐ Unique Drug Ingredient Special Fill** Peri‐Op*** Drug Class Reference in ACOEM Guidelines * Dosage Form Strength Pharmaceutical Name Exempt* Identifier(s) ✓ Chronic Pain Endocrine and ✓⦸ Hip and Groin Disorders Metabolic Agents‐ Alendronate Sodium Fosamax Non‐Exempt ⦸ Knee Disorders Misc. ✕ Low Back Disorders (Bisphosphonate) ✓ Shoulder Antiparkinson Agents ✕ Chronic Pain Amantadine HCL Symmetrel Non‐Exempt (NMDA receptor ✕ Low Back Disorders antagonist) Amcinonide Cyclocort Non‐Exempt Dermatologicals ✓ Ankle and Foot Disorders ✓✕ Cervical and Thoracic Spine Disorders ✓✕ Chronic Pain Antidepressants ✕⦸ Hip and Groin Disorders Amitriptyline HCL Elavil Non‐Exempt (TCAs) ✓✕⦸ Knee Disorders ✓⦸ Low Back Disorders ✓✕ 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 14 Days Apixaban Eliquis Non‐Exempt Anticoagulants ✓ Hip and Groin Disorders ✓ Knee Disorders 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 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) ✓ Ankle and Foot Disorders Anti‐Infective Agents ‐ Bacitracin Exempt ⦸ Hand, Wrist, and Forearm Disorders Misc.
*ACOEM Guidelines Copyright Reed Group Ltd.
Effective October 1, 2018 2 of 26 MTUS Drug List v.3 (8 CCR § 9792.27.15)
Reference Brand Exempt/Non‐ Unique Drug Ingredient Special Fill** Peri‐Op*** Drug Class Reference in ACOEM Guidelines * Dosage Form Strength Pharmaceutical Name 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 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 Ophthalmic Agents Bromfenac Prolensa Exempt ✓✕ Eye (NSAID) 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 ✕ Ankle and Foot Disorders ✕ Cervical and Thoracic Spine Disorders ✕ Chronic Pain ✕ Elbow Disorders ✕ Hand, Wrist, and Forearm Disorders Buprenorphine HCL/Naloxone Suboxone Non‐Exempt Analgesics ‐ Opioid ✕ Hip and Groin Disorders ✕ Knee Disorders ✕ Low Back Disorders ✓ Opioid ✕ Shoulder
*ACOEM Guidelines Copyright Reed Group Ltd.
Effective October 1, 2018 3 of 26 MTUS Drug List v.3 (8 CCR § 9792.27.15)
Reference Brand Exempt/Non‐ Unique Drug Ingredient Special Fill** Peri‐Op*** Drug Class Reference in ACOEM Guidelines * Dosage Form Strength Pharmaceutical Name Exempt* Identifier(s) ✕ Cervical and Thoracic Spine Disorders ✓✕⦸ Chronic Pain Wellbutrin, Wellbutrin XL, Antidepressants ✕ Hip and Groin Disorders Bupropion HCL Non‐Exempt Wellbutrin SR (SSRI) ✕ Knee Disorders ✕ Low Back Disorders ✕ Shoulder Analgesics ‐ Butalbital/Apap/Caffeine Non‐Exempt ✕ Hand, Wrist, and Forearm Disorders NonNarcotic Analgesics ‐ Butalbital/Asa/Caffeine Non‐Exempt ✕ Hand, Wrist, and Forearm Disorders NonNarcotic 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 ✕ 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 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)
*ACOEM Guidelines Copyright Reed Group Ltd.
Effective October 1, 2018 4 of 26 MTUS Drug List v.3 (8 CCR § 9792.27.15)
Reference Brand Exempt/Non‐ Unique Drug Ingredient Special Fill** Peri‐Op*** Drug Class Reference in ACOEM Guidelines * Dosage Form Strength Pharmaceutical Name Exempt* Identifier(s) ✓ Ankle and Foot Disorders ✓ Cervical and Thoracic Spine Disorders ✓ Chronic Pain ✓✕⦸ Elbow Disorders Analgesics ‐ Anti‐ Celecoxib Celebrex Exempt ✓✕⦸ Hand, Wrist, and Forearm Disorders Inflammatory (NSAID) ✓⦸ Hip and Groin Disorders ✓⦸ Knee Disorders ✓ Low Back Disorders ✓ Shoulder ✓⦸ Ankle and Foot Disorders Antibiotics Cephalexin Keflex Exempt ✕ Hand, Wrist, and Forearm Disorders (Cephalosporins)
✕ 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 ‐ Choline Magnesium Trisalicylate Trilisate Exempt ✓✕⦸ Hand, Wrist, and Forearm Disorders NonNarcotic (NSAID) ✓⦸ Hip and Groin Disorders ✓⦸ Knee Disorders ✓ Low Back Disorders ✓ Shoulder ⦸ 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 ✓ Cervical and Thoracic Spine Disorders ✓ Elbow Disorders ✓ Hand, Wrist, and Forearm Disorders Ulcer Drugs (H2 Cimetidine Tagamet Exempt ✓ Hip and Groin Disorders receptor blocker) ✓ Knee Disorders ✓ Low Back Disorders ✓ Shoulder ✓ Ankle and Foot Disorders Antibiotics Ciprofloxacin Cipro Exempt ✓ Hand, Wrist, and Forearm Disorders (Fluoroquinolones) Ophthalmic Agents Ciprofloxacin HCL Ophthalmic Ciloxan Exempt ✓✕⦸ Eye (Antibiotics) ✕ Cervical and Thoracic Spine Disorders ✓✕ Chronic Pain Antidepressants ✕ Hip and Groin Disorders Citalopram Hydrobromide Celexa Non‐Exempt (SSRI) ✓✕ Knee Disorders ✕ Low Back Disorders ✕ Shoulder Antibiotics Clarithromycin Biaxin Non‐Exempt ✕ Hand, Wrist, and Forearm Disorders (Macrolides)
*ACOEM Guidelines Copyright Reed Group Ltd.
Effective October 1, 2018 5 of 26 MTUS Drug List v.3 (8 CCR § 9792.27.15)
Reference Brand Exempt/Non‐ Unique Drug Ingredient Special Fill** Peri‐Op*** Drug Class Reference in ACOEM Guidelines * Dosage Form Strength Pharmaceutical Name Exempt* Identifier(s) ✓⦸ 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 ✕ Shoulder 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 Phosphate 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 Codeine Sulfate 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 Codeine/Acetaminophen Tylenol #3, Tylenol #4 Non‐Exempt Analgesics ‐ Opioid ✕ Hand, Wrist, and Forearm Disorders ✕ Hip and Groin Disorders ✕ Knee Disorders ✕ Low Back Disorders ✕ Shoulder
Coenzyme Q10 CoQ10 Non‐Exempt Alternative Medicines ⦸ Chronic Pain
✕ Cervical and Thoracic Spine Disorders Colchicine Non‐Exempt Gout Agents ✕ Low Back Disorders
*ACOEM Guidelines Copyright Reed Group Ltd.
Effective October 1, 2018 6 of 26 MTUS Drug List v.3 (8 CCR § 9792.27.15)
Reference Brand Exempt/Non‐ Unique Drug Ingredient Special Fill** Peri‐Op*** Drug Class Reference in ACOEM Guidelines * Dosage Form Strength Pharmaceutical Name Exempt* Identifier(s) ✓✕⦸ 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) 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 Therapy Agents ✕ Knee Disorders (Muscle Relaxants) ✕ Low Back Disorders ✕ Shoulder
Dehydroepiandrosterone (DHEA) Non‐Exempt Chemicals ⦸ Chronic Pain
✓✕ Cervical and Thoracic Spine Disorders ✓ Chronic Pain Antidepressants ⦸ Hip and Groin Disorders Desipramine HCL Norpramin Non‐Exempt (TCAs) ✓✕⦸ Knee Disorders ✓⦸ Low Back Disorders ✓✕ Shoulder Antihistamine and/or Desloratadine Clarinex Exempt ✓ Eye mast cell stabilization
Desonide Desowen Non‐Exempt Dermatologicals ✓ Ankle and Foot Disorders
Desoximetasone Topicort Non‐Exempt Dermatologicals ✓ Ankle and Foot Disorders
*ACOEM Guidelines Copyright Reed Group Ltd.
Effective October 1, 2018 7 of 26 MTUS Drug List v.3 (8 CCR § 9792.27.15)
Reference Brand Exempt/Non‐ Unique Drug Ingredient Special Fill** Peri‐Op*** Drug Class Reference in ACOEM Guidelines * Dosage Form Strength Pharmaceutical Name Exempt* Identifier(s) ✕ 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 Dexamethasone Decadron Non‐Exempt 4 Days Corticosteroids ✓✕⦸ Hand, Wrist, and Forearm Disorders ✕ Hip and Groin Disorders ✓⦸ Knee Disorders ✓✕⦸ Low Back Disorders ✓✕⦸ Shoulder 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 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‐ Diclofenac Potassium Cataflam Exempt ✓✕⦸ Hand, Wrist, and Forearm Disorders Inflammatory (NSAID) ✓⦸ Hip and Groin Disorders ✓⦸ Knee Disorders ✓ Low Back Disorders ✓ Shoulder
Analgesics ‐ Diclofenac Sodium Voltaren Non‐Exempt ⦸ Chronic Pain Antiinflammatory
✓✕⦸ 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)
*ACOEM Guidelines Copyright Reed Group Ltd.
Effective October 1, 2018 8 of 26 MTUS Drug List v.3 (8 CCR § 9792.27.15)
Reference Brand Exempt/Non‐ Unique Drug Ingredient Special Fill** Peri‐Op*** Drug Class Reference in ACOEM Guidelines * Dosage Form Strength Pharmaceutical Name Exempt* Identifier(s) ✓⦸ Ankle and Foot Disorders ✓ Cervical and Thoracic Spine Disorders ✕ Chronic Pain Analgesics ‐ Anti‐ ✓ Elbow Disorders Diclofenac Sodium/Misoprostol Arthrotec Exempt Inflammatory (NSAID/ ✓ Hand, Wrist, and Forearm Disorders Ulcer drug) ✓ Hip and Groin Disorders ✓ Knee Disorders ✓ Low Back Disorders ✓ Shoulder 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‐ Diflunisal Dolobid Exempt ✓✕⦸ Hand, Wrist, and Forearm Disorders Inflammatory (NSAID) ✓⦸ Hip and Groin Disorders ✓⦸ Knee Disorders ✓ Low Back Disorders ✓ Shoulder ✕ 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
Dolasetron Mesylate Anzemet Non‐Exempt Antiemetics ⦸ Chronic Pain
✓✕ 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 ✓ Hand, Wrist, and Forearm Disorders Doxycycline Vibramycin Exempt (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 Antihistamine and/or Emedastine Ophth Emadine Exempt ✓ Eye mast cell stabilization ⦸ Ankle and Foot Disorders 14 Days Enoxaparin Sodium Lovenox Non‐Exempt 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 Antidepressants Escitalopram Oxalate Lexapro Non‐Exempt ✓✕ Chronic Pain (SSRI) ✕ Hip and Groin Disorders
*ACOEM Guidelines Copyright Reed Group Ltd.
Effective October 1, 2018 9 of 26 MTUS Drug List v.3 (8 CCR § 9792.27.15)
Reference Brand Exempt/Non‐ Unique Drug Ingredient Special Fill** Peri‐Op*** Drug Class Reference in ACOEM Guidelines * Dosage Form Strength Pharmaceutical Name Exempt* Identifier(s) ✓ Cervical and Thoracic Spine Disorders ✓ Elbow Disorders ✓ Hand, Wrist, and Forearm Disorders Ulcer Drugs (Proton ✓ Hip and Groin Disorders Esomeprazole Magnesium Nexium Exempt 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 Esomeprazole/Naproxen Vimovo Non‐Exempt ✕ Hand, Wrist, and Forearm Disorders Pump Inhibitor ✕ Hip and Groin Disorders /NSAID) ✕ Knee Disorders ✕ Low Back Disorders ✕ Shoulder
Estradiol Climara, Estraderm Non‐Exempt Estrogens ✕ Chronic Pain
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‐ Etodolac Lodine Exempt ✓✕⦸ Hand, Wrist, and Forearm Disorders Inflammatory (NSAID) ✓⦸ Hip and Groin Disorders ✓⦸ Knee Disorders ✓ Low Back Disorders ✓ Shoulder
Famciclovir Famvir Non‐Exempt Antivirals ⦸ Chronic Pain
✓ Cervical and Thoracic Spine Disorders ✓ Elbow Disorders ✓ Hand, Wrist, and Forearm Disorders Ulcer Drugs (H2 Famotidine Pepcid Exempt ✓ Hip and Groin Disorders receptor blocker) ✓ Knee Disorders ✓ Low Back Disorders ✓ Shoulder
*ACOEM Guidelines Copyright Reed Group Ltd.
Effective October 1, 2018 10 of 26 MTUS Drug List v.3 (8 CCR § 9792.27.15)
Reference Brand Exempt/Non‐ Unique Drug Ingredient Special Fill** Peri‐Op*** Drug Class Reference in ACOEM Guidelines * Dosage Form Strength Pharmaceutical Name Exempt* Identifier(s) ✕ Ankle and Foot Disorders ✕ Cervical and Thoracic Spine Disorders ✕ Chronic Pain Analgesics ‐ Anti‐ ✕ Elbow Disorders Inflammatory (H2 Famotidine/Ibuprofen Duexis Non‐Exempt ✕ Hand, Wrist, and Forearm Disorders Receptor Blocker ✕ Hip and Groin Disorders /NSAID) ✕ Knee Disorders ✕ Low Back Disorders ✕ Shoulder ✓ Ankle and Foot Disorders ✓ Cervical and Thoracic Spine Disorders ✓ Chronic Pain ✓✕⦸ Elbow Disorders Analgesics ‐ Anti‐ Fenoprofen Calcium Nalfon Exempt ✓✕⦸ Hand, Wrist, and Forearm Disorders Inflammatory (NSAID) ✓⦸ Hip and Groin Disorders ✓⦸ Knee Disorders ✓ Low Back Disorders ✓ Shoulder ✕ 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 ✕ Ankle and Foot Disorders ✕ Cervical and Thoracic Spine Disorders ✕ Chronic Pain ✕ Elbow Disorders Fentanyl Citrate Oral Transmucosal Actiq, Fentora Non‐Exempt Analgesics ‐ Opioid ✕ Hand, Wrist, and Forearm Disorders ✕ Hip and Groin Disorders ✕ Knee Disorders ✕ Low Back Disorders ✕ Shoulder Fluconazole Diflucan Non‐Exempt Antifungals ✓ Ankle and Foot Disorders
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 Antidepressants ✕ Hip and Groin Disorders Fluoxetine HCL Prozac Non‐Exempt (SSRI) ✓✕ Knee Disorders ✕ Low Back Disorders ✕ Shoulder
*ACOEM Guidelines Copyright Reed Group Ltd.
Effective October 1, 2018 11 of 26 MTUS Drug List v.3 (8 CCR § 9792.27.15)
Reference Brand Exempt/Non‐ Unique Drug Ingredient Special Fill** Peri‐Op*** Drug Class Reference in ACOEM Guidelines * Dosage Form Strength Pharmaceutical Name Exempt* Identifier(s) ✓ Ankle and Foot Disorders ✓ Cervical and Thoracic Spine Disorders ✓ Chronic Pain ✓✕⦸ Elbow Disorders Analgesics ‐ Anti‐ Flurbiprofen Ansaid Exempt ✓✕⦸ Hand, Wrist, and Forearm Disorders Inflammatory (NSAID) ✓⦸ Hip and Groin Disorders ✓⦸ Knee Disorders ✓ Low Back Disorders ✓ Shoulder 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 Antidepressants ✕ Hip and Groin Disorders Fluvoxamine Maleate Luvox Non‐Exempt (SSRI) ✕ Knee Disorders ✕ Low Back Disorders ✕ Shoulder
Folic Acid Non‐Exempt Hematopoietic Agents ✕ Cervical and Thoracic Spine Disorders
⦸ Ankle and Foot Disorders 14 Days Fondaparinux Sodium Arixtra Non‐Exempt Anticoagulants ✓ Hip and Groin Disorders ✓ Knee Disorders Antiasthmatic and Formoterol Fumarate Foradil Non‐Exempt ✓ Work Related Asthma Bronchodilator Agents
Antiasthmatic and Formoterol/Mometasone Dulera Non‐Exempt ✓ Work Related Asthma Bronchodilator Agents ✓✕⦸ Cervical and Thoracic Spine Disorders ✓ Chronic Pain ✓✕⦸ Hip and Groin Disorders Gabapentin Neurontin Non‐Exempt 4 Days Anticonvulsants ✓✕⦸ Knee Disorders ✓⦸Low Back Disorders ✓✕⦸ Shoulder
Psychotherapeutic and Gabapentin (Once‐daily) Gralise Non‐Exempt Neurological Agents ‐ ✕ Chronic Pain Misc
Psychotherapeutic and Gabapentin Enacarbil Horizant Non‐Exempt Neurological Agents ‐ ✓✕ Chronic Pain Misc
Ophthalmic Agents Gatifloxacin Zymaxid Exempt ✓✕ Eye (Anti‐bacterial)
Gentamicin (Topical) Exempt Dermatologicals ✓Ankle and Foot Disorders
*ACOEM Guidelines Copyright Reed Group Ltd.
Effective October 1, 2018 12 of 26 MTUS Drug List v.3 (8 CCR § 9792.27.15)
Reference Brand Exempt/Non‐ Unique Drug Ingredient Special Fill** Peri‐Op*** Drug Class Reference in ACOEM Guidelines * Dosage Form Strength Pharmaceutical Name Exempt* Identifier(s) 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 ✕⦸ Ankle and Foot Disorders 14 Days Heparin Sodium Non‐Exempt 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 ✕ Ankle and Foot Disorders ✕ Cervical and Thoracic Spine Disorders ✕ Chronic Pain ✕ Elbow Disorders Hydrocodone Bitartrate Zohydro ER, Hysingla ER 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 Hydrocodone/Acetaminophen Norco, Vicodin, Xodol 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 Hydrocodone/Ibuprofen Vicoprofen 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 Hydrocortisone Cortef Non‐Exempt 4 Days Corticosteroids ✓✕⦸ Hand, Wrist, and Forearm Disorders ✕ Hip and Groin Disorders ⦸ Knee Disorders ✓✕⦸ Low Back Disorders ✓✕⦸ Shoulder Hydrocortisone (Topical) Non‐Exempt Dermatologicals ✓ Ankle and Foot Disorders
Hydrocortisone Valerate Westcort Non‐Exempt Dermatologicals ✓ Ankle and Foot Disorders
*ACOEM Guidelines Copyright Reed Group Ltd.
Effective October 1, 2018 13 of 26 MTUS Drug List v.3 (8 CCR § 9792.27.15)
Reference Brand Exempt/Non‐ Unique Drug Ingredient Special Fill** Peri‐Op*** Drug Class Reference in ACOEM Guidelines * Dosage Form Strength Pharmaceutical Name Exempt* Identifier(s) ✕ 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 ✓ Ankle and Foot Disorders ✓ Cervical and Thoracic Spine Disorders ✓ Chronic Pain ✓✕⦸ Elbow Disorders Analgesics ‐ Anti‐ Ibuprofen Motrin Exempt ✓✕⦸ Hand, Wrist, and Forearm Disorders Inflammatory (NSAID) ✓⦸ Hip and Groin Disorders ✓✕⦸ Knee Disorders ✓ Low Back Disorders ✓ Shoulder ✓✕ Cervical and Thoracic Spine Disorders ✕ Chronic Pain Antidepressants ⦸ Hip and Groin Disorders Imipramine HCL Tofranil Non‐Exempt (TCAs) ✕ Knee Disorders ✓⦸ Low Back Disorders ✕ Shoulder ✓ Ankle and Foot Disorders ✓ Cervical and Thoracic Spine Disorders ✓ Chronic Pain ✓✕⦸ Elbow Disorders Analgesics ‐ Anti‐ Indomethacin Indocin Exempt ✓✕⦸ Hand, Wrist, and Forearm Disorders Inflammatory (NSAID) ✓⦸ Hip and Groin Disorders ✓⦸ Knee Disorders ✓ Low Back Disorders ✓ Shoulder
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‐ Ketoprofen Oruvail Exempt ✓✕⦸ Hand, Wrist, and Forearm Disorders Inflammatory (NSAID) ✓⦸ Hip and Groin Disorders ✓⦸ Knee Disorders ✓ Low Back Disorders ✓ Shoulder
*ACOEM Guidelines Copyright Reed Group Ltd.
Effective October 1, 2018 14 of 26 MTUS Drug List v.3 (8 CCR § 9792.27.15)
Reference Brand Exempt/Non‐ Unique Drug Ingredient Special Fill** Peri‐Op*** Drug Class Reference in ACOEM Guidelines * Dosage Form Strength Pharmaceutical Name Exempt* Identifier(s) ✕ Ankle and Foot Disorders ✕ Cervical and Thoracic Spine Disorders ✕ Chronic Pain ✕ Elbow Disorders Analgesics ‐ Anti‐ Ketorolac Tromethamine Non‐Exempt ✕ Hand, Wrist, and Forearm Disorders Inflammatory (NSAID) ✕ Hip and Groin Disorders ✕ Knee Disorders ✕ Low Back Disorders ✕ Shoulder Ophthalmic Agents Ketorolac Tromethamine Ophthalmic Acular Exempt ✓✕ Eye (NSAID) Ketotifen Fumarate Zaditor Exempt Ophthalmic Agents ✓ Eye ✓ Cervical and Thoracic Spine Disorders ✓ Chronic Pain Lamotrigine Lamictal Non‐Exempt Anticonvulsants ⦸ Low Back Disorders ✕ Shoulder ✓ Cervical and Thoracic Spine Disorders ✓ Elbow Disorders ✓ Hand, Wrist, and Forearm Disorders Ulcer Drugs (Proton Lansoprazole Prevacid Exempt ✓ Hip and Groin Disorders pump inhibitor) ✓ Knee Disorders ✓ Low Back Disorders ✓ Shoulder
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 ✓✕ Hand, Wrist, and Forearm Disorders Levofloxacin Levaquin Exempt (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
*ACOEM Guidelines Copyright Reed Group Ltd.
Effective October 1, 2018 15 of 26 MTUS Drug List v.3 (8 CCR § 9792.27.15)
Reference Brand Exempt/Non‐ Unique Drug Ingredient Special Fill** Peri‐Op*** Drug Class Reference in ACOEM Guidelines * Dosage Form Strength Pharmaceutical Name Exempt* Identifier(s) ✓⦸ 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 ✕ 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 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‐ Meclofenamate Sodium Meclomen Exempt ✓✕⦸ Hand, Wrist, and Forearm Disorders Inflammatory (NSAID) ✓⦸ Hip and Groin Disorders ✓⦸ Knee Disorders ✓ Low Back Disorders ✓ Shoulder ✓ Ankle and Foot Disorders ✓ Cervical and Thoracic Spine Disorders ✓ Chronic Pain ✓✕⦸ Elbow Disorders Analgesics ‐ Anti‐ Mefenamic Acid Ponstel Exempt ✓✕⦸ Hand, Wrist, and Forearm Disorders Inflammatory (NSAID) ✓⦸ Hip and Groin Disorders ✓⦸ Knee Disorders ✓ Low Back Disorders ✓ Shoulder
*ACOEM Guidelines Copyright Reed Group Ltd.
Effective October 1, 2018 16 of 26 MTUS Drug List v.3 (8 CCR § 9792.27.15)
Reference Brand Exempt/Non‐ Unique Drug Ingredient Special Fill** Peri‐Op*** Drug Class Reference in ACOEM Guidelines * Dosage Form Strength Pharmaceutical Name Exempt* Identifier(s)
Melatonin Non‐Exempt ✓ Chronic Pain
✓ Ankle and Foot Disorders ✓ Cervical and Thoracic Spine Disorders ✓ Chronic Pain ✓✕⦸ Elbow Disorders Analgesics ‐ Anti‐ Meloxicam Mobic Exempt ✓✕⦸ Hand, Wrist, and Forearm Disorders Inflammatory (NSAID) ✓⦸ Hip and Groin Disorders ✓⦸ Knee Disorders ✓ Low Back Disorders ✓ Shoulder Psychotherapeutic and Neurological Agents ‐ ✕⦸ Chronic Pain Memantine HCL Namenda Non‐Exempt Misc. ✕ Low Back Disorders (NDMA Receptor 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
*ACOEM Guidelines Copyright Reed Group Ltd.
Effective October 1, 2018 17 of 26 MTUS Drug List v.3 (8 CCR § 9792.27.15)
Reference Brand Exempt/Non‐ Unique Drug Ingredient Special Fill** Peri‐Op*** Drug Class Reference in ACOEM Guidelines * Dosage Form Strength Pharmaceutical Name Exempt* Identifier(s) ⦸ 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 ✓✕ Ankle and Foot Disorders ✓✕ Cervical and Thoracic Spine Disorders ✓✕ Chronic Pain ⦸ Elbow Disorders Methylprednisolone Medrol Non‐Exempt 4 Days Corticosteroids ✓⦸ Hand, Wrist, and Forearm Disorders ✕ Hip and Groin Disorders ✓✕⦸ Low Back Disorders ✓✕⦸ Shoulder ✓ Work Related Asthma ⦸ 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 ✕ 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) Mirtazapine Remeron Non‐Exempt Antidepressants ✓ Chronic Pain ✓ Cervical and Thoracic Spine Disorders ✓ Elbow Disorders ✓ Hand, Wrist, and Forearm Disorders Misoprostol Cytotec Exempt Ulcer Drugs ✓ Hip and Groin Disorders ✓ Knee Disorders ✓ Low Back Disorders ✓ Shoulder 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 ✓✕ Ankle and Foot Disorders ✓✕ Cervical and Thoracic Spine Disorders ✓✕ Chronic Pain ✓✕ Elbow Disorders Morphine Sulfate Non‐Exempt 4 Days 4 Days Analgesics ‐ Opioid ✓✕ Hand, Wrist, and Forearm Disorders ✓ Hip and Groin Disorders ✓ Knee Disorders ✓✕ Low Back Disorders ✓✕ Shoulder
*ACOEM Guidelines Copyright Reed Group Ltd.
Effective October 1, 2018 18 of 26 MTUS Drug List v.3 (8 CCR § 9792.27.15)
Reference Brand Exempt/Non‐ Unique Drug Ingredient Special Fill** Peri‐Op*** Drug Class Reference in ACOEM Guidelines * Dosage Form Strength Pharmaceutical Name Exempt* Identifier(s) ✕ Ankle and Foot Disorders ✕ Cervical and Thoracic Spine Disorders ✓✕ Chronic Pain ✕ Elbow Disorders Morphine Sulfate Extended Release MS Contin, Kadian, Avinza 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 Morphine/Naltrexone Embeda Non‐Exempt Analgesics ‐ Opioid ✕ Hand, Wrist, and Forearm Disorders ✕ Hip and Groin Disorders ✕ Knee Disorders ✕ Low Back Disorders ✕ Shoulder ✓ Ankle and Foot Disorders Antibiotics Moxifloxacin HCL Avelox Exempt ✓Hand, Wrist, and Forearm Disorders (Fluoroquinolones) Ophthalmic Agents Moxifloxacin HCL Ophthalmic Vigamox Exempt ✓✕⦸ Eye (Antibiotics) Mupirocin Bactroban Exempt Dermatologicals ✓Ankle and Foot Disorders ✓ Ankle and Foot Disorders ✓ Cervical and Thoracic Spine Disorders ✓ Chronic Pain ✓✕⦸ Elbow Disorders Analgesics ‐ Anti‐ Nabumetone Relafen Exempt ✓✕⦸ Hand, Wrist, and Forearm Disorders Inflammatory (NSAID) ✓⦸ Hip and Groin Disorders ✓⦸ Knee Disorders ✓ Low Back Disorders ✓ Shoulder ✕ 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
✓⦸ Ankle and Foot Disorders ✓✕ Cervical and Thoracic Spine Disorders ✓ Chronic Pain ✓✕⦸ Elbow Disorders Analgesics ‐ Anti‐ Naproxen Aleve, Naprosyn Exempt ✓✕⦸ Hand, Wrist, and Forearm Disorders Inflammatory (NSAID) ✓⦸ Hip and Groin Disorders ✓⦸ Knee Disorders ✓⦸ Low Back Disorders ✓⦸ Shoulder
Natamycin Ophth Natacyn Exempt Antifungals ✓✕ Eye
Nedocromil Alocril Exempt Ophtalmic Agents ✓ Eye
Neomycin Sulfate Non‐Exempt Dermatologicals ⦸ Hand, Wrist, and Forearm Disorders
Neomycin/Polymyxin B/Bacitracin Neosporin Exempt Dermatologicals ✓ Ankle and Foot Disorders
*ACOEM Guidelines Copyright Reed Group Ltd.
Effective October 1, 2018 19 of 26 MTUS Drug List v.3 (8 CCR § 9792.27.15)
Reference Brand Exempt/Non‐ Unique Drug Ingredient Special Fill** Peri‐Op*** Drug Class Reference in ACOEM Guidelines * Dosage Form Strength Pharmaceutical Name Exempt* Identifier(s) 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 Antidepressants ⦸ Hip and Groin Disorders Nortriptyline HCL Pamelor Non‐Exempt (TCAs) ✓✕⦸ Knee Disorders ✓⦸ Low Back Disorders ✓✕ Shoulder Nystatin/Triamcinolone Mycolog II Non‐Exempt Dermatologicals ✓Ankle and Foot Disorders Ophthalmic Agents Ofloxacin Ophthalmic Solution Ocuflox Exempt ✓✕⦸ Eye (Anti‐bacterial) Antihistamine and/or Olopatadine HCL Pataday, Patanol Exempt ✓ Eye mast cell stabilization ✓ Cervical and Thoracic Spine Disorders ✓ Elbow Disorders ✓ Hand, Wrist, and Forearm Disorders Ulcer Drugs (Proton Omeprazole Prilosec Exempt ✓ Hip and Groin Disorders pump inhibitor) ✓ Knee Disorders ✓ Low Back Disorders ✓ Shoulder
Ondansetron Zofran Non‐Exempt Antiemetics ⦸ Chronic Pain
✕ 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‐ Oxaprozin Daypro Exempt ✓✕⦸ Hand, Wrist, and Forearm Disorders Inflammatory (NSAID) ✓⦸ Hip and Groin Disorders ✓⦸ Knee Disorders ✓ Low Back Disorders ✓ Shoulder ✓ Cervical and Thoracic Spine Disorders ✓ Chronic Pain Oxcarbazepine Trileptal Non‐Exempt Anticonvulsants ⦸ Low Back Disorders ✕ Shoulder
*ACOEM Guidelines Copyright Reed Group Ltd.
Effective October 1, 2018 20 of 26 MTUS Drug List v.3 (8 CCR § 9792.27.15)
Reference Brand Exempt/Non‐ Unique Drug Ingredient Special Fill** Peri‐Op*** Drug Class Reference in ACOEM Guidelines * Dosage Form Strength Pharmaceutical Name Exempt* Identifier(s) ✓✕ 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 ✕ Ankle and Foot Disorders ✕ Cervical and Thoracic Spine Disorders ✕ Chronic Pain ✕ Elbow Disorders Oxymorphone HCL Opana, Opana ER Non‐Exempt Analgesics ‐ Opioid ✕ Hand, Wrist, and Forearm Disorders ✕ Hip and Groin Disorders ✕ Knee Disorders ✕ Low Back Disorders ✕ Shoulder
Oxytocin Pitocin Non‐Exempt Oxytocics ✕ Chronic Pain
✓ Cervical and Thoracic Spine Disorders ✓ Elbow Disorders ✓ Hand, Wrist, and Forearm Disorders Ulcer Drugs (Proton Pantoprazole Sodium Protonix Exempt ✓ Hip and Groin Disorders pump inhibitor) ✓ Knee Disorders ✓ Low Back Disorders ✓ Shoulder
*ACOEM Guidelines Copyright Reed Group Ltd.
Effective October 1, 2018 21 of 26 MTUS Drug List v.3 (8 CCR § 9792.27.15)
Reference Brand Exempt/Non‐ Unique Drug Ingredient Special Fill** Peri‐Op*** Drug Class Reference in ACOEM Guidelines * Dosage Form Strength Pharmaceutical Name Exempt* Identifier(s) ✕ Cervical and Thoracic Spine Disorders ✓✕ Chronic Pain Antidepressants ✕ Hip and Groin Disorders Paroxetine HCL Paxil Non‐Exempt (SSRI) ✓✕ Knee Disorders ✕ Low Back Disorders ✕ Shoulder 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 ✕ Chronic Pain Phenytoin Dilantin Non‐Exempt Anticonvulsants ⦸ Low Back Disorders ✕ Shoulder ✕ Ankle and Foot Disorders ✕ Cervical and Thoracic Spine Disorders ✕ Chronic Pain ✕ Elbow Disorders Analgesics ‐ Anti‐ Piroxicam Feldene Non‐Exempt ✕ Hand, Wrist, and Forearm Disorders Inflammatory (NSAID) ✕ Hip and Groin Disorders ✕ Knee Disorders ✕ Low Back Disorders ✕ Shoulder
Antiparkinson and Pramipexole Dihydrochloride Mirapex Non‐Exempt Related Therapy ⦸ Chronic Pain Agents
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
*ACOEM Guidelines Copyright Reed Group Ltd.
Effective October 1, 2018 22 of 26 MTUS Drug List v.3 (8 CCR § 9792.27.15)
Reference Brand Exempt/Non‐ Unique Drug Ingredient Special Fill** Peri‐Op*** Drug Class Reference in ACOEM Guidelines * Dosage Form Strength Pharmaceutical Name Exempt* Identifier(s) ⦸ 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 Ophthalmic Agents Proparacaine HCL Alcaine Exempt ✓ Eye (Anesthetic) Antidepressants ✕ Chronic Pain Protriptyline HCL Non‐Exempt (TCAs) ✕ Knee Disorders Antimyasthenic / Pyridostigmine Bromide Mestinon Non‐Exempt ✕ Chronic Pain Cholinergic Agents Antipsychotics / Quetiapine Fumarate Seroquel Non‐Exempt ⦸ Chronic Pain Antimanic Agents ✓ Cervical and Thoracic Spine Disorders ✓ Elbow Disorders ✓ Hand, Wrist, and Forearm Disorders Ulcer Drugs (Proton Rabeprazole Sodium Aciphex Exempt ✓ Hip and Groin Disorders pump inhibitor) ✓ Knee Disorders ✓ Low Back Disorders ✓ Shoulder
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 Ranitidine HCL Zantac Exempt ✓ Hip and Groin Disorders receptor blocker) ✓ Knee Disorders ✓ Low Back Disorders ✓ Shoulder ✕ 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 ⦸ Ankle and Foot Disorders 14 Days Rivaroxaban Xarelto Non‐Exempt Anticoagulants ✓ Hip and Groin Disorders ✓ Knee Disorders
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 ‐ Salsalate Disalcid Exempt ✓✕⦸ Hand, Wrist, and Forearm Disorders NonNarcotic (NSAID) ✓⦸ Hip and Groin Disorders ✓⦸ Knee Disorders ✓ Low Back Disorders ✓ Shoulder
*ACOEM Guidelines Copyright Reed Group Ltd.
Effective October 1, 2018 23 of 26 MTUS Drug List v.3 (8 CCR § 9792.27.15)
Reference Brand Exempt/Non‐ Unique Drug Ingredient Special Fill** Peri‐Op*** Drug Class Reference in ACOEM Guidelines * Dosage Form Strength Pharmaceutical Name Exempt* Identifier(s) ✕ Cervical and Thoracic Spine Disorders ✓✕ Chronic Pain Antidepressants ✕ Hip and Groin Disorders Sertraline HCL Zoloft Non‐Exempt (SSRI) ✓✕ Knee Disorders ✕ Low Back Disorders ✕ Shoulder Silver Sulfadiazine Silvadene Non‐Exempt Dermatologicals ⦸ Hand, Wrist, and Forearm Disorders
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 ✓⦸ Ankle and Foot Disorders Anti‐Infective Agents ‐ Sulfamethoxazole/Trimethoprim Bactrim Exempt ✓✕⦸ Hand, Wrist, and Forearm Disorders Misc. ✓ Ankle and Foot Disorders ✓ Cervical and Thoracic Spine Disorders ✓ Chronic Pain ✓✕⦸ Elbow Disorders Analgesics ‐ Anti‐ Sulindac Clinoril Exempt ✓✕⦸ Hand, Wrist, and Forearm Disorders Inflammatory (NSAID) ✓⦸ Hip and Groin Disorders ✓⦸ Knee Disorders ✓ Low Back Disorders ✓ Shoulder 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 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 ✕ Chronic Pain Tiagabine HCL Gabitril Non‐Exempt Anticonvulsants ⦸ Low Back Disorders ✕ Shoulder
*ACOEM Guidelines Copyright Reed Group Ltd.
Effective October 1, 2018 24 of 26 MTUS Drug List v.3 (8 CCR § 9792.27.15)
Reference Brand Exempt/Non‐ Unique Drug Ingredient Special Fill** Peri‐Op*** Drug Class Reference in ACOEM Guidelines * Dosage Form Strength Pharmaceutical Name Exempt* Identifier(s) ✓✕ 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 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‐ Tolmetin Sodium Tolectin Exempt ✓✕⦸ Hand, Wrist, and Forearm Disorders Inflammatory (NSAID) ✓⦸ Hip and Groin Disorders ✓⦸ Knee Disorders ✓ Low Back Disorders ✓ Shoulder ✓✕ Cervical and Thoracic Spine Disorders ✓ Chronic Pain ✕⦸ Hip and Groin Disorders Topiramate Topamax Non‐Exempt Anticonvulsants ✕⦸ Knee Disorders ✓⦸ Low Back Disorders ✕⦸ 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
Tranexamic Acid Lysteda Exempt Hemostatics ✓ Eye
✕ Cervical and Thoracic Spine Disorders ✓✕⦸ Chronic Pain Antidepressants ✕ Hip and Groin Disorders Trazodone HCL Desyrel, Oleptro Non‐Exempt (SSRI) ✕ Knee Disorders ✕ Low Back Disorders ✕ 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)
*ACOEM Guidelines Copyright Reed Group Ltd.
Effective October 1, 2018 25 of 26 MTUS Drug List v.3 (8 CCR § 9792.27.15)
Reference Brand Exempt/Non‐ Unique Drug Ingredient Special Fill** Peri‐Op*** Drug Class Reference in ACOEM Guidelines * Dosage Form Strength Pharmaceutical Name Exempt* Identifier(s)
Valacyclovir HCL Valtrex Non‐Exempt Antivirals ✕⦸ Chronic Pain
✕ Chronic Pain Depakote, Depakene, Valproic Acid Non‐Exempt Anticonvulsants ⦸ Low Back Disorders Depacon ✕ Shoulder ✓✕ Cervical and Thoracic Spine Disorders ✓ Chronic Pain Antidepressants ⦸ Hip and Groin Disorders Venlafaxine HCL Effexor Non‐Exempt (SNRI) ✓✕⦸ Knee Disorders ✓⦸ Low Back Disorders ✓✕ Shoulder ✕ Cervical and Thoracic Spine Disorders ✕ Chronic Pain Antidepressants ✕ Hip and Groin Disorders Vilazodone Viibryd Non‐Exempt (SSRI) ✕ Knee Disorders ✕ Low Back Disorders ✕ 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 14 Days Warfarin Sodium Coumadin Non‐Exempt Anticoagulants ✓ Hip and Groin Disorders ✓ Knee Disorders Antiasthmatic and Zafirlukast Accolate Non‐Exempt ✓ Work Related Asthma Bronchodilator Agents
Antiasthmatic and Zileuton Zyflo Non‐Exempt ✓ Work Related Asthma Bronchodilator Agents 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 October 1, 2018 26 of 26