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Outpatient Drug Formulary

Outpatient Drug Formulary

Washington State Department of Labor and Industries Outpatient Formulary

The following is a list of and therapeutic classes (or class codes) and their status on L&I’s outpatient formulary. The formulary may change from time to time to reflect the Washington State Pharmacy and Therapeutics Committee’s recommendations or administrative changes.

PLEASE NOTE:  This is an outpatient formulary. Many of the drugs not included on the formulary may be appropriate in other settings, such as inpatient, outpatient surgery, emergency room, and clinics or offices, and are covered when billed appropriately.  Drugs listed on the formulary do not guarantee coverage and may be subject to the department’s policy and appropriateness for the accepted conditions.  Status of the therapeutic classes depends on the drugs’ approved indication and is as followed:  A = Allowed  PA = Prior Authorization required  D = Denied  Drugs that are included in the Washington State’s evidence-based Preferred Drug List may be subject to the provisions of the Therapeutic Interchange Program.  See the Washington Program for additional information and exceptions.

Page 1 of 40 L&I Outpatient Drug Formulary October 1, 2021 Washington State Department of Labor and Industries Outpatient Formulary

L&I Preferred Drug List Status TCC Therapeutic Class Description Preferred Drug(s) Beclomethasone dipropionate MDI (Qvar RediHaler) Inhaled (, nebulizer suspension A B6M Orally Inhaled) (generics only) propionate MDI/DPI (Flovent Diskus/HFA) Albuterol sulfate solution (generics only) Albuterol sulfate HFA (generics Beta Agents, Orally Inhaled, Short A B6W only) Acting Levalbuterol HCl solution (generics only) Levalbuterol tartrate HFA (generics only) Beta Adrenergic Agents, Orally Inhaled, Long (Striverdi Respimat) – B6Y Acting when COPD accepted PA B6Z Beta Adrenergic Agents, Orally Inhaled, Ultra diskus (Serevent) – Long Acting when or COPD accepted , Quaternary Ammonium, monohydrate PA B61 Orally Inhaled, Long Acting (Spiriva Handihaler/Respimat) – when COPD accepted Beta Adrenergic & Tiotropium bromide/Olodaterol PA B62 Combinations, Orally Inhaled (Long Acting) (Stiolto Respimat) – when COPD accepted Fluticasone/Salmeterol (Advair Beta- & Glucocorticoids Diskus/HFA, Wixela Inhub) – when Combination PA B63 asthma or COPD accepted

Beta-Adrenergic, Anticholinergic and PA B64 Combinations, Orally Inhaled None

Omeprazole magnesium (generics Proton Pump Inhibitors only) A D4J (generics only) (generics only) -, Non- ***Acute use only*** H2E A H8B Receptor Zaleplon (generics only)

Zolpidem (generics only) Hypnotics, Melatonin MT1/MT2 Receptor Ramelteon (Rozerem) Agonists (generics only) (generics only) Methocarbamol (generics only) A H6H Relaxants Tizanidine (generics only) **Carisoprodol products are non- covered**

Page 2 of 40 L&I Outpatient Drug Formulary October 1, 2021 Washington State Department of Labor and Industries Outpatient Formulary

Status TCC Therapeutic Class Description Preferred Drug(s) Second Generation

Serotonin Specific Reuptake Inhibitors (SSRIs) (except solution) Alpha-2 Receptor Antagonists (except solution) H2S (except tablet) H7B Serotonin- Reuptake Inhibitors (except ER capsule) A H7C (SNRIs) (except CR/ER tablet) H7D (except concentrate) Norepinephrine & Dopamine Reuptake (generics only) Inhibitors (NDRIs) (generics only) Venlafaxine/ER (except ER tablet) /SR/XL (generics only) Atypical

Aripiprazole (generics only) Antipsychotic, Atypical, Dopamine & Serotonin Asenapine (Saphris SL) Brexpiprazole (Rexulti) Cariprazine (Vraylar) (generics only) H7T Iloperidone (Fanapt) A H7X Antipsychotic, Atypical, D2 Partial / (Latuda) H8W 5HT Mixed (generic oral formulations only) Paliperidone ER (generics only) (generics only) Antipsychotic, Atypical, D3/D2 Partial Agonist Quetiapine ER (generics only) 5HT Mixed (generics only) Ziprasidone (generics only) Budesonide (OTC only) Nose Preparations, Anti-inflammatory Fluticasone proprionate (OTC only) A Q7P acetonide (OTC only) Agents

Urinary Tract Agents R1A ER (generic only) A R1I Urinary Tract Antispasmodic, M(3) Selective /ER (generics only) R1V Antagonists (generic only) /ER (generics only) Overactive Bladder Agents, Beta-3 Adrenergic Trospium/ER (generics only) Receptors

Page 3 of 40 L&I Outpatient Drug Formulary October 1, 2021 Washington State Department of Labor and Industries Outpatient Formulary

Status TCC Therapeutic Class Description Preferred Drug(s) Diclofenac Potassium/Sodium/DR/EC/ER (generics only) NSAIDs, Inhibitors Etodolac/ER (generics only) Flurbiprofen Ibuprofen (generics only) Indomethacin/ER (generics only) S2B A Ketoprofen/ER S2L Ketorolac (generics only) Meloxicam (generics only) Nabumetone (generics only) NSAIDs, Cyclooxygenase-2 Selective Inhibitor Naproxen/Sodium (generics only) Piroxicam (generics only) Oxaprozin (generics only) Sulindac Direct-acting Antivirals for Hepatitis C

Hepatitis C Virus – NS5A Replication Complex Inhibitors Hepatitis C Virus – NS5B Polymerase & NS5A Glecaprevir/pibrentasvir (Mavyret) W0A Inhibitor Combinations /velpatasvir/voxilaprevir W0B Hepatitis C Virus – NS5A, NS3/4, NS5B (Vosevi) – limited to FDA-approved W0D Inhibitor Combinations indications PA W0E Sofosbuvir/velpatasvir (Epclusa) - Hepatitis C Virus – NS5A and NS3/4A Inhibitor W0G Combinations for decompensated cirrhosis W5V Hepatitis C Virus –NS5A, NS3/4A Protease, *see Direct-acting Antivirals for W5Y Nucleotide NS5B Polymerase Inhibitor Hepatitis C policy for coverage Combination criteria* Hepatitis C Virus – NS3/4A Serine Protease Inhibitors Hepatitis C Virus – Nucleotide Analog NS5B Polymerase Inhibitors (generics only) /ER (generics only) base (generics only) Erythromycin EC (generics only) A W1D Macrolides Erythromycin ethylsuccinate (generics only) Erythromycin stearate (generics only) (generics only) A Z2Q – 2nd Generation (generics only) Phosphodiesterase-4 (PDE4) Inhibitors (Daliresp) – when PA Z2X COPD accepted Leukotriene Modifier

Z4B A (generic tablet and Z4E Leukotriene Receptor Antagonists granule packet only) 5-Lipoxygenase Inhibitor

Page 4 of 40 L&I Outpatient Drug Formulary October 1, 2021 Washington State Department of Labor and Industries Outpatient Formulary

L&I Wrap-around Formulary

Compound Drugs Status TCC Therapeutic Class Description Preferred Drug(s) PA 000 Compound Drugs None

Cardiovascular System Status TCC Therapeutic Class Description Preferred Drug(s) PA A1A Digitalis Glycosides None (generics only) (generics only) A A1B /SA (generics only) Theophylline anhydrous/SR (generics only) D A1C Inotropic Drugs None PA A1D General Agents, Oral None Xanthines & Dietary Supplement D A1E None Combinations PA A2A Antiarrhythmics None Heart Rate Reducing, Sinus Node Selective PA A2B None I(f) Current Inhibitor & Anti-ischemic Agents, Non- PA A2C None hemodynamic PA A4A Hypotensives-Vasodilators None PA A4B Hypotensives-Sympatholytic None Hypotensives-Angiotensin Converting PA A4D None Enzyme Blockers Hypotensives, Angiotensin Receptor PA A4F None Antagonist Angiotensin & Calcium PA A4H None Channel Blockers ACE Inhibitor/ & Thiazide-like PA A4I None Combination Angiotensin Receptor Antagonist/Thiazide PA A4J None and Thiazide-related Diuretic Combinations ACE Inhibitor/Calcium PA A4K None Combination Angiotensin Receptor and Neprilysin Inhibitor PA A4L None (ARNi) Combinations Angiotensin II Receptor Blocker (ARB) – PA A4N None Beta-adrenergic Blocker Combination PA A4T , Direct None Renin Inhibitor, Direct and Thiazide Diuretic PA A4U None Combination Angiotensin Receptor Antagonist/Calcium PA A4V None Channel Blocker/Thiazide Combination Renin Inhibitor, Direct & Angiotensin Receptor PA A4W None Antagonist Combinations Renin Inhibitor, Direct & Calcium Channel PA A4X None Blocker Combinations

Page 5 of 40 L&I Outpatient Drug Formulary October 1, 2021 Washington State Department of Labor and Industries Outpatient Formulary

Status TCC Therapeutic Class Description Preferred Drug(s) PA A4Y Hypotensives-Miscellaneous None Renin Inhibitor, Direct, Calcium Channel PA A4Z None Blocker and Thiazide Combinations Patent Ductus Arteriosus Treating Agents, D A5A None NSAID-Type Hypertrophic Cardiomyopathy Treatment D A5B Agents, Ablative None

D A6U Cardiovascular Diagnostics None Cardiovascular Diagnostics – D A6V None Non Radiopaque Cardiovascular Diagnostics – Radioactive D A6W None

PA A7B Coronary Vasodilators None PA A7C Peripheral Vasodilators None PA A7E Vasodilators-Miscellaneous None PA A7J Vasodilators, Combination None D A7M Bradykinin B2 Receptor Antagonists None D A7N Plasma Kallikrein Inhibitors None D A8O Venosclerosing Agents None PA A9A Calcium Channel Blocking Agents None and NSAID, COX-2 D A9C Selective Inhibitor None

Respiratory System Status TCC Therapeutic Class Description Preferred Drug(s) A B0A Miscellaneous Respiratory Inhalants Sodium chloride (generics only) CFTR (Cystic Fibrosis Transmembrane D B0B None Conductance Regulator) Potentiator Cystic Fibrosis – Inhaled Osmotic Agents D B0C None

Pulmonary Fibrosis – Systemic Enzyme D B0D None Inhibitors Cystic Fibrosis Transmembrane Conductance D B0F Regulator (CFTR) Potentiator and Corrector None Combinations D B1A Lung Surfactants None Pulm Antihypertensive, Endothelin Receptor D B1B None Antagonist-Type Pulmonary Antihypertensive Agents, PA B1C None Prostacyclin-Type Pulmonary Antihypertensive, Selective C- PA B1D None GMP Phosphodiesterase T5 Inhibitors. Pulmonary Antihypertensives, CGMP PA B1E None Pathway, Gases Pulmonary Antihypertensive Agents, Soluble D B1F None Guanylate Cyclase (sGC) Stimulator A B3A Mucolytics Acetylcysteine (generics only) A B3J Expectorants (generics only)

Page 6 of 40 L&I Outpatient Drug Formulary October 1, 2021 Washington State Department of Labor and Industries Outpatient Formulary

Status TCC Therapeutic Class Description Preferred Drug(s) PA B3K Cough and Cold Preparations None --Expectorant PA B3N None Combination 1st Generation -Decongestant- PA B3O None Analgesic Combination Non- Antitussive-1st Generation PA B3P Antihistamine-Decongestant-Analgesic None Combination Opioid Antitussive-1st Generation PA B3Q None Antihistamine-Decongestant Combination Non-opioid Antitussive-1st Generation PA B3R None Antihistamine-Decongestant Combination Non-opioid Antitussive-1st Generation PA B3S Antihistamine-Decongestant Expectorant None Combination Non-opioid Antitussive and Expectorant PA B3T None Combination 1st Generation Antihistamine-Decongestant- PA B3V None Analgesic-Expectorant Combination 1st Generation Antihistamine-Decongestant- PA B3X None Anticholinergic Combination 1st Generation Antihistamine-Decongestant- PA B3Y None Analgesic-Expectorant Combination Non-opioid Antitussive-Analgesic PA B4A None Combination Non-Opioid Antitussive-Analgesic- PA B4B None Expectorant Combination Opioid Antitussive-Anticholinergic PA B4C None Combination Opioid Antitussive-1st Generation PA B4D None Antihistamine Combination Non-opioid Antitussive-1st Generation /Dextromethorphan A B4E Antihistamine Combination (generics only) Opioid Antitussive-1st Generation PA B4F None Antihistamine-Analgesic Combination Non-opioid Antitussive-1st Generation PA B4G None Antihistamine-Analgesic Combination Opioid Antitussive-1st Generation PA B4H Antihistamine-Expectorant Combination None

Non-opioid Antitussive-1st Generation PA B4I None Antihistamine-Expectorant Combination Opioid Antitussive-1st Generation PA B4J Antihistamine-Decongestant-Expectorant None Combination PA B4K Opioid Antitussive-Decongestant Combination None Non-opioid Antitussive-Decongestant PA B4L None Combination Non-opioid Antitussive-Decongestant- PA B4M None Analgesic Combination Opioid Antitussive-1st Generation PA B4N Antihistamine-Decongestant-Analgesic None Combination

Page 7 of 40 L&I Outpatient Drug Formulary October 1, 2021 Washington State Department of Labor and Industries Outpatient Formulary

Status TCC Therapeutic Class Description Preferred Drug(s) Non-opioid Antitussive-1st Generation PA B4O Antihistamine-Decongestant-Analgesic None Expectorant Combination Non-opioid Antitussive-Decongestant- PA B4P None Analgesic-Expectorant Combination Opioid Antitussive-Decongestant-Expectorant PA B4Q None Combination Non-opioid Antitussive-Decongestant- PA B4R None Expectorant Combination PA B4S Opioid Antitussive-Expectorant Combination None Decongestant-Analgesic, Non-Salicylate PA B4T None Combination PA B4U Decongestant-Anticholinergic Combination None Antitussive-1st Generation Antihistamine- PA B4V None Analgesic-Expectorant Combination Guaifenesin/ A B4W Decongestant-Expectorant Combination (generics only)

PA B4X Expectorant Combination, Other None Decongestant-Analgesic, Non-Salicylate- PA B5D None Anticholinergic- Combination Decongestant-Analgesic, Mixed-Xanthine PA B5E None Combination Decongestant-, Salicylate PA B5F None Combination Decongestant-NSAID, COX Non-Specific PA B5G None Combination 1st Generation Antihistamine-Decongestant- PA B5H None NSAID, COX Non-specific Combination Decongestant-Analgesic, Non-Salicylate- PA B5I None Expectorant-Xanthine Combination Decongestant-Analgesic, Salicylate-Xanthine PA B5K None Combination Decongestant-Analgesic, Non-Salicylate- PA B5J None Xanthine Combination 1st Generation Antihistamine-Decongestant- PA B5M None Analgesic, Mixed 1st Generation Antihistamine-Decongestant- PA B5N None Analgesic, Salicylate Non-opioid Antitussive-Analgesic-Salicylate PA B5O None Combination Decongestant-Analgesic, Salicylate- PA B5P None Expectorant Combination Non-opioid Antitussive-1st Generation PA B5Q Antihistamine-Decongestant-, Salicylate None Combination Analgesic, Mixed-1ST Generation PA B5R None Antihistamine-Xanthine Combination 1st Generation Antihistamine-Analgesic, Non- PA B5S None Salicylate Combination 1st Generation Antihistamine-Anticholinergic PA B5T None Combination

Page 8 of 40 L&I Outpatient Drug Formulary October 1, 2021 Washington State Department of Labor and Industries Outpatient Formulary

Status TCC Therapeutic Class Description Preferred Drug(s) Non-opioid Antitussive-1st Generation PA B5W None Antihistamine-Anticholinergic Combination Analgesic, Non-Salicylate–Expectorant PA B5X None Combination Analgesic, Non-Salicylate–1st Generation PA B5Y None Antihistamine-Xanthine 1st Generation Antihistamine-Decongestant- PA B5Z None Analgesic, Salicylate-Xanthine Combination Non-opioid Antitussive-Decongestant- D B6A None Expectorant-Zinc Combination Non-opioid Antitussive-Decongestant-Zinc D B6B None Combination Opioid Antitussive-1st Generation D B6C Antihistamine-Decongestant-Analgesic- None Xanthine Combination Decongestant-Expectorant with Zinc D B6D None Combination 1st Generation Antihistamine-Decongestant D B6F None with Zinc Combination 1st Generation Antihistamine-Decongestant- D B6G None Anticholinergic with Zinc Combination 1st Generation Antihistamine-Decongestant- D B6H None Anticholinergic-Expectorant Combination Opioid Antitussive-Decongestant-Analgesic- D B6I None Expectorant Combination Opioid Antitussive-1st Generation D B6J Antihistamine-Analgesic, Non-Salicylate None Combination Non-opioid Antitussive-1st Generation D B6K Antihistamine-Decongestant-Expectorant- None Anticholinergic Combination Analgesic, Salicylate and 1st Generation D B6L None Antihistamine Combination PA B6R Aromatic Antitussives for Vaporization None Non-Opioid Antitussive and Mucolytic D B6T None Combination PA B6V , Oral None Opioid Antitussive-Decongestant-Analgesic PA B6U None Combination D B6X Opioid Antitussive and Mucolytic Combination None Anticholinergics, Quaternary Ammonium, PA B60 None Orally Inhaled, Short Acting

Electrolyte Balancing Sys/Metabolic Sys/Nutrition Status TCC Therapeutic Class Description Preferred Drug(s) PA C0B Water None D C0C Drugs Used To Treat Acidosis None PA C0D Antialcoholic Preparations None PA C0K Bicarbonate Producing/Containing Agents None PA C1A Electrolyte Depleters None PA C1B Sodium Replacement None

Page 9 of 40 L&I Outpatient Drug Formulary October 1, 2021 Washington State Department of Labor and Industries Outpatient Formulary

Status TCC Therapeutic Class Description Preferred Drug(s) PA C1D Potassium Replacement None PA C1F Calcium Replacement None PA C1H Magnesium Replacement None D C1K Cardioplegic Solutions None PA C1P Phosphate Replacement None PA C1W Electrolyte Replacement None PA C1Y Dialysis Solutions None D C2H Respiratory Gases None PA C3B Iron Replacement None PA C3C Zinc Replacement None PA C3H Iodine Replacement None PA C3M Miscellaneous Replacement None Antihyperglycemic, (DPP-4) Inhibitor & D C4A Antihyperlipidemic HMG CoA Reductase None Inhibitors () Antihyperglycemic Glucocorticoid () D C4B None Receptor Blocker (GR-II) Antihyperglycemic Dipeptidyl Peptidase-4 PA C4C None (DPP-4) Inhibitor & Thiazolidinedione Antihyperglycemic Sodium Glucocorticoid PA C4D None CoTransport 2 (SGLT2) Inhibitor Antihyperglycemic SGLT2 Inhibitor & PA C4E Biguanide Combination None

Antihyperglycemic, (DPP-4) PA C4F None & Biguanide Type (N-S) Combination PA C4G Insulins None PA C4H Antihyperglycemic, Amylin Analog-Type None Antihyperglycemic, Incretin Mimetic (GLP-1 PA C4I None Receptor Agonist) PA C4J Antihyperglycemic, DPP-4 Inhibitors None PA C4K Hypoglycemics, Insulin-Release Stim. Type None PA C4L Hypoglycemics, Biguanide Type (N-S) None Hypoglycemics, Alpha-Glucosidase PA C4M None Inhibitor Type (N-S) Hypoglycemics, Insulin-Response PA C4N None Enhancer (N-S) PA C4Q Hypoglycemics, Combination None Hypoglycemics, Insulin-Response & Insulin PA C4R None Release Combinations Hypoglycemics, Insulin-Release & PA C4S None Biguanide (N-S) Combinations Hypoglycemics, Insulin-Response Enhancer PA C4T None & Biguanide Type (N-S) Combinations Hypoglycemics, Biguanide Type & Dietary D C4U None Supplement Combinations Antihyperglycemic – Dopamine Receptor PA C4V None Agonists

Page 10 of 40 L&I Outpatient Drug Formulary October 1, 2021 Washington State Department of Labor and Industries Outpatient Formulary

Status TCC Therapeutic Class Description Preferred Drug(s) Antihyperglycemic, Sodium-glucose Cotransporter-2 Inhibitor and Dipeptidyl PA C4W None Peptidase-4 Inhibitor Combination

Antihyperglycemic – Insulin, Long-acting and PA C4X Incretin Mimetic (GLP-1 Receptor Agonist) None

Antihyperglycemic – SGLT-2 Inhibitor, DPP-4 PA C4Y Inhibitor and Biguanide Combination None

PA C5A Carbohydrates None PA C5B Protein Replacement None D C5C Infant Formulas None D C5D Diet Foods None D C5E Geriatric Supplements None D C5F Miscellaneous Food Supplements None D C5H Nucleic Acid/Nucleotide Supplements None D C5G Food Oils None PA C5J IV Solutions: Dextrose/Water None PA C5K IV Solutions: Dextrose/ None PA C5L IV Solutions: Dextrose/Ringers None PA C5M IV Solutions: Dextrose/Lactated Ringers None PA C5O Solutions, Miscellaneous None Nutritional Therapy, Phenylketonuria (PKU) D C5X None Formulation Nutritional Therapy, Glucose Intolerance D C5U None Formulation D C6A A Preparations None D C6B Vitamin B Preparations None PA C6C Vitamin C Preparations None D C6D Preparations None D C6E Vitamin E Preparations None D C6F Prenatal Vitamin Preparations None D C6G Geriatric Vitamin Preparations None D C6H Pediatric Vitamin Preparations None D C6I Antioxidant Multivitamin Combinations None D C6J Bioflavonoids None PA C6K Vitamin K Preparations None PA C6L Vitamin B12 Preparations None PA C6M Folic Acid Preparations None D C6N Niacin Preparations None D C6P Panthenol Preparations None D C6Q Vitamin B6 Preparations None D C6R Vitamin B2 Preparations None D C6T Vitamin B1 Preparations None D C6Z Miscellaneous Multivitamin Preparations None D C7A Purine Inhibitors None PA C7B Decarboxylase Inhibitors None D C7D Metabolic Deficiency Agents None

Page 11 of 40 L&I Outpatient Drug Formulary October 1, 2021 Washington State Department of Labor and Industries Outpatient Formulary

Status TCC Therapeutic Class Description Preferred Drug(s) Appetite for Anorexia, Cachexia, PA C7F None Wasting Syndrome Hyperuricemia Treatments – Urate-Oxidase D C7G None Enzyme-Type PKU Treatment Agent - Cofactor of D C7H None Phenylalanine Hydroxylate D C7I Cytochrome P450 Inhibitors None Fibroblast Growth Factor 23 (FGF23) D C7J Inhibitors, Monoclonal Antibody None

Phenylketonuria (PKU) Treatment Agents – D C7K Phenylalanine Ammonia Lyase None

A C8A Metallic Poison All A C8B Acid And Alkali Poison Antidotes All Lead Poisoning, Agents to Treat (Chelating- A C8C All Type) A C8E Miscellaneous Antidotes All Reactivating & Muscarinic A C8F All Antagonist Hypercalcemia, Agents to Treat (Chelating- A C8G All Type) Parenteral Amino Acid Solutions and PA C9C None Combinations

Biliary System/Gastro-Intestinal System Status TCC Therapeutic Class Description Preferred Drug(s) D D0U Gastrointestinal Radiopaque Diagnostics None D D0V Gastrointestinal Radioactive Diagnostics None D D1B Periodontal None PA D1D Dental Aids & Preparations None PA D1E Periodontal Anti-infective, Local None D D2A Fluoride Preparations None D D2D Tooth Ache Preparations None PA D4A Acid Replacement None Sodium bicarbonate (generics only) Aluminum hydroxide (generics only) A D4B /Simethicone (generics only) Calcium carbonate (generics only) PA D4C Agents for Stomatological Use None PA D4D Antidiarrheal Microorganisms Agents None Misoprostol (generics only) A D4E Antiulcer Preparations Sucralfate (generics only) D D4F Antiulcer -- H. Pylori Agents None PA D4G Gastric Enzymes None PA D4H Oral Mucositis/Stomatitis Agents None

Page 12 of 40 L&I Outpatient Drug Formulary October 1, 2021 Washington State Department of Labor and Industries Outpatient Formulary

Status TCC Therapeutic Class Description Preferred Drug(s) Oral Mucositis/Stomatitis Anti-inflammatory PA D4I None Agents PA D4L Saliva Substitute Agents None PA D4N Antiflatulents None Gastrointestinal Ultrasound Image Enhancing D D4O None Adjnct, Diag PA D4Q Digestive Agents, Other None A D4R Saliva Stimulant Agents All Antidiarrheal – Gastrointestinal Chloride PA D4X None Channel Inhibitors Antidiarrheal – Tryptophan Hydroxylase PA D40 Inhibitor None

A D5P Intestinal Adsorbents And Protectives All Drugs To Treat Chronic Inflammatory PA D6A None Diseases Of The Colon Irritable Bowel Syndrome Agent, 5HT-3 D D6C None Antagonist-Type PA D6D Antidiarrheals None Irritable Bowel Syndrome Agents, D D6E None 5HT-4 Partial Agonist Drugs To Treat Chronic Inflammatory Colon PA D6F None Dx 5 – Aminosalicylate Irritable Bowel Syndrome Agents, D D6G None Guanylate Cylase-C Agonist A D6H Hemorrhoidal Agents All Short Bowel Syndrome Agents - D D6I None Glucagon-like Peptide-2 (GLP-2) Analogs IBS Agents, Mixed Opioid D D6L None ReceptorAgonists/Antagonists Bisacodyl (generics only) (generics only)Lactulose (generics only) Magnesium citrate (generics only) A D6S & Cathartics Mineral oil (generics only) Polyethylene glycol (generics only) Psyllium (generics only) Senna (generics only) Senna-docusate (generics only) PA D7A Bile Salts None PA D7B Choleretics None D D7C Hepatic Diagnostics None D D7D Drugs To Treat Hereditary Tyrosinemia None Farnesoid X Receptor (FXR) Agonist, Bile PA D7E None Acid Analogue Ileal Bile Acid Transporter (IBAT) Inhibitor D D7F None ***New *** Hepatic Dysfunction Preventive/ PA D7J None Therapy Agents Drugs to Treat Acute Hepatic Porphyria D D7K None

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Status TCC Therapeutic Class Description Preferred Drug(s) PA D7L Bile Salt Inhibitors None D D7T Biliary Diagnostics None D D7U Biliary Diagnostics, Radiopaque None PA D8A Pancreatic Enzymes None PA D9A Ammonia Inhibitors None

Electrolyte Balancing Sys/Metabolic Sys/Nutrition (CONT.) Status TCC Therapeutic Class Description Preferred Drug(s) PA E0A Vitamin A & D Preparations None PA E0G Prenatal Without Iron None

Male Genital System Status TCC Therapeutic Class Description Preferred Drug(s) PA F1A Androgenic Agents None PA F2A Drugs To Treat Impotency None

Female Genital System Status TCC Therapeutic Class Description Preferred Drug(s) Fallopian Tube Ultrasound Contrast Agents D G0A None

D G0U Uterine Radiopaque Diagnostic Agents None D G1A Estrogenic Agents None / Combination D G1B None Preparations Menopausal Symptom Supp-Sel Estrogen D G1E None Receptor Modulation Estrogen & Progestin with D G1D None Antimineralocorticoid Combination Estrogen and Progestin Combinations D G1F None

D G2A Progestational Agents None D G3A Oxytocics None Androgen/estrogen Preps for Female Sexual D G5B Dysfunction None

Menopausal Symptom Suppressants – SSRIs D G6A None

D G8A Contraceptives, Oral None D G8B Contraceptives, Implantable None D G8C Contraceptives, Injectable None Abortifacient, Receptor PA G8D None Antagonist Type D G8F Contraceptives, Transdermal None D G9A Contraceptives, Intravaginal None D G9B Contraceptives, Intravaginal, Systemic None

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Nervous System (Except Autonomic) Status TCC Therapeutic Class Description Preferred Drug(s) A H0A Local Anesthetics Cepacol D H0D Postherpetic Neuralgia Agents None D H0E Agents To Treat Multiple Sclerosis None Agents To Treat Neuromuscular Transmission D H0F None Disease, Blocker Type Fibromyalgia Agents, Serotonin- D H0G None Norepinephrine Reuptake Inhibitors (SNRIs) Alzheimer's Tx, N-Methyl-D-Aspartate (NMDA) D H1A None Receptor Antagonists Alzheimer's Disease Therapy, NMDA D H1C Receptor Antagonist & Cholinesterase None Inhibitor Combination Calcitonin Gene-Related Peptide (CGRP) PA H1D Inhibitors None

Narcolepsy Therapy Agents – H3-receptor PA H1G None Antagonist/ Amyloid-directed Monoclonal Antibody D H1H None ***New Drug Class*** Cerebral Spinal Radiopaque D H1U None Diagnostics D H1V Cerebral Spinal Radioactive Diagnostics None Diagnostic Radiopharmaceuticals – Dopamine D H1W None Transporter(DAT) Imaging Diagnostic Radiopharmaceuticals – Amyloid D H1Y None Plaque Imaging Diagnostic Radiopharmaceuticals – D H1Z None Nerve Terminal Imaging PA H2A Central Stimulants None D H2B General Anesthetics, Inhalant None D H2C General Anesthetics, Injectable None PA H2D (Phenobarbital Only) None Non-Barbiturate, Sedative-Hypnotics ***Acute use only*** (generics only) Zaleplon (generics only) A H2E (generics only)

Antianxiety Drugs ***Acute use only*** Buspirone (generics only) A H2F

Chlorpromazine (generics only) Fluphenazine (generics only) A H2G Anti-Psychotics, Perphenazine (generics only) (generics only) Trifluoperazinel (generics only) PA H2H Monoamine Oxidase (MAO) Inhibitors None carbonate/CR (generics A H2M Anti-Mania Drugs only) Lithium citrate (generics only)

Page 15 of 40 L&I Outpatient Drug Formulary October 1, 2021 Washington State Department of Labor and Industries Outpatient Formulary

Status TCC Therapeutic Class Description Preferred Drug(s) D H2T -Systemic Use None (generics only) (generics only) (generics only) A H2U Tricyclic Antidepressants & Related Non-SRI (generic tablet only) (generics ony) (generic capsule only) Treatment for Attention Deficit-Hyperactivitiy PA H2V None Disorder (ADHD)/Narcolepsy Tricyclic / Amitriptyline/Perphenazine A H2W Combinations (generics only) /Benzodiazepine PA H2X None Combination None PA H20 Anti-anxiety –

None PA H21 Sedative-hypnotics – Benzodiazepines

General Anesthetics, Injectable – D H22 Benzodiazepine Type None

Antidepressant – Postpartum Depression D H24 (PPD) None

Opioid Analgesics ***Acute use only*** Codeine sulfate/phosphate (generics only) Hydromorphone (generics only) Meperidine (generics only) A H3A sulfate (generics only) Short Acting Oxycodone (generics only)

Pentazocine/Naloxone (generics only) Pentazocine/Acetaminophen (generics only) (generics only) PA H3A Long Acting Opioids None PA H3C Analgesics, Non-Opioid None mag trisalicylate (generics A H3D Salicylate Analgesics only) Diflunisal Salsalate A H3E Analgesic/Antipyretics, Non-Salicylate Acetaminophen (generics only) Generic (almotriptan, eletriptan, frovatriptan, naratriptan, PA H3F Antimigraine Preparations , sumatriptan, zolmitriptan) D H3H Opioid Analgesic, Adjunct Agents None Analgesics, Neuronal-type Calcium Channel D H3I None Blocker Analgesics, Opioid-Dietary Supplement D H3J None Combinations

Page 16 of 40 L&I Outpatient Drug Formulary October 1, 2021 Washington State Department of Labor and Industries Outpatient Formulary

Status TCC Therapeutic Class Description Preferred Drug(s) Analgesics, Non-salicylate & Barbiturate Acetaminophen/Butalbital (generic A H3K Combination 50/325 strength only) Analgesics, Non-salicylate, Barbiturate & Acetaminophen/Caffeine/Butalbital A H3L Xanthine Combination (generic tablet only) Opioid, Non-salicylate Analgesic, Barbiturate PA H3M None & Xanthine Combination Opioid Analgesic and NSAID Combination Hydrocodone/Ibuprofen (generics A H3N ***Acute use only*** only) Analgesics, Salicylate, Barbiturate & Xanthine Aspirin/Caffeine/Butalbital (generics A H3O Combination only) Opioid and Non-Salicylate Analgesics, PA H3Q None Barbiturate Opioid and Salicylate Analgesics, Barbiturate, PA H3R None Xanthine PA H3T Opioid Antagonists None Codeine/Acetaminophen (generics only) Opioid Analgesic and Non-salicylate Hydrocodone/Acetaminophen Analgesics (generics only) A H3U ***Acute use only*** Oxycodone/Acetaminophen (generics only) Tramadol/Acetaminophen (generics only) Analgesics, Salicylate & Non-salicylate A H3V All Combination Opioid Withdrawal Therapy Agents, Opioid- PA H3W Type None

Opioid Analgesic and Salicylate Analgesic Aspirin/Codeine phosphate A H3X Combination (generics only) ***Acute use only*** Oxycodone/Aspirin (generics only) Mu-Opioid Receptor Antagonists, Peripherally- PA H3Y None Acting Opioid Analgesic,Non-salicylate,Xanthine PA H3Z None Combination Opioid Analgesic, Salicylate and Xanthine PA H30 None Combination Opioid Withdrawal Therapy Agents, Alpha-2 PA H33 None Adrenergic Agonist None PA H4A – Benzodiazepine Type

Carbamazepine/XR (generics only) Depakote (generics only) (generics only) Mephobarbital (generics only) Anticonvulsants (generics only) A H4B sodium ER (generics

only) (generics only) (generics only) Valproic acid (generics only) /Dietary Supplement D H4D None Combinations

Page 17 of 40 L&I Outpatient Drug Formulary October 1, 2021 Washington State Department of Labor and Industries Outpatient Formulary

Status TCC Therapeutic Class Description Preferred Drug(s) Anticonvulsants – Cannabinoid Type PA H4E None

Neuropathic Agents PA H5B None

PA H6A Antiparkinsonism Drugs, Other None PA H6B Antiparkinsonism Drugs, Anticholinergic None Antitussives, Non-Opioid Benzonatate (generics only) A H6C Dextromethorphan (generics only) A H6E Emetics Ipecac (generics only) Skeletal Muscle Relaxants/Dietary D H6F None Supplement Combinations Skeletal & Topical Irritant PA H6G None Counter-Irritant Combinations D H6I Amyotrophic Lateral Sclerosis Agents None (generics only) (generics only) Prochlorperazine (generic tablet form only) A H6J Anti-Emetics Promethazine (generics only) Trimethobenzamide (generics only) **5HT3 products require prior authorization** D H6L Movement Disorders (Drug Therapy) None A H6N Antitussives, Opioid Type None , Cannabinoid Type PA H6O None

Serotonin-2 Antagonist/Reuptake Inhib A H7E Trazodone (generics only) (SARIs) PA H7J MAOIs - Non-Selective & Irreversible None PA H7N Smoking Deterrents, Others None Antipsychotic, , A H7O All Butyrophenones Antipsychotic, Dopamine Antagonist, A H7P Thiothixene (generics only) Thioxanthenes Antipsychotic, Dopamine Antagonist, A H7R (Orap) Diphenylbutylpiperidines Antipsychotic, Dopamine & Serotonin A H7S Molidone (Moban) Antagonist Antipsychotic, Dopamine & Serotonin succinate (oral generics A H7U Antagonist only) Anti-Narcolepsy/Anti-Cataplexy, Sedative- D H7W None Type Agent Tx For Attn Deficit-Hyperactivity PA H7Y None Disorder (ADHD), NRI-Type SSRI & Antipsych, Atyp, Dopamine & PA H7Z None Serotonin Antagonist Combination PA H8A Antianxiety, Antispasmodic Combination None D H8D , Melatonin and Herbal Combinations None D H8F Hypnotic, Melatonin Combinations Other None Selective Serotonin Reuptake Inhibitor D H8I None (SSRI)/Dietary Supplement Combinations

Page 18 of 40 L&I Outpatient Drug Formulary October 1, 2021 Washington State Department of Labor and Industries Outpatient Formulary

Status TCC Therapeutic Class Description Preferred Drug(s) Norepinephrine and Dopamine Reuptake D H8J Inhibitor (NDRI)/Dietary Supplement None Combinations Antianxiety Drug/Dietary Supplement D H8K None Combinations Tx for ADHD – Selective Alpha 2A-Adrenergic D H8M None Receptor Agonist Pseudobulbar Affect (PBA) Agents, NMDA PA H8O None Antagonists D H8P SSRI & 5HT1A Partial Agonist Antidepressant None Narcolepsy and Sleep Disorder Therapy D H8Q None Agents D H8R Benzodiazepines None SSRI & Serotonin (5-HT) D H8T None Antidepressant Cannabis and Cannabinoid Receptor Agonists D H8U None

Hypoactive Sexual Desire Disorder (HSDD) D H8V None Treatment Agents Antipsychotic-Atypical, Dopamine D3/D2 PA H8W Receptor Partial Agonist-5HT Mixed None

Selective Serotonin 5-HT2A inverse Agonists PA H8Y (SSIA) None

Antidepressant – N-methyl D-aspartate PA H8Z (NMDA) Receptor Antagonist None

Autonomic Nervous System Status TCC Therapeutic Class Description Preferred Drug(s) chloride (generics A J1A Parasympathetic Agents only) (generics only) PA J1B Cholinesterase Inhibitors None

PA J2A Belladonna Alkaloids None

PA J2B Anticholinergics, Quaternary None A J2D Anticholinergics/ Dicyclomine (generics only) PA J2G Muscarinic Receptor Antagonists None PA J2H Anticholinergics/Microorganisms Combinations None Smoking Deterrent Agents-Ganglionic PA J3A None Stimulant Smoking Deterrent-Nicotinic Receptor Partial PA J3C None Agonist D J5A Adrenergic Agents, Catecholamines None Adrenergics, Aromatic Non-Catecholamines D J5B None () A J5C Adrenergic Agents, Non-Aromatic All

Page 19 of 40 L&I Outpatient Drug Formulary October 1, 2021 Washington State Department of Labor and Industries Outpatient Formulary

Status TCC Therapeutic Class Description Preferred Drug(s) PA J5D Beta Adrenergic Agents, Oral None PA J5E Sympathomimetic Agents None PA J5F Therapy Agents None A J5H  Adrenergic Vasopressor Agents Midodrine HCl PA J7A Alpha/Beta Adrenergic Blocking Agents None Doxazosin mesylate A J7B  Alpha-Adrenergic Blocking Agents Prazosin Terazosin PA J7C Beta-Adrenergic Blocking Agents None Alpha-Adrenergic Blocking Agent/ PA J7E None Thiazide Combination Beta Adrenergic Agent/Dietary Supplement D J7G None Combinations Beta Adrenergic Agents/Thiazide & Thiazide- PA J7H None like Combinations D J8A Anorexic Agents None D J8B Cannabinoid-1 Receptor (CB1) Antagonist None D J8C Serotonin 2C Receptor Agonists None Anti-Obesity – Opioid D J8D Antagonist/Norepinephrine & Dopamine None Reuptake Inhibitor (NDRIs) Anti-obesity Glucagon-like Peptide-1 (GLP-1) D J8E None Receptor Agonist Anti-obesity – Melanocortin 4 (MC4) Receptor D J8F Agonists None

Metoclopramide (generic tablet and A J9A Intestinal Motility Stimulants solution only) PA J9B Antispasmodic Agents None

Skin/Subcutaneous Tissue Status TCC Therapeutic Class Description Preferred Drug(s) Topical/Mucous Membrane/Sub-Q Enzyme A L0B Collagenase (Santyl) Preps PA L1A Antipsoriatic Agents, Systemic None D L1B Acne Agents, Systemic None D L1D Hyperpigmentation Agents, Systemic None Eczema Agents, Systemic, Interleukin-4 (IL-4) D L1G Receptor Alpha Antagonist, Monoclonal None Antibody A L2A Emollients All generic products A L3A Protectives All generic products Calamine/Pamoxine (Caladryl) Diphenhydramine (generics only) A L3P , Topical Pramoxine/zinc oxide/calamine cream and lotion (Dermagesic) Topical Neutralizing Agents for Hydrogen D L3Q None Fluoride A L4A Astringents All D L5A Keratolytics None

Page 20 of 40 L&I Outpatient Drug Formulary October 1, 2021 Washington State Department of Labor and Industries Outpatient Formulary

Status TCC Therapeutic Class Description Preferred Drug(s) D L5B Sunscreens None D L5C Abrasives None D L5E Antiseborrheic Agents None PA L5F Antipsoriatic Agents, Topical None D L5G Rosacea Agents, Topical None D L5H Acne Agents, Topical None Hyalofill-F A L5I Wound Healing Agents, Local Peviderm Wound Care Solution Photoactivated Agents, Antineoplastic & PA L5J None Premalignant Lesion, Topical D L5M Keratinocyte Growth Factor (KGF) None Capsaicin (generics only) Capsaicin/ (generics only) Capsaicin/Methyl Salicylate/Menthol (generics only) Menthol (generics only) A L6A Irritants/Counter-Irritants Menthol/Aloe (generics only) Methyl salicylate/Menthol/Camphor (generics only) Methyl salicylate/Menthol (generics only) Trolamine salicylate (generics only) D L7A Shampoos None D L8A Deodorants None D L8B Antiperspirants None A L9A Miscellaneous Topical Agents All D L9B Vitamin A Derivatives None D L9C Hypopigmentation Agents None D L9D Topical Hyperpigmentation Agents None Cosmetic/Skin Coloring/Dye Agents, D L9F None Topical D L9G Skin Tissue Replacement None D L9H Vitamin A Derivatives, Topical Acne Agents None Vitamin A Derivatives, Topical Cosmetic D L9I None Agents D L9K Tissue/Wound Adhesives None

Blood Status TCC Therapeutic Class Description Preferred Drug(s) PA M0B Plasma Proteins None PA M0C Factors, Miscellaneous None PA M0D Plasma Expanders None PA M0E Antihemophilic Factors None PA M0F Factor IX Preparations None D M0G Antiporphyria Factors None Factor IX Complex (Prothrombin Complex PA M0I None Concentrate) Preparations D M0K Factor X Preparations None

Page 21 of 40 L&I Outpatient Drug Formulary October 1, 2021 Washington State Department of Labor and Industries Outpatient Formulary

Human Monoclonal Antibody Complement D M0L None (C5) Inhibitors PA M0M Protein C Preparations None D M0N C1 Esterase Inhibitors None PA M0O Factor XIII Preparations None Hemophilia Treatment Agents, Non-Factor D M0P None Replacements Complement (C3) Inhibitors D M0Q None

A M3A Occult Blood Tests All PA M4A Blood Sugar Diagnostics None PA M4B IV Fat Emulsions None D M4D Antihyperlipidemic – HMG CoA None D M4E Lipotropics None D M4G Hyperglycemics None Antihyperlipid (HMG CoA) & Calcium Channel D M4I None Blocker Antihyperlipidemic – HMG CoA Reductase D M4M Inhibitors & Absorption Inhibitor None Combination D M4O Oral Lipid Supplements None D M4Q Antihyperlipidemic – MTP Inhibitor None Antihyperlipidemic – Apolipoprotein B-100 D M4R None Synthesis Inhibitor D M4T Antihyperlipidemic – PCSK9 Inhibitors None Antihyperlipidemic – ATP Citrate Lyase D M4V Inhibitor None

Antihyperlipidemic – ATP Citrate Lyase and D M4W Cholesterol Absorption Inhibitor None

PA M9A Topical Hemostatics None PA M9D Agents None PA M9E Thrombin Inhibitors, Hirudin Type Agents None PA M9F Thrombolytic Enzymes None PA M9J Citrates As None Enoxaparin 30/40mg (generics only) A M9K Heparin Preparations Fondaparinux 2.5mg (generics only) Heparin (generics only) PA M9L Oral Anticoagulants, Coumarin Type Warfarin sodium (generics only) PA M9P Aggregation Inhibitors None Thombin Inhibitors, Selective, Direct & PA M9T None Reversible D M9U Thrombolytic – Nucleotide Type None PA M9V Direct Factor Xa Inhibitors None PA M9W Reversal Agents None Anticoagulant Reversal Agent for Factor Xa PA M9Y Inhibitors None

Page 22 of 40 L&I Outpatient Drug Formulary October 1, 2021 Washington State Department of Labor and Industries Outpatient Formulary

Bone Marrow Status TCC Therapeutic Class Description Preferred Drug(s) PA N1B Erythropoiesis Stimulating Agents None D N1C Leukocyte (WBC) Stimulants None PA N1D Platelet Reducing Agents None PA N1E Platelet Proliferation Stimulants None D N1F Thrombopoietin Receptor Agonists None PA N1G CXCR4 Chemokine Receptor Antagonists None D N1H Sickle Cell Anemia Agents None D N1I Erythroid Maturation Agents None

Endocrine System (Except Gonads) Status TCC Therapeutic Class Description Preferred Drug(s) D P0B Follicle Stimulating Hormones None Facilitating/Maintaining Agent, D P0C Hormonal None

D P0D Human Chorionic Gonadotropin (HCG) None D P0E Follicle Stimulating Hormone (FSH) None Follicle Stimulating Hormone & GNRH D P0F None Antagonist Pregnancy Maintaining Agent, Hormonal D P0G None

D P1A Growth Hormones None D P1B Somatostatic Agents None D P1E Adrenocorticotrophic Hormones None D P1F Pituitary Suppressive Agents None D P1G Adrenal Inhibitors None D P1H Growth Hormone Releasing Hormone None D P1L Luteinizing Hormone Releasing-Hormone None LHRH/GNRH Agonist Analog Pituitary D P1M None Suppressants LHRH Antagonist Pituitary Suppressant D P1N None Agents LHRH/GNRH Agonist Analog Pituitary D P1O None Suppressants and Progestin Combination LHRH/GNRH Agonist Pituitary Suppressants- D P1P None C Prec Puberty Growth Hormone Receptor D P1Q None Antagonists LHRH (GnRH) Antagonist, Estrogen and D P1R Progestin Combinations None

D P1U Metabolic Function Diagnostics None Antidiuretic & Vasopressor D P2B None Hormones D P3A None D P3B Thyroid Function Diagnostic Agents None D P3L Antithyroid Preparations None

Page 23 of 40 L&I Outpatient Drug Formulary October 1, 2021 Washington State Department of Labor and Industries Outpatient Formulary

Status TCC Therapeutic Class Description Preferred Drug(s) Formation Stimulating Agents – D P4B None Parathyroid Hormone Hyperparathyroid Treatment Agents – Vitamin D P4D None D Analog-Type PA P4E Bone Morphogenic Agents None Bone Formation Stimulating Agents – PA P4F Parathyroid Hormone Related Peptides None

PA P4L Bone Resorption Suppression Agents None D P4M Calcimimetic, Parathyroid Calcium Enhancer None Bone Resorption Inhibitor & Calcium D P4O None Combinations Done Formation Agents – Sclerostin Inhibitor, PA P4Q Monoclonal Antibody None

Glucocorticoids (generics only) acetate (generics only) (generics only) A P5A (generics only) Oral Corticosteroids (generics only) (generics only) (generics only) PA P5S None D P6A Pineal Hormone Agents None D P8A Pineal Hormone Agents None Protein Stabilizers D P9A None

Amyloidosis Agents – Transthyretin (TTR) D P9B None Suppression

Ear, Eye, Nose, Rectum, Topical, Vagina, Spec Status TCC Therapeutic Class Description Preferred Drug(s) D Q2B Ophthalmic Surgical Aids None Ophthalmic Anti-inflammatory PA Q2C None Immunomodulator Type Ophthalmic Selective Vascular Endothelial D Q2D None Growth Factor (VEGF) Antagonists Ophthalmic VEGF-A Receptor Antagonist D Q2F None RCMB MC Antibody PA Q2G Ophthalmic Antifibrotic Agents None Eye Antihistamine-Vasoconstrictor A Q2H None Combinations D Q2L Ophthalmic Cystine Depleting Agents None D Q2M Ophthalmic Proteolytic Agents None PA Q2N Ophthalmic Agents None Eye Mydriatic and NSAID Combinations PA Q2O None

Agents for Corneal Collagen Cross-linking D Q2P None

Page 24 of 40 L&I Outpatient Drug Formulary October 1, 2021 Washington State Department of Labor and Industries Outpatient Formulary

Status TCC Therapeutic Class Description Preferred Drug(s) Eye , Glucocorticoid and NSAID PA Q2Q Combination None

Ophthalmic Human Nerve Growth Factor D Q2S (hNGF) None

D Q2U Eye Diagnostic Agents None Retinal Enzyme Replacement D Q2V None

PA Q3A Rectal Preparations None Rectal/Lower Bowel Prep, A Q3B All Glucocorticoid, Non-Hemorrhoidal /Benzethonium (Americaine Hemorrhoidal) Hydrocortisone/Pamoxine (Analpram-HC) A Q3D Hemorrhoidal Preparations (generics only) (Anusol HC) Pramoxine (generics only) Chronic Inflm Colon Dx PA Q3E None 5 - Aminosalicylates Hemorrhoidal Preparations, Local A Q3H Dibucaine (generics only) Anesthetics Hemorrhoidal Preparations, Anti-inflammatory PA Q3I None Steroid/Local Anesthetics A Q3S Laxatives, Local/Rectal All PA Q3T Local Anorectal Nitrate Preparations All PA Q4A Vaginal Preparations None PA Q4B Vaginal Antiseptics None PA Q4C Vaginal Deodorants None Vaginal Estrogen for Sexual Dysfunction PA Q4D None

PA Q4F Vaginal None PA Q4H Vaginal/Cervical Care and Treatment Agents None D Q4K Vaginal Estrogen Preparations None Vaginal Lubricants Preparations PA Q4L None

PA Q4S Vaginal Sulfonamides None PA Q4W Vaginal None D Q5A Topical Preparations, Miscellaneous None

Page 25 of 40 L&I Outpatient Drug Formulary October 1, 2021 Washington State Department of Labor and Industries Outpatient Formulary

Status TCC Therapeutic Class Description Preferred Drug(s) Betadine (generics only) Boric acid (generics only) Cetaphil Chlorhexidine gluconate (generics only) Clioquinol/Hydrocortisone (generics A Q5B Topical Preparations, Antibacterials only) Iodochlorhydroxyquin/HC (generics only) Povidone-Iodine (generics only) Silver nitrate (generics only) Zephiran chloride (generics only) D Q5C Topical Preparations, Hypertrichotic Agents None Topical Anti-inflammatory, PA Q5E None Non-Steroidal PA Q5F Topical Antifungals None (OTC 4% cream, 4% gel, A Q5H Topical Local Anesthetics and 4% patch formulations) Pramoxine 1% lotion PA Q5K Topical Immunosuppressive Agents None Topical Antifungal/Anti-inflammatory Steroid PA Q5M None Agents Topical Antineoplastic & Premalignant Lesion PA Q5N None Agents Amcinonide (generics only) Betamethasone dipropionate (generics only) (generics only) propionate (generics only) (generics only) (generics only) A Q5P Topical Anti-inflammatory Preparations diacetate (generics only) (generics only) Embeline (generics only) acetonide (generics only) (generics only) Hydrocortisone (generics only) furoate (generics only) Cromtamiton (Eurax) A Q5R Topical Permethrin (generics only) Silver sulfadiazine (generics only) A Q5S Topical Sulfonamides Sodium sulfacetamide/Sulfur (generics only) PA Q5V Topical Antivirals None

Page 26 of 40 L&I Outpatient Drug Formulary October 1, 2021 Washington State Department of Labor and Industries Outpatient Formulary

Status TCC Therapeutic Class Description Preferred Drug(s) Bacitracin (generics only) Bacitracin/Polymyxin B (generics only) sulfate (generics only) (generics only) A Q5W Topical Antibiotics /Bacitracin/Polymyxin B (generics only) Neomycin/Bacitracin/Polymyxin B/Pramoxine (generics only) Neomycin/Polymyxin B/Pramoxine (generics only) Topical Antibiotics/Anti-inflammatory, PA Q5X None Steroidal Topical Antiandrogenic Agents D Q50 None

A Q6A Eye Preparations, Miscellaneous All A Q6C Eye Vasoconstrictors (Rx Only) All A Q6D Eye Vasoconstrictors (OTC Only) All A Q6E Eye Irrigations All Brinzolamide (Azopt) Betaxolol (generics only) Brimonidine tartrate (generics only) Carteolol (generics only) /Dorzolamide (Cosopt) (generics only) Levobunolol (generics only) Metipranolol (generics only) Miotics And Other Intraocular A Q6G P1E1 Pressure Reducers P2E1 P4E1 P6E1 Phospholine iodide (generics only) Pilocarpine (generics only) Timolol maleate (generics only) Dorzolamide (Trusopt) Latanoprost (Xalatan) PA Q6H Eye Local Anesthetics None A Q6I Eye Antibiotic-Corticoid Combinations All PA Q6J Mydriatics None Dexamethasone sod phosphate (generics only) Diclofenac sodium (generics only) (generics only) Flurbiprofen sodium(generics only) A Q6P Eye Anti-inflammatory Agents Ketorolac tromethamine (generics only) etabonate (generics only) /sod phosphate (generics only)

Page 27 of 40 L&I Outpatient Drug Formulary October 1, 2021 Washington State Department of Labor and Industries Outpatient Formulary

Status TCC Therapeutic Class Description Preferred Drug(s) Levocarbastine (Livostin) A Q6R Eye Antihistamines (Patanol) Ketotifen (Zaditor) Sulfacetamide sodium (generics only) A Q6S Eye Sulfonamides Sulfacetamide/Prednisolone (generics only) A Q6T Artificial Tears All PA Q6U Ophthalmic Mast Cell Stabilizers None PA Q6V Eye Antivirals None Bacitracin (generics only) Bacitracin/Polymyxin (generics only) (generics only) Erythromycin (generics only) Gatifloxacin (generics only) Gentamicin sulfate (generics only) (generics only) A Q6W Eye Antibiotics (generics only) Neomycin/Bacitracin/Polymyxin (generics only) Neomycin sulfate/polymyxin B sulfate/gramicidin D Ofloxacin (generics only) Polymyxin B sulfate/Trimethoprim (generics only) Tobramycin (generics only) A Q6Y Eye Preparations, Miscellaneous (OTC Only) All Nose Preparations, Miscellaneous A Q7A (generics only) (Rx Only) Nose Preparations, Vasoconstrictors PA Q7C None (Rx Only) Nose Preparations, Vasoconstrictors PA Q7D None (OTC Only) PA Q7E Nasal Antihistamine None PA Q7H Nasal Agents None NSAIDs, COX Non-selective, Systemic PA Q7K None Analgesic Nasal Antihistamine and Anti-inflammatory PA Q7O None Steroid Combination PA Q7Q Nasal Moisturizer None PA Q7R Nasal Washes None PA Q7W Nose Preparations, Antibiotics None Nose Preparations, Miscellaneous A Q7Y All (OTC Only) Acetasol (generics only) Ear Preparations, Miscellaneous Acetic acid (generics only) A Q8B Antiinfectives Acetic acid/Hydrocortisone (generics only) Otic, Antiinfective- PA Q8C None Combinations

Page 28 of 40 L&I Outpatient Drug Formulary October 1, 2021 Washington State Department of Labor and Industries Outpatient Formulary

Status TCC Therapeutic Class Description Preferred Drug(s) Otic, Antiinfective, Local Anesthetic & Anti- PA Q8D None inflammatory Combinations Ear Preparations, Anti-inflammatory- Ciprofloxacin/Hydrocortisone (Cipro A Q8F Antibiotics HC) PA Q8H Ear Preparations, Local Anesthetics None D Q8R Ear Preparations, Ear Wax Removers None Neomycin/Polymyxin/HC (generics A Q8W Ear Preparations, Antibiotics only) Ofloxacin PA Q8Y Ear Preparations, Miscellaneous (OTC Only) None Benign Prostatic Hypertrophy/ D Q9B None Micturition Agents

Kidney/Urinary Tract Status TCC Therapeutic Class Description Preferred Drug(s) PA R1B Osmotic None PA R1E Carbonic Anhydrase Inhibitors None PA R1F Thiazide Diuretics & Related Agents None PA R1H Potassium Sparing Diuretics None PA R1K Miscellaneous Diuretics None Potassium Sparing Diuretics Inhibitor PA R1L None Combinations PA R1M Loop Diuretics None Arginine Vasopressin (AVP) Receptor PA R1N None Antagonists Polycystic Disease Agent, Arginine D R1O Vasopressin (AVP) Receptor Antagonists None

Uricosuric and Xanthine Oxidase Inhibitor D R1Q None Combinations D R1R Uricosuric Agents None Potassium citrate/Sodium citrate (Citrolith) Potassium phosphate monobasic (K-Phos Original) Potassium citrate/ (generics only) A R1S Urinary pH Modifiers Citric acid/Gluconolactone/Magnesium carbonate (Renacidin) Sodium citrate/Citric acid (generics only) Potassium citrate (generics only) D R1U Renal Function Diagnostic Agents None Overactive Bladder Agents, Beta-3 PA R1V None Agonists Cystine Depleting Agents, Nephropathic PA R1W None Cystinosis Fluorescence Cystoscopy/Optical Imaging D R2A None Agents D R2U Urinary Tract Radiopaque Diagnostics None

Page 29 of 40 L&I Outpatient Drug Formulary October 1, 2021 Washington State Department of Labor and Industries Outpatient Formulary

Status TCC Therapeutic Class Description Preferred Drug(s) PA R3D Drug Detection Tests, Urine None PA R3U Urine Glucose Test Aids None PA R3V Miscellaneous Urine Test Aids None PA R3W Urine Acetone Test Aids None PA R3Y Urine Multiple Test Aids None PA R4A Kidney Stone Agents None PA R5A Urinary Tract Anesthetic/Analgesic Agents None

Locomotor System Status TCC Therapeutic Class Description Preferred Drug(s) Tissue Replacement D S1A None

D S2A Colchicine None PA S2C Gold Salts None Anti-Inflammatory/Antiarthritic Agents, PA S2H None Miscellaneous Anti-Inflammatory, Pyrimidine Synthesis PA S2I None Inhibitor Anti-Inflammatory, Tumor Necrosis Factor PA S2J None Inhibitor PA S2K Anti-Arthritic and Chelating Agents None PA S2N Anti-Arthritic, Folate Antagonist Agents None NSAIDs, Cyclooxygenase 2 Inhibitor-Type & PA S2P None Proton Pump Inhibitor Combinations Anti-inflammatory, Selective Costimulation PA S2Q None Modulator, T-Cell Activation Inhibitors NSAIDs ( Anti-inflammatory D S2R Drugs) Cyclooxygenase Inhibitor/Dietary None Supplement Combination Analgesic, NSAID COX Type-1st Generation D S2S None Antihistamine, Sedative Combination NSAIDs (COX Non-Specific Inhibitor) & PA S2T None Combination NSAIDs, COX Non-Selective & Topical Irritant D S2U None Counter-irritant Combination D S2V Anti-inflammatory, Interleukin-1 Beta Blockers None Joint Contracture Therapy, Collagenase D S2W None Enzyme NSAID (COX Non-Specific Inhibitor) & PA S2X Histamine H2 Receptor Antagonist None Combination NSAID Analgesic (COX Non-Specific Inhibitor) & Non-salicylate Analgesic PA S2Y None Combination

Anti-inflammatory, Phosphodiesterase-4 PA S2Z None (PDE4) Inhibitors NSAIDs, COX-2 Selective Inhibitor (systemic) D S20 Topical Irritant Counter-irritant Combination None

Page 30 of 40 L&I Outpatient Drug Formulary October 1, 2021 Washington State Department of Labor and Industries Outpatient Formulary

Status TCC Therapeutic Class Description Preferred Drug(s) NSAIDs Analgesic (Systemic) and Topical D S26 Local Anesthetic Combinations None

D S7A Neuromuscular Blocking Agents None Selective Relaxant Binding Agents (SRBA) D S7D None

Skeletal Muscle Relaxant, Salicylate, Opioid D S7G Analgesic Combination None

Neuromuscular Blocking Agents (Cosmetic) D S7H None

Ear, Eye, Nose, Rectum, Topical, Vagina, Spec Senses (CONT.) Status TCC Therapeutic Class Description Preferred Drug(s) Topical Vit D Analog/Anti-inflammatory PA T0A None Steroidal PA T0B Topical Pleuromutilin Derivatives None D T0C Topical Genital Wart-HPV Treatment Agent None Topical Antiviral & Anti-inflammatory steroid PA T0E None combinations Hydrocortisone acetate/Pramoxine Topical Anti-inflammatory steroid & Local (generics only) A T0F Anesthetic combinations Hydrocortisone acetate/Lidocaine (generics only) Topical Antiviral & Local Anesthetic D T0G None combinations Topical Anti-inflammatory, Phosphodiesterase PA T0I 4 (PDE4) Inhibitors None

Topical Anti-inflammatory, NSAID and Local PA T0J Anesthetic Combination None

Topical Antifungal Antibiotic Anti-inflammatory PA T0K None Steroid Combination

Miscellaneous Drugs and Pharmaceutical Adjuvants Status TCC Therapeutic Class Description Preferred Drug(s) D U3E Cryopreservative Agents None Adjuvants D U3H None

D U5A Homeopathic Drugs None D U5B Herbal Drugs None D U5F Animal/Human Derived Agents None Multiple Herbal Ingredient Combinations D U5M None

Pharmaceutical Adjuvants, Tableting PA U6A None Agents Pharmaceutical Adjuvants, PA U6B None Coating Agents PA U6C Thickening Agents None

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Status TCC Therapeutic Class Description Preferred Drug(s) PA U6E Ointment/cream Bases None PA U6F Hydrophilic Cream/Ointment Bases None PA U6H Solvents None PA U6N Vehicles None PA U6S Propellants None PA U6W Bulk Chemicals None PA U7A Suspending Agents None PA U7D Surfactants None PA U7H Anticorrosive Agents None PA U7K Flavoring Agents None PA U7N Sweeteners None PA U7P Perfumes None PA U7Q Coloring Agents None

Neoplasms Status TCC Therapeutic Class Description Preferred Drug(s) PA V1A Alkylating Agents None PA V1B None PA V1C Vinca Alkaloids None PA V1D Antibiotic Antineoplastics None PA V1E Steroid Antineoplastics None PA V1F Miscellaneous Antineoplastics None PA V1G Radioactive Therapeutic Agents None PA V1I Antidotes None PA V1J Antineoplastic – Antiandrogenic Agents None Antineoplastics Antibody/Antibody- PA V1K None Drug Complexes PA V1M Antineoplastics Immunomodulator Agents None Antineoplastic Lhrh Agonists, Pituitary D V1O None Suppressant PA V1Q Antineoplastic Systemic Enzyme Inhibitor None Photoactivated, Antineoplastic Agents, PA V1R None Systemic Intrapleural Sclerosing Agents. Antineoplastic PA V1S None Adjuvant Selective Estrogen Receptor PA V1T None Modulators (Serm) Antineoplastics Antibody/Antibody-drug D V1U None Complexes Antineoplastic LHRH (GNRH) Antagonist, D V1V None Pitiutary Suppressors Antineoplastic EGF Recceptor Blocker RCMB PA V1W None MC Antibody Antineoplastic Hum VEGF Inhibitor RCMB PA V1X None MC Antibody Antineoplastic – Selective Inhibitors of PA V10 Nuclear Export (SINE) None

Page 32 of 40 L&I Outpatient Drug Formulary October 1, 2021 Washington State Department of Labor and Industries Outpatient Formulary

Status TCC Therapeutic Class Description Preferred Drug(s) Antineoplastic – Protein Methyltransferase PA V11 (PMT) Inhibitors None

Antineoplastic - EGFR and Mesenchymal- Epithelial Transition (MET) Receptor Inhibitor, PA V15 None Monoclonal Antibody ***New Drug Class*** Antineoplastic Histone Deacetylase Inhibitors PA V3A None (HDIs, HDACIs) PA V3C Antineoplastic – MTOR Kinase Inhibitors None PA V3D Antineoplastic – Epothilones and Analogs None PA V3E Antineoplastic – Topoisomerase I Inhibitors None PA V3F Antineoplastic – Aromatase Inhibitors None Antineoplastic – , Therapeutic PA V3H None PA V3I Antineoplastic – Halichondrin B Analogs None Tissue Protective Agents for Treatment of PA V3K None Cancer Chemotherapy Extravasation PA V3L Antineoplastic – Janus Kinase (JAK) Inhibitors None PA V3M Antineoplastic – Hedgehog Pathway Inhibitor None Antineoplastic – Vascular Endothelial Growth D V3N None Factor (VEGF-A, B&P1GF) Inhibitor Antineoplastic – Interleukin-6 (IL-6) Inhibitors, D V3O None Monoclonal antibody Antineoplastic – Anti-Programmed Death-1 D V3R None (PD-1) Monoclonal Antibody Antineoplastic – Immunotherapy, Virus-Based PA V3T None Agents Antineoplastic – MEK1 And MEK2 Kinase PA V3U None Inhibitors Antineoplastic – Anti-CD38 Monoclonal D V3V None Antibody Antineoplastic – Anti-SLAMF7 Monoclonal D V3W None Antibody Antineoplastic – B-Cell Lymphoma-2 (BCL-2) PA V3X Inhibitors None

Antineoplastic – Anti-Programmed Cell Death- PA V3Y Ligand 1 (PD-L1) Monoclonal Antibody None

Antineoplastic – Platelet-derived Growth PA V3Z Factor Receptor MC Ab None

Antineoplastic Combination – Kinase Inhibitor PA V31 and None

Antineoplastic – Isocitrate Dehydrogenase PA V32 (IDH) Inhibitors None

Antineoplastic – Antibiotic and PA V33 None

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Status TCC Therapeutic Class Description Preferred Drug(s) Antineoplastic – CD22 Specific Antibody and PA V34 Cytotoxic Antibiotic Conjugate None

Antineoplastic – CD19-Directed Chimeric PA V35 Antigen Receptor T Cell Immunotherapy None

Antineoplastic – CD33 Specific Antibody and PA V36 Cytotoxic Antibiotic Conjugate None

Antineoplastic – BRAF Kinase Inhibitors PA V37 None

Antineoplastic – CD22-Directed PA V38 Antibody/Cytotoxin Conjugate None

Antineoplastic – CD123-Directed Cytotoxin PA V39 Conjugate None

Interleukin-4 (IL-4) Receptor Alpha PA V4D Antagonist, MAB None

Antineoplastic – KRAS Protein Inhibitor PA V5A None ***New Drug Class***

Anti-Infecting Agents Status TCC Therapeutic Class Description Preferred Drug(s) Antiretroviral – Nucleoside and Nucleotide PA W0H Analogs, Protease Inhibitor Combination None

Antiretroviral – Integrase Inhibitor and Non- A W0I Nucleoside Reverse Transcriptase Inhibitor All Combination Antiretroviral – Anti-CD4 Domain 2 PA W0J Monoclonal Antibody None

Antiretroviral – Integrase Inhibitor and Nucleoside Reverse Transcriptase Inhibitor PA W0K None Combination

Amoxicillin trihydrate/Potassium Clavulanate (generics only) (generics only) A W1A Penicillins (generics only) Dicloxacillin sodium (generics only) Penicillin V potassium (generics only) Doxycycline (generics only) A W1C Tetracycline (generics only) A W1E Chloramphenicol and Derivatives All PA W1F Aminoglycosides None A W1G Antitubercular Antibiotics Rifampin (generics only) PA W1J and Derivatives None

Page 34 of 40 L&I Outpatient Drug Formulary October 1, 2021 Washington State Department of Labor and Industries Outpatient Formulary

Status TCC Therapeutic Class Description Preferred Drug(s) (generics only) A W1K Lincosamides Lincomycin (generics only) A W1L Topical Antibiotics All A W1M Streptogramins All Colistimethate sodium (generics A W1N Polymyxin And Derivatives only) Polymyxin B sulfate (generics only) PA W1O Oxazolidones None A W1P Oxabeta-Lactams All Moxifloxacin (generics only) Ciprofloxacin (generics only) A W1Q Quinolones Levofloxacin (generics only) Ofloxacin (generics only) A W1S Carbapenems (Thienamycins) All Cefadroxil (generics only) A W1W -1st Generation Cephalexin (generic capsule and suspension forms only) Cefaclor (generics only) A W1X Cephalosporins-2nd Generation axetil (generics only) Cefprozil (generics only) Cefdinir A W1Y Cephalosporins-3rd Generation Cefpodoxime A W1Z Cephalosporins-4th Generation All Sulfadiazine (generics only) Sulfamethoxazole/Trimethoprim A W2A Absorbable Sulfonamides (generics only) Sulfisoxazole (generics only) Ethambutol (generics only) A W2E Antitubercular Agents Isoniazid (generics only) Pyrazinamide (generics only) Nitrofurantoin macrocrystal A W2F Nitrofuran Derivatives (generics only) Nitrofurantoin (generics only) Methenamine mandelate (generics Antibacterial Chemotherapeutic only) A W2G Agents, Misc. Trimethoprim (generics only) Urinary antiseptic (generics only) Antibacterial Monoclonal Antibodies PA W2H None

A W2Y Miscellaneous Anti-infectives All Griseofluvin ultramicroside A W3A Antifungal Antibiotics (generics only) (generics only) (generics only) Clotrimazole (generics only) Fluconazole (generics only) A W3B Antifungal Agents Terbinafine (generics only) Itraconazole (generics only) Voriconazole (generics only) Antifungal Anti-inflammatory Steroid- PA W3F None Antihistamine

Page 35 of 40 L&I Outpatient Drug Formulary October 1, 2021 Washington State Department of Labor and Industries Outpatient Formulary

Status TCC Therapeutic Class Description Preferred Drug(s) Antifungal-Antibiotic-Steroid-Antihistamine PA W3G None Combination PA W4A Antimalarial Drugs None D W4C Amebacides None A W4E Trichomonacides Metronidazole (generics only) 2nd Generation Anaerobic PA W4G None Antibacterial Agents D W4K Miscellaneous Antiprotozoal Drugs None D W4L None D W4M Topical Antiparasitics None D W4N Insect Repellants None D W4P Antileprotics None D W4Q Insecticides None PA W5A Antivirals None A W5C Antivirals, HIV-Specific, Protease Inhibitors All PA W5D Antiviral Monoclonal Antibodies None PA W5E Hepatitis A Treatment Agents None PA W5F Hepatitis B Treatment Agents None PA W5G Hepatitis C Treatment Agents None Antivirals, HIV-Spec, Nucleotide Analog, A W5I All RTIs A W5J Antivirals, HIV-Spec, Nucleoside Analog, RTIs All Antivirals, HIV-Spec, Non-Nucleoside A W5K All RTIs Antivirals, HIV-Spec, Nucleoside Analog, A W5L All RTI Combinations Antivirals, HIV-Specific, Protease A W5M All Inhibitor Combinations A W5N Antivirals, HIV-Specific, Fusion Inhibitors All Antivirals, HIV-Specific, Nucleoside- A W5O All Nucleotide Analog Antivirals, HIV-Specific, Non-Peptidic A W5P All Protease Inhibitors ARTV Comb – Nucleoside-Nucleotide Analog A W5Q All & Non-nucleoside RTIS Antivirals, General/Dietary Supplement D W5S None Combinations Antivirals, HIV-Specific, CCR5 Co-receptor A W5T All Antagonist Antivirals, HIV-1 Integrase Strand Transfer A W5U All Inhibitor Antiretrovirals – Nucleoside Analogs & Non- A W5W nucleoside Reverse Transcriptase Inhibitors All Combination Antiretroviral Combination – Nucleoside & A W5X Nucleotide Analogs, Integrase Strand All Transfer Inhibitors Antiretroviral – NRTIS and Integrase Inhibitors A W5Z Combination All ***New Drug Class***

Page 36 of 40 L&I Outpatient Drug Formulary October 1, 2021 Washington State Department of Labor and Industries Outpatient Formulary

Status TCC Therapeutic Class Description Preferred Drug(s) Antivirals, HIV-Specific, CD4 Attachment A W50 Inhibitor All ***New Drug Class*** Drugs To Treat Sepsis Syndrome, D W6A None Non-Antibiotic D W7B Viral/Tumorigenic Vaccines None D W7C Virus Vaccines None Arthropod-Borne And Other D W7J None Neurotoxic Virus Vaccines D W7K Antisera None D W7L Gram-positive Cocci Vaccines None Gram Negative Bacilli (Non-Enteric) D W7M None Vaccines Toxin Producing Bacteria Vaccines And D W7N None Toxoids D W7Q Gram-negative Cocci Vaccines None D W7S Antivenins None D W7T Antigenic Skin Tests None D W7U Hymenoptera Extracts None Miscellaneous Therapeutic Allergenic D W7W None Extracts Combination Vaccine And Toxoid D W7Z None Preparations Environmental and Irritants, Other D W70 None

A W8A Heavy Metal Antiseptics All A W8B Surface Active Agents All Iodine Antiseptics A W8C All

Carbamide peroxide (generics only) A W8D Oxidizing Agents Hydrogen peroxide (generics only) Sodium hypochlorite (generics only) A W8E Antiseptics, General All A W8F Irrigants All D W8G Miscellaneous Antiseptics None D W8H Mouthwashes None A W8J Miscellaneous Antibacterial Agents All D W8T Preservatives None PA W9A Ketolides None PA W9B Cyclic Lipopeptides None PA W9C Rifamycins & Related Derivative Antibiotics None PA W9D Glycylcyclines None PA W9E Pleuromutilin Derivatives None PA W9G Cephalosporins-5th Generation None PA W9I Antibiotics None Aminoglycoside Antibiotics – Anticoagulant PA W9K None Combination

Page 37 of 40 L&I Outpatient Drug Formulary October 1, 2021 Washington State Department of Labor and Industries Outpatient Formulary

Status TCC Therapeutic Class Description Preferred Drug(s) Antibiotics – Siderophore PA W9O None

Body as a Whole Status TCC Therapeutic Class Description Preferred Drug(s) Gene Therapy Agents – SMN Protein D Z0K Deficiency None

COVID-19 Vaccines PA Z0L None

Enzyme Replacements D Z1D None (Ubiquitous Enzymes) D Z1E Antioxidant Agents None Metabolic Disease Enzyme Replacement, D Z1H None Fabry’s Disease Metabolic Disease Enzyme Replacement, D Z1I None Gaucher’s Disease Metabolic Disease Enzyme Replacement, D Z1J None Mucopolysaccharidosis Metabolic Disease Enzyme Replacement, D Z1K Severe Combined Immunodeficiency None Disease Metabolic Disease Enzyme Replacement, D Z1L None Pompe Disease D Z1M Antifibrotic Therapy – Pyridone Analogs None Oxalosis Agent – Oxalate Inhibitor, siRNA- D Z1N based None

Metabolic Disease Enzyme Replace, D Z1P None Hypophosphatas Metabolic Dx Enzyme Replacement, Lyso. D Z1Q None Acid Lip. Def Genetic Disorder Therapy – Exon Skipping D Z1R None Antisense Oligonucleotide Pharmacological Chaperone Therapy – D Z1S None Alpha-galactosidase A Enzyme Stabilizer Genetic Disorder Therapy – Exon Inclusion D Z1T None Antisense Oligonucleotide Metabolic Disease Enzyme Replacement, D Z1U None Batten Disease Soluble Guanylate Cyclase (sGC) Stimulator PA Z1Z None

Metabolic Disease Enzyme Replacement, D Z10 Molybdenum Cofactor Deficiency (MoCD) None

D Z2B Radiopharmaceuticals Elements None Cimetidine (generics only) Famotidine (generics only) A Z2D Histamine H2 Receptor Inhibitors Nizatidine (generics only) (generics only) PA Z2E Immunosuppressives None

Page 38 of 40 L&I Outpatient Drug Formulary October 1, 2021 Washington State Department of Labor and Industries Outpatient Formulary

Status TCC Therapeutic Class Description Preferred Drug(s) Cromolyn sodium inhalation A Z2F Mast Cell Stabilizers (generics only) PA Z2G Immunomodulators None D Z2H Systemic Enzyme Inhibitors None Monoclonal Antibodies to Immunoglobulin E D Z2L None (IgE) Immunosuppressive - Monoclone Antibody D Z2M None Inhibiting T Lymph Function /Pseudoephedrine (generics only) 1st Generation Antihistamine-Decongestant Chlorpheniramine/Pseudoephedrine A Z2N Combinations (generics only) /Pseudoephedrine (generics only) 2nd Generation Antihistamine-Decongestant Loratadine/Pseudoephedrine A Z2O Combinations (generics only) D Z2V Interleukin-6 (IL-6) Receptor Inhibitors None Chlorpheniramine maleate (generics only) (generics only) Diphenhydramine (generics only) A Z2P Antihistamine – 1st Generation HCl (generics only) Hydroxyzine pamoate (generics only) Promethazine (generics only) Leukocyte Adhesion Inhibitors, Alpha 4 D Z2R None Mediated, IGG4K MC AB Type Histamine H2-Receptor Inhibitor/Dietary D Z2T None Supplement Combinations Monoclonal Antibody-human Interleukin 12/23 D Z2U None Inhibitors Anti-CD20 (B Lymphocyte) Monoclonal D Z2W None Antibody D Z2X Phosphodiesterase-4 (PDE4) Inhibitors None Immunomodulator, B-Lymphocyte Stimulator D Z2Y None (BLyS)-specific Inhibitor Monoclonal Antibody D Z2Z Janus Kinase (JAK) Inhibitors None D Z5B Radiopharmaceuticals Elements None D Z5D Radioactive Diagnostics, General None Radioactive Metabolic Function Diagnostics D Z5E None

Radioactive Diagnostics – Radiolabeling of D Z5F None Autologous Leukocytes Radioactive Diagnostics – Radiolabeling of D Z5G None Synthetic Amino Acids Radioactive Diagnostics – Radiolabeling for D Z5H Lymphatic Mapping None

Insulin-like Growth Factor Receptor (IGF-R) D Z6B Inhibitor, Monoclonal Antibody None

Page 39 of 40 L&I Outpatient Drug Formulary October 1, 2021 Washington State Department of Labor and Industries Outpatient Formulary

Status TCC Therapeutic Class Description Preferred Drug(s) Fluorescence Imaging Agents – Malignant D Z7A None Tissue D Z9D Diagnostic Preparations, OU None Monoclonal Antibody – Interleukin-5 PA Z20 None Antagonists Interleukin-5 (IL-5) Receptor Alpha PA Z23 None Antagonist, Monoclonal Antibody PA Z24 Spleen Tyrosine Kinase Inhibitors None Immunosuppressant – Interferon Gamma PA Z25 Inhibitor, Monoclonal Antibody None

Agents to Treat Thrombotic PA Z26 Thrombocytopenic Purpura (aTTP) None

Anti-CD19 (B Lymphocyte) Monoclonal PA Z27 Antibody None

Page 40 of 40 L&I Outpatient Drug Formulary October 1, 2021

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