Drug Formulary New York State Workers’ Compensation Effective August 7, 2019

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DRUG FORMULARY NEW YORK STATE WORKERS’ COMPENSATION EFFECTIVE AUGUST 7, 2019

“Adapted by NYS Workers’ Compensation Board (“WCB”) from MDGuidelines® with permission of Reed Group, Ltd. (“ReedGroup”), which is not responsible for WCB’s modifications. MDGuidelines® are Copyright 2019 Reed Group, Ltd. All Rights Reserved. No part of this publication may be reproduced, displayed, disseminated, modified, or incorporated in any form without prior written permission from ReedGroup and WCB. Notwithstanding the foregoing, this publication may be viewed and printed solely for internal use as a reference, including to assist in compliance with WCL Sec. 13-0 and 12 NYCRR Part 44[0], provided that (i) users shall not sell or distribute, display, or otherwise provide such copies to others or otherwise commercially exploit the material. Commercial licenses, which provide access to the online text-searchable version of MDGuidelines®, are available from ReedGroup at www.mdguidelines.com. NYS Workers’ Compensation Drug Formulary August 7, 2019 Introduction Legislation enacted in April 2017 required the New York State Workers’ Phase A Drug List Compensation Board to establish a drug formulary. The New York State Drugs on this list may be prescribed and dispensed subject to the Workers’ Compensation Drug Formulary (Formulary) is based on a following: medication’s effectiveness and appropriateness for the treatment of (1) Within the first 30 days following an accident or injury or until illnesses and injuries covered under the Workers’ Compensation Law. the carrier accepts the claim or the Board establishes a claim, The Formulary is a list of drugs that are designated as either “Phase A”, whichever occurs sooner. “Phase B” or “Perioperative”. Additionally, some drugs are listed as (2) For up to a 30-day supply. second-line therapy (2nd) and may only be used when other drugs associated with the phase of treatment have been deemed ineffective. Phase B Drug List Drugs not listed on the Formulary are considered non-Formulary. Drugs on this list may be prescribed and dispensed subject to the following: Formulary drugs do not require prior authorization. Prior authorization from the insurer or self-insured employer is required for: (1) After 30 days following an accident or injury or when the carrier has accepted the claim or the Board has established a 1. Drugs not listed on the formulary, claim, whichever occurs sooner. 2. A formulary brand name drug, when a generic is available, (2) For up to a 90-day supply. 3. Combination products, unless specifically listed in the formulary, (3) When a body part or illness has been accepted (with or without 4. A brand name drug when a generic version with the same active liability) or established, drugs must be prescribed in accordance ingredient(s) is commercially available in a different strength/ with, as applicable, the adopted Medical Treatment Guidelines dosage (i.e., A product is generically available in 5mg and 10mg, (MTG). and brand in 7.5mg. The 7.5mg product would be considered (4) Phase B drugs designated as “2nd” may be prescribed and non-formulary and could only be dispensed via prior authorization), dispensed following an unsuccessful trial of a first-line drug and prescribed in accordance with Phase B and, as applicable, the 5. Compounded drugs. adopted MTG. Perioperative Formulary Application of the Formulary Drugs listed on the Perioperative Drug List may be prescribed/dispensed The Formulary sets forth drugs in three lists: Phase A, Phase B and when: Perioperative. These three lists of drugs are considered Formulary and (1) The drug is prescribed during the perioperative period (four days can be prescribed per the following framework. For more detailed before through four days following surgery). information about Phase A, Phase B and the Perioperative drugs see the drug formulary on the following pages. Second-Line Drugs Drugs designated as ”2nd” line may be prescribed and dispensed following a trial of a first-line drug prescribed in accordance with Phase B and, as applicable, the adopted Medical Treatment Guideline.

Page 1 Special Considerations First Level Review Some drugs are marked with a Special Consideration indication. The provider shall submit a request for Prior Authorization, in the manner These include: prescribed by the Chair, to the insurer, self-insured employer, or, when • “1. Not to exceed a single seven (7) day supply” – meaning that a designated, the pharmacy benefits manager. specific Formulary drug can be prescribed and dispensed one The First Level Review has these requirements and timeframes: time only without a prior authorization, for a maximum of a (1) The Prior Authorization request may include the quantity to be seven-day supply, during the phase of the formulary under which prescribed and the number of refills or the duration of the it is contained (i.e. controlled substances), prescription. If the duration is not stated, the default shall be • “2. For the prescribed course of therapy” – meaning that a specific 30 days. In no event may a Prior Authorization request exceed Formulary drug can be prescribed and dispensed, during the 365 days. applicable phase of the formulary, for the quantity indicated by (2) The carrier, self-insured employer or pharmacy benefits the prescriber (i.e. antibiotics), and manager shall approve, partially approve or deny a Prior • “3. Short acting only” – meaning that a specific Formulary drug Authorization request within four calendar days of submission by can only be prescribed and dispensed for the short acting the provider: formulation of the product. a. A partial approval authorizes the requested drug, but limits the length of time, quantity prescribed or number of refills from that Prior Authorization requested by the prescriber. A medical provider must obtain Prior Authorization before prescribing or b. A request for Prior Authorization that is not responded to within dispensing a drug other than as described in the Application of the four calendar days (by an approval, denial or partial approval) Formulary section (see above), or when prescribing: may be deemed approved as prescribed, not to exceed a (1) A drug not listed on the Formulary, 365 day supply, upon issuance of an Order of the Chair. (2) A Formulary brand name drug, when a generic is available, (3) A partial approval or denial of a request for Prior Authorization must: (3) Combination products, unless specifically listed on the Formulary, a. Provide a specific reason for the denial or partial approval with (4) A brand name drug when a generic version of the same active reference to the specific Prior Authorization request made by ingredient(s) is a commercially available in a different strength/ the prescriber. dosage, or (5) A compounded drug. If prior authorization is not obtained prior to the dispensing of the drug, the insurer or self-insured employer may deny payment.

Prior Authorization Process The Prior Authorization process shall consist of a review, which may incorporate up to three levels of review, as described below.

Page 2 Second Level Review (3) All requests shall be submitted to the Medical Director’s Office in Within ten calendar days of a denial or partial approval of a First Level the format prescribed by the Chair. Prior Authorization request, the prescriber may request review of such (4) To ensure the timely review of requests, the Chair or Medical denial or partial approval by the carrier’s physician. Director may designate private entities to evaluate such requests The Second Level Review has these requirements and timeframes: for review of denials of a Second Level Review, provided the (1) The Prior Authorization request shall include: entity has: a. All information submitted by the prescriber for the First Level a. The appropriate URAC accreditation or such accreditation/ Review and the response from the insurer, self-insured certification as designated by the Chair, employer, or when designated, the pharmacy benefits manager, b. Other demonstrated expertise and criteria established by the b. All information provided to the prescriber related to the First Board, and Level Review denial or partial approval, and c. No conflict of interest related to the review and resolution of c. Additional information from the prescriber further justifying the the request. need for the requested non-Formulary medication responding The decision by the Medical Director’s Office is final and binding on the to the reason(s) stated in the First Level Denial. prescriber, the insurer, self-insured employer and pharmacy network. (2) The insurer’s physician shall approve, partially approve or deny a In the event a Third Level Review is denied, the prescriber may not Prior Authorization request within four calendar days of submission submit a request for Prior Authorization for the same medication unless by the prescriber. he or she submits evidence that there has been a change in the (3) A request for Second Level Review that is not responded to within claimant’s medical condition that renders the denial of the request for four calendar days (by an approval, denial or partial approval) may the Prior Authorization no longer applicable to the claimant’s current be deemed approved as prescribed, not to exceed a 365 day supply, medical condition. upon issuance of an Order of the Chair.

Third Level Review – Review by the Board of a Prior Authorization Denial or Partial Approval Within ten calendar days of a denial or a partial approval by the insurer’s physician of a Second Level Review, the prescriber may seek review by the Board’s Medical Director’s Office. The Third Level Review has these requirements and timeframes: (1) The prescriber shall submit the Prior Authorization request to the Medical Director’s Office within ten calendar days of Second the Level Review denial date. (2) The request must include all documentation submitted in support of the First and Second Level Review and the information associated with the denial or partial approval issued from the First Level Review and the Second Level Review. The prescriber should respond to the reason(s) stated in the Second Level Denial.

Page 3 Carpal Pain Non Ankle / Back Mid / Hip / Knee Neck Shoulder Therapeutic Category Generic Name Asthma Tunnel CRPS Elbow Eye Acute

Special Foot Low (MTG) Groin (MTG) (MTG) (MTG) Phase B Phase A (MTG) (MTG) Peri Operative Considerations

Analgesics - Narcotic** Codeine-Acetaminophen 1,3 x x Analgesics - Narcotic** Hydrocodone-Acetaminophen 1,3 x x Analgesics - Narcotic** Hydrocodone-Ibuprofen 1,3 x x Analgesics - Narcotic** Morphine 1,3 x x Analgesics - Narcotic** Oxycodone HCl 1,3 x x Analgesics - Narcotic** Oxycodone-Acetaminophen 1,3 x x Analgesics - Narcotic** Oxycodone-Aspirin 1,3 x x Analgesics - Narcotic** Tapentadol 1,3 x Analgesics - Narcotic** Tramadol HCl 1,3 x x Analgesics - Narcotic** Tramadol-Acetaminophen 1,3 x x Analgesics - Nonnarcotic Acetaminophen x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Analgesics - Nonnarcotic Aspirin x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Analgesics - Nonnarcotic Choline - Magnesium Salicylates x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Analgesics - Nonnarcotic Diflunisal x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Analgesics - Topical Capsaicin x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Analgesics - Topical Diclofenac Na (1% only) x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Antacids Alum Hydrox-Mag Trisil-Alginic Acid-Sod Bicarb x x Antacids Aluminum - Magnesium Hydroxides x x Aluminum Hydroxide-Magnesium Carbonate Antacids x x Susp Aluminum Hydroxide-Magnesium Trisilicate Antacids x x Chew Tab Antacids Calcium - Magnesium Carbonates x x Antacids Calcium Carbonate x x Antacids Calcium Carbonate - Simethicone x x Antacids Calcium Carbonate-Mag Hydroxide x x Antianxiety Agents Alprazolam 1 x Antianxiety Agents Buspirone 1 x Antiasthmatics Aclidinium Bromide Aerosol Powd x x Antiasthmatics Albuterol Inhal x x Yes Antiasthmatics Albuterol Sulfate x x Yes Antiasthmatics Beclomethasone Inh x x Yes Antiasthmatics Budesonide x x Yes Antiasthmatics Budesonide Inh x x Yes Antiasthmatics Budesonide-Formoterol Fumarate Inh x x Yes Antiasthmatics Ciclesonide Inh x x Yes Antiasthmatics Cromolyn Na Inhal x x Yes Antiasthmatics Epinephrine Inhal x x Yes Antiasthmatics Flunisolide Inh x x Yes Antiasthmatics Fluticasone Furoate-Vilanterol Inh x x Yes Antiasthmatics Fluticasone Inh x x Yes Antiasthmatics Fluticasone-Salmeterol Inhal x x Yes Antiasthmatics Formoterol Fumarate Soln Nebu x x Yes Antiasthmatics Formoterol/Mometasone x x Yes Antiasthmatics Indacaterol Maleate Inhal x x Yes Antiasthmatics Ipratropium Bromide Inhal x x Yes Antiasthmatics Ipratropium-Albuterol Inh x x Yes Antiasthmatics Levalbuterol HCl Inhal x x Yes Antiasthmatics Methacholine Chloride Inhal x x Yes Antiasthmatics Mometasone Furoate Inh x x Yes Mometasone Furoate-Formoterol Fumarate Antiasthmatics x x Yes Inh Antiasthmatics Montelukast x x Yes Antiasthmatics Roflumilast x x Yes Antiasthmatics Salmeterol x x Yes Antiasthmatics Terbutaline x x Yes Rev. August 7, 2019 Antiasthmatics Theophylline x x Page 4 Yes Antiasthmatics Tiotropium Bromide Monohydrate Inhal x x Yes Antiasthmatics Triamcinolone Acetonide Inh x x Yes Antiasthmatics Zafirlukast x x Yes Antiasthmatics Zileuton x x Yes Anticoagulants Apixaban x x Yes Yes Anticoagulants Dalteparin x x Yes Yes Anticoagulants Enoxaparin Na x x Yes Yes Anticoagulants Fondaparinux Na x x Yes Yes Anticoagulants Rivaroxaban x x Yes Yes Anticoagulants Warfarin Na x x Yes Yes Anticonvulsant Carbamazepine x 2nd 2nd 2nd 2nd Anticonvulsant Clonazepam x Anticonvulsant Divalproex x Anticonvulsant Gabapentin x x 2nd 2nd 2nd 2nd Anticonvulsant Lamotrigine x 2nd 2nd 2nd 2nd Anticonvulsant Levetiracetam x Anticonvulsant Oxcarbazepine x 2nd 2nd 2nd 2nd Anticonvulsant Pregabalin x 2nd 2nd 2nd 2nd Anticonvulsant Topiramate x 2nd 2nd 2nd 2nd Anticonvulsant Valproic Acid x x Antidepressants Amitriptyline x x Yes Yes Yes Yes Antidepressants Bupropion x 2nd 2nd 2nd 2nd Antidepressants Citalopram x Antidepressants Clomipramine x Antidepressants Desipramine x Yes Yes Yes Yes Antidepressants Desvenlafaxine x Antidepressants Doxepin x Yes Yes Yes Yes Antidepressants Duloxetine x 2nd 2nd 2nd 2nd Antidepressants Escitalopram x Antidepressants Fluoxetine x Antidepressants Fluvoxamine x Antidepressants Imipramine x x Yes Yes Yes Yes Antidepressants Isocarboxazid x Antidepressants Mirtazapine x Antidepressants Nefazodone x Antidepressants Nortriptyline x Yes Yes Yes Yes Antidepressants Paroxetine x Antidepressants Phenelzine x Antidepressants Protriptyline x Antidepressants Sertraline x Antidepressants Tranylcypromine x Antidepressants Trazodone x Antidepressants Trimipramine x Yes Yes Yes Yes Antidepressants Venlafaxine x 2nd 2nd 2nd 2nd Antidepressants Vilazodone x

REV: July 30, 2019 Page 1 of 5 Carpal Pain Non Ankle / Back Mid / Hip / Knee Neck Shoulder Therapeutic Category Generic Name Asthma Tunnel CRPS Elbow Eye Acute

Special Foot Low (MTG) Groin (MTG) (MTG) (MTG) Phase B Phase A (MTG) (MTG) Peri Operative Considerations

Special Foot Low (MTG) Groin (MTG) (MTG) (MTG) Phase B Phase A (MTG) (MTG)

Antiasthmatics Roflumilast x x Peri Operative Yes Considerations Antiasthmatics Salmeterol x x Yes Antiasthmatics Analgesics - Narcotic** Terbutaline Codeine-Acetaminophen 1,3 xx x x Yes Antiasthmatics Analgesics - Narcotic** Theophylline Hydrocodone-Acetaminophen 1,3 x x x Yes Analgesics - Narcotic** Antiasthmatics Tiotropium Bromide Monohydrate Inhal Hydrocodone-Ibuprofen 1,3 x x x Yes Analgesics - Narcotic** Antiasthmatics MorphineTriamcinolone Acetonide Inh 1,3 x x x Yes Analgesics - Narcotic** Antiasthmatics Oxycodone HCl Zafirlukast 1,3 x x x Yes Analgesics - Narcotic** Antiasthmatics Oxycodone-Acetaminophen Zileuton 1,3 x x x Yes Analgesics - Narcotic** Anticoagulants Oxycodone-AspirinApixaban 1,3 x x x Yes Yes Analgesics - Narcotic** Anticoagulants TapentadolDalteparin 1,3 x x Yes Yes Analgesics - Narcotic** Anticoagulants Tramadol HCl Enoxaparin Na 1,3 x x x Yes Yes Analgesics - Narcotic** Anticoagulants Tramadol-AcetaminophenFondaparinux Na 1,3 x x x Yes Yes Analgesics - Nonnarcotic Anticoagulants Acetaminophen Rivaroxaban x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Analgesics - Nonnarcotic Anticoagulants Aspirin Warfarin Na x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Analgesics - Nonnarcotic Anticonvulsant Choline - Magnesium SalicylatesCarbamazepine x x x Yes 2ndYes Yes 2ndYes Yes Yes Yes 2ndYes 2ndYes Yes Analgesics - Nonnarcotic Anticonvulsant Diflunisal Clonazepam x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Analgesics - TopicalAnticonvulsant CapsaicinDivalproex x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Analgesics - TopicalAnticonvulsant Diclofenac Na (1% only)Gabapentin x x x Yes 2ndYes Yes 2ndYes Yes Yes Yes 2ndYes 2ndYes Yes Antacids Anticonvulsant Alum Hydrox-Mag Trisil-Alginic Acid-Sod Bicarb Lamotrigine x x 2nd 2nd 2nd 2nd Antacids Anticonvulsant Aluminum - Magnesium Hydroxides Levetiracetam x x Anticonvulsant Aluminum Hydroxide-Magnesium Carbonate Oxcarbazepine x 2nd 2nd 2nd 2nd Antacids x x Anticonvulsant Susp Pregabalin x 2nd 2nd 2nd 2nd Anticonvulsant Aluminum Hydroxide-Magnesium Trisilicate Topiramate x 2nd 2nd 2nd 2nd Antacids x x Anticonvulsant Chew Tab Valproic Acid x x Antacids Antidepressants Calcium - Magnesium CarbonatesAmitriptyline x x Yes Yes Yes Yes Antacids Antidepressants Calcium Carbonate Bupropion x x 2nd 2nd 2nd 2nd Antacids Antidepressants Calcium Carbonate - Simethicone Citalopram x x Antacids Antidepressants Calcium Carbonate-Mag HydroxideClomipramine x x Antianxiety Agents Antidepressants AlprazolamDesipramine 1 x x Yes Yes Yes Yes Antianxiety Agents Antidepressants Buspirone Desvenlafaxine 1 x x Antiasthmatics Antidepressants Aclidinium Bromide Aerosol Powd Doxepin x x Yes Yes Yes Yes Antiasthmatics Antidepressants Albuterol InhalDuloxetine x x Yes 2nd 2nd 2nd 2nd Antiasthmatics Antidepressants Albuterol SulfateEscitalopram x x Yes Antiasthmatics Antidepressants Beclomethasone InhFluoxetine x x Yes Antiasthmatics Antidepressants BudesonideFluvoxamine x x Yes Antiasthmatics Antidepressants Budesonide InhImipramine x x Yes Yes Yes Yes Yes Antiasthmatics Antidepressants Budesonide-Formoterol Fumarate InhIsocarboxazid x x Yes Antiasthmatics Antidepressants Ciclesonide InhMirtazapine x x Yes Antiasthmatics Antidepressants Cromolyn Na Inhal Nefazodone x x Yes Antiasthmatics Antidepressants Epinephrine Inhal Nortriptyline x x Yes Yes Yes Yes Yes Antiasthmatics Antidepressants Flunisolide InhParoxetine x x Yes Antiasthmatics Antidepressants Fluticasone Furoate-Vilanterol InhPhenelzine x x Yes Antiasthmatics Antidepressants Fluticasone InhProtriptyline x x Yes Antiasthmatics Antidepressants Fluticasone-Salmeterol Inhal Sertraline x x Yes Antiasthmatics Antidepressants Formoterol Fumarate Soln Nebu Tranylcypromine x x Yes Antiasthmatics Antidepressants Formoterol/MometasoneTrazodone x x Yes Antiasthmatics Antidepressants Indacaterol Maleate Inhal Trimipramine x x Yes Yes Yes Yes Yes Antiasthmatics Antidepressants Ipratropium Bromide Inhal Venlafaxine x x Yes 2nd 2nd 2nd 2nd Antiasthmatics Antidepressants Ipratropium-Albuterol Inh Vilazodone x x Yes Rev.Antiasthmatics August 7, 2019 Levalbuterol HCl Inhal x x Yes Antiasthmatics Methacholine Chloride Inhal x x Yes Antiasthmatics Mometasone Furoate Inh x x Yes Mometasone Furoate-Formoterol Fumarate Antiasthmatics x x Yes Inh Antiasthmatics REV: July 30, 2019 Montelukast x x Yes Page 1 of 5 Antiasthmatics Roflumilast x x Yes Antiasthmatics Salmeterol x x Yes Antiasthmatics Terbutaline x x Yes Antiasthmatics Theophylline x x Page 5 Yes Antiasthmatics Tiotropium Bromide Monohydrate Inhal x x Yes Antiasthmatics Triamcinolone Acetonide Inh x x Yes Antiasthmatics Zafirlukast x x Yes Antiasthmatics Zileuton x x Yes Anticoagulants Apixaban x x Yes Yes Anticoagulants Dalteparin x x Yes Yes Anticoagulants Enoxaparin Na x x Yes Yes Anticoagulants Fondaparinux Na x x Yes Yes Anticoagulants Rivaroxaban x x Yes Yes Anticoagulants Warfarin Na x x Yes Yes Anticonvulsant Carbamazepine x 2nd 2nd 2nd 2nd Anticonvulsant Clonazepam x Anticonvulsant Divalproex x Anticonvulsant Gabapentin x x 2nd 2nd 2nd 2nd Anticonvulsant Lamotrigine x 2nd 2nd 2nd 2nd Anticonvulsant Levetiracetam x Anticonvulsant Oxcarbazepine x 2nd 2nd 2nd 2nd Anticonvulsant Pregabalin x 2nd 2nd 2nd 2nd Anticonvulsant Topiramate x 2nd 2nd 2nd 2nd Anticonvulsant Valproic Acid x x Antidepressants Amitriptyline x x Yes Yes Yes Yes Antidepressants Bupropion x 2nd 2nd 2nd 2nd Antidepressants Citalopram x Antidepressants Clomipramine x Antidepressants Desipramine x Yes Yes Yes Yes Antidepressants Desvenlafaxine x Antidepressants Doxepin x Yes Yes Yes Yes Antidepressants Duloxetine x 2nd 2nd 2nd 2nd Antidepressants Escitalopram x Antidepressants Fluoxetine x Antidepressants Fluvoxamine x Antidepressants Imipramine x x Yes Yes Yes Yes Antidepressants Isocarboxazid x Antidepressants Mirtazapine x Antidepressants Nefazodone x Antidepressants Nortriptyline x Yes Yes Yes Yes Antidepressants Paroxetine x Antidepressants Phenelzine x Antidepressants Protriptyline x Antidepressants Sertraline x Antidepressants Tranylcypromine x Antidepressants Trazodone x Antidepressants Trimipramine x Yes Yes Yes Yes Antidepressants Venlafaxine x 2nd 2nd 2nd 2nd Antidepressants Vilazodone x

REV: July 30, 2019 Page 1 of 5 Carpal Pain Non Ankle / Back Mid / Hip / Knee Neck Shoulder Therapeutic Category Generic Name Asthma Tunnel CRPS Elbow Eye Acute

Special Foot Low (MTG) Groin (MTG) (MTG) (MTG) Phase B Phase A (MTG) (MTG) Peri Operative Considerations

Antidiabetics Glipizide x Antidiabetics Glucose Tablets/Gel x Antidiabetics Glyburide x Antidiabetics Insulin x Antidiabetics Metformin HCl x Antidiabetics Sitagliptin Phosphate x Antidiarrheals Diphenoxylate w/ Atropine x x Antidiarrheals Loperamide x x Antiemetic - Antivertigo Meclizine x x Antifungals Fluconazole 2 x x Yes Antifungals Itraconazole 2 x x Yes Antifungals Ketoconazole 2 x x Yes Antifungals Nystatin 2 x x Antifungals Terbinafine 2 x x Yes Antihistamines Cetirizine x x Antihistamines Cyproheptadine x x Antihistamines Desloratadine x x Antihistamines Diphenhydramine x x Antihistamines Fexofenadine x x Antihistamines Hydroxyzine x x Antihistamines Levocetirizine x x Antihistamines Loratadine x x Antihistamines Promethazine x x Antihypertensive Clonidine HCl x Antihypertensive Lisinopril x Antihypertensive Losartan x Antihypertensive Prazosin x Anti-Infectives, Misc. Clindamycin 2 x x Yes Yes Yes Yes Anti-Infectives, Misc. Linezolid 2 x Anti-Infectives, Misc. Metronidazole 2 x x Yes Yes Yes Yes Anti-Infectives, Misc. Sulfamethoxazole-Trimethoprim 2 x x Yes Yes Yes Yes Anti-Infectives, Misc. Vancomycin 2 x x Anti-Inflammatory Celecoxib x 2nd 2nd 2nd 2nd 2nd 2nd 2nd 2nd 2nd 2nd Anti-Inflammatory Diclofenac x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Anti-Inflammatory Etodolac x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Anti-Inflammatory Ibuprofen x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Anti-Inflammatory Indomethacin x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Anti-Inflammatory Meloxicam x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Anti-Inflammatory Naproxen x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Anti-Inflammatory Sulindac x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Antimalarial Hydroxychloroquine 2 x Antineoplastic Cabozantinib x Antineoplastic Dabrafenib x Antineoplastic Doxorubicin x Antineoplastic Interferon Gamma-1B x Antineoplastic Methotrexate x Antineoplastic Trametinib x Antineoplastic Vandetanib x Antineoplastic Vismodegib x Antipsychotics Aripiprazole x x Antipsychotics Asenapine Maleate x Antipsychotics Chlorpromazine x x Antipsychotics Haloperidol x x Antipsychotics Lithium x x Antipsychotics Lurasidone x Rev.Antipsychotics August 7, 2019 Olanzapine x x Antipsychotics Paliperidone x Page 6 Antipsychotics Perphenazine x Antipsychotics Prochlorperazine x Antipsychotics Quetiapine x x Antipsychotics Risperidone x Antipsychotics Ziprasidone x Antiretrovirals Atazanavir 2 x Antiretrovirals Darunavir 2 x Antiretrovirals Emtricitabine 2 x Antiretrovirals Fosamprenavir 2 x Antiretrovirals Lamivudine 2 x Antiretrovirals Raltegravir 2 x Antiretrovirals Ritonavir 2 x Antiretrovirals Stavudine 2 x Antiretrovirals Tenofovir 2 x Antiretrovirals Zidovudine 2 x Antitubercular Ethambutol 2 x Antitubercular Isoniazid 2 x Antitubercular Rifabutin 2 x Antitubercular Rifampin 2 x Antiviral Acyclovir 2 x Antiviral Oseltamivir 2 x Antiviral Zanamivir 2 x Beta Blockers Carvedilol x x Beta Blockers Metoprolol Tartrate x x Beta Blockers Nebivolol x x Beta Blockers Propranolol HCl x x Calcium Blockers Amlodipine x x Calcium Blockers Diltiazem x x Calcium Blockers Nifedipine x x Cephalosporins Cefaclor 2 x x Yes Yes Yes Yes Yes Yes Yes Cephalosporins Cefadroxil 2 x x Yes Yes Yes Yes Yes Yes Yes Cephalosporins Cefdinir 2 x x Yes Yes Yes Yes Yes Yes Yes Cephalosporins Cefixime 2 x x Yes Yes Yes Yes Yes Yes Yes Cephalosporins Cefpodoxime 2 x x Yes Yes Yes Yes Yes Yes Yes Cephalosporins Cefprozil 2 x x Yes Yes Yes Yes Yes Yes Yes Cephalosporins Cephalexin 2 x x Yes Yes Yes Yes Yes Yes Yes Corticosteroids Methylprednisolone x x Yes Yes Yes Corticosteroids Prednisolone x x Yes Yes Yes Corticosteroids Prednisone x x Yes Yes Yes Cough/Cold Acetylcysteine Inhal x Cough/Cold Benzonatate x Cough/Cold Cetirizine-Pseudoephedrine x Cough/Cold Chlorpheniramine - Phenylephrine x Cough/Cold Chlorpheniramine-Acetaminophen x Cough/Cold Chlorpheniramine-DM x

REV: July 30, 2019 Page 2 of 5 Carpal Pain Non Ankle / Back Mid / Hip / Knee Neck Shoulder Therapeutic Category Generic Name Asthma Tunnel CRPS Elbow Eye Acute

Special Foot Low (MTG) Groin (MTG) (MTG) (MTG) Phase B Phase A (MTG) (MTG) Peri Operative Considerations

Special Foot Low (MTG) Groin (MTG) (MTG) (MTG) Phase B Phase A (MTG) (MTG)

Antipsychotics Lithium x x Peri Operative Antipsychotics Lurasidone Considerations x Antipsychotics Antidiabetics OlanzapineGlipizide x x Antipsychotics Antidiabetics PaliperidoneGlucose Tablets/Gel x x Antipsychotics Antidiabetics Perphenazine Glyburide x x Antipsychotics Antidiabetics ProchlorperazineInsulin x x Antipsychotics Antidiabetics Quetiapine Metformin HCl x x Antipsychotics Antidiabetics Risperidone Sitagliptin Phosphate x x Antipsychotics Antidiarrheals Ziprasidone Diphenoxylate w/ Atropine x x AntiretroviralsAntidiarrheals Atazanavir Loperamide 2 x x AntiretroviralsAntiemetic - Antivertigo Darunavir Meclizine 2 x x AntiretroviralsAntifungals EmtricitabineFluconazole 2 x x Yes AntiretroviralsAntifungals Fosamprenavir Itraconazole 2 x x Yes AntiretroviralsAntifungals LamivudineKetoconazole 2 x x Yes AntiretroviralsAntifungals RaltegravirNystatin 2 x x AntiretroviralsAntifungals Ritonavir Terbinafine 2 x x Yes AntiretroviralsAntihistamines StavudineCetirizine 2 x x AntiretroviralsAntihistamines TenofovirCyproheptadine 2 x x AntiretroviralsAntihistamines ZidovudineDesloratadine 2 x x Antitubercular Antihistamines Ethambutol Diphenhydramine 2 x x Antitubercular Antihistamines Isoniazid Fexofenadine 2 x x Antitubercular Antihistamines RifabutinHydroxyzine 2 x x Antitubercular Antihistamines Rifampin Levocetirizine 2 x x Antiviral Antihistamines Acyclovir Loratadine 2 x x Antiviral Antihistamines Oseltamivir Promethazine 2 x x Antiviral Antihypertensive Zanamivir Clonidine HCl 2 x Beta Blockers Antihypertensive CarvedilolLisinopril x x Beta Blockers Antihypertensive Metoprolol TartrateLosartan x x Beta Blockers Antihypertensive Nebivolol Prazosin x x Beta Blockers Anti-Infectives, Misc. Propranolol HClClindamycin 2 x x Yes Yes Yes Yes Calcium Blockers Anti-Infectives, Misc. Amlodipine Linezolid 2 x x Calcium Blockers Anti-Infectives, Misc. Diltiazem Metronidazole 2 x x Yes Yes Yes Yes Calcium Blockers Anti-Infectives, Misc. NifedipineSulfamethoxazole-Trimethoprim 2 x x Yes Yes Yes Yes Cephalosporins Anti-Infectives, Misc. CefaclorVancomycin 2 x x Yes Yes Yes Yes Yes Yes Yes Cephalosporins Anti-Inflammatory Cefadroxil Celecoxib 2 x x 2ndYes 2ndYes 2nd 2nd 2ndYes 2ndYes 2ndYes 2ndYes 2nd 2ndYes Cephalosporins Anti-Inflammatory Cefdinir Diclofenac 2 x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Cephalosporins Anti-Inflammatory Cefixime Etodolac 2 x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Cephalosporins Anti-Inflammatory Cefpodoxime Ibuprofen 2 x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Cephalosporins Anti-Inflammatory Cefprozil Indomethacin 2 x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Cephalosporins Anti-Inflammatory Cephalexin Meloxicam 2 x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes CorticosteroidsAnti-Inflammatory MethylprednisoloneNaproxen x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes CorticosteroidsAnti-Inflammatory Prednisolone Sulindac x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes CorticosteroidsAntimalarial Prednisone Hydroxychloroquine 2 x x Yes Yes Yes Cough/Cold Antineoplastic Acetylcysteine Inhal Cabozantinib x x Cough/Cold Antineoplastic Benzonatate Dabrafenib x x Cough/Cold Antineoplastic Cetirizine-PseudoephedrineDoxorubicin x x Cough/Cold Antineoplastic Chlorpheniramine - PhenylephrineInterferon Gamma-1B x x Cough/Cold Antineoplastic Chlorpheniramine-Acetaminophen Methotrexate x x Cough/Cold Antineoplastic Chlorpheniramine-DM Trametinib x x Rev.Antineoplastic August 7, 2019 Vandetanib x Antineoplastic Vismodegib x Antipsychotics Aripiprazole x x Antipsychotics Asenapine Maleate x Antipsychotics Chlorpromazine x x Antipsychotics REV: July 30, 2019 Haloperidol x x Page 2 of 5 Antipsychotics Lithium x x Antipsychotics Lurasidone x Antipsychotics Olanzapine x x Antipsychotics Paliperidone x Page 7 Antipsychotics Perphenazine x Antipsychotics Prochlorperazine x Antipsychotics Quetiapine x x Antipsychotics Risperidone x Antipsychotics Ziprasidone x Antiretrovirals Atazanavir 2 x Antiretrovirals Darunavir 2 x Antiretrovirals Emtricitabine 2 x Antiretrovirals Fosamprenavir 2 x Antiretrovirals Lamivudine 2 x Antiretrovirals Raltegravir 2 x Antiretrovirals Ritonavir 2 x Antiretrovirals Stavudine 2 x Antiretrovirals Tenofovir 2 x Antiretrovirals Zidovudine 2 x Antitubercular Ethambutol 2 x Antitubercular Isoniazid 2 x Antitubercular Rifabutin 2 x Antitubercular Rifampin 2 x Antiviral Acyclovir 2 x Antiviral Oseltamivir 2 x Antiviral Zanamivir 2 x Beta Blockers Carvedilol x x Beta Blockers Metoprolol Tartrate x x Beta Blockers Nebivolol x x Beta Blockers Propranolol HCl x x Calcium Blockers Amlodipine x x Calcium Blockers Diltiazem x x Calcium Blockers Nifedipine x x Cephalosporins Cefaclor 2 x x Yes Yes Yes Yes Yes Yes Yes Cephalosporins Cefadroxil 2 x x Yes Yes Yes Yes Yes Yes Yes Cephalosporins Cefdinir 2 x x Yes Yes Yes Yes Yes Yes Yes Cephalosporins Cefixime 2 x x Yes Yes Yes Yes Yes Yes Yes Cephalosporins Cefpodoxime 2 x x Yes Yes Yes Yes Yes Yes Yes Cephalosporins Cefprozil 2 x x Yes Yes Yes Yes Yes Yes Yes Cephalosporins Cephalexin 2 x x Yes Yes Yes Yes Yes Yes Yes Corticosteroids Methylprednisolone x x Yes Yes Yes Corticosteroids Prednisolone x x Yes Yes Yes Corticosteroids Prednisone x x Yes Yes Yes Cough/Cold Acetylcysteine Inhal x Cough/Cold Benzonatate x Cough/Cold Cetirizine-Pseudoephedrine x Cough/Cold Chlorpheniramine - Phenylephrine x Cough/Cold Chlorpheniramine-Acetaminophen x Cough/Cold Chlorpheniramine-DM x

REV: July 30, 2019 Page 2 of 5 Carpal Pain Non Ankle / Back Mid / Hip / Knee Neck Shoulder Therapeutic Category Generic Name Asthma Tunnel CRPS Elbow Eye Acute

Special Foot Low (MTG) Groin (MTG) (MTG) (MTG) Phase B Phase A (MTG) (MTG) Peri Operative Considerations

Cough/Cold Dextromethorphan x Cough/Cold Dextromethorphan-APAP-Chlorpheniramine x Cough/Cold Dextromethorphan-Diphenhyd-APAP x Decongestants Cromolyn Nasal x Decongestants Oxymetazoline x Decongestants Phenylephrine Nasal x Decongestants Pseudoephedrine x Decongestants Saline Nasal x Decongestants Tetrahydrozoline Nasal x Decongestants Triamcinolone Acetonide Nasal x Decongestants (Nasal Steroids) Budesonide Nasal x Decongestants (Nasal Steroids) Flunisolide Nasal x Decongestants (Nasal Steroids) Fluticasone Propionate Nasal x Decongestants (Nasal Steroids) Mometasone Furoate Nasal x Dermatological Bacitracin x x Yes Yes Yes Yes Yes Yes Yes Dermatological Betamethasone x x Yes Dermatological Capsicum x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Dermatological Ciclopirox Olamine x x Yes Dermatological Clobetasol x x Dermatological Clotrimazole x x Yes Dermatological Clotrimazole w/ Betamethasone Topical x x Dermatological Desonide x x Yes Dermatological Desoximetasone x x Yes Dermatological Diclofenac x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Dermatological Econazole x x Yes Dermatological Fluocinolone Acetonide x x Yes Dermatological Fluticasone Prop x x Yes Dermatological Gentamicin x x Yes Dermatological Hydrocortisone x x Yes Dermatological Ketoconazole x x Yes Dermatological Lidocaine Patch (4% Only) x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Dermatological Methyl Salicylate x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Dermatological Metronidazole x x Yes Dermatological Miconazole Nitrate x x Yes Dermatological Mupirocin x x Yes Dermatological Neomycin Sulfate x x Yes Yes Yes Yes Yes Yes Yes Dermatological Neomycin-Polymyxin-Bacitracin x x Yes Dermatological Nystatin x x Yes Dermatological Nystatin-Triamcinolone x x Yes Dermatological Silver Sulfadiazine x x Dermatological Tolnaftate x x Yes Dermatological Triamcinolone x x Yes Diuretics Bumetanide x Diuretics Furosemide x Diuretics Spironolactone x Fluoroquinolones Ciprofloxacin 2 x x Yes Yes Yes Yes Yes Yes Yes Fluoroquinolones Levofloxacin 2 x x Yes Yes Yes Yes Yes Yes Yes Fluoroquinolones Moxifloxacin 2 x x Yes Yes Yes Yes Yes Yes Yes GI, Misc Metoclopramide x GI, Misc Simethicone x x Hematopoetic Agents Folic Acid x Hypnotics Doxepin x Hypnotics Temazepam x Hypnotics Zolpidem x Laxatives Bisacodyl x Rev.Laxatives August 7, 2019 Docusate Calcium x Laxatives Docusate Na x Page 8 Laxatives Glycerin x Laxatives Lactulose x Laxatives Mineral Oil x Laxatives Na Phosphates - Enema x Laxatives Polyethylene Glycol 3350 x Laxatives Psyllium x Macrolide Antibiotics Azithromycin 2 x x Yes Yes Yes Yes Yes Yes Macrolide Antibiotics Clarithromycin 2 x x Yes Yes Yes Yes Yes Yes Macrolide Antibiotics Erythromycin 2 x x Yes Yes Yes Yes Yes Yes Migraine Products Butalbital-Acetaminophen-Caffeine x x Migraine Products Butalbital-Aspirin-Caffeine x x Migraine Products Sumatriptan x Mouth - Throat (local) Clotrimazole Troche x x Mouth - Throat (local) Lidocaine Viscous 2% x x Mouth - Throat (local) Nystatin Suspension x x Ophthalmic Alcaftadine x x Yes Ophthalmic Apraclonidine HCL x x Yes Ophthalmic Artificial Tear Ophth x x Yes Ophthalmic Atropine Sulfate Solution x x Yes Ophthalmic Azelastine x x Yes Ophthalmic Azithromycin x x Yes Ophthalmic Bacitracin Ophth x x Yes Ophthalmic Bacitracin-Polymyxin B x x Yes Ophthalmic Bacitracin-Polymyxin-Neomycin-HC x x Yes Ophthalmic Bepotastine x x Yes Ophthalmic Besifloxacin x x Yes Ophthalmic Betaxolol x x Yes Ophthalmic Bevacizumab x x Yes Ophthalmic Bimatoprost Ophth x x Yes Ophthalmic Brimonidine Tartrate Ophth x x Yes Ophthalmic Brimonidine Tartrate-Timolol Maleate Ophth x x Yes Ophthalmic Brinzolamide Ophth x x Yes Ophthalmic Bromfenac Na Ophth x x Yes Ophthalmic Carboxymethylcell-Glycerin-Polysorb 80 Ophth x x Yes Ophthalmic Carboxymethylcellulose x x Yes Ophthalmic Carteolol x x Yes Ophthalmic Carteolol HCL x x Yes Ophthalmic Ciprofloxacin x x Yes Ophthalmic Cromolyn x x Yes Ophthalmic Cyclopentolate x x Yes Ophthalmic Dexamethasone x x Yes Ophthalmic Diclofenac x x Yes Ophthalmic Dorzolamide x x Yes Ophthalmic Dorzolamide HCL x x Yes Ophthalmic Emedastine x x Yes

REV: July 30, 2019 Page 3 of 5 Carpal Pain Non Ankle / Back Mid / Hip / Knee Neck Shoulder Therapeutic Category Generic Name Asthma Tunnel CRPS Elbow Eye Acute

Special Foot Low (MTG) Groin (MTG) (MTG) (MTG) Phase B Phase A (MTG) (MTG) Peri Operative Considerations

Special Foot Low (MTG) Groin (MTG) (MTG) (MTG) Phase B Phase A (MTG) (MTG)

Hypnotics Zolpidem x Peri Operative Laxatives Bisacodyl Considerations x Laxatives Cough/Cold Docusate CalciumDextromethorphan x x Laxatives Cough/Cold Docusate NaDextromethorphan-APAP-Chlorpheniramine x x Laxatives Cough/Cold Glycerin Dextromethorphan-Diphenhyd-APAP x x Laxatives Decongestants Lactulose Cromolyn Nasal x Laxatives Decongestants Mineral Oil Oxymetazoline x x Laxatives Decongestants Na Phosphates - EnemaPhenylephrine Nasal x x Laxatives Decongestants Polyethylene Glycol 3350 Pseudoephedrine x x Laxatives Decongestants Psyllium Saline Nasal x x Macrolide Antibiotics Decongestants AzithromycinTetrahydrozoline Nasal 2 x x Yes Yes Yes Yes Yes Yes Macrolide Antibiotics Decongestants Clarithromycin Triamcinolone Acetonide Nasal 2 x x Yes Yes Yes Yes Yes Yes Macrolide Antibiotics Decongestants (Nasal Steroids) ErythromycinBudesonide Nasal 2 x x Yes Yes Yes Yes Yes Yes Migraine Products Decongestants (Nasal Steroids) Butalbital-Acetaminophen-CaffeineFlunisolide Nasal x x Migraine Products Decongestants (Nasal Steroids) Butalbital-Aspirin-CaffeineFluticasone Propionate Nasal x x Migraine Products Decongestants (Nasal Steroids) SumatriptanMometasone Furoate Nasal x Mouth - Throat (local) Dermatological Clotrimazole Troche Bacitracin x x Yes Yes Yes Yes Yes Yes Yes Mouth - Throat (local) Dermatological Lidocaine Viscous 2%Betamethasone x x Yes Mouth - Throat (local) Dermatological Nystatin SuspensionCapsicum x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes OphthalmicDermatological AlcaftadineCiclopirox Olamine x x Yes Yes OphthalmicDermatological Apraclonidine HCLClobetasol x x Yes OphthalmicDermatological Artificial Tear Ophth Clotrimazole x x Yes Yes OphthalmicDermatological Atropine Sulfate SolutionClotrimazole w/ Betamethasone Topical x x Yes OphthalmicDermatological AzelastineDesonide x x Yes Yes OphthalmicDermatological AzithromycinDesoximetasone x x Yes Yes OphthalmicDermatological Bacitracin Ophth Diclofenac x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes OphthalmicDermatological Bacitracin-Polymyxin BEconazole x x Yes Yes OphthalmicDermatological Bacitracin-Polymyxin-Neomycin-HCFluocinolone Acetonide x x Yes Yes OphthalmicDermatological BepotastineFluticasone Prop x x Yes Yes OphthalmicDermatological BesifloxacinGentamicin x x Yes Yes OphthalmicDermatological BetaxololHydrocortisone x x Yes Yes OphthalmicDermatological BevacizumabKetoconazole x x Yes Yes OphthalmicDermatological Bimatoprost Ophth Lidocaine Patch (4% Only) x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes OphthalmicDermatological Brimonidine Tartrate OphthMethyl Salicylate x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes OphthalmicDermatological Brimonidine Tartrate-Timolol Maleate Ophth Metronidazole x x Yes Yes OphthalmicDermatological Brinzolamide Ophth Miconazole Nitrate x x Yes Yes OphthalmicDermatological Bromfenac Na OphthMupirocin x x Yes Yes OphthalmicDermatological Carboxymethylcell-Glycerin-Polysorb 80 Ophth Neomycin Sulfate x x Yes Yes Yes Yes Yes Yes Yes Yes OphthalmicDermatological Carboxymethylcellulose Neomycin-Polymyxin-Bacitracin x x Yes Yes OphthalmicDermatological CarteololNystatin x x Yes Yes OphthalmicDermatological Carteolol HCL Nystatin-Triamcinolone x x Yes Yes OphthalmicDermatological Ciprofloxacin Silver Sulfadiazine x x Yes OphthalmicDermatological Cromolyn Tolnaftate x x Yes Yes OphthalmicDermatological CyclopentolateTriamcinolone x x Yes Yes OphthalmicDiuretics Dexamethasone Bumetanide x x Yes OphthalmicDiuretics DiclofenacFurosemide x x Yes OphthalmicDiuretics DorzolamideSpironolactone x x Yes OphthalmicFluoroquinolones Dorzolamide HCL Ciprofloxacin 2 x x Yes Yes Yes Yes Yes Yes Yes Yes OphthalmicFluoroquinolones EmedastineLevofloxacin 2 x x Yes Yes Yes Yes Yes Yes Yes Yes Fluoroquinolones Moxifloxacin 2 x x Yes Yes Yes Yes Yes Yes Yes Rev.GI, Misc August 7, 2019 Metoclopramide x GI, Misc Simethicone x x Hematopoetic Agents Folic Acid x Hypnotics Doxepin x REV: July 30, 2019 Page 3 of 5 Hypnotics Temazepam x Hypnotics Zolpidem x Laxatives Bisacodyl x Laxatives Docusate Calcium x Laxatives Docusate Na x Page 9 Laxatives Glycerin x Laxatives Lactulose x Laxatives Mineral Oil x Laxatives Na Phosphates - Enema x Laxatives Polyethylene Glycol 3350 x Laxatives Psyllium x Macrolide Antibiotics Azithromycin 2 x x Yes Yes Yes Yes Yes Yes Macrolide Antibiotics Clarithromycin 2 x x Yes Yes Yes Yes Yes Yes Macrolide Antibiotics Erythromycin 2 x x Yes Yes Yes Yes Yes Yes Migraine Products Butalbital-Acetaminophen-Caffeine x x Migraine Products Butalbital-Aspirin-Caffeine x x Migraine Products Sumatriptan x Mouth - Throat (local) Clotrimazole Troche x x Mouth - Throat (local) Lidocaine Viscous 2% x x Mouth - Throat (local) Nystatin Suspension x x Ophthalmic Alcaftadine x x Yes Ophthalmic Apraclonidine HCL x x Yes Ophthalmic Artificial Tear Ophth x x Yes Ophthalmic Atropine Sulfate Solution x x Yes Ophthalmic Azelastine x x Yes Ophthalmic Azithromycin x x Yes Ophthalmic Bacitracin Ophth x x Yes Ophthalmic Bacitracin-Polymyxin B x x Yes Ophthalmic Bacitracin-Polymyxin-Neomycin-HC x x Yes Ophthalmic Bepotastine x x Yes Ophthalmic Besifloxacin x x Yes Ophthalmic Betaxolol x x Yes Ophthalmic Bevacizumab x x Yes Ophthalmic Bimatoprost Ophth x x Yes Ophthalmic Brimonidine Tartrate Ophth x x Yes Ophthalmic Brimonidine Tartrate-Timolol Maleate Ophth x x Yes Ophthalmic Brinzolamide Ophth x x Yes Ophthalmic Bromfenac Na Ophth x x Yes Ophthalmic Carboxymethylcell-Glycerin-Polysorb 80 Ophth x x Yes Ophthalmic Carboxymethylcellulose x x Yes Ophthalmic Carteolol x x Yes Ophthalmic Carteolol HCL x x Yes Ophthalmic Ciprofloxacin x x Yes Ophthalmic Cromolyn x x Yes Ophthalmic Cyclopentolate x x Yes Ophthalmic Dexamethasone x x Yes Ophthalmic Diclofenac x x Yes Ophthalmic Dorzolamide x x Yes Ophthalmic Dorzolamide HCL x x Yes Ophthalmic Emedastine x x Yes

REV: July 30, 2019 Page 3 of 5 Carpal Pain Non Ankle / Back Mid / Hip / Knee Neck Shoulder Therapeutic Category Generic Name Asthma Tunnel CRPS Elbow Eye Acute

Special Foot Low (MTG) Groin (MTG) (MTG) (MTG) Phase B Phase A (MTG) (MTG) Peri Operative Considerations

Ophthalmic Epinastine x x Yes Ophthalmic Erythromycin x x Yes Ophthalmic Fluorometholone x x Yes Ophthalmic Flurbiprofen x x Yes Ophthalmic Gatifloxacin x x Yes Ophthalmic Gentamicin x x Yes Ophthalmic Glycerin (Ophth Lubricant) x x Yes Ophthalmic Glycerin-Hypromellose-PEG 400 x x Yes Ophthalmic Homatropine x x Yes Ophthalmic Hypromellose x x Yes Ophthalmic Irrigating Eyewash x x Yes Ophthalmic Ketorolac Trometh x x Yes Ophthalmic Ketotifen x x Yes Ophthalmic Latanoprost Ophth x x Yes Ophthalmic Levobunolol HCL x x Yes Ophthalmic Levofloxacin x x Yes Ophthalmic Lodoxamide x x Yes Ophthalmic Loteprednol x x Yes Ophthalmic Methylcellulose Ophth x x Yes Ophthalmic Metipranolol x x Yes Ophthalmic Moxifloxacin HCl x x Yes Ophthalmic Na Chloride Hypertonic x x Yes Ophthalmic Naphazoline HCl x x Yes Ophthalmic Natamycin x x Yes Ophthalmic Nedocromil x x Yes Ophthalmic Neomycin-Bacitracin-Polymyxin x x Yes Ophthalmic Neomycin-Polymyxin-Dexamethasone x x Yes Ophthalmic Neomycin-Polymyxin-Gramicidin x x Yes Ophthalmic Neomycin-Polymyxin-HC x x Yes Ophthalmic Ofloxacin x x Yes Ophthalmic Olopatadine x x Yes Ophthalmic Phenylephrine HCL x x Yes Ophthalmic Pilocarpine HCL x x Yes Ophthalmic Polyethylene Glycol 400 x x Yes Ophthalmic Polyethylene Glycol-Polyvinyl Alcohol x x Yes Ophthalmic Polymyxin B-Trimethoprim x x Yes Ophthalmic Polysorbate 80 x x Yes Ophthalmic Polyvinyl Alcohol x x Yes Ophthalmic Polyvinyl Alcohol-Povidone x x Yes Ophthalmic Prednisolone Acetate x x Yes Ophthalmic Prednisolone Na Phosphate x x Yes Ophthalmic Proparacaine HCL x x Yes Ophthalmic Sulfacetamide-Prednisolone x x Yes Ophthalmic Sulfacetamine x x Yes Ophthalmic Tetracaine HCL x x Yes Ophthalmic Timolol Maleate x x Yes Ophthalmic Tobramycin x x Yes Ophthalmic Tobramycin-Dexamethasone x x Yes Ophthalmic Tranexamic Acid x x Yes Ophthalmic Travoprost x x Yes Ophthalmic Trifluridine x x Yes Ophthalmic Tropicamide x x Yes Ophthalmic White Petrolatum-Mineral Oil x x Yes OTIC Acetic Acid x x OTIC Antipyrine-Benzocaine Otic Soln x x OTIC Antipyrine-Benzocaine-Glycerin-Zinc Ace x x Rev. August 7, 2019 OTIC Antipyrine-Benzocaine-Polycosanol x x Page 10 OTIC Ciprofloxacin x x OTIC Fluocinolone x x OTIC Hydrocortisone w/ Acetic Acid x x OTIC Neomycin-Polymyxin-HC x x OTIC Ofloxacin x x OTIC Pramoxine-Chloroxylenol x x OTIC Pramoxine-HC-Chloroxylenol x x Penicillins Amoxicillin 2 x x Yes Yes Yes Yes Yes Yes Penicillins Amoxicillin-Clavulanate 2 x x Yes Yes Yes Yes Yes Yes Penicillins Ampicillin 2 x x Yes Yes Yes Yes Yes Penicillins Dicloxacillin 2 x x Yes Yes Yes Yes Yes Yes Penicillins Penicillin 2 x x Yes Yes Yes Yes Yes Yes Pressors Epinephrine x Respiratory, Misc Nintedanib Esylate x Respiratory, Misc Pirfenidone x Skeletal Muscle Relaxants Baclofen 1 x 2nd 2nd 2nd 2nd Skeletal Muscle Relaxants Carisoprodol 1 x 2nd 2nd 2nd 2nd Skeletal Muscle Relaxants Cyclobenzaprine 1, 3 x Yes Yes Yes Yes Skeletal Muscle Relaxants Metaxalone 1 x 2nd 2nd 2nd 2nd Skeletal Muscle Relaxants Methocarbamol 1 x 2nd 2nd 2nd 2nd Skeletal Muscle Relaxants Tizanidine HCl 1 x 2nd 2nd 2nd 2nd Tetracyclines Doxycycline 2 x x Yes Yes Yes Yes Yes Yes Tetracyclines Minocycline 2 x x Yes Yes Yes Yes Yes Yes Tetracyclines Tetracycline 2 x x Ulcer Drugs Cimetidine x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Ulcer Drugs Dicyclomine HCl x x Ulcer Drugs Esomeprazole x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Ulcer Drugs Famotidine x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Ulcer Drugs Hyoscyamine x x Ulcer Drugs Lansoprazole x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Ulcer Drugs Misoprostol x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Ulcer Drugs Nizatidine x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Ulcer Drugs Omeprazole x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Ulcer Drugs Pantoprazole x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Ulcer Drugs Rabeprazole x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Ulcer Drugs Ranitidine x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Ulcer Drugs Sucralfate x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

NOTES:

1. Not to exceed a single seven (7) day supply. 2. For the prescribed course of therapy. 3. Short acting only.

REV: July 30, 2019 Page 4 of 5 Carpal Pain Non Ankle / Back Mid / Hip / Knee Neck Shoulder Therapeutic Category Generic Name Asthma Tunnel CRPS Elbow Eye Acute

Special Foot Low (MTG) Groin (MTG) (MTG) (MTG) Phase B Phase A (MTG) (MTG) Peri Operative Considerations

Special Foot Low (MTG) Groin (MTG) (MTG) (MTG) Phase B Phase A (MTG) (MTG)

OTIC Acetic Acid x x Peri Operative Considerations OTIC Antipyrine-Benzocaine Otic Soln x x OTIC Ophthalmic Antipyrine-Benzocaine-Glycerin-Zinc Ace Epinastine xx x Yes OTIC Ophthalmic Antipyrine-Benzocaine-Polycosanol Erythromycin x x Yes OTIC Ophthalmic Ciprofloxacin Fluorometholone x x Yes OTIC Ophthalmic FluocinoloneFlurbiprofen x x Yes OTIC Ophthalmic Hydrocortisone w/ Acetic Acid Gatifloxacin x x Yes OTIC Ophthalmic Neomycin-Polymyxin-HC Gentamicin x x Yes OTIC Ophthalmic Ofloxacin Glycerin (Ophth Lubricant) x x Yes OTIC Ophthalmic Pramoxine-Chloroxylenol Glycerin-Hypromellose-PEG 400 x x Yes OTIC Ophthalmic Pramoxine-HC-Chloroxylenol Homatropine x x Yes Penicillins Ophthalmic Amoxicillin Hypromellose 2 x x Yes Yes Yes Yes Yes Yes Yes Penicillins Ophthalmic Amoxicillin-Clavulanate Irrigating Eyewash 2 x x Yes Yes Yes Yes Yes Yes Yes Penicillins Ophthalmic Ampicillin Ketorolac Trometh 2 x x Yes Yes Yes Yes Yes Yes Penicillins Ophthalmic DicloxacillinKetotifen 2 x x Yes Yes Yes Yes Yes Yes Yes Penicillins Ophthalmic Penicillin Latanoprost Ophth 2 x x Yes Yes Yes Yes Yes Yes Yes Pressors Ophthalmic Epinephrine Levobunolol HCL x x Yes Respiratory, MiscOphthalmic Nintedanib Esylate Levofloxacin x x Yes Respiratory, MiscOphthalmic Pirfenidone Lodoxamide x x Yes Skeletal Muscle RelaxantsOphthalmic Baclofen Loteprednol 1 x x 2nd 2nd Yes 2nd 2nd Skeletal Muscle RelaxantsOphthalmic Carisoprodol Methylcellulose Ophth 1 x x 2nd 2nd Yes 2nd 2nd Skeletal Muscle RelaxantsOphthalmic Cyclobenzaprine Metipranolol 1, 3 x x Yes Yes Yes Yes Yes Skeletal Muscle RelaxantsOphthalmic Metaxalone Moxifloxacin HCl 1 x x 2nd 2nd Yes 2nd 2nd Skeletal Muscle RelaxantsOphthalmic Methocarbamol Na Chloride Hypertonic 1 x x 2nd 2nd Yes 2nd 2nd Skeletal Muscle RelaxantsOphthalmic Tizanidine HCl Naphazoline HCl 1 x x 2nd 2nd Yes 2nd 2nd Tetracyclines Ophthalmic Doxycycline Natamycin 2 x x Yes Yes Yes Yes Yes Yes Yes Tetracyclines Ophthalmic MinocyclineNedocromil 2 x x Yes Yes Yes Yes Yes Yes Yes Tetracyclines Ophthalmic Tetracycline Neomycin-Bacitracin-Polymyxin 2 x x Yes Ulcer Drugs Ophthalmic Cimetidine Neomycin-Polymyxin-Dexamethasone x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Ulcer Drugs Ophthalmic Dicyclomine HCl Neomycin-Polymyxin-Gramicidin x x Yes Ulcer Drugs Ophthalmic EsomeprazoleNeomycin-Polymyxin-HC x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Ulcer Drugs Ophthalmic Famotidine Ofloxacin x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Ulcer Drugs Ophthalmic HyoscyamineOlopatadine x x Yes Ulcer Drugs Ophthalmic LansoprazolePhenylephrine HCL x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Ulcer Drugs Ophthalmic MisoprostolPilocarpine HCL x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Ulcer Drugs Ophthalmic Nizatidine Polyethylene Glycol 400 x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Ulcer Drugs Ophthalmic OmeprazolePolyethylene Glycol-Polyvinyl Alcohol x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Ulcer Drugs Ophthalmic PantoprazolePolymyxin B-Trimethoprim x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Ulcer Drugs Ophthalmic RabeprazolePolysorbate 80 x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Ulcer Drugs Ophthalmic Ranitidine Polyvinyl Alcohol x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Ulcer Drugs Ophthalmic SucralfatePolyvinyl Alcohol-Povidone x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Rev.Ophthalmic August 7, 2019 Prednisolone Acetate x x Yes WCB-drug-formulary-1-v1 8/19 Ophthalmic Prednisolone Na Phosphate x x Yes SPECIALOphthalmic CONSIDERATIONSProparacaine HCL: x x Yes NOTES:Ophthalmic Sulfacetamide-Prednisolone x x Yes 1.Ophthalmic Not to exceed a single Sulfacetamineseven (7) day supply. x x Yes 2.1. Not to exceed a single seven (7) day supply.Ophthalmic For the prescribed courseTetracaine HCL of therapy. x x Yes 3.2. For the prescribed course of therapy.Ophthalmic Short acting only. Timolol Maleate x x Yes 3. Short acting only.Ophthalmic Tobramycin x x Yes Ophthalmic Tobramycin-Dexamethasone x x Yes **Ophthalmic Prescriber should considerTranexamic Acid appropriateness of naloxone when prescribingx x opioids. The WCB supports the Yes NYSOphthalmic DOH recommendations.Travoprost After appropriate claimant assessment,x if inx the prescriber’s judgement it is Yes Ophthalmic Trifluridine x x Yes appropriateOphthalmic for the claimantTropicamide to obtain naloxone, the provider shouldx submitx a prior authorization request. Yes OphthalmicREV: July 30, 2019 White Petrolatum-Mineral Oil x x Yes Page 4 of 5 https://www.health.ny.gov/professionals/ems/policy/13-10.htmOTIC Acetic Acid x x OTIC Antipyrine-Benzocaine Otic Soln x x https://www.governor.ny.gov/news/governor-cuomo-announces-narcan-now-available-independent-pharmaciesOTIC Antipyrine-Benzocaine-Glycerin-Zinc Ace x x OTIC Antipyrine-Benzocaine-Polycosanol x x Page 11 OTIC Ciprofloxacin x x OTIC Fluocinolone x x OTIC Hydrocortisone w/ Acetic Acid x x OTIC Neomycin-Polymyxin-HC x x OTIC Ofloxacin x x OTIC Pramoxine-Chloroxylenol x x OTIC Pramoxine-HC-Chloroxylenol x x Penicillins Amoxicillin 2 x x Yes Yes Yes Yes Yes Yes Penicillins Amoxicillin-Clavulanate 2 x x Yes Yes Yes Yes Yes Yes Penicillins Ampicillin 2 x x Yes Yes Yes Yes Yes Penicillins Dicloxacillin 2 x x Yes Yes Yes Yes Yes Yes Penicillins Penicillin 2 x x Yes Yes Yes Yes Yes Yes Pressors Epinephrine x Respiratory, Misc Nintedanib Esylate x Respiratory, Misc Pirfenidone x Skeletal Muscle Relaxants Baclofen 1 x 2nd 2nd 2nd 2nd Skeletal Muscle Relaxants Carisoprodol 1 x 2nd 2nd 2nd 2nd Skeletal Muscle Relaxants Cyclobenzaprine 1, 3 x Yes Yes Yes Yes Skeletal Muscle Relaxants Metaxalone 1 x 2nd 2nd 2nd 2nd Skeletal Muscle Relaxants Methocarbamol 1 x 2nd 2nd 2nd 2nd Skeletal Muscle Relaxants Tizanidine HCl 1 x 2nd 2nd 2nd 2nd Tetracyclines Doxycycline 2 x x Yes Yes Yes Yes Yes Yes Tetracyclines Minocycline 2 x x Yes Yes Yes Yes Yes Yes Tetracyclines Tetracycline 2 x x Ulcer Drugs Cimetidine x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Ulcer Drugs Dicyclomine HCl x x Ulcer Drugs Esomeprazole x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Ulcer Drugs Famotidine x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Ulcer Drugs Hyoscyamine x x Ulcer Drugs Lansoprazole x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Ulcer Drugs Misoprostol x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Ulcer Drugs Nizatidine x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Ulcer Drugs Omeprazole x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Ulcer Drugs Pantoprazole x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Ulcer Drugs Rabeprazole x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Ulcer Drugs Ranitidine x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Ulcer Drugs Sucralfate x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

NOTES:

1. Not to exceed a single seven (7) day supply. 2. For the prescribed course of therapy. 3. Short acting only.

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