DRUG FORMULARY NEW YORK STATE WORKERS’ COMPENSATION EFFECTIVE APRIL 1, 2020

“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 mdguidelines.com. New York Workers’ Compensation Formulary Effective April 1, 2020

Introduction Phase A Drug List Drugs on this list may be prescribed and dispensed subject to the following: Legislation enacted in April 2017 required the New York State Workers’ Compensation Board to establish a drug formulary. The New York Workers’ (1) Within the first 30 days following an accident or injury or until the Compensation Formulary (NY WC Formulary) is based on a medication’s insurer accepts the claim or the Board establishes a claim, whichever effectiveness and appropriateness for the treatment of illnesses and injuries occurs sooner. covered under the Workers’ Compensation Law. (2) For up to a 30-day supply. The NY WC Formulary drug list designates drugs as either “Phase A”, Phase B Drug List “Phase B” or “Perioperative.” Additionally, some drugs are listed as second- line therapy (2nd line) and may only be used when other drugs associated Drugs on this list may be prescribed and dispensed subject to the following: with the phase of treatment have been deemed ineffective. Drugs not listed (1) After 30 days following an accident or injury or when the carrier has on the NY WC Formulary are considered non-formulary. accepted the claim or the Board has established a claim, whichever Formulary drugs do not require prior authorization. Prior authorization from occurs sooner. the insurer or self-insured employer is required for: (2) For up to a 90-day supply. 1. Drugs not listed on the NY WC Formulary; (3) When a body part or illness has been accepted (with or without 2. A formulary brand name drug, when a generic is available; liability) or established, drugs must be prescribed in accordance with, as applicable, the Workers’ Compensation Board’s adopted 3. Combination products, unless specifically listed in the New York Medical Treatment Guidelines (NY WCB MTG). NY WC Formulary; (4) Phase B drugs designated as 2nd line may be prescribed and 4. A brand name drug when a generic version with the same active dispensed following an unsuccessful trial of a first-line drug ingredient(s) is commercially available in a different strength/dosage prescribed in accordance with Phase B and, as applicable, the (e.g., a generic drug available in 5 mg and 10 mg, but brand name drug adopted NY WCB MTG. available in 7.5 mg would be considered non-formulary and could only be dispensed via prior authorization.); and Perioperative Drug List 5. Compounded drugs. Drugs listed on the Perioperative Drug List may be prescribed/dispensed when: (1) The drug is prescribed during the perioperative period (four days Application of the NY WC Formulary before through four days following surgery). The NY WC Formulary sets forth drugs in three lists: Phase A, Phase B and Perioperative. These three lists of drugs are considered formulary Second-Line Drugs and can be prescribed per the following framework. For more detailed Drugs designated as 2nd line may be prescribed and dispensed following information about the Phase A, Phase B and Perioperative drugs, see the a trial of a first-line drug prescribed in accordance with Phase B and, as NY WC Formulary on the following pages. applicable, the adopted NY WCB MTG.

Page 1 Special Considerations Prior Authorization Process Some drugs are marked with a Special Consideration indication. These include: The Prior Authorization process shall consist of a review, which may ■ “1. Not to exceed a single seven (7) day supply” — meaning that incorporate up to three levels of review, as described below. a specific formulary drug can be prescribed and dispensed one time only without a prior authorization, for a maximum of a First Level Review seven-day supply, during the phase of the NY WC Formulary The provider shall submit a Prior Authorization request, in the manner under which it is contained (e.g., controlled substances); prescribed by the Chair, to the insurer, self-insured employer, or, when ■ “2. For the prescribed course of therapy” — meaning that a specific designated, the pharmacy benefits manager. formulary drug can be prescribed and dispensed, during the The First Level Review has these requirements and time frames: applicable phase of the NY WC Formulary, for the quantity (1) The Prior Authorization request may include the quantity to be indicated by the prescriber (e.g., antibiotics); prescribed and the number of refills or the duration of the prescription. ■ “3. Short acting only” — meaning that a specific formulary drug can If the duration is not stated, the default shall be 30 days. In no event only be prescribed and dispensed for the short-acting formulation may a Prior Authorization request exceed 365 days. of the product; and (2) The insurer, self-insured employer or pharmacy benefits manager ■ “4. As clinically indicated for causally related injuries or conditions shall approve, partially approve or deny a Prior Authorization request utilizing accepted standards of medical care” — meaning that within four calendar days of submission by the provider: the item can be prescribed and dispensed when there is no a. A partial approval authorizes the requested drug, but limits the adopted NY WCB MTG for the established/accepted body part length of time, quantity prescribed or number of refills from that or condition, and/or for a condition directly associated with an requested by the prescriber. established/accepted body part, but not specifically addressed in the NY WCB MTG. (e.g., treatment of a post-operative infection b. A Prior Authorization request that is not responded to within four following a knee replacement). calendar days (by an approval, denial or partial approval) may be deemed approved as prescribed, not to exceed a 365-day supply, upon issuance of an Order of the Chair. Prior Authorization (3) A partial approval or denial of a Prior Authorization request must: A medical provider must obtain prior authorization before prescribing a. Provide a specific reason for the denial or partial approval with or dispensing a drug other than as described in the Application of the reference to the specific Prior Authorization request made by the Formulary section (see above), or when prescribing: prescriber. (1) A drug not listed on the NY WC Formulary, (2) A formulary brand name drug, when a generic is available, (3) Combination products, unless specifically listed on the NY WC Formulary, (4) A brand name drug when a generic version containing the same active ingredient(s) is commercially available in a different strength/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.

Page 2 Second Level Review (3) All requests shall be submitted to the Medical Director’s Office in the format prescribed by the Chair. Within ten calendar days of a denial or partial approval of a First Level Prior Authorization request, the prescriber may request review of such denial or (4) To ensure the timely review of requests, the Chair or Medical partial approval by the carrier’s physician. Director may designate private entities to evaluate such requests for The Second Level Review has these requirements and time frames: review of denials of a Second Level Review, provided the entity has: a. The appropriate URAC accreditation or such accreditation/ (1) The Prior Authorization request shall include: certification as designated by the Chair, a. All information submitted by the prescriber for the First Level b. Other demonstrated expertise and criteria established by the Review and the response from the insurer, self-insured employer, Board, and or when designated, the pharmacy benefits manager, c. No conflict of interest related to the review and resolution of the b. All information provided to the prescriber related to the First Level request. Review denial or partial approval, and c. Additional information from the prescriber further justifying the The decision by the Medical Director’s Office is final and binding on the need for the requested non-formulary medication responding to prescriber, the insurer, self-insured employer and pharmacy network. the reason(s) stated in the First Level Denial. In the event a Third Level Review is denied, the prescriber may not submit (2) The insurer’s physician shall approve, partially approve or deny a a Prior Authorization request for the same medication unless he or she Prior Authorization request within four calendar days of submission by submits evidence that there has been a change in the claimant’s medical the prescriber. condition that renders the denial of the Prior Authorization request no longer applicable to the claimant’s current medical condition. (3) A request for Second Level Review that is not responded to within four calendar days (by an approval, denial or partial approval) may be deemed approved as prescribed, not to exceed a 365-day supply, 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 time frames: (1) The prescriber shall submit the Prior Authorization request to the Medical Director’s Office within ten calendar days of the Second 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 Asthma Tunnel CRPS Elbow Eye Acute Therapeutic Category Generic Name Foot Low (MTG) Groin (MTG) (MTG) (MTG) Special Phase A Phase B (MTG) (MTG) Perioperative Considerations Analgesics - Narcotic** Codeine-Acetaminophen 1,3 x x Analgesics - Narcotic** Hydrocodone-Acetaminophen 1,3 x x Analgesics - Narcotic** Hydrocodone-Ibuprofen 1,3 x x Analgesics - Narcotic** Morphine 1,3 x x Analgesics - Narcotic** Oxycodone HCl 1,3 x x Analgesics - Narcotic** Oxycodone-Acetaminophen 1,3 x x Analgesics - Narcotic** Oxycodone-Aspirin 1,3 x x Analgesics - Narcotic** Tapentadol 1,3 x Analgesics - Narcotic** Tramadol HCl 1,3 x x Analgesics - Narcotic** Tramadol-Acetaminophen 1,3 x x Analgesics - Non-Narcotic Acetaminophen x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Analgesics - Non-Narcotic Aspirin x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Analgesics - Non-Narcotic Choline - Magnesium Salicylates x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Analgesics - Non-Narcotic Diflunisal x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Analgesics - Topical Capsaicin x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Analgesics - Topical Diclofenac Na (1% only) x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Analgesics - Topical Lidocaine Patch (4% Only) x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Analgesics - Topical Methyl Salicylate x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Antacids Al Hydrox-Mag Trisil-Alginic Acid-Sod Bicarb 4 x x Antacids Al - Mag Hydroxides 4 x x Antacids Al Hydrox-Mag Carbonate Susp 4 x x Antacids Al Hydro-Mag Trisilicate Chew Tab 4 x x Antacids Calcium-Magnesium Carbonates 4 x x Antacids Calcium Carbonate 4 x x Antacids Calcium Carbonate - Simethicone 4 x x Antacids Calcium Carbonate-Mag Hydro 4 x x Antianxiety Agents Alprazolam 1 x Antianxiety Agents Buspirone 1 x Antiasthmatics Aclidinium Bromide Aerosol Powd x x Antiasthmatics Albuterol Inhal x x Yes Antiasthmatics Albuterol Sulfate x x Yes Antiasthmatics Beclomethasone Inha. x x Yes Antiasthmatics Budesonide x x Yes Antiasthmatics Budesonide Inhal x x Yes Antiasthmatics Budesonide-Formoterol Fumarate Inh x x Yes Antiasthmatics Ciclesonide Inhal x x Yes Antiasthmatics Cromolyn Na Inhal x x Yes Antiasthmatics Epinephrine Inhal x x Yes Antiasthmatics Flunisolide Inhal x x Yes Antiasthmatics Fluticasone Furoate-Vilanterol Inhal x x Yes Antiasthmatics Fluticasone Inhal x x Yes Antiasthmatics Fluticasone-Salmeterol Inhalal x x Yes Antiasthmatics Formoterol Fumarate Soln x x Yes Antiasthmatics Formoterol-Glycopyrrolate x x Yes Antiasthmatics Formoterol/Mometasone x x Yes Antiasthmatics Indacaterol Maleate Inhalal x x Yes Antiasthmatics Ipratropium Bromide Inhal x x Yes Antiasthmatics Ipratropium-Albuterol Inhal x x Yes Antiasthmatics Levalbuterol HCl Inhal x x Yes Antiasthmatics Methacholine Chloride Inhal x x Yes Antiasthmatics Mometasone Furoate Inhal x x Yes Mometasone Furoate-Formoterol Fumarate Antiasthmatics x x Yes Inhal Antiasthmatics Montelukast x x Yes Antiasthmatics Roflumilast x x Yes Antiasthmatics Salmeterol x x Yes Antiasthmatics Terbutaline x x Yes Antiasthmatics Theophylline x x Yes EffectiveAntiasthmatics April 1, 2020 Tiotropium Bromide Monohydrate Inhal x x Yes Antiasthmatics Tiotropium-Olodaterol x x Page 4 Yes Antiasthmatics Triamcinolone Acetonide Inhal x x Yes Antiasthmatics Umeclidinium-Vilanterol 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 x 2nd 2nd 2nd 2nd Anticonvulsant Clonazepam x Anticonvulsant Divalproex x Anticonvulsant Gabapentin x x x 2nd 2nd 2nd 2nd Anticonvulsant Lamotrigine x x 2nd 2nd 2nd 2nd Anticonvulsant Levetiracetam x Anticonvulsant Oxcarbazepine x x 2nd 2nd 2nd 2nd Anticonvulsant Phenytoin x Anticonvulsant Pregabalin x x 2nd 2nd 2nd 2nd Anticonvulsant Topiramate x x 2nd 2nd 2nd 2nd Anticonvulsant Valproic Acid x Antidepressants Amitriptyline x x Yes Yes Yes Yes Antidepressants Bupropion x 2nd 2nd 2nd 2nd Antidepressants Citalopram 4 x Antidepressants Clomipramine 4 x Antidepressants Desipramine x Yes Yes Yes Yes Antidepressants Desvenlafaxine 4 x Antidepressants Doxepin x Yes Yes Yes Yes Antidepressants Duloxetine x 2nd 2nd 2nd 2nd Antidepressants Escitalopram 4 x Antidepressants Fluoxetine 4 x Antidepressants Fluvoxamine 4 x Antidepressants Imipramine x x Yes Yes Yes Yes Antidepressants Isocarboxazid 4 x Antidepressants Mirtazapine 4 x Antidepressants Nefazodone 4 x Antidepressants Nortriptyline x Yes Yes Yes Yes Antidepressants Paroxetine 4 x Antidepressants Phenelzine 4 x Antidepressants Protriptyline 4 x Antidepressants Sertraline 4 x Antidepressants Tranylcypromine 4 x Antidepressants Trazodone 4 x Antidepressants Trimipramine x Yes Yes Yes Yes Antidepressants Venlafaxine x 2nd 2nd 2nd 2nd

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

Antiasthmatics Salmeterol x x Perioperative Yes Antiasthmatics Terbutaline Considerations x x Yes AntiasthmaticsAnalgesics - Narcotic** TheophyllineCodeine-Acetaminophen 1,3 x x x Yes AntiasthmaticsAnalgesics - Narcotic** TiotropiumHydrocodone-Acetaminophen Bromide Monohydrate Inhal 1,3 x x x Yes AntiasthmaticsAnalgesics - Narcotic** Tiotropium-OlodaterolHydrocodone-Ibuprofen 1,3 x x x Yes AntiasthmaticsAnalgesics - Narcotic** TriamcinoloneMorphine Acetonide Inhal 1,3 x x x Yes AntiasthmaticsAnalgesics - Narcotic** Umeclidinium-VilanterolOxycodone HCl 1,3 x x x Yes AntiasthmaticsAnalgesics - Narcotic** ZafirlukastOxycodone-Acetaminophen 1,3 x x x Yes AntiasthmaticsAnalgesics - Narcotic** ZileutonOxycodone-Aspirin 1,3 x x x Yes AnticoagulantsAnalgesics - Narcotic** ApixabanTapentadol 1,3 x x Yes Yes Analgesics - Narcotic** Tramadol HCl 1,3 x x Anticoagulants Dalteparin x x Yes Yes Analgesics - Narcotic** Tramadol-Acetaminophen 1,3 x x Anticoagulants Enoxaparin Na x x Yes Yes Analgesics - Non-Narcotic Acetaminophen x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Anticoagulants Fondaparinux Na x x Yes Yes Analgesics - Non-Narcotic Aspirin x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes AnticoagulantsAnalgesics - Non-Narcotic RivaroxabanCholine - Magnesium Salicylates x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes AnticoagulantsAnalgesics - Non-Narcotic WarfarinDiflunisal Na x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes AnticonvulsantAnalgesics - Topical CarbamazepineCapsaicin x x Yes 2ndYes Yes 2ndYes Yes Yes Yes 2ndYes 2ndYes Yes AnticonvulsantAnalgesics - Topical ClonazepamDiclofenac Na (1% only) x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes AnticonvulsantAnalgesics - Topical DivalproexLidocaine Patch (4% Only) x x Yes Yes Yes Yes Yes Yes Yes Yes Yes AnticonvulsantAnalgesics - Topical GabapentinMethyl Salicylate x x x 2ndYes Yes 2ndYes Yes Yes Yes 2ndYes 2ndYes Yes AnticonvulsantAntacids LamotrigineAl Hydrox-Mag Trisil-Alginic Acid-Sod Bicarb 4 x x 2nd 2nd 2nd 2nd AnticonvulsantAntacids LevetiracetamAl - Mag Hydroxides 4 x x AnticonvulsantAntacids OxcarbazepineAl Hydrox-Mag Carbonate Susp 4 x x 2nd 2nd 2nd 2nd AnticonvulsantAntacids PhenytoinAl Hydro-Mag Trisilicate Chew Tab 4 x x AnticonvulsantAntacids PregabalinCalcium-Magnesium Carbonates 4 x x 2nd 2nd 2nd 2nd AnticonvulsantAntacids TopiramateCalcium Carbonate 4 x x 2nd 2nd 2nd 2nd AnticonvulsantAntacids ValproicCalcium CarbonateAcid - Simethicone 4 x x AntidepressantsAntacids AmitriptylineCalcium Carbonate-Mag Hydro 4 x x Yes Yes Yes Yes AntidepressantsAntianxiety Agents BupropionAlprazolam 1 x x 2nd 2nd 2nd 2nd AntidepressantsAntianxiety Agents CitalopramBuspirone 41 x x AntidepressantsAntiasthmatics ClomipramineAclidinium Bromide Aerosol Powd 4 x x AntidepressantsAntiasthmatics DesipramineAlbuterol Inhal x x Yes Yes Yes Yes Yes Antiasthmatics Albuterol Sulfate x x Yes Antidepressants Desvenlafaxine 4 x Antiasthmatics Beclomethasone Inha. x x Yes Antidepressants Doxepin x Yes Yes Yes Yes Antiasthmatics Budesonide x x Yes Antidepressants Duloxetine x 2nd 2nd 2nd 2nd Antiasthmatics Budesonide Inhal x x Yes AntidepressantsAntiasthmatics EscitalopramBudesonide-Formoterol Fumarate Inh 4 x x Yes AntidepressantsAntiasthmatics FluoxetineCiclesonide Inhal 4 x x Yes AntidepressantsAntiasthmatics FluvoxamineCromolyn Na Inhal 4 x x Yes AntidepressantsAntiasthmatics ImipramineEpinephrine Inhal x x Yes Yes Yes Yes Yes AntidepressantsAntiasthmatics IsocarboxazidFlunisolide Inhal 4 x x Yes AntidepressantsAntiasthmatics MirtazapineFluticasone Furoate-Vilanterol Inhal 4 x x Yes AntidepressantsAntiasthmatics NefazodoneFluticasone Inhal 4 x x Yes AntidepressantsAntiasthmatics NortriptylineFluticasone-Salmeterol Inhalal x x Yes Yes Yes Yes Yes AntidepressantsAntiasthmatics ParoxetineFormoterol Fumarate Soln 4 x x Yes AntidepressantsAntiasthmatics PhenelzineFormoterol-Glycopyrrolate 4 x x Yes AntidepressantsAntiasthmatics ProtriptylineFormoterol/Mometasone 4 x x Yes AntidepressantsAntiasthmatics SertralineIndacaterol Maleate Inhalal 4 x x Yes Antidepressants Tranylcypromine 4 x Carpal Pain Non Antiasthmatics Ipratropium Bromide Inhal x x Ankle / Yes Back Mid / Hip / Knee Neck Shoulder Asthma Tunnel CRPS Elbow Eye Acute AntidepressantsAntiasthmaticsTherapeutic Category TrazodoneIpratropium-Albuterol Generic Inhal Name 4 x x Foot Yes Low (MTG) Groin (MTG) (MTG) (MTG) Special Phase A Phase B (MTG) (MTG) AntidepressantsAntiasthmatics TrimipramineLevalbuterol HCl Inhal x x Perioperative Yes Yes Yes Yes Yes AntidepressantsAntiasthmatics VenlafaxineMethacholine Chloride Inhal Considerations x x Yes 2nd 2nd 2nd 2nd AntidepressantsAntiasthmatics VilazodoneMometasone Furoate Inhal 4 x x Yes Antidiabetics GlipizideMometasone Furoate-Formoterol Fumarate x Antiasthmatics x x Yes Antidiabetics GlucoseInhal Tablets/Gel x AntidiabeticsAntiasthmatics GlyburideMontelukast x x Yes AntidiabeticsAntiasthmatics InsulinRoflumilast x x Yes REV:AntidiabeticsAntiasthmatics November 1, 2019 MetforminSalmeterol HCl x x Yes Page 1 of 4 AntidiabeticsAntiasthmatics SitagliptinTerbutaline Phosphate x x Yes AntidiarrhealsAntiasthmatics DiphenoxylateTheophylline w/ Atropine 4 x x Yes EffectiveAntidiarrhealsAntiasthmatics April 1, 2020 LoperamideTiotropium Bromide Monohydrate Inhal 4 x x Page 5 Yes AntiemeticAntiasthmatics - Antivertigo MeclizineTiotropium-Olodaterol 4 x x Yes AntiemeticAntiasthmatics - Antivertigo OndansetronTriamcinolone Acetonide Inhal 4 x x Yes AntifungalsAntiasthmatics FluconazoleUmeclidinium-Vilanterol 2 x x Yes Yes AntifungalsAntiasthmatics ItraconazoleZafirlukast 2 x x Yes Yes AntifungalsAntiasthmatics KetoconazoleZileuton 2 x x Yes Yes AntifungalsAnticoagulants NystatinApixaban 2 x x Yes Yes Yes AntifungalsAnticoagulants TerbinafineDalteparin 2 x x Yes Yes Yes AntihistaminesAnticoagulants CetirizineEnoxaparin Na 4 x x Yes Yes AntihistaminesAnticoagulants CyproheptadineFondaparinux Na 4 x x Yes Yes AntihistaminesAnticoagulants DesloratadineRivaroxaban 4 x x Yes Yes AntihistaminesAnticoagulants DiphenhydramineWarfarin Na 4 x x Yes Yes AntihistaminesAnticonvulsant FexofenadineCarbamazepine 4 x x 2nd 2nd 2nd 2nd AntihistaminesAnticonvulsant HydroxyzineClonazepam 4 x x AntihistaminesAnticonvulsant LevocetirizineDivalproex 4 x x AntihistaminesAnticonvulsant LoratadineGabapentin 4 x x x 2nd 2nd 2nd 2nd AntihistaminesAnticonvulsant PromethazineLamotrigine 4 x x 2nd 2nd 2nd 2nd AntihypertensiveAnticonvulsant ClonidineLevetiracetam HCl x AntihypertensiveAnticonvulsant LisinoprilOxcarbazepine x x 2nd 2nd 2nd 2nd AntihypertensiveAnticonvulsant LosartanPhenytoin x AntihypertensiveAnticonvulsant PrazosinPregabalin x x 2nd 2nd 2nd 2nd Anti-Infectives,Anticonvulsant Misc. ClindamycinTopiramate 2,4 x x 2nd 2nd 2nd 2nd Anti-Infectives,Anticonvulsant Misc. LinezolidValproic Acid 2,4 x x Anti-Infectives,Antidepressants Misc. MetronidazoleAmitriptyline 2,4 x x Yes Yes Yes Yes Anti-Infectives,Antidepressants Misc. Sulfamethoxazole-TrimethoprimBupropion 2,4 x x 2nd 2nd 2nd 2nd Anti-Infectives,Antidepressants Misc. VancomycinCitalopram 2,44 x x Anti-InflammatoryAntidepressants CelecoxibClomipramine 4 x 2nd 2nd 2nd 2nd 2nd 2nd 2nd 2nd 2nd 2nd Anti-InflammatoryAntidepressants DiclofenacDesipramine x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Anti-InflammatoryAntidepressants EtodolacDesvenlafaxine 4 x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Anti-InflammatoryAntidepressants IbuprofenDoxepin x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Anti-InflammatoryAntidepressants IndomethacinDuloxetine x x x Yes 2ndYes Yes 2ndYes Yes Yes Yes 2ndYes 2ndYes Yes Anti-InflammatoryAntidepressants MeloxicamEscitalopram 4 x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Anti-InflammatoryAntidepressants NaproxenFluoxetine 4 x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Anti-InflammatoryAntidepressants SulindacFluvoxamine 4 x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes AntimalarialAntidepressants HydroxychloroquineImipramine 2 x x Yes Yes Yes Yes AntineoplasticAntidepressants CabozantinibIsocarboxazid 4 x AntineoplasticAntidepressants DabrafenibMirtazapine 4 x AntineoplasticAntidepressants DoxorubicinNefazodone 4 x AntineoplasticAntidepressants InterferonNortriptyline Gamma-1B 4 x Yes Yes Yes Yes AntineoplasticAntidepressants MethotrexateParoxetine 4 x AntineoplasticAntidepressants TrametinibPhenelzine 4 x AntineoplasticAntidepressants VandetanibProtriptyline 4 x AntineoplasticAntidepressants VismodegibSertraline 4 x AntipsychoticsAntidepressants AripiprazoleTranylcypromine 4 x x AntipsychoticsAntidepressants AsenapineTrazodone Maleate 4 x AntipsychoticsAntidepressants ChlorpromazineTrimipramine 4 x x Yes Yes Yes Yes AntipsychoticsAntidepressants HaloperidolVenlafaxine 4 x x 2nd 2nd 2nd 2nd Antipsychotics Lithium 4 x x Antipsychotics Lurasidone 4 x Antipsychotics Olanzapine 4 x x Antipsychotics Paliperidone 4 x Antipsychotics Perphenazine 4 x REV:Antipsychotics November 1, 2019 Prochlorperazine 4 x Page 1 of 4 Antipsychotics Quetiapine 4 x x Antipsychotics Risperidone 4 x Antipsychotics Ziprasidone 4 x Antiretrovirals Atazanavir 2,4 x x Antiretrovirals Darunavir 2,4 x x Antiretrovirals Dolutegravir 2,4 x x Antiretrovirals Emtricitabine 2,4 x x Antiretrovirals Fosamprenavir 2,4 x x Antiretrovirals Lamivudine 2,4 x x Antiretrovirals Raltegravir 2,4 x x Antiretrovirals Ritonavir 2,4 x x Antiretrovirals Stavudine 2,4 x x Antiretrovirals Tenofovir 2,4 x x Antiretrovirals Zidovudine 2,4 x x Antitubercular Ethambutol 2,4 x Antitubercular Isoniazid 2,4 x Antitubercular Rifabutin 2,4 x Antitubercular Rifampin 2,4 x Antiviral Acyclovir 2 x Antiviral Oseltamivir 2 x Antiviral Zanamivir 2 x Beta Blockers Carvedilol x Beta Blockers Metoprolol Tartrate x Beta Blockers Nebivolol x Beta Blockers Propranolol HCl x Calcium Blockers Amlodipine x Calcium Blockers Diltiazem x Calcium Blockers Nifedipine 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

REV: November 1, 2019 Page 2 of 4 Carpal Pain Non Ankle / Back Mid / Hip / Knee Neck Shoulder Asthma Tunnel CRPS Elbow Eye Acute Therapeutic Category Generic Name Foot Low (MTG) Groin (MTG) (MTG) (MTG) Special Phase A Phase B (MTG) (MTG) Perioperative Considerations Antidepressants Vilazodone 4 x Antidiabetics Glipizide x Antidiabetics Glucose Tablets/Gel x Antidiabetics Glyburide x Carpal Pain Non Ankle / Back Mid / Hip / Knee Neck Shoulder Antidiabetics Insulin x Asthma Tunnel CRPS Elbow Eye Acute Therapeutic Category Generic Name Foot Low (MTG) Groin (MTG) (MTG) (MTG) Special Antidiabetics Metformin HCl x Phase A Phase B (MTG) (MTG) Perioperative

Antidiabetics Sitagliptin Phosphate Considerations x AnalgesicsAntidiarrheals - Narcotic** Codeine-AcetaminophenDiphenoxylate w/ Atropine 1,34 x x x AnalgesicsAntidiarrheals - Narcotic** Hydrocodone-AcetaminophenLoperamide 1,34 x x x AnalgesicsAntiemetic - - Narcotic** Antivertigo Hydrocodone-IbuprofenMeclizine 1,34 x x x AntiemeticAnalgesics - - Narcotic** Antivertigo OndansetronMorphine 1,34 x x x AntifungalsAnalgesics - Narcotic** FluconazoleOxycodone HCl 1,32 x x x Yes AntifungalsAnalgesics - Narcotic** ItraconazoleOxycodone-Acetaminophen 1,32 x x x Yes AntifungalsAnalgesics - Narcotic** KetoconazoleOxycodone-Aspirin 1,32 x x x Yes AntifungalsAnalgesics - Narcotic** NystatinTapentadol 1,32 x x Yes Analgesics - Narcotic** Tramadol HCl 1,3 x x Antifungals Terbinafine 2 x x Yes Analgesics - Narcotic** Tramadol-Acetaminophen 1,3 x x Antihistamines Cetirizine 4 x x Analgesics - Non-Narcotic Acetaminophen x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Antihistamines Cyproheptadine 4 x x Analgesics - Non-Narcotic Aspirin x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes AnalgesicsAntihistamines - Non-Narcotic CholineDesloratadine - Magnesium Salicylates 4 x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes AnalgesicsAntihistamines - Non-Narcotic DiflunisalDiphenhydramine 4 x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes AnalgesicsAntihistamines - Topical CapsaicinFexofenadine 4 x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes AnalgesicsAntihistamines - Topical DiclofenacHydroxyzine Na (1% only) 4 x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes AnalgesicsAntihistamines - Topical LidocaineLevocetirizine Patch (4% Only) 4 x x Yes Yes Yes Yes Yes Yes Yes Yes Yes AnalgesicsAntihistamines - Topical MethylLoratadine Salicylate 4 x x Yes Yes Yes Yes Yes Yes Yes Yes Yes AntacidsAntihistamines AlPromethazine Hydrox-Mag Trisil-Alginic Acid-Sod Bicarb 4 x x AntacidsAntihypertensive AlClonidine - Mag Hydroxides HCl 4 x x AntacidsAntihypertensive AlLisinopril Hydrox-Mag Carbonate Susp 4 x x AntacidsAntihypertensive AlLosartan Hydro-Mag Trisilicate Chew Tab 4 x x AntacidsAntihypertensive Calcium-MagnesiumPrazosin Carbonates 4 x x AntacidsAnti-Infectives, Misc. CalciumClindamycin Carbonate 2,44 x x AntacidsAnti-Infectives, Misc. CalciumLinezolid Carbonate - Simethicone 2,44 x x AntacidsAnti-Infectives, Misc. CalciumMetronidazole Carbonate-Mag Hydro 2,44 x x AntianxietyAnti-Infectives, Agents Misc. AlprazolamSulfamethoxazole-Trimethoprim 2,41 x x Anti-Infectives,Antianxiety Agents Misc. VancomycinBuspirone 2,41 x x Anti-InflammatoryAntiasthmatics CelecoxibAclidinium Bromide Aerosol Powd x x 2nd 2nd 2nd 2nd 2nd 2nd 2nd 2nd 2nd 2nd Anti-InflammatoryAntiasthmatics DiclofenacAlbuterol Inhal x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Anti-InflammatoryAntiasthmatics EtodolacAlbuterol Sulfate x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Anti-InflammatoryAntiasthmatics IbuprofenBeclomethasone Inha. x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Antiasthmatics Budesonide x x Yes Anti-Inflammatory Indomethacin x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Antiasthmatics Budesonide Inhal x x Yes Anti-Inflammatory Meloxicam x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Antiasthmatics Budesonide-Formoterol Fumarate Inh x x Yes Anti-Inflammatory Naproxen x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Antiasthmatics Ciclesonide Inhal x x Yes Anti-Inflammatory Sulindac x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Antiasthmatics Cromolyn Na Inhal x x Yes Antimalarial Hydroxychloroquine 2 x Antiasthmatics Epinephrine Inhal x x Yes Antineoplastic Cabozantinib 4 x Antiasthmatics Flunisolide Inhal x x Yes Antineoplastic Dabrafenib 4 x Antiasthmatics Fluticasone Furoate-Vilanterol Inhal x x Yes Antineoplastic Doxorubicin 4 x Antiasthmatics Fluticasone Inhal x x Yes Antineoplastic Interferon Gamma-1B 4 x Antiasthmatics Fluticasone-Salmeterol Inhalal x x Yes Antineoplastic Methotrexate 4 x Antiasthmatics Formoterol Fumarate Soln x x Yes Antineoplastic Trametinib 4 x Antiasthmatics Formoterol-Glycopyrrolate x x Yes Antineoplastic Vandetanib 4 x Antiasthmatics Formoterol/Mometasone x x Yes Antineoplastic Vismodegib 4 x Antiasthmatics Indacaterol Maleate Inhalal x x Yes Antipsychotics Aripiprazole 4 x x Antiasthmatics Ipratropium Bromide Inhal x x Yes Antipsychotics Asenapine Maleate 4 x Antiasthmatics Ipratropium-Albuterol Inhal x x Yes Antipsychotics Chlorpromazine 4 x x Antiasthmatics Levalbuterol HCl Inhal x x Yes Antipsychotics Haloperidol 4 x x Antiasthmatics Methacholine Chloride Inhal x x Yes AntiasthmaticsAntipsychotics MometasoneLithium Furoate Inhal 4 x x Yes Antipsychotics MometasoneLurasidone Furoate-Formoterol Fumarate 4 x Antiasthmatics x x Yes Antipsychotics InhalOlanzapine 4 x x AntiasthmaticsAntipsychotics MontelukastPaliperidone 4 x x Yes AntiasthmaticsAntipsychotics RoflumilastPerphenazine 4 x x Yes AntiasthmaticsAntipsychotics SalmeterolProchlorperazine 4 x x Yes AntiasthmaticsAntipsychotics TerbutalineQuetiapine 4 x x Yes AntiasthmaticsAntipsychotics TheophyllineRisperidone 4 x x Yes EffectiveAntiasthmaticsAntipsychotics April 1, 2020 TiotropiumZiprasidone Bromide Monohydrate Inhal 4 x x Page 6 Yes AntiasthmaticsAntiretrovirals Tiotropium-OlodaterolAtazanavir 2,4 x x Yes AntiasthmaticsAntiretrovirals TriamcinoloneDarunavir Acetonide Inhal 2,4 x x Yes AntiasthmaticsAntiretrovirals Umeclidinium-VilanterolDolutegravir 2,4 x x Yes AntiasthmaticsAntiretrovirals ZafirlukastEmtricitabine 2,4 x x Yes AntiasthmaticsAntiretrovirals ZileutonFosamprenavir 2,4 x x Yes AnticoagulantsAntiretrovirals ApixabanLamivudine 2,4 x x Yes Yes AnticoagulantsAntiretrovirals DalteparinRaltegravir 2,4 x x Yes Yes AnticoagulantsAntiretrovirals EnoxaparinRitonavir Na 2,4 x xx Yes Yes AnticoagulantsAntiretrovirals FondaparinuxStavudine Na 2,4 x x Yes Yes AnticoagulantsAntiretrovirals RivaroxabanTenofovir 2,4 x xx Yes Yes AnticoagulantsAntiretrovirals WarfarinZidovudine Na 2,4 x x Yes Yes AnticonvulsantAntitubercular CarbamazepineEthambutol 2,4 x x 2nd 2nd 2nd 2nd AnticonvulsantAntitubercular ClonazepamIsoniazid 2,4 x x AnticonvulsantAntitubercular DivalproexRifabutin 2,4 x x AnticonvulsantAntitubercular GabapentinRifampin 2,4 x x x 2nd 2nd 2nd 2nd AnticonvulsantAntiviral LamotrigineAcyclovir 2 x x 2nd 2nd 2nd 2nd AnticonvulsantAntiviral LevetiracetamOseltamivir 2 x AnticonvulsantAntiviral OxcarbazepineZanamivir 2 x x 2nd 2nd 2nd 2nd AnticonvulsantBeta Blockers PhenytoinCarvedilol x AnticonvulsantBeta Blockers PregabalinMetoprolol Tartrate x x 2nd 2nd 2nd 2nd AnticonvulsantBeta Blockers TopiramateNebivolol x x 2nd 2nd 2nd 2nd AnticonvulsantBeta Blockers ValproicPropranolol Acid HCl x AntidepressantsCalcium Blockers AmitriptylineAmlodipine x x Yes Yes Yes Yes AntidepressantsCalcium Blockers BupropionDiltiazem x x 2nd 2nd 2nd 2nd AntidepressantsCalcium Blockers CitalopramNifedipine 4 x x AntidepressantsCephalosporins ClomipramineCefaclor 42 x x Yes Yes Yes Yes Yes Yes Yes AntidepressantsCephalosporins DesipramineCefadroxil 2 x x Yes Yes Yes Yes Yes Yes Yes Yes Yes AntidepressantsCephalosporins DesvenlafaxineCefdinir 42 x x Yes Yes Yes Yes Yes Yes Yes AntidepressantsCephalosporins DoxepinCefixime 2 x x Yes Yes Yes Yes Yes Yes Yes Yes Yes AntidepressantsCephalosporins DuloxetineCefpodoxime 2 x x Yes 2ndYes 2nd Yes Yes Yes 2ndYes 2nd Yes AntidepressantsCephalosporins EscitalopramCefprozil 42 x x Yes Yes Yes Yes Yes Yes Yes AntidepressantsCephalosporins FluoxetineCephalexin 42 x x Yes Yes Yes Yes Yes Yes Yes AntidepressantsCorticosteroids FluvoxamineMethylprednisolone 4 x x Yes Yes Yes AntidepressantsCorticosteroids ImipraminePrednisolone x x Yes Yes Yes Yes Yes AntidepressantsCorticosteroids IsocarboxazidPrednisone 4 x x Yes Yes Yes AntidepressantsCough/Cold MirtazapineAcetylcysteine Inhal 4 x x AntidepressantsCough/Cold NefazodoneBenzonatate 4 x x AntidepressantsCough/Cold NortriptylineCetirizine-Pseudoephedrine x x Yes Yes Yes Yes AntidepressantsCough/Cold ParoxetineChlorpheniramine - Phenylephrine 4 x x Antidepressants Phenelzine 4 x Antidepressants Protriptyline 4 x Antidepressants Sertraline 4 x Antidepressants Tranylcypromine 4 x Antidepressants Trazodone 4 x REV: November 1, 2019 Page 2 of 4 Antidepressants Trimipramine x Yes Yes Yes Yes Antidepressants Venlafaxine x 2nd 2nd 2nd 2nd

REV: November 1, 2019 Page 1 of 4 Carpal Pain Non Ankle / Back Mid / Hip / Knee Neck Shoulder Asthma Tunnel CRPS Elbow Eye Acute Therapeutic Category Generic Name Foot Low (MTG) Groin (MTG) (MTG) (MTG) Special Phase A Phase B (MTG) (MTG) Perioperative Considerations Antidepressants Vilazodone 4 x 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 4 x x Antidiarrheals Loperamide 4 x x Antiemetic - Antivertigo Meclizine 4 x x Antiemetic - Antivertigo Ondansetron 4 x x Antifungals Fluconazole 2 x x Yes Antifungals Itraconazole 2 x x Yes Antifungals Ketoconazole 2 x x Yes Antifungals Nystatin 2 x x Yes Antifungals Terbinafine 2 x x Yes Antihistamines Cetirizine 4 x x Antihistamines Cyproheptadine 4 x x Antihistamines Desloratadine 4 x x Antihistamines Diphenhydramine 4 x x Antihistamines Fexofenadine 4 x x Antihistamines Hydroxyzine 4 x x Antihistamines Levocetirizine 4 x x Antihistamines Loratadine 4 x x Antihistamines Promethazine 4 x x Antihypertensive Clonidine HCl x Antihypertensive Lisinopril x Antihypertensive Losartan x Antihypertensive Prazosin x Anti-Infectives, Misc. Clindamycin 2,4 x x Anti-Infectives, Misc. Linezolid 2,4 x Anti-Infectives, Misc. Metronidazole 2,4 x x Anti-Infectives, Misc. Sulfamethoxazole-Trimethoprim 2,4 x x Anti-Infectives, Misc. Vancomycin 2,4 x x Anti-Inflammatory Celecoxib x 2nd 2nd 2nd 2nd 2nd 2nd 2nd 2nd 2nd 2nd Anti-Inflammatory Diclofenac x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Anti-Inflammatory Etodolac x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Anti-Inflammatory Ibuprofen x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Anti-Inflammatory Indomethacin x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Anti-Inflammatory Meloxicam x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Anti-Inflammatory Naproxen x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Anti-Inflammatory Sulindac x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Antimalarial Hydroxychloroquine 2 x Antineoplastic Cabozantinib 4 x Antineoplastic Dabrafenib 4 x Antineoplastic Doxorubicin 4 x Antineoplastic Interferon Gamma-1B 4 x Antineoplastic Methotrexate 4 x Antineoplastic Trametinib 4 x Antineoplastic Vandetanib 4 x Antineoplastic Vismodegib 4 x Antipsychotics Aripiprazole 4 x x Antipsychotics Asenapine Maleate 4 x Antipsychotics Chlorpromazine 4 x x Antipsychotics Haloperidol 4 x x Antipsychotics Lithium 4 x x Antipsychotics Lurasidone 4 x Antipsychotics Olanzapine 4 x x Antipsychotics Paliperidone 4 x Carpal Pain Non Ankle / Back Mid / Hip / Knee Neck Shoulder Antipsychotics Perphenazine 4 x Asthma Tunnel CRPS Elbow Eye Acute Therapeutic Category Generic Name Foot Low (MTG) Groin (MTG) (MTG) (MTG) Special Antipsychotics Prochlorperazine 4 Phase A x Phase B (MTG) (MTG) Perioperative

Antipsychotics Quetiapine 4 Considerations x x AntipsychoticsAnalgesics - Narcotic** Codeine-AcetaminophenRisperidone 1,34 x x x AntipsychoticsAnalgesics - Narcotic** Hydrocodone-AcetaminophenZiprasidone 1,34 x x x AntiretroviralsAnalgesics - Narcotic** Hydrocodone-IbuprofenAtazanavir 1,32,4 x x x AntiretroviralsAnalgesics - Narcotic** MorphineDarunavir 1,32,4 x x x AntiretroviralsAnalgesics - Narcotic** OxycodoneDolutegravir HCl 1,32,4 x x x AntiretroviralsAnalgesics - Narcotic** Oxycodone-AcetaminophenEmtricitabine 1,32,4 x x x AntiretroviralsAnalgesics - Narcotic** Oxycodone-AspirinFosamprenavir 1,32,4 x x x AntiretroviralsAnalgesics - Narcotic** TapentadolLamivudine 1,32,4 x x Analgesics - Narcotic** Tramadol HCl 1,3 x x Antiretrovirals Raltegravir 2,4 x x Analgesics - Narcotic** Tramadol-Acetaminophen 1,3 x x Antiretrovirals Ritonavir 2,4 x x Analgesics - Non-Narcotic Acetaminophen x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Antiretrovirals Stavudine 2,4 x x Analgesics - Non-Narcotic Aspirin x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes AntiretroviralsAnalgesics - Non-Narcotic CholineTenofovir - Magnesium Salicylates 2,4 x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes AntiretroviralsAnalgesics - Non-Narcotic DiflunisalZidovudine 2,4 x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes AntitubercularAnalgesics - Topical CapsaicinEthambutol 2,4 x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes AntitubercularAnalgesics - Topical DiclofenacIsoniazid Na (1% only) 2,4 x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes AntitubercularAnalgesics - Topical LidocaineRifabutin Patch (4% Only) 2,4 x x Yes Yes Yes Yes Yes Yes Yes Yes Yes AntitubercularAnalgesics - Topical MethylRifampin Salicylate 2,4 x x Yes Yes Yes Yes Yes Yes Yes Yes Yes AntiviralAntacids AlAcyclovir Hydrox-Mag Trisil-Alginic Acid-Sod Bicarb 42 x x AntiviralAntacids AlOseltamivir - Mag Hydroxides 42 x x AntiviralAntacids AlZanamivir Hydrox-Mag Carbonate Susp 42 x x BetaAntacids Blockers AlCarvedilol Hydro-Mag Trisilicate Chew Tab 4 x x BetaAntacids Blockers Calcium-MagnesiumMetoprolol Tartrate Carbonates 4 x x BetaAntacids Blockers CalciumNebivolol Carbonate 4 x x BetaAntacids Blockers CalciumPropranolol Carbonate HCl - Simethicone 4 x x CalciumAntacids Blockers CalciumAmlodipine Carbonate-Mag Hydro 4 x x CalciumAntianxiety Blockers Agents AlprazolamDiltiazem 1 x CalciumAntianxiety Blockers Agents BuspironeNifedipine 1 x CephalosporinsAntiasthmatics AclidiniumCefaclor Bromide Aerosol Powd 2 x x Yes Yes Yes Yes Yes Yes Yes CephalosporinsAntiasthmatics AlbuterolCefadroxil Inhal 2 x x Yes Yes Yes Yes Yes Yes Yes Yes Antiasthmatics Albuterol Sulfate x x Yes Cephalosporins Cefdinir 2 x x Yes Yes Yes Yes Yes Yes Yes Antiasthmatics Beclomethasone Inha. x x Yes Cephalosporins Cefixime 2 x x Yes Yes Yes Yes Yes Yes Yes Antiasthmatics Budesonide x x Yes Cephalosporins Cefpodoxime 2 x x Yes Yes Yes Yes Yes Yes Yes Antiasthmatics Budesonide Inhal x x Yes CephalosporinsAntiasthmatics Budesonide-FormoterolCefprozil Fumarate Inh 2 x x Yes Yes Yes Yes Yes Yes Yes Yes CephalosporinsAntiasthmatics CiclesonideCephalexin Inhal 2 x x Yes Yes Yes Yes Yes Yes Yes Yes CorticosteroidsAntiasthmatics CromolynMethylprednisolone Na Inhal x x Yes Yes Yes Yes CorticosteroidsAntiasthmatics EpinephrinePrednisolone Inhal x x Yes Yes Yes Yes CorticosteroidsAntiasthmatics FlunisolidePrednisone Inhal x x Yes Yes Yes Yes Cough/Cold Acetylcysteine Inhal x Carpal Pain Non Antiasthmatics Fluticasone Furoate-Vilanterol Inhal x x Ankle / Yes Back Mid / Hip / Knee Neck Shoulder Asthma Tunnel CRPS Elbow Eye Acute Cough/ColdAntiasthmaticsTherapeutic Category FluticasoneBenzonatate Inhal Generic Name x x Foot Yes Low (MTG) Groin (MTG) (MTG) (MTG) Special Phase A Phase B (MTG) (MTG) Cough/ColdAntiasthmatics Fluticasone-SalmeterolCetirizine-Pseudoephedrine Inhalal x x Perioperative Yes Cough/ColdAntiasthmatics FormoterolChlorpheniramine Fumarate - Phenylephrine Soln Considerations x x Yes Cough/ColdAntiasthmatics Formoterol-GlycopyrrolateChlorpheniramine-Acetaminophen x x Yes Cough/ColdAntiasthmatics Formoterol/MometasoneChlorpheniramine-DM x x Yes Cough/ColdAntiasthmatics IndacaterolDextromethorphan Maleate Inhalal x x Yes Cough/ColdAntiasthmatics IpratropiumDextromethorphan-APAP-Chlorpheniramine Bromide Inhal x x Yes Cough/ColdAntiasthmatics Ipratropium-AlbuterolDextromethorphan-Diphenhyd-APAP Inhal x x Yes REV: November 1, 2019 Page 2 of 4 DecongestantsAntiasthmatics LevalbuterolOxymetazoline HCl Inhal x x Yes DecongestantsAntiasthmatics MethacholinePhenylephrine Chloride Nasal Inhal x x Yes DecongestantsAntiasthmatics MometasonePseudoephedrine Furoate Inhal x x Yes Decongestants MometasoneSaline Nasal Furoate-Formoterol Fumarate x Antiasthmatics x x Yes Decongestants InhalTetrahydrozoline Nasal x DecongestantsAntiasthmatics MontelukastTriamcinolone Acetonide Nasal x x Yes DecongestantsAntiasthmatics (Nasal Steroids) RoflumilastBudesonide Nasal x x Yes DecongestantsAntiasthmatics (Nasal Steroids) SalmeterolFlunisolide Nasal x x Yes DecongestantsAntiasthmatics (Nasal Steroids) TerbutalineFluticasone Propionate Nasal x x Yes DecongestantsAntiasthmatics (Nasal Steroids) TheophyllineMometasone Furoate Nasal x x Yes EffectiveDermatologicalAntiasthmatics April 1, 2020 TiotropiumBacitracin Bromide Monohydrate Inhal 4 x x Page 7 Yes DermatologicalAntiasthmatics Tiotropium-OlodaterolBetamethasone 4 x x Yes DermatologicalAntiasthmatics TriamcinoloneCiclopirox Olamine Acetonide Inhal 4 x x Yes DermatologicalAntiasthmatics Umeclidinium-VilanterolClobetasol 4 x x Yes DermatologicalAntiasthmatics ZafirlukastClotrimazole 4 x x Yes DermatologicalAntiasthmatics ZileutonClotrimazole w/ Betamethasone Topical 4 x x Yes DermatologicalAnticoagulants ApixabanDesonide 4 x x Yes Yes DermatologicalAnticoagulants DalteparinDesoximetasone 4 x x Yes Yes DermatologicalAnticoagulants EnoxaparinEconazole Na 4 x x Yes Yes DermatologicalAnticoagulants FondaparinuxFluocinolone Acetonide Na 4 x x Yes Yes DermatologicalAnticoagulants RivaroxabanFluticasone Prop 4 x x Yes Yes DermatologicalAnticoagulants WarfarinGentamicin Na 4 x x Yes Yes DermatologicalAnticonvulsant CarbamazepineHydrocortisone 4 x x 2nd 2nd 2nd 2nd DermatologicalAnticonvulsant ClonazepamKetoconazole 4 x x DermatologicalAnticonvulsant DivalproexMetronidazole 4 x x DermatologicalAnticonvulsant GabapentinMiconazole Nitrate 4 x x x 2nd 2nd 2nd 2nd DermatologicalAnticonvulsant LamotrigineMupirocin x x 2nd 2nd 2nd 2nd DermatologicalAnticonvulsant LevetiracetamNeomycin Sulfate 4 x x DermatologicalAnticonvulsant OxcarbazepineNeomycin-Polymyxin-Bacitracin 4 x x 2nd 2nd 2nd 2nd DermatologicalAnticonvulsant PhenytoinNystatin 4 x x DermatologicalAnticonvulsant PregabalinNystatin-Triamcinolone 4 x x 2nd 2nd 2nd 2nd DermatologicalAnticonvulsant TopiramateSilver Sulfadiazine x x 2nd 2nd 2nd 2nd DermatologicalAnticonvulsant ValproicTolnaftate Acid 4 x x DermatologicalAntidepressants AmitriptylineTriamcinolone 4 x x Yes Yes Yes Yes DiureticsAntidepressants BupropionBumetanide x x 2nd 2nd 2nd 2nd DiureticsAntidepressants CitalopramFurosemide 4 x x DiureticsAntidepressants ClomipramineSpironolactone 4 x x FluoroquinolonesAntidepressants DesipramineCiprofloxacin 2 x x Yes Yes Yes Yes Yes Yes Yes Yes Yes FluoroquinolonesAntidepressants DesvenlafaxineLevofloxacin 42 x x Yes Yes Yes Yes Yes Yes Yes FluoroquinolonesAntidepressants DoxepinMoxifloxacin 2 x x Yes Yes Yes Yes Yes Yes Yes Yes Yes GI,Antidepressants Misc DuloxetineMetoclopramide 4 x 2nd 2nd 2nd 2nd GI,Antidepressants Misc EscitalopramSimethicone 4 x x HematopoeticAntidepressants Agents FluoxetineFolic Acid 4 x HypnoticsAntidepressants FluvoxamineDoxepin 4 x HypnoticsAntidepressants ImipramineTemazepam 4 x x Yes Yes Yes Yes HypnoticsAntidepressants IsocarboxazidZolpidem 4 x LaxativesAntidepressants MirtazapineBisacodyl 4 x x LaxativesAntidepressants NefazodoneDocusate Calcium 4 x x LaxativesAntidepressants NortriptylineDocusate Na 4 x x Yes Yes Yes Yes LaxativesAntidepressants ParoxetineGlycerin 4 x x LaxativesAntidepressants PhenelzineLactulose 4 x x LaxativesAntidepressants ProtriptylineMineral Oil 4 x x LaxativesAntidepressants SertralineNa Phosphates - Enema 4 x x LaxativesAntidepressants TranylcyprominePolyethylene Glycol 3350 4 x x LaxativesAntidepressants TrazodonePsyllium 4 x x MacrolideAntidepressants Antibiotics TrimipramineAzithromycin 2 x x Yes Yes Yes Yes Yes Yes Yes Yes Yes MacrolideAntidepressants Antibiotics VenlafaxineClarithromycin 2 x x Yes 2ndYes 2nd Yes Yes Yes 2ndYes 2nd Yes Macrolide Antibiotics Erythromycin 2 x x Yes Yes Yes Yes Yes Yes Yes Migraine Products Butalbital-Acetaminophen-Caffeine 4 x x Migraine Products Butalbital-Aspirin-Caffeine 4 x x Mouth - Throat (local) Clotrimazole Troche 4 x x Mouth - Throat (local) Lidocaine Viscous 2% 4 x x REV: November 1, 2019 Page 1 of 4 Mouth - Throat (local) Nystatin Suspension 4 x x Ophthalmic Alcaftadine x x Yes Ophthalmic Apraclonidine HCL x x Yes Ophthalmic Artificial Tear Ophth x x Yes Ophthalmic Atropine Sulfate Solution x x Yes Ophthalmic Azelastine x x Yes Ophthalmic Azithromycin x x Yes Ophthalmic Bacitracin Ophth x x Yes Ophthalmic Bacitracin-Polymyxin B x x Yes Ophthalmic Bacitracin-Polymyxin-Neomycin-HC x x Yes Ophthalmic Bepotastine x x Yes Ophthalmic Besifloxacin x x Yes Ophthalmic Betaxolol x x Yes Ophthalmic Bevacizumab x x Yes Ophthalmic Bimatoprost Ophth x x Yes Ophthalmic Brimonidine Tartrate Ophth x x Yes Ophthalmic Brimonidine Tartrate-Timolol Maleate Ophth x x Yes Ophthalmic Brinzolamide Ophth x x Yes Ophthalmic Bromfenac Na Ophth x x Yes Carboxymethylcell-Glycerin-Polysorb 80 Ophthalmic x x Yes Ophth Ophthalmic Carboxymethylcellulose x x Yes Ophthalmic Carteolol x x Yes Ophthalmic Carteolol HCL x x Yes Ophthalmic Ciprofloxacin x x Yes Ophthalmic Cromolyn x x Yes Ophthalmic Cyclopentolate x x Yes Ophthalmic Dexamethasone x x Yes Ophthalmic Diclofenac x x Yes Ophthalmic Dorzolamide x x Yes Ophthalmic Dorzolamide HCL x x Yes Ophthalmic Emedastine x x Yes Ophthalmic Epinastine x x Yes Ophthalmic Erythromycin x x Yes Ophthalmic Fluorometholone x x Yes Ophthalmic Flurbiprofen x x Yes

REV: November 1, 2019 Page 3 of 4 Carpal Pain Non Ankle / Back Mid / Hip / Knee Neck Shoulder Asthma Tunnel CRPS Elbow Eye Acute Therapeutic Category Generic Name Foot Low (MTG) Groin (MTG) (MTG) (MTG) Special Phase A Phase B (MTG) (MTG) Perioperative Considerations Cough/Cold Chlorpheniramine-Acetaminophen x Cough/Cold Chlorpheniramine-DM x Cough/Cold Dextromethorphan x Cough/Cold Dextromethorphan-APAP-Chlorpheniramine x Cough/Cold Dextromethorphan-Diphenhyd-APAP x Decongestants Oxymetazoline x Decongestants Phenylephrine Nasal x Decongestants Pseudoephedrine x Decongestants Saline Nasal x Decongestants Tetrahydrozoline Nasal x Decongestants Triamcinolone Acetonide Nasal x Carpal Pain Non Ankle / Back Mid / Hip / Knee Neck Shoulder Asthma Tunnel CRPS Elbow Eye Acute DecongestantsTherapeutic (Nasal CategorySteroids) Budesonide NasalGeneric Name x Foot Low (MTG) Groin (MTG) (MTG) (MTG) Special Phase A Phase B (MTG) (MTG)

Decongestants (Nasal Steroids) Flunisolide Nasal x Perioperative

Decongestants (Nasal Steroids) Fluticasone Propionate Nasal Considerations x DecongestantsAnalgesics - Narcotic** (Nasal Steroids) MometasoneCodeine-Acetaminophen Furoate Nasal 1,3 x x DermatologicalAnalgesics - Narcotic** BacitracinHydrocodone-Acetaminophen 1,34 x x x DermatologicalAnalgesics - Narcotic** BetamethasoneHydrocodone-Ibuprofen 1,34 x x x DermatologicalAnalgesics - Narcotic** CiclopiroxMorphine Olamine 1,34 x x x DermatologicalAnalgesics - Narcotic** ClobetasolOxycodone HCl 1,34 x x x DermatologicalAnalgesics - Narcotic** ClotrimazoleOxycodone-Acetaminophen 1,34 x x x Analgesics - Narcotic** Oxycodone-Aspirin 1,3 x x Dermatological Clotrimazole w/ Betamethasone Topical 4 x x Analgesics - Narcotic** Tapentadol 1,3 x Dermatological Desonide 4 x x Analgesics - Narcotic** Tramadol HCl 1,3 x x Dermatological Desoximetasone 4 x x Analgesics - Narcotic** Tramadol-Acetaminophen 1,3 x x Dermatological Econazole 4 x x Analgesics - Non-Narcotic Acetaminophen x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Dermatological Fluocinolone Acetonide 4 x x Analgesics - Non-Narcotic Aspirin x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes DermatologicalAnalgesics - Non-Narcotic FluticasoneCholine - Magnesium Prop Salicylates 4 x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes DermatologicalAnalgesics - Non-Narcotic GentamicinDiflunisal 4 x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes DermatologicalAnalgesics - Topical HydrocortisoneCapsaicin 4 x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes DermatologicalAnalgesics - Topical KetoconazoleDiclofenac Na (1% only) 4 x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes DermatologicalAnalgesics - Topical MetronidazoleLidocaine Patch (4% Only) 4 x x Yes Yes Yes Yes Yes Yes Yes Yes Yes DermatologicalAnalgesics - Topical MiconazoleMethyl Salicylate Nitrate 4 x x Yes Yes Yes Yes Yes Yes Yes Yes Yes DermatologicalAntacids MupirocinAl Hydrox-Mag Trisil-Alginic Acid-Sod Bicarb 4 x x DermatologicalAntacids NeomycinAl - Mag Hydroxides Sulfate 4 x x DermatologicalAntacids Neomycin-Polymyxin-BacitracinAl Hydrox-Mag Carbonate Susp 4 x x DermatologicalAntacids NystatinAl Hydro-Mag Trisilicate Chew Tab 4 x x DermatologicalAntacids Nystatin-TriamcinoloneCalcium-Magnesium Carbonates 4 x x DermatologicalAntacids SilverCalcium Sulfadiazine Carbonate 4 x x DermatologicalAntacids TolnaftateCalcium Carbonate - Simethicone 4 x x DermatologicalAntacids TriamcinoloneCalcium Carbonate-Mag Hydro 4 x x DiureticsAntianxiety Agents BumetanideAlprazolam 1 x DiureticsAntianxiety Agents FurosemideBuspirone 1 x DiureticsAntiasthmatics SpironolactoneAclidinium Bromide Aerosol Powd x x FluoroquinolonesAntiasthmatics CiprofloxacinAlbuterol Inhal 2 x x Yes Yes Yes Yes Yes Yes Yes Yes Antiasthmatics Albuterol Sulfate x x Yes Fluoroquinolones Levofloxacin 2 x x Yes Yes Yes Yes Yes Yes Yes Antiasthmatics Beclomethasone Inha. x x Yes Fluoroquinolones Moxifloxacin 2 x x Yes Yes Yes Yes Yes Yes Yes Antiasthmatics Budesonide x x Yes GI, Misc Metoclopramide 4 x Antiasthmatics Budesonide Inhal x x Yes GI,Antiasthmatics Misc SimethiconeBudesonide-Formoterol Fumarate Inh 4 x x Yes HematopoeticAntiasthmatics Agents FolicCiclesonide Acid Inhal 4 x x Yes HypnoticsAntiasthmatics DoxepinCromolyn Na Inhal 4 x x Yes HypnoticsAntiasthmatics TemazepamEpinephrine Inhal 4 x x Yes HypnoticsAntiasthmatics ZolpidemFlunisolide Inhal 4 x x Yes LaxativesAntiasthmatics BisacodylFluticasone Furoate-Vilanterol Inhal 4 x x Yes LaxativesAntiasthmatics DocusateFluticasone Calcium Inhal 4 x x Yes LaxativesAntiasthmatics DocusateFluticasone-Salmeterol Na Inhalal 4 x x Yes LaxativesAntiasthmatics GlycerinFormoterol Fumarate Soln 4 x x Yes LaxativesAntiasthmatics LactuloseFormoterol-Glycopyrrolate 4 x x Yes LaxativesAntiasthmatics MineralFormoterol/Mometasone Oil 4 x x Yes LaxativesAntiasthmatics NaIndacaterol Phosphates Maleate - Enema Inhalal 4 x x Yes LaxativesAntiasthmatics PolyethyleneIpratropium Bromide Glycol 3350 Inhal 4 x x Yes LaxativesAntiasthmatics PsylliumIpratropium-Albuterol Inhal 4 x x Yes MacrolideAntiasthmatics Antibiotics AzithromycinLevalbuterol HCl Inhal 2 x x Yes Yes Yes Yes Yes Yes Yes Yes MacrolideAntiasthmatics Antibiotics ClarithromycinMethacholine Chloride Inhal 2 x x Yes Yes Yes Yes Yes Yes Yes Yes MacrolideAntiasthmatics Antibiotics ErythromycinMometasone Furoate Inhal 2 x x Yes Yes Yes Yes Yes Yes Yes Yes Migraine Products Butalbital-Acetaminophen-CaffeineMometasone Furoate-Formoterol Fumarate 4 x x Antiasthmatics x x Yes Migraine Products Butalbital-Aspirin-CaffeineInhal 4 x x MouthAntiasthmatics - Throat (local) ClotrimazoleMontelukast Troche 4 x x Yes MouthAntiasthmatics - Throat (local) LidocaineRoflumilast Viscous 2% 4 x x Yes MouthAntiasthmatics - Throat (local) NystatinSalmeterol Suspension 4 x x Yes OphthalmicAntiasthmatics AlcaftadineTerbutaline x x Yes Yes OphthalmicAntiasthmatics ApraclonidineTheophylline HCL x x Yes Yes EffectiveOphthalmicAntiasthmatics April 1, 2020 ArtificialTiotropium Tear Bromide Ophth Monohydrate Inhal x x Page 8 Yes Yes OphthalmicAntiasthmatics AtropineTiotropium-Olodaterol Sulfate Solution x x Yes Yes Antiasthmatics Triamcinolone Acetonide Inhal x x Yes Ophthalmic Azelastine x x Yes Antiasthmatics Umeclidinium-Vilanterol x x Yes Ophthalmic Azithromycin x x Yes Antiasthmatics Zafirlukast x x Yes Ophthalmic Bacitracin Ophth x x Yes Antiasthmatics Zileuton x x Yes Ophthalmic Bacitracin-Polymyxin B x x Yes Anticoagulants Apixaban x x Yes Yes Ophthalmic Bacitracin-Polymyxin-Neomycin-HC x x Yes Anticoagulants Dalteparin x x Yes Yes Ophthalmic Bepotastine x x Yes Anticoagulants Enoxaparin Na x x Yes Yes Ophthalmic Besifloxacin x x Yes Anticoagulants Fondaparinux Na x x Yes Yes Ophthalmic Betaxolol x x Yes Anticoagulants Rivaroxaban x x Yes Yes Ophthalmic Bevacizumab x x Yes Anticoagulants Warfarin Na x x Yes Yes Ophthalmic Bimatoprost Ophth x x Yes Anticonvulsant Carbamazepine x x 2nd 2nd 2nd 2nd Ophthalmic Brimonidine Tartrate Ophth x x Yes Anticonvulsant Clonazepam x Ophthalmic Brimonidine Tartrate-Timolol Maleate Ophth x x Yes Anticonvulsant Divalproex x Ophthalmic Brinzolamide Ophth x x Yes Anticonvulsant Gabapentin x x 2nd 2nd 2nd 2nd Ophthalmic Bromfenac Na Ophth x x x Yes Anticonvulsant Lamotrigine x x 2nd 2nd 2nd 2nd Carboxymethylcell-Glycerin-Polysorb 80 Ophthalmic x x Yes Anticonvulsant OphthLevetiracetam x OphthalmicAnticonvulsant CarboxymethylcelluloseOxcarbazepine x x 2nd 2nd Yes 2nd 2nd OphthalmicAnticonvulsant CarteololPhenytoin x x Yes OphthalmicAnticonvulsant CarteololPregabalin HCL x x 2nd 2nd Yes 2nd 2nd OphthalmicAnticonvulsant CiprofloxacinTopiramate x x 2nd 2nd Yes 2nd 2nd OphthalmicAnticonvulsant CromolynValproic Acid x x Yes OphthalmicAntidepressants CyclopentolateAmitriptyline x x Yes Yes Yes Yes Yes OphthalmicAntidepressants DexamethasoneBupropion x x 2nd 2nd Yes 2nd 2nd OphthalmicAntidepressants DiclofenacCitalopram 4 x x Yes OphthalmicAntidepressants DorzolamideClomipramine 4 x x Yes OphthalmicAntidepressants DorzolamideDesipramine HCL x x Yes Yes Yes Yes Yes OphthalmicAntidepressants EmedastineDesvenlafaxine 4 x x Yes OphthalmicAntidepressants EpinastineDoxepin x x Yes Yes Yes Yes Yes OphthalmicAntidepressants ErythromycinDuloxetine x x 2nd 2nd Yes 2nd 2nd OphthalmicAntidepressants FluorometholoneEscitalopram 4 x x Yes OphthalmicAntidepressants FlurbiprofenFluoxetine 4 x x Yes Antidepressants Fluvoxamine 4 x Antidepressants Imipramine x x Yes Yes Yes Yes Antidepressants Isocarboxazid 4 x Antidepressants Mirtazapine 4 x Antidepressants Nefazodone 4 x REV:Antidepressants November 1, 2019 Nortriptyline x Yes Yes Yes Yes Page 3 of 4 Antidepressants Paroxetine 4 x Antidepressants Phenelzine 4 x Antidepressants Protriptyline 4 x Antidepressants Sertraline 4 x Antidepressants Tranylcypromine 4 x Antidepressants Trazodone 4 x Antidepressants Trimipramine x Yes Yes Yes Yes Antidepressants Venlafaxine x 2nd 2nd 2nd 2nd

REV: November 1, 2019 Page 1 of 4 Carpal Pain Non Ankle / Back Mid / Hip / Knee Neck Shoulder Asthma Tunnel CRPS Elbow Eye Acute Therapeutic Category Generic Name Foot Low (MTG) Groin (MTG) (MTG) (MTG) Special Phase A Phase B (MTG) (MTG) Perioperative Considerations Cough/Cold Chlorpheniramine-Acetaminophen x Cough/Cold Chlorpheniramine-DM x Cough/Cold Dextromethorphan x Cough/Cold Dextromethorphan-APAP-Chlorpheniramine x Cough/Cold Dextromethorphan-Diphenhyd-APAP 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 4 x x Dermatological Betamethasone 4 x x Dermatological Ciclopirox Olamine 4 x x Dermatological Clobetasol 4 x x Dermatological Clotrimazole 4 x x Dermatological Clotrimazole w/ Betamethasone Topical 4 x x Dermatological Desonide 4 x x Dermatological Desoximetasone 4 x x Dermatological Econazole 4 x x Dermatological Fluocinolone Acetonide 4 x x Dermatological Fluticasone Prop 4 x x Dermatological Gentamicin 4 x x Dermatological Hydrocortisone 4 x x Dermatological Ketoconazole 4 x x Dermatological Metronidazole 4 x x Dermatological Miconazole Nitrate 4 x x Dermatological Mupirocin x Dermatological Neomycin Sulfate 4 x x Dermatological Neomycin-Polymyxin-Bacitracin 4 x x Dermatological Nystatin 4 x x Dermatological Nystatin-Triamcinolone 4 x x Dermatological Silver Sulfadiazine x Dermatological Tolnaftate 4 x x Dermatological Triamcinolone 4 x x 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 4 x GI, Misc Simethicone 4 x x Hematopoetic Agents Folic Acid 4 x Hypnotics Doxepin 4 x Hypnotics Temazepam 4 x Hypnotics Zolpidem 4 x Laxatives Bisacodyl 4 x x Laxatives Docusate Calcium 4 x x Laxatives Docusate Na 4 x x Laxatives Glycerin 4 x x Laxatives Lactulose 4 x x Laxatives Mineral Oil 4 x x Laxatives Na Phosphates - Enema 4 x x Laxatives Polyethylene Glycol 3350 4 x x Laxatives Psyllium 4 x x Macrolide Antibiotics Azithromycin 2 x x Yes Yes Yes Yes Yes Yes Yes Macrolide Antibiotics Clarithromycin 2 x x Yes Yes Yes Yes Yes Yes Yes Macrolide Antibiotics Erythromycin 2 x x Yes Yes Yes Yes Yes Yes Yes Migraine Products Butalbital-Acetaminophen-Caffeine 4 x x Migraine Products Butalbital-Aspirin-Caffeine 4 x x Mouth - Throat (local) Clotrimazole Troche 4 x x Carpal Pain Non Ankle / Back Mid / Hip / Knee Neck Shoulder Mouth - Throat (local) Lidocaine Viscous 2% 4 x x Asthma Tunnel CRPS Elbow Eye Acute Therapeutic Category Generic Name Foot Low (MTG) Groin (MTG) (MTG) (MTG) Special Mouth - Throat (local) Nystatin Suspension 4 x Phase A x Phase B (MTG) (MTG) Perioperative

Ophthalmic Alcaftadine Considerations x x Yes AnalgesicsOphthalmic - Narcotic** Codeine-AcetaminophenApraclonidine HCL 1,3 x x x Yes AnalgesicsOphthalmic - Narcotic** Hydrocodone-AcetaminophenArtificial Tear Ophth 1,3 x x x Yes AnalgesicsOphthalmic - Narcotic** Hydrocodone-IbuprofenAtropine Sulfate Solution 1,3 x x x Yes AnalgesicsOphthalmic - Narcotic** MorphineAzelastine 1,3 x x x Yes AnalgesicsOphthalmic - Narcotic** OxycodoneAzithromycin HCl 1,3 x x x Yes AnalgesicsOphthalmic - Narcotic** Oxycodone-AcetaminophenBacitracin Ophth 1,3 x x x Yes AnalgesicsOphthalmic - Narcotic** Oxycodone-AspirinBacitracin-Polymyxin B 1,3 x x x Yes Analgesics - Narcotic** Tapentadol 1,3 x Ophthalmic Bacitracin-Polymyxin-Neomycin-HC x x Yes Analgesics - Narcotic** Tramadol HCl 1,3 x x Ophthalmic Bepotastine x x Yes Analgesics - Narcotic** Tramadol-Acetaminophen 1,3 x x Ophthalmic Besifloxacin x x Yes Analgesics - Non-Narcotic Acetaminophen x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes AnalgesicsOphthalmic - Non-Narcotic AspirinBetaxolol x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes AnalgesicsOphthalmic - Non-Narcotic CholineBevacizumab - Magnesium Salicylates x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes AnalgesicsOphthalmic - Non-Narcotic DiflunisalBimatoprost Ophth x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes AnalgesicsOphthalmic - Topical CapsaicinBrimonidine Tartrate Ophth x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes AnalgesicsOphthalmic - Topical DiclofenacBrimonidine Na Tartrate-Timolol (1% only) Maleate Ophth x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes AnalgesicsOphthalmic - Topical LidocaineBrinzolamide Patch Ophth (4% Only) x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes AnalgesicsOphthalmic - Topical MethylBromfenac Salicylate Na Ophth x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Antacids AlCarboxymethylcell-Glycerin-Polysorb Hydrox-Mag Trisil-Alginic Acid-Sod Bicarb80 4 x x Ophthalmic x x Yes Antacids AlOphth - Mag Hydroxides 4 x x AntacidsOphthalmic AlCarboxymethylcellulose Hydrox-Mag Carbonate Susp 4 x x Yes AntacidsOphthalmic AlCarteolol Hydro-Mag Trisilicate Chew Tab 4 x x Yes AntacidsOphthalmic Calcium-MagnesiumCarteolol HCL Carbonates 4 x x Yes AntacidsOphthalmic CalciumCiprofloxacin Carbonate 4 x x Yes AntacidsOphthalmic CalciumCromolyn Carbonate - Simethicone 4 x x Yes AntacidsOphthalmic CalciumCyclopentolate Carbonate-Mag Hydro 4 x x Yes AntianxietyOphthalmic Agents AlprazolamDexamethasone 1 x x Yes AntianxietyOphthalmic Agents BuspironeDiclofenac 1 x x Yes AntiasthmaticsOphthalmic AclidiniumDorzolamide Bromide Aerosol Powd x x Yes AntiasthmaticsOphthalmic AlbuterolDorzolamide Inhal HCL x x Yes Yes AntiasthmaticsOphthalmic AlbuterolEmedastine Sulfate x x Yes Yes AntiasthmaticsOphthalmic BeclomethasoneEpinastine Inha. x x Yes Carpal Yes Pain Non Ankle / Back Mid / Hip / Knee Neck Shoulder Antiasthmatics Budesonide x x AsthmaYes Tunnel CRPS Elbow Eye Acute OphthalmicTherapeutic Category ErythromycinGeneric Name x x Foot Low (MTG) Yes Groin (MTG) (MTG) (MTG) Special Antiasthmatics Budesonide Inhal x Phase A x Phase B Yes (MTG) (MTG)

Ophthalmic Fluorometholone x x Perioperative Yes Antiasthmatics Budesonide-Formoterol Fumarate Inh x x Yes Ophthalmic Flurbiprofen Considerations x x Yes Antiasthmatics Ciclesonide Inhal x x Yes Ophthalmic Gatifloxacin x x Yes Antiasthmatics Cromolyn Na Inhal x x Yes AntiasthmaticsOphthalmic EpinephrineGentamicin Inhal x x Yes Yes AntiasthmaticsOphthalmic FlunisolideGlycerin (Ophth Inhal Lubricant) x x Yes Yes AntiasthmaticsOphthalmic FluticasoneGlycerin-Hypromellose-PEG Furoate-Vilanterol 400 Inhal x x Yes Yes Ophthalmic Homatropine x x Yes REV:Antiasthmatics November 1, 2019 Fluticasone Inhal x x Yes Page 3 of 4 AntiasthmaticsOphthalmic Fluticasone-SalmeterolHypromellose Inhalal x x Yes Yes AntiasthmaticsOphthalmic FormoterolIrrigating Eyewash Fumarate Soln x x Yes Yes AntiasthmaticsOphthalmic Formoterol-GlycopyrrolateKetorolac Trometh x x Yes Yes AntiasthmaticsOphthalmic Formoterol/MometasoneKetotifen x x Yes Yes AntiasthmaticsOphthalmic IndacaterolLatanoprost Maleate Ophth Inhalal x x Yes Yes AntiasthmaticsOphthalmic IpratropiumLevobunolol BromideHCL Inhal x x Yes Yes AntiasthmaticsOphthalmic Ipratropium-AlbuterolLevofloxacin Inhal x x Yes Yes AntiasthmaticsOphthalmic LevalbuterolLodoxamide HCl Inhal x x Yes Yes AntiasthmaticsOphthalmic MethacholineLoteprednol Chloride Inhal x x Yes Yes AntiasthmaticsOphthalmic MometasoneMethylcellulose Furoate Ophth Inhal x x Yes Yes Ophthalmic MometasoneMetipranolol Furoate-Formoterol Fumarate x x Yes Antiasthmatics x x Yes Ophthalmic InhalMoxifloxacin HCl x x Yes AntiasthmaticsOphthalmic MontelukastNa Chloride Hypertonic x x Yes Yes AntiasthmaticsOphthalmic RoflumilastNaphazoline HCl x x Yes Yes AntiasthmaticsOphthalmic SalmeterolNatamycin x x Yes Yes AntiasthmaticsOphthalmic TerbutalineNedocromil x x Yes Yes AntiasthmaticsOphthalmic TheophyllineNeomycin-Bacitracin-Polymyxin x x Yes Yes EffectiveAntiasthmaticsOphthalmic April 1, 2020 TiotropiumNeomycin-Polymyxin-Dexamethasone Bromide Monohydrate Inhal x x Yes Yes AntiasthmaticsOphthalmic Tiotropium-OlodaterolNeomycin-Polymyxin-Gramicidin x x Page 9 Yes Yes AntiasthmaticsOphthalmic TriamcinoloneNeomycin-Polymyxin-HC Acetonide Inhal x x Yes Yes AntiasthmaticsOphthalmic Umeclidinium-VilanterolOfloxacin x x Yes Yes AntiasthmaticsOphthalmic ZafirlukastOlopatadine x x Yes Yes AntiasthmaticsOphthalmic ZileutonPhenylephrine HCL x x Yes Yes AnticoagulantsOphthalmic ApixabanPilocarpine HCL x x Yes Yes Yes AnticoagulantsOphthalmic DalteparinPolyethylene Glycol 400 x x Yes Yes Yes AnticoagulantsOphthalmic EnoxaparinPolyethylene Na Glycol-Polyvinyl Alcohol x x Yes Yes Yes AnticoagulantsOphthalmic FondaparinuxPolymyxin B-Trimethoprim Na x x Yes Yes Yes AnticoagulantsOphthalmic RivaroxabanPolysorbate 80 x x Yes Yes Yes AnticoagulantsOphthalmic WarfarinPolyvinyl NaAlcohol x x Yes Yes Yes AnticonvulsantOphthalmic CarbamazepinePolyvinyl Alcohol-Povidone x x 2nd 2nd Yes 2nd 2nd AnticonvulsantOphthalmic ClonazepamPrednisolone Acetate x x Yes AnticonvulsantOphthalmic DivalproexPrednisolone Na Phosphate x x Yes AnticonvulsantOphthalmic GabapentinProparacaine HCL x x x 2nd 2nd Yes 2nd 2nd AnticonvulsantOphthalmic LamotrigineSulfacetamide-Prednisolone x x 2nd 2nd Yes 2nd 2nd AnticonvulsantOphthalmic LevetiracetamSulfacetamine x x Yes AnticonvulsantOphthalmic OxcarbazepineTetracaine HCL x x 2nd 2nd Yes 2nd 2nd AnticonvulsantOphthalmic PhenytoinTimolol Maleate x x Yes AnticonvulsantOphthalmic PregabalinTobramycin x x 2nd 2nd Yes 2nd 2nd AnticonvulsantOphthalmic TopiramateTobramycin-Dexamethasone x x 2nd 2nd Yes 2nd 2nd AnticonvulsantOphthalmic ValproicTranexamic Acid Acid x x Yes AntidepressantsOphthalmic AmitriptylineTravoprost x x Yes Yes Yes Yes Yes AntidepressantsOphthalmic BupropionTrifluridine x x 2nd 2nd Yes 2nd 2nd AntidepressantsOphthalmic CitalopramTropicamide 4 x x Yes AntidepressantsOphthalmic ClomipramineWhite Petrolatum-Mineral Oil 4 x x Yes AntidepressantsOTIC DesipramineAcetic Acid x x Yes Yes Yes Yes AntidepressantsOTIC DesvenlafaxineAntipyrine-Benzocaine Otic Soln 4 x x AntidepressantsOTIC DoxepinAntipyrine-Benzocaine-Glycerin-Zinc Ace x x Yes Yes Yes Yes AntidepressantsOTIC DuloxetineAntipyrine-Benzocaine-Polycosanol x x 2nd 2nd 2nd 2nd AntidepressantsOTIC EscitalopramCiprofloxacin 4 x x AntidepressantsOTIC FluoxetineFluocinolone 4 x x AntidepressantsOTIC FluvoxamineHydrocortisone w/ Acetic Acid 4 x x AntidepressantsOTIC ImipramineNeomycin-Polymyxin-HC x x Yes Yes Yes Yes AntidepressantsOTIC IsocarboxazidOfloxacin 4 x x AntidepressantsOTIC MirtazapinePramoxine-Chloroxylenol 4 x x AntidepressantsOTIC NefazodonePramoxine-HC-Chloroxylenol 4 x x AntidepressantsPenicillins NortriptylineAmoxicillin 2 x x Yes Yes Yes Yes Yes Yes Yes Yes Yes AntidepressantsPenicillins ParoxetineAmoxicillin-Clavulanate 42 x x Yes Yes Yes Yes Yes Yes Yes AntidepressantsPenicillins PhenelzineAmpicillin 42 x x Yes Yes Yes Yes Yes Yes Yes AntidepressantsPenicillins ProtriptylineDicloxacillin 42 x x Yes Yes Yes Yes Yes Yes Yes AntidepressantsPenicillins SertralinePenicillin 42 x x Yes Yes Yes Yes Yes Yes Yes AntidepressantsPressors TranylcypromineEpinephrine 4 x x AntidepressantsRespiratory, Misc TrazodoneNintedanib Esylate 4 x AntidepressantsRespiratory, Misc TrimipraminePirfenidone 4 x Yes Yes Yes Yes AntidepressantsSkeletal Muscle Relaxants VenlafaxineBaclofen 1 x x 2nd 2nd 2nd 2nd Skeletal Muscle Relaxants Carisoprodol 1 x x 2nd 2nd 2nd 2nd Skeletal Muscle Relaxants Cyclobenzaprine 1, 3 x x Yes Yes Yes Yes Skeletal Muscle Relaxants Metaxalone 1 x x 2nd 2nd 2nd 2nd Skeletal Muscle Relaxants Methocarbamol 1 x x 2nd 2nd 2nd 2nd Skeletal Muscle Relaxants Tizanidine HCl 1 x x 2nd 2nd 2nd 2nd REV:Tetracyclines November 1, 2019 Doxycycline 2 x x Yes Yes Yes Yes Yes Yes PageYes 1 of 4 Tetracyclines Minocycline 2 x x Yes Yes Yes Yes Yes Yes Yes Tetracyclines Tetracycline 2 x x Yes Yes Yes Yes Yes Yes Yes Ulcer Drugs Cimetidine x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 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 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

REV: November 1, 2019 Page 4 of 4 Carpal Pain Non Ankle / Back Mid / Hip / Knee Neck Shoulder Asthma Tunnel CRPS Elbow Eye Acute Therapeutic Category Generic Name Foot Low (MTG) Groin (MTG) (MTG) (MTG) Special Phase A Phase B (MTG) (MTG) Perioperative Considerations 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 Carpal Yes Pain Non Ankle / Back Mid / Hip / Knee Neck Shoulder Asthma Tunnel CRPS Elbow Eye Acute OphthalmicTherapeutic Category Naphazoline GenericHCl Name x x Foot Low (MTG) Yes Groin (MTG) (MTG) (MTG) Special Phase A Phase B (MTG) (MTG)

Ophthalmic Natamycin x x Perioperative Yes

Ophthalmic Nedocromil Considerations x x Yes AnalgesicsOphthalmic - Narcotic** Codeine-AcetaminophenNeomycin-Bacitracin-Polymyxin 1,3 x x x Yes AnalgesicsOphthalmic - Narcotic** Hydrocodone-AcetaminophenNeomycin-Polymyxin-Dexamethasone 1,3 x x x Yes AnalgesicsOphthalmic - Narcotic** Hydrocodone-IbuprofenNeomycin-Polymyxin-Gramicidin 1,3 x x x Yes AnalgesicsOphthalmic - Narcotic** MorphineNeomycin-Polymyxin-HC 1,3 x x x Yes AnalgesicsOphthalmic - Narcotic** OxycodoneOfloxacin HCl 1,3 x x x Yes AnalgesicsOphthalmic - Narcotic** Oxycodone-AcetaminophenOlopatadine 1,3 x x x Yes Analgesics - Narcotic** Oxycodone-Aspirin 1,3 x x Ophthalmic Phenylephrine HCL x x Yes Analgesics - Narcotic** Tapentadol 1,3 x Ophthalmic Pilocarpine HCL x x Yes Analgesics - Narcotic** Tramadol HCl 1,3 x x Ophthalmic Polyethylene Glycol 400 x x Yes Analgesics - Narcotic** Tramadol-Acetaminophen 1,3 x x AnalgesicsOphthalmic - Non-Narcotic AcetaminophenPolyethylene Glycol-Polyvinyl Alcohol x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes AnalgesicsOphthalmic - Non-Narcotic AspirinPolymyxin B-Trimethoprim x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes AnalgesicsOphthalmic - Non-Narcotic CholinePolysorbate - Magnesium 80 Salicylates x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes AnalgesicsOphthalmic - Non-Narcotic DiflunisalPolyvinyl Alcohol x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes AnalgesicsOphthalmic - Topical CapsaicinPolyvinyl Alcohol-Povidone x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes AnalgesicsOphthalmic - Topical DiclofenacPrednisolone Na Acetate (1% only) x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes AnalgesicsOphthalmic - Topical LidocainePrednisolone Patch Na (4%Phosphate Only) x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes AnalgesicsOphthalmic - Topical MethylProparacaine Salicylate HCL x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes AntacidsOphthalmic AlSulfacetamide-Prednisolone Hydrox-Mag Trisil-Alginic Acid-Sod Bicarb 4 x x Yes AntacidsOphthalmic AlSulfacetamine - Mag Hydroxides 4 x x Yes AntacidsOphthalmic AlTetracaine Hydrox-Mag HCL Carbonate Susp 4 x x Yes AntacidsOphthalmic AlTimolol Hydro-Mag Maleate Trisilicate Chew Tab 4 x x Yes AntacidsOphthalmic Calcium-MagnesiumTobramycin Carbonates 4 x x Yes AntacidsOphthalmic CalciumTobramycin-Dexamethasone Carbonate 4 x x Yes AntacidsOphthalmic CalciumTranexamic Carbonate Acid - Simethicone 4 x x Yes AntacidsOphthalmic CalciumTravoprost Carbonate-Mag Hydro 4 x x Yes AntianxietyOphthalmic Agents AlprazolamTrifluridine 1 x x Yes Antianxiety Agents Buspirone 1 x Ophthalmic Tropicamide x x Yes Antiasthmatics Aclidinium Bromide Aerosol Powd x x Ophthalmic White Petrolatum-Mineral Oil x x Yes Antiasthmatics Albuterol Inhal x x Yes OTIC Acetic Acid x Antiasthmatics Albuterol Sulfate x x Yes OTIC Antipyrine-Benzocaine Otic Soln x Antiasthmatics Beclomethasone Inha. x x Yes AntiasthmaticsOTIC BudesonideAntipyrine-Benzocaine-Glycerin-Zinc Ace x x Yes AntiasthmaticsOTIC BudesonideAntipyrine-Benzocaine-Polycosanol Inhal x x Yes AntiasthmaticsOTIC Budesonide-FormoterolCiprofloxacin Fumarate Inh x x Yes AntiasthmaticsOTIC CiclesonideFluocinolone Inhal x x Yes AntiasthmaticsOTIC CromolynHydrocortisone Na Inhal w/ Acetic Acid x x Yes AntiasthmaticsOTIC EpinephrineNeomycin-Polymyxin-HC Inhal x x Yes AntiasthmaticsOTIC FlunisolideOfloxacin Inhal x x Yes AntiasthmaticsOTIC FluticasonePramoxine-Chloroxylenol Furoate-Vilanterol Inhal x x Yes AntiasthmaticsOTIC FluticasonePramoxine-HC-Chloroxylenol Inhal x x Yes AntiasthmaticsPenicillins Fluticasone-SalmeterolAmoxicillin Inhalal 2 x x Yes Yes Yes Yes Yes Yes Yes Yes AntiasthmaticsPenicillins FormoterolAmoxicillin-Clavulanate Fumarate Soln 2 x x Yes Yes Yes Yes Yes Yes Yes Yes AntiasthmaticsPenicillins Formoterol-GlycopyrrolateAmpicillin 2 x x Yes Yes Yes Yes Yes Yes Yes Yes AntiasthmaticsPenicillins Formoterol/MometasoneDicloxacillin 2 x x Yes Yes Yes Yes Yes Yes Yes Yes AntiasthmaticsPenicillins IndacaterolPenicillin Maleate Inhalal 2 x x Yes Yes Yes Yes Yes Yes Yes Yes AntiasthmaticsPressors IpratropiumEpinephrine Bromide Inhal x x Yes AntiasthmaticsRespiratory, Misc Ipratropium-AlbuterolNintedanib Esylate Inhal 4 x x Yes AntiasthmaticsRespiratory, Misc LevalbuterolPirfenidone HCl Inhal 4 x x Yes AntiasthmaticsSkeletal Muscle Relaxants MethacholineBaclofen Chloride Inhal 1 x x Yes 2nd 2nd 2nd 2nd AntiasthmaticsSkeletal Muscle Relaxants MometasoneCarisoprodol Furoate Inhal 1 x x Yes 2nd 2nd 2nd 2nd Skeletal Muscle Relaxants MometasoneCyclobenzaprine Furoate-Formoterol Fumarate 1, 3 x x Yes Yes Yes Yes Antiasthmatics x x Yes Skeletal Muscle Relaxants InhalMetaxalone 1 x x 2nd 2nd 2nd 2nd AntiasthmaticsSkeletal Muscle Relaxants MontelukastMethocarbamol 1 x x Yes 2nd 2nd 2nd 2nd AntiasthmaticsSkeletal Muscle Relaxants RoflumilastTizanidine HCl 1 x x Yes 2nd 2nd 2nd 2nd AntiasthmaticsTetracyclines SalmeterolDoxycycline 2 x x Yes Yes Yes Yes Yes Yes Yes Yes AntiasthmaticsTetracyclines TerbutalineMinocycline 2 x x Yes Yes Yes Yes Yes Yes Yes Yes EffectiveAntiasthmaticsTetracyclines April 1, 2020 TheophyllineTetracycline 2 x x Yes Yes Yes Yes Yes Yes Yes Yes AntiasthmaticsUlcer Drugs TiotropiumCimetidine Bromide Monohydrate Inhal x x Page 10 Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes AntiasthmaticsUlcer Drugs Tiotropium-OlodaterolEsomeprazole x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes AntiasthmaticsUlcer Drugs TriamcinoloneFamotidine Acetonide Inhal x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes AntiasthmaticsUlcer Drugs Umeclidinium-VilanterolLansoprazole x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes AntiasthmaticsUlcer Drugs ZafirlukastMisoprostol x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes AntiasthmaticsUlcer Drugs ZileutonNizatidine x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes AnticoagulantsUlcer Drugs ApixabanOmeprazole x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes AnticoagulantsUlcer Drugs DalteparinPantoprazole x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes AnticoagulantsUlcer Drugs EnoxaparinRabeprazole Na x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes AnticoagulantsUlcer Drugs FondaparinuxRanitidine Na x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes AnticoagulantsUlcer Drugs RivaroxabanSucralfate x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Anticoagulants Warfarin Na x x Yes Yes Anticonvulsant Carbamazepine x x 2nd 2nd 2nd 2nd Anticonvulsant Clonazepam x Anticonvulsant Divalproex x Anticonvulsant Gabapentin x x x 2nd 2nd 2nd 2nd Anticonvulsant Lamotrigine x x 2nd 2nd 2nd 2nd Anticonvulsant Levetiracetam x Anticonvulsant Oxcarbazepine x x 2nd 2nd 2nd 2nd Anticonvulsant Phenytoin x Anticonvulsant Pregabalin x x 2nd 2nd 2nd 2nd Anticonvulsant Topiramate x x 2nd 2nd 2nd 2nd Anticonvulsant Valproic Acid x Antidepressants Amitriptyline x x Yes Yes Yes Yes Antidepressants Bupropion x 2nd 2nd 2nd 2nd Antidepressants Citalopram 4 x Antidepressants Clomipramine 4 x Antidepressants Desipramine x Yes Yes Yes Yes Antidepressants Desvenlafaxine 4 x Antidepressants Doxepin x Yes Yes Yes Yes Antidepressants Duloxetine x 2nd 2nd 2nd 2nd REV:Antidepressants November 1, 2019 Escitalopram 4 x Page 4 of 4 Antidepressants Fluoxetine 4 x Antidepressants Fluvoxamine 4 x Antidepressants Imipramine x x Yes Yes Yes Yes Antidepressants Isocarboxazid 4 x Antidepressants Mirtazapine 4 x Antidepressants Nefazodone 4 x Antidepressants Nortriptyline x Yes Yes Yes Yes Antidepressants Paroxetine 4 x Antidepressants Phenelzine 4 x Antidepressants Protriptyline 4 x Antidepressants Sertraline 4 x Antidepressants Tranylcypromine 4 x Antidepressants Trazodone 4 x Antidepressants Trimipramine x Yes Yes Yes Yes Antidepressants Venlafaxine x 2nd 2nd 2nd 2nd

REV: November 1, 2019 Page 1 of 4 Carpal Pain Non Ankle / Back Mid / Hip / Knee Neck Shoulder Asthma Tunnel CRPS Elbow Eye Acute Therapeutic Category Generic Name Foot Low (MTG) Groin (MTG) (MTG) (MTG) Special Phase A Phase B (MTG) (MTG) Perioperative Considerations 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 OTIC Antipyrine-Benzocaine Otic Soln x OTIC Antipyrine-Benzocaine-Glycerin-Zinc Ace x OTIC Antipyrine-Benzocaine-Polycosanol x OTIC Ciprofloxacin x OTIC Fluocinolone x OTIC Hydrocortisone w/ Acetic Acid x OTIC Neomycin-Polymyxin-HC x OTIC Ofloxacin x OTIC Pramoxine-Chloroxylenol x OTIC Pramoxine-HC-Chloroxylenol x Penicillins Amoxicillin 2 x x Yes Yes Yes Yes Yes Yes Yes Penicillins Amoxicillin-Clavulanate 2 x x Yes Yes Yes Yes Yes Yes Yes Penicillins Ampicillin 2 x x Yes Yes Yes Yes Yes Yes Yes Penicillins Dicloxacillin 2 x x Yes Yes Yes Yes Yes Yes Yes Penicillins Penicillin 2 x x Yes Yes Yes Yes Yes Yes Yes Pressors Epinephrine x Respiratory, Misc Nintedanib Esylate 4 x Respiratory, Misc Pirfenidone 4 x Skeletal Muscle Relaxants Baclofen 1 x x 2nd 2nd 2nd 2nd Skeletal Muscle Relaxants Carisoprodol 1 x x 2nd 2nd 2nd 2nd Skeletal Muscle Relaxants Cyclobenzaprine 1, 3 x x Yes Carpal Yes Yes PainYes Non Ankle / Back Mid / Hip / Knee Neck Shoulder Asthma Tunnel CRPS Elbow Eye Acute SkeletalTherapeutic Muscle Relaxants Category Metaxalone Generic Name 1 x x Foot Low2nd (MTG) 2nd Groin (MTG) (MTG)2nd 2nd (MTG) Special Phase A Phase B (MTG) (MTG)

Skeletal Muscle Relaxants Methocarbamol 1 x x Perioperative 2nd 2nd 2nd 2nd

Skeletal Muscle Relaxants Tizanidine HCl 1 Considerations x x 2nd 2nd 2nd 2nd AnalgesicsTetracyclines - Narcotic** Codeine-AcetaminophenDoxycycline 1,32 x x x Yes Yes Yes Yes Yes Yes Yes AnalgesicsTetracyclines - Narcotic** Hydrocodone-AcetaminophenMinocycline 1,32 x x x Yes Yes Yes Yes Yes Yes Yes AnalgesicsTetracyclines - Narcotic** Hydrocodone-IbuprofenTetracycline 1,32 x x x Yes Yes Yes Yes Yes Yes Yes AnalgesicsUlcer Drugs - Narcotic** MorphineCimetidine 1,3 x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes AnalgesicsUlcer Drugs - Narcotic** OxycodoneEsomeprazole HCl 1,3 x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes AnalgesicsUlcer Drugs - Narcotic** Oxycodone-AcetaminophenFamotidine 1,3 x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Analgesics - Narcotic** Oxycodone-Aspirin 1,3 x x Ulcer Drugs Lansoprazole x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Analgesics - Narcotic** Tapentadol 1,3 x Ulcer Drugs Misoprostol x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Analgesics - Narcotic** Tramadol HCl 1,3 x x Ulcer Drugs Nizatidine x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Analgesics - Narcotic** Tramadol-Acetaminophen 1,3 x x AnalgesicsUlcer Drugs - Non-Narcotic AcetaminophenOmeprazole x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes AnalgesicsUlcer Drugs - Non-Narcotic AspirinPantoprazole x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes AnalgesicsUlcer Drugs - Non-Narcotic CholineRabeprazole - Magnesium Salicylates x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes AnalgesicsUlcer Drugs - Non-Narcotic DiflunisalRanitidine x x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes AnalgesicsUlcer Drugs - Topical CapsaicinSucralfate 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 EffectiveAnalgesics - Topical April 1, 2020 Lidocaine Patch (4% Only) x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Analgesics - Topical Methyl Salicylate x x Yes Yes Yes Yes Yes Yes Yes Yes Yes Antacids Al Hydrox-Mag Trisil-Alginic Acid-Sod Bicarb 4 x x Antacids Al - Mag Hydroxides 4 x x SPECIALAntacids CONSIDERATIONS Al Hydrox-Mag: Carbonate Susp 4 x x 1.Antacids Not to exceed a single sevenAl Hydro-Mag (7) Trisilicateday supply. Chew Tab 4 x x 2.Antacids For the prescribed courseCalcium-Magnesium of therapy. Carbonates 4 x x Antacids Calcium Carbonate 4 x x 3.Antacids Short acting only. Calcium Carbonate - Simethicone 4 x x 4.Antacids As clinically indicated forCalcium causally Carbonate-Mag related Hydro injuries or conditions4 utilizingx x accepted standards of medical care. Antianxiety Agents Alprazolam 1 x Antianxiety Agents Buspirone 1 x **Antiasthmatics Prescriber should considerAclidinium appropriateness Bromide Aerosol Powd of naloxone when prescribingx x opioids. The WCB supports the NYSAntiasthmatics DOH recommendations. Albuterol After Inhal appropriate claimant assessment,x if inx the prescriber’s judgementYes it is Antiasthmatics Albuterol Sulfate x x Yes appropriateAntiasthmatics for the claimantBeclomethasone to obtain Inha. naloxone, the provider shouldx submitx a prior authorizationYes request. Antiasthmatics Budesonide x x Yes health.ny.gov/professionals/ems/policy/13-10.htmAntiasthmatics Budesonide Inhal x x Yes governor.ny.gov/news/governor-cuomo-announces-narcan-now-available-independent-pharmaciesAntiasthmatics Budesonide-Formoterol Fumarate Inh x x Yes REV:Antiasthmatics November 1, 2019 Ciclesonide Inhal x x Yes Page 4 of 4 Antiasthmatics Cromolyn Na Inhal x x Yes Antiasthmatics Epinephrine Inhal x x Yes Antiasthmatics Flunisolide Inhal x x Yes Antiasthmatics Fluticasone Furoate-Vilanterol Inhal x x Yes Antiasthmatics Fluticasone Inhal x x Yes Antiasthmatics Fluticasone-Salmeterol Inhalal x x Yes Antiasthmatics Formoterol Fumarate Soln x x Yes Antiasthmatics Formoterol-Glycopyrrolate x x Yes Antiasthmatics Formoterol/Mometasone x x Yes Antiasthmatics Indacaterol Maleate Inhalal x x Yes Antiasthmatics Ipratropium Bromide Inhal x x Yes Antiasthmatics Ipratropium-Albuterol Inhal x x Yes Antiasthmatics Levalbuterol HCl Inhal x x Yes Antiasthmatics Methacholine Chloride Inhal x x Yes Antiasthmatics Mometasone Furoate Inhal x x Yes Mometasone Furoate-Formoterol Fumarate Antiasthmatics x x Yes Inhal Antiasthmatics Montelukast x x Yes Antiasthmatics Roflumilast x x Yes Antiasthmatics Salmeterol x x Yes Antiasthmatics Terbutaline x x Yes WCB.NY.GOVAntiasthmatics Theophylline x x Yes WCB-drug-formulary-1-v3Antiasthmatics 3-5-20 (Eff.Tiotropium April 1) Bromide Monohydrate Inhal x x Yes Antiasthmatics Tiotropium-Olodaterol x x Page 11 Yes Antiasthmatics Triamcinolone Acetonide Inhal x x Yes Antiasthmatics Umeclidinium-Vilanterol 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 x 2nd 2nd 2nd 2nd Anticonvulsant Clonazepam x Anticonvulsant Divalproex x Anticonvulsant Gabapentin x x x 2nd 2nd 2nd 2nd Anticonvulsant Lamotrigine x x 2nd 2nd 2nd 2nd Anticonvulsant Levetiracetam x Anticonvulsant Oxcarbazepine x x 2nd 2nd 2nd 2nd Anticonvulsant Phenytoin x Anticonvulsant Pregabalin x x 2nd 2nd 2nd 2nd Anticonvulsant Topiramate x x 2nd 2nd 2nd 2nd Anticonvulsant Valproic Acid x Antidepressants Amitriptyline x x Yes Yes Yes Yes Antidepressants Bupropion x 2nd 2nd 2nd 2nd Antidepressants Citalopram 4 x Antidepressants Clomipramine 4 x Antidepressants Desipramine x Yes Yes Yes Yes Antidepressants Desvenlafaxine 4 x Antidepressants Doxepin x Yes Yes Yes Yes Antidepressants Duloxetine x 2nd 2nd 2nd 2nd Antidepressants Escitalopram 4 x Antidepressants Fluoxetine 4 x Antidepressants Fluvoxamine 4 x Antidepressants Imipramine x x Yes Yes Yes Yes Antidepressants Isocarboxazid 4 x Antidepressants Mirtazapine 4 x Antidepressants Nefazodone 4 x Antidepressants Nortriptyline x Yes Yes Yes Yes Antidepressants Paroxetine 4 x Antidepressants Phenelzine 4 x Antidepressants Protriptyline 4 x Antidepressants Sertraline 4 x Antidepressants Tranylcypromine 4 x Antidepressants Trazodone 4 x Antidepressants Trimipramine x Yes Yes Yes Yes Antidepressants Venlafaxine x 2nd 2nd 2nd 2nd

REV: November 1, 2019 Page 1 of 4