MTUS Drug List ( 8 CCR §9792.27.15)

MTUS Drug List ( 8 CCR § 9792.27.15)

✓ ✕ *The Exempt/Non-Exempt MTUS Drug List must be used in conjunction with 1) the MTUS Guidelines, which contain specific treatment recommendations based on condition and phase of treatment and 2) the drug formulary rules. (See 8 CCR §9792.20 - §9792.27.23.) "Reference in Guidelines" indicates guideline topic(s) which discuss the drug. In each guideline there may be conditions for which the drug is Recommended ( ), Not Recommended ( ), or No Recommendation (⦸). Consult guideline to determine the recommendation for the condition to be treated and to assure proper phase of care use.

"Exempt" indicates drug may be prescribed/dispensed without seeking authorization through Prospective Review if in accordance with MTUS. 1) Physician dispensed "Exempt" drugs limited to one 7-day supply at initial visit within seven days of the date of injury without Prospective Review. 2) Prescription/dispensing of Brand name "Exempt"drug where generic is available requires authorization through Prospective Review. "Non-Exempt" or “Unlisted” drug requires authorization through Prospective Review prior to prescribing or dispensing. (See 8 CCR §9792.27.1 through §9792.27.23 for complete rules.) ** Special Fill - Indicates the Non-Exempt drug may be prescribed/dispensed without Prospective Review: 1) Rx at initial visit within 7 days of injury, and 2) Supply not to exceed #days indicated, and 3) is a generic or single source brand, or brand where physician substantiates medical necessity, and 4) if in accord with MTUS. (See 8 CCR § 9792.27.12.) ***Perioperative Fill – Indicates the Non-Exempt drug may be prescribed/dispensed without Prospective Review: 1) Rx issued during the perioperative period (4 days before through 4 days after surgery), and 2) Supply not to exceed #days indicated, and 3) is a generic or single source brand, or brand where physician substantiates medical necessity, and 4) is in accord with MTUS. (See 8 CCR § 9792.27.13.)

Alclometasone Dipropionate Dermatologicals ✓✕ Ankle Chronic and PainFoot Disorders ✓ Metabolic Agents- Non-Exempt 5 EndocrineMisc. and ✕⦸ Hip and Groin Disorders Alendronate Sodium Fosamax ⦸✓ Knee Disorders Low Back Disorders (Bisphosphonate) Non-Exempt ✕ ShoulderChronic Pain 6 Antiparkinson Agents ✕ Amantadine HCL Symmetrel (NMDA receptor 7 Cyclocort Non-Exempt antagonist) ✓ Low Back Disorders Amcinonide Dermatologicals ✓✕ Ankle and Foot Disorders ✓ Chronic Pain ✕ Cervical and Thoracic Spine Disorders Amitriptyline HCL Elavil Non-Exempt 8 ✓✕ Antidepressants ✓⦸ Hip and Groin Disorders (TCAs) ✓✕⦸ Knee Disorders ⦸ Low Back Disorders Norvasc Non-Exempt ✓ 9 Shoulder Calcium Channel ✓ Amlodipine Besylate Antibiotics Hand, Wrist, and Forearm Disorders Exempt Blockers ✓ 10 ✓⦸ Ankle and Foot Disorders Amoxicillin/Clavulanate P Augmentin Analgesics - Anti- Hand, Wrist, and Forearm Disorders 11 Kineret Non-Exempt (Penicillins) ✕ inflammatory Low Back Disorders Anakinra Knee Disorders Apixaban Non-Exempt ✓ 12 ⦸ Ankle and Foot Disorders 14 Days ✓ Eliquis OphthalmicAnticoagulants Agents Hip and Groin Disorders Artificial Tear Ointments Exempt 13 ✓ EyeKnee Disorders Refresh PM (Artificial Tears)

Effective January 1, 2018 1 of 21 MTUS Drug List ( 8 CCR § 9792.27.15)

Reference Brand Unique Drug Ingredient Exempt/Non-Exempt* Special Fill** Peri-Op*** Drug Class Reference in Guidelines Dosage Form Strength Pharmaceutical Name Identifier(s) ✕ ✕ Vitamin C Non-Exempt Vitamins 14 ✓✕⦸ Chronic Ankle and Pain Foot Disorders Cervical and Thoracic Spine Disorders Ascorbic Acid ✕ ✓ Low Back Disorders ✓ ✕ AnkleChronic and Pain Foot Disorders Cervical and Thoracic Spine Disorders Analgesics - ✓ Aspirin Bayer Exempt 15 NonNarcotic ✓✕ ✓ Elbow Disorders ✓ ⦸ Hand, Wrist, and Forearm Disorders ✓ Hip and Groin Disorders ✓ Knee Disorders Low Back Disorders ✕ Shoulder ✕ ✕ ChronicAnkle and Pain Foot Disorders ✕ Cervical and Thoracic Spine Disorders Non-Exempt ✕ 16 ✕ Elbow Disorders Aspirin/Caffeine/Dihydrocodeine Bitartrate Synalgos-DC Analgesics - Opioid ✕ Hand, Wrist, and Forearm Disorders ✕ Hip and Groin Disorders ✕ Knee Disorders Low Back Disorders Antibiotics Zithromax Non-Exempt ✕ Shoulder 17 ✓ Azithromycin Anti-Infective Agents - Hand, Wrist, and Forearm Disorders Bacitracin Exempt (Macrolides) 18 Misc. Ankle and Foot Disorders Ophthalmic Agents ⦸ Hand, Wrist, and Forearm Disorders Bacitracin Ophthalmic AK-Tracin Exempt ✓ Eye 19 Ophthalmic Agents Bacitracin-Polymyxin B Ophthalmic AK-Poly-Bac Exempt 20 (Antibiotics) ✓ Eye ✓✕ (Antibiotics) ✓✕ ✓✕ Cervical and Thoracic Spine Disorders Baclofen Lioresal Non-Exempt Therapy Agents ⦸ Chronic Pain 21 Musculoskeletal ✕ Hip and Groin Disorders 4 Days 4 Days ✓✕ ⦸ Knee Disorders (Muscle Relaxants) ✓✕ Low Back Disorders 22 Becaplermin Non-Exempt ✓ Shoulder

Regranex Exempt OphthalmicDermatologicals Agents ✓ AnkleEye and Foot Disorders 23 Balanced Salt Solution BSS Qvar Non-Exempt ✓ 24 Antiasthmatic and Beclomethasone Dipropionate Work Related Asthma Bronchodilator Agents ✓✕ ✓✕ ✓ ⦸ Ankle and Foot Disorders Cervical and Thoracic Spine Disorders Betamethasone Celestone Non-Exempt ✓✕ 25 ✓✕⦸ Elbow Disorders Corticosteroids ✓ ⦸ Hand, Wrist, and Forearm Disorders ✓✕ Hip and Groin Disorders ✓✕⦸ Knee Disorders ⦸ Low Back Disorders 26 Non-Exempt ✓ ⦸ Shoulder

27 BetamethasoneBetamethasone Dipropionat Valerate DiprosoneValisone Non-Exempt Dermatologicals ✓ Ankle and Foot Disorders Ophthalmic Agents Bromfenac Prolensa Exempt Dermatologicals Ankle and Foot Disorders 28 ✓✕ Eye

Non-Exempt (NSAID) ✓ 29 Antiasthmatic and Budesonide Pulmicort Work Related Asthma Bronchodilator Agents Non-Exempt 30 Antiasthmatic and ✓ Budesonide/Formoterol Symbicort Bronchodilator Agents Work Related Asthma

Effective January 1, 2018 2 of 21 MTUS Drug List ( 8 CCR § 9792.27.15)

Calcium Phosphate Tribasic ⦸ Ankle and Foot Disorders

✓⦸ Cervical and Thoracic Spine Disorders Camphor Bengay Ultra Non-Exempt 40 ✕⦸ Chronic Pain Hand, Wrist, and Forearm Disorders Dermatologicals ⦸ Hip and Groin Disorders ✓⦸ Low Back Disorders ✓⦸ Shoulder ✓ Cervical and Thoracic Spine Disorders Capsaicin Zostrix Exempt ⦸ Chronic Pain 41 Dermatologicals ✓ Hand, Wrist, and Forearm Disorders (Topical creams and ✓ Hip and Groin Disorders ointments) ✓ Low Back Disorders ✓ ⦸ Shoulder ✓✕ Tegretol Non-Exempt 42 Cervical and Thoracic Spine Disorders ⦸ Chronic Pain Carbamazepine Anticonvulsants ✓✕ Ophthalmic Agents ⦸ Low Back Disorders Exempt 43 ✓ Eye Shoulder Carboxymethylcellulose Sodium Ophthalmic Refresh Plus (Artificial Tears)

Effective January 1, 2018 3 of 21 MTUS Drug List ( 8 CCR § 9792.27.15)

Reference Brand Unique Drug Ingredient Exempt/Non-Exempt* Special Fill** Peri-Op*** Drug Class Reference in Guidelines Dosage Form Strength Pharmaceutical Name Identifier(s) ✕ ✕ Chronic Pain ✕ Cervical and Thoracic Spine Disorders Non-Exempt Therapy Agents 44 Musculoskeletal ✕ Hip and Groin Disorders Carisoprodol Soma ✕ Knee Disorders (Muscle Relaxants) ✕ Antibiotics Low Back Disorders Ceftin Exempt 45 ✓ Shoulder Cefuroxime Axetil ✓ (Cephalosporins) Hand, Wrist, and Forearm Disorders ✓ ✓ ⦸Chronic Ankle Painand Foot Disorders Cervical and Thoracic Spine Disorders Analgesics - Anti- ✓✕ Celecoxib Celebrex Exempt 46 ✓✕ ✓ ⦸ Elbow Disorders Inflammatory (NSAID) ✓ ⦸ Hand, Wrist, and Forearm Disorders ✓⦸ Hip and Groin Disorders ✓⦸ Knee Disorders ✓ Low Back Disorders Antibiotics Cephalexin Keflex Exempt ✕ Shoulder 47 ⦸ Ankle and Foot Disorders Hand, Wrist, and Forearm Disorders (Cephalosporins) ✕ Chronic Pain ✕ Non-Exempt 48 ✕ Gastrointestinal Agents Hip and Groin Disorders Certolizumab Pegol Cimzia ✕ (TNF Blocker) Knee Disorders ✕ Low Back Disorders ✕ Chronic Pain ✕ Cervical and Thoracic Spine Disorders Non-Exempt Therapy Agents 49 Musculoskeletal ✕ Hip and Groin Disorders Chlorzoxazone Loxone, Parafon Forte ✕ Knee Disorders (Muscle Relaxants) ✕ Low Back Disorders ✓ Shoulder ✓ ✓ ⦸Chronic Ankle Painand Foot Disorders Cervical and Thoracic Spine Disorders Analgesics - ✓✕ Trilisate Exempt 50 ✓✕ ✓ ⦸ Elbow Disorders Choline Magnesium Trisalicylate NonNarcotic (NSAID) ✓ ⦸ Hand, Wrist, and Forearm Disorders ✓⦸ Hip and Groin Disorders ✓⦸ Knee Disorders Low Back Disorders ✕ Shoulder Non-Exempt 51 ✕⦸ Hand, Wrist, and Forearm Disorders Alternative Medicines Hip and Groin Disorders Chondroitin Sulfate ✕ (OTC nutraceutical) Knee Disorders Alvesco Non-Exempt ✓ Shoulder 52 Antiasthmatic and Ciclesonide Work Related Asthma 53 Ciclopirox Olamine Loprox Non-Exempt Bronchodilator Agents ✓

Dermatologicals ✓ Ankle and Foot Disorders ✓ ✓ Cervical and Thoracic Spine Disorders Tagamet Exempt ✓ Elbow Disorders 54 Hand, Wrist, and Forearm Disorders Ulcer Drugs (H2 ✓ Cimetidine Hip and Groin Disorders receptor blocker) ✓ ✓ Knee Disorders ✓ Low Back Disorders Antibiotics Ciprofloxacin Cipro Exempt ✓ Shoulder 55 Ankle and Foot Disorders Ophthalmic Agents Hand, Wrist, and Forearm Disorders Ciprofloxacin HCL Ophthalmic Ciloxan Exempt (Fluoroquinolones) ✓✕ Eye 56 ✕ (Antibiotics) ✕ ✕ Cervical and Thoracic Spine Disorders Celexa Non-Exempt 57 ✓✕⦸ Chronic Pain Hip and Groin Disorders Citalopram Hydrobromide Antidepressants (SSRI) ✕ ✕ Knee Disorders Low Back Disorders Shoulder

Effective January 1, 2018 4 of 21 MTUS Drug List ( 8 CCR § 9792.27.15)

Reference Brand Unique Drug Ingredient Exempt/Non-Exempt* Special Fill** Peri-Op*** Drug Class Reference in Guidelines Dosage Form Strength Pharmaceutical Name Identifier(s) Antibiotics Clarithromycin Biaxin Non-Exempt 58 ✕ ✓ Anti-Infective(Macrolides) Agents - ✓✕ Hand, Wrist, and Forearm Disorders Cleocin Exempt 59 Misc. ✓ Ankle and Foot Disorders ⦸ Hand, Wrist, and Forearm Disorders Clindamycin HCL ✓ Hip and Groin Disorders ✕ Knee Disorders ✓✕ Chronic Pain ✕ Cervical and Thoracic Spine Disorders Clomipramine HCL Anafranil Non-Exempt 60 ✕ Antidepressants ✕⦸ Hip and Groin Disorders (TCAs) ✕⦸ Knee Disorders ✕ ChronicLow Back Pain Disorders Klonopin Non-Exempt Shoulder 61 ✕ Clonazepam AnticonvulsantsAnalgesics - ✓✕⦸ Low Chronic Back Pain Disorders Non-Exempt 62 NonNarcotic ✕ Shoulder 63 Clonidine HCL Catapres, Duraclon Non-Exempt ✓⦸ Low Back Disorders Clotrimazole Antifungal Lotrimin AF Dermatologicals ✕ Ankle and Foot Disorders ✕ ✕ ChronicAnkle and Pain Foot Disorders ✕ Cervical and Thoracic Spine Disorders Non-Exempt 64 ✕ ✕ Elbow Disorders Codeine Phosphate Analgesics - Opioid ✕ Hand, Wrist, and Forearm Disorders ✕ Hip and Groin Disorders ✕ Knee Disorders Low Back Disorders ✕ Shoulder ✕ ✕ ChronicAnkle and Pain Foot Disorders ✕ Cervical and Thoracic Spine Disorders Non-Exempt 65 ✕ ✕ Elbow Disorders Codeine Sulfate Analgesics - Opioid ✕ Hand, Wrist, and Forearm Disorders ✕ Hip and Groin Disorders ✕ Knee Disorders Low Back Disorders ✕ Shoulder ✕ ✕ ChronicAnkle and Pain Foot Disorders ✕ Cervical and Thoracic Spine Disorders Non-Exempt 66 ✕ ✕ Elbow Disorders Codeine/Acetaminophen Tylenol #3, Tylenol #4 Analgesics - Opioid ✕ Hand, Wrist, and Forearm Disorders ✕ Hip and Groin Disorders ✕ Knee Disorders ✕ Low Back Disorders Colchicine Non-Exempt 67 ✕ Shoulder Cervical and Thoracic Spine Disorders Gout Agents ✓✕ Low Back Disorders ✓✕ ✓✕ Chronic⦸ Ankle Pain and Foot Disorders Cervical and Thoracic Spine Disorders Cortisone Cortone Non-Exempt 68 ✓ ⦸ Elbow Disorders 4 Days Corticosteroids ✕ ✓✕⦸ Hand, Wrist, and Forearm Disorders ✓✕ Hip and Groin Disorders ⦸ Low Back Disorders ⦸ Shoulder Intal Non-Exempt 69 Antiasthmatic and ✓ Cromolyn Sodium Bronchodilator Agents ✓✕ ✕ WorkChronic Related Pain Asthma ✕ Cervical and Thoracic Spine Disorders Non-Exempt Therapy Agents 70 Musculoskeletal ✕ Hip and Groin Disorders Cyclobenzaprine HCL Flexeril 4 Days ✓✕ ⦸ Knee Disorders (Muscle Relaxants) ✓✕ Ophthalmic Agents Low Back Disorders Cyclopentolate HCL Cyclogyl Exempt ✓✕ Eye 71 Shoulder

(Anticholinergics)

Effective January 1, 2018 5 of 21 MTUS Drug List ( 8 CCR § 9792.27.15)

Reference Brand Unique Drug Ingredient Exempt/Non-Exempt* Special Fill** Peri-Op*** Drug Class Reference in Guidelines Dosage Form Strength Pharmaceutical Name Identifier(s) Non-Exempt 72 Dalteparin Fragmin Anticoagulants ✕ ⦸ Ankle and Foot Disorders ✕ Chronic Pain ✕ Cervical and Thoracic Spine Disorders Non-Exempt Therapy Agents 73 Musculoskeletal ✕ Hip and Groin Disorders Dantrolene Sodium Dantrium ✕ Knee Disorders (Muscle Relaxants) ✕ Low Back Disorders ✓✕ Shoulder ✓ Chronic Pain Cervical and Thoracic Spine Disorders Norpramin Non-Exempt 74 ✓✕ Antidepressants Desipramine HCL ✓⦸ Hip and Groin Disorders (TCAs) ✓✕⦸ Knee Disorders ⦸ Low Back Disorders 75 Non-Exempt ✓ Shoulder 76 Desonide DesowenTopicort Non-Exempt Dermatologicals ✓ Ankle and Foot Disorders Desoximetasone Dermatologicals ✕ Ankle and Foot Disorders ✕ Chronic Pain ✕ Cervical and Thoracic Spine Disorders Pristiq Non-Exempt 77 ✕ Antidepressants Desvenlafaxine ER ✓ Hip and Groin Disorders (SNRI) ✕ Knee Disorders ⦸ Low Back Disorders ✓✕ Shoulder ✓✕ ✓✕ ⦸Chronic Ankle Painand Foot Disorders ✓ Cervical and Thoracic Spine Disorders Non-Exempt 78 ✓✕ ✕⦸ Elbow Disorders Dexamethasone 4 Days Decadron Corticosteroids ✓ ⦸ Hand, Wrist, and Forearm Disorders ✓✕ Hip and Groin Disorders ✓✕⦸ Knee Disorders Ophthalmic Agents ⦸ Low Back Disorders Non-Exempt 79 ✕ Eye⦸ Shoulder Dexamethasone Sodium Phosphate Ophthalmic ✓ (Steroid) ✓ Exempt ✓ Cervical and Thoracic Spine Disorders 80 Elbow Disorders Ulcer Drugs (Proton ✓ Dexlansoprazole Dexilant Hand, Wrist, and Forearm Disorders pump inhibitor) ✓ ✓✕ Knee Chronic Disorders Pain Non-Exempt ✕ Shoulder 81 Cough/Cold/Allergy ✓ Dextromethorphan Delsym Antianxiety(NMDA Receptor Agents Low Back Disorders Non-Exempt 82 Antagonist) ✕ ShoulderChronic Pain Diazepam Valium ✓ (Muscle relaxant) ✓ ✓⦸ Ankle and Foot Disorders ✓✕ Cervical and Thoracic Spine Disorders Analgesics - Anti- Exempt ✓✕⦸ Chronic Pain 83 ✓ ⦸ Elbow Disorders Diclofenac Potassium Cataflam, Voltaren ⦸ Hand, Wrist, and Forearm Disorders Inflammatory (NSAID) ✓ ✓⦸ Hip and Groin Disorders ✓⦸ Knee Disorders Low Back Disorders ✓✕ Shoulder

✓ ⦸ Ankle and Foot Disorders ⦸ Cervical and Thoracic Spine Disorders Voltaren 1% gel Exempt ✓ 84 ✓⦸ Chronic Pain Diclofenac Sodium Dermatologicals ✕⦸ Elbow Disorders Hand, Wrist, and Forearm Disorders ⦸ Hip and Groin Disorders Ophthalmic Agents ⦸ Low Back Disorders Voltaren Exempt 85 ✓✕⦸ Shoulder Eye Diclofenac Sodium Ophthalmic (NSAID)

Effective January 1, 2018 6 of 21 MTUS Drug List ( 8 CCR § 9792.27.15)

Reference Brand Unique Drug Ingredient Exempt/Non-Exempt* Special Fill** Peri-Op*** Drug Class Reference in Guidelines Dosage Form Strength Pharmaceutical Name Identifier(s) ✓ ✓ Analgesics - Anti- ✓ Cervical and Thoracic Spine Disorders Arthrotec Exempt Elbow Disorders 86 ✓ ✓ Hand, Wrist, and Forearm Disorders Diclofenac Sodium/Misoprostol Inflammatory (NSAID/ ✓ Hip and Groin Disorders Ulcer drug) ✓ Knee Disorders Antibiotics Low Back Disorders 87 Exempt ✓ Shoulder Dicloxacillin Sodium Dynapen ✓⦸ Ankle and Foot Disorders (Penicillins) ✓ ✓ ⦸Chronic Ankle Painand Foot Disorders ✓✕ Cervical and Thoracic Spine Disorders Analgesics - Anti- Exempt ✓✕ 88 ✓ ⦸ Elbow Disorders Diflunisal Dolobid ⦸ Hand, Wrist, and Forearm Disorders Inflammatory (NSAID) ✓ ✓⦸ Hip and Groin Disorders ✓⦸ Knee Disorders Low Back Disorders ✕ Shoulder ✓✕ Chronic Pain Non-Exempt Cervical and Thoracic Spine Disorders 89 Genitourinary - Misc. ✕ Dimethyl Sulfoxide DMSO (Ointments and topical ✕ ⦸ Hip and Groin Disorders agents) ✓✕ Low Back Disorders ✕ Chronic Pain Cervical and Thoracic Spine Disorders Non-Exempt 90 ✕ Antidepressants ⦸ Hip and Groin Disorders Doxepin HCL Sinequan ✓ (TCAs) ✕⦸ Knee Disorders ⦸ Low Back Disorders ✓ Shoulder ✓ Eye Antibiotics Vibramycin Exempt ✓⦸ Ankle and Foot Disorders 91 ✓ Doxycycline Hand, Wrist, and Forearm Disorders (Tetracyclines) Hip and Groin Disorders ✓✕ ✓ Cervical and Thoracic Spine Disorders Cymbalta Non-Exempt 92 ✓✕⦸ Chronic Pain Antidepressants Duloxetine HCL ✓⦸ Hip and Groin Disorders (SNRI) ✓✕⦸ Knee Disorders ⦸ Low Back Disorders 93 Non-Exempt ✓ ⦸ Shoulder Econazole Nitrate Spectazole Dermatologicals Ankle and Foot Disorders Lovenox Non-Exempt ✓ 94 ⦸ Ankle and Foot Disorders 14 Days ✓ Enoxaparin Sodium AnticoagulantsAntibiotics Hip and Groin Disorders Erythromycin Ery-Tab Non-Exempt ✕ 95 Knee Disorders Ophthalmic Agents Erythromycin Ophthalmic Ointment Ilotycin Exempt ✓✕ Hand, Eye Wrist, and Forearm Disorders 96 (Macrolides) ✕ (Antibiotics) ✕ ✕ Cervical and Thoracic Spine Disorders Escitalopram Oxalate Lexapro Non-Exempt 97 ✓✕⦸ Chronic Pain Hip and Groin Disorders Antidepressants (SSRI) ✕ ✕ Knee Disorders Low Back Disorders ✓ Shoulder ✓ ✓ Cervical and Thoracic Spine Disorders Elbow Disorders Exempt ✓ 98 ✓ Hand, Wrist, and Forearm Disorders Ulcer Drugs (Proton Esomeprazole Magnesium Nexium ✓ Hip and Groin Disorders pump inhibitor) ✓ Knee Disorders Low Back Disorders Shoulder

Effective January 1, 2018 7 of 21 MTUS Drug List ( 8 CCR § 9792.27.15)

Reference Brand Unique Drug Ingredient Exempt/Non-Exempt* Special Fill** Peri-Op*** Drug Class Reference in Guidelines Dosage Form Strength Pharmaceutical Name Identifier(s) ✕ ✕ Ankle and Foot Disorders Analgesics - Anti- ✕ Chronic Pain Cervical and Thoracic Spine Disorders Inflammatory (Proton ✕ Vimovo Non-Exempt 99 ✕ ✕ Elbow Disorders Esomeprazole/Naproxen Pump Inhibitor ✕ Hand, Wrist, and Forearm Disorders /NSAID) ✕ Hip and Groin Disorders ✕ Knee Disorders ✕ ChronicLow Back Pain Disorders Analgesics - Anti- ✕ Shoulder Etanercept Enbrel Non-Exempt 100 ✕ Hip and Groin Disorders Inflammatory (TNF- ✕ Knee Disorders alpha blocker) ✓✕ Chronic Pain Low Back Disorders ✓ Metabolic Agents- Non-Exempt 101 EndocrineMisc. and ✕⦸ Hip and Groin Disorders Etidronate Disodium Didronel ⦸✓ Knee Disorders Low Back Disorders (Bisphosphonate) ✓ Shoulder ✓ ✓⦸ Chronic Ankle Painand Foot Disorders ✓✕ Cervical and Thoracic Spine Disorders Analgesics - Anti- Exempt ✓✕ 102 ✓ ⦸ Elbow Disorders Etodolac Lodine ⦸ Hand, Wrist, and Forearm Disorders Inflammatory (NSAID) ✓ ✓⦸ Hip and Groin Disorders ✓⦸ Knee Disorders Low Back Disorders ✓ Shoulder ✓ ✓ Cervical and Thoracic Spine Disorders Exempt ✓ Elbow Disorders 103 Hand, Wrist, and Forearm Disorders Ulcer Drugs (H2 ✓ Famotidine Pepcid Hip and Groin Disorders receptor blocker) ✓ ✓ Knee Disorders Low Back Disorders ✕ Shoulder ✕ ✕ ChronicAnkle and Pain Foot Disorders Analgesics - Anti- ✕ Cervical and Thoracic Spine Disorders Inflammatory (H2 Non-Exempt ✕ 104 ✕ Elbow Disorders Famotidine/Ibuprofen Duexis Hand, Wrist, and Forearm Disorders Receptor Blocker ✕ Hip and Groin Disorders /NSAID) ✕ ✕ Knee Disorders Low Back Disorders ✓ Shoulder ✓ ✓ ⦸Chronic Ankle Painand Foot Disorders Cervical and Thoracic Spine Disorders Analgesics - Anti- ✓✕ Nalfon Exempt 105 ✓✕ ✓ ⦸ Elbow Disorders Fenoprofen Calcium Inflammatory (NSAID) ✓ ⦸ Hand, Wrist, and Forearm Disorders ✓⦸ Hip and Groin Disorders ✓⦸ Knee Disorders Low Back Disorders ✕ Shoulder ✕ ✕ ChronicAnkle and Pain Foot Disorders ✕ Cervical and Thoracic Spine Disorders Non-Exempt 106 ✕ ✕ Elbow Disorders Fentanyl Duragesic Analgesics - Opioid ✕ Hand, Wrist, and Forearm Disorders ✕ Hip and Groin Disorders ✕ Knee Disorders Low Back Disorders Shoulder

Effective January 1, 2018 8 of 21 MTUS Drug List ( 8 CCR § 9792.27.15)

Fluocinolone Acetonide Synalar Non-Exempt Dermatologicals Ankle and Foot Disorders 111 ✕ Fluocinonide Non-Exempt OphthalmicDermatologicals Agents 112 ✕e ⦸Ey Elbow Disorders Fluorometholone FML ✕ ✓✕ Chronic Pain ✕ Cervical and Thoracic Spine Disorders Non-Exempt 113 ✓✕ Hip and Groin Disorders Fluoxetine HCL Prozac Antidepressants (SSRI) ✕ ✕ Knee Disorders Low Back Disorders ✓ Shoulder ✓ ✓ ⦸Chronic Ankle Painand Foot Disorders ✓✕ Cervical and Thoracic Spine Disorders Analgesics - Anti- Exempt ✓✕ 114 ✓ ⦸ Elbow Disorders Flurbiprofen Ansaid ⦸ Hand, Wrist, and Forearm Disorders Inflammatory (NSAID) ✓ ✓⦸ Hip and Groin Disorders ✓⦸ Knee Disorders Low Back Disorders Shoulder Non-Exempt 115 Antiasthmatic and ✓ Fluticasone Propionate Flovent Bronchodilator Agents 116 Non-Exempt ✓ Work Related Asthma Fluticasone Prop (Topical) Cutivate Dermatologicals Ankle and Foot Disorders Non-Exempt 117 Antiasthmatic and ✓ Fluticasone-Salmeterol Advair Bronchodilator Agents ✕ Work Related Asthma ✕ ✕ Cervical and Thoracic Spine Disorders Non-Exempt 118 ✕⦸ Chronic Pain Hip and Groin Disorders Fluvoxamine Maleate Luvox Antidepressants (SSRI) ✕ ✕ Knee Disorders Low Back Disorders Non-Exempt Hematopoietic Agents ✕ 119 Shoulder Folic Acid Cervical and Thoracic Spine Disorders Arixtra Non-Exempt ✓ 120 ⦸ Ankle and Foot Disorders 14 Days ✓ Fondaparinux Sodium Anticoagulants Hip and Groin Disorders 121 Non-Exempt Knee Disorders Antiasthmatic and ✓ Formoterol Fumarate Foradil Bronchodilator Agents Non-Exempt ✓ Work Related Asthma 122 Antiasthmatic and Formoterol/Mometasone Dulera Work Related Asthma Bronchodilator Agents ✓✕ ✓✕ ✓✕⦸ Cervical and Thoracic Spine Disorders Non-Exempt 123 ✓✕⦸ Chronic Pain ⦸ Hip and Groin Disorders Gabapentin Neurontin 4 Days Anticonvulsants ✓ ✓✕⦸ Knee Disorders ⦸ Low Back Disorders ⦸ Shoulder

Effective January 1, 2018 9 of 21 MTUS Drug List ( 8 CCR § 9792.27.15)

Reference Brand Unique Drug Ingredient Exempt/Non-Exempt* Special Fill** Peri-Op*** Drug Class Reference in Guidelines Dosage Form Strength Pharmaceutical Name Identifier(s) Ophthalmic Agents Exempt 124 ✓✕ Eye Gatifloxacin Zymaxid 125 Exempt (Anti-bacterial) ✓ Ophthalmic Agents Gentamicin (Topical) Exempt Dermatologicals Ankle and Foot Disorders 126 ✓✕ Eye Gentamicin Sulfate Ophthalmic Gentak Ophthalmic Agents Non-Exempt (Anti-bacterial)(Anti- 127 ✕ Eye Gentamicin-Prednisolone Ace Ophthalmic Pred-G bacterial/steroid) ✕ Non-Exempt 128 ✕⦸ Hand, Wrist, and Forearm Disorders Alternative Medicines Hip and Groin Disorders Glucosamine Sulfate ✕ (OTC nutraceutical) Knee Disorders ✕ Chronic Pain Analgesics - Anti- Shoulder ✕ Non-Exempt 129 ✕ Hip and Groin Disorders Golimumab Simponi Inflammatory (TNF- ✕ Knee Disorders alpha blocker) ✕ Non-Exempt ✓ Low Back Disorders 130 ⦸ Ankle and Foot Disorders 14 Days ✓ Heparin Sodium OphthalmicAnticoagulants Agents Hip and Groin Disorders 131 Homatropine HBr Ophthalmic Isopto Homatropine Exempt ✓✕ Knee Eye Disorders ✕ Non-Exempt 132 (Anticholinergics) ✕ Ankle and Foot Disorders Hydrochlorothiazide Microzide Diuretics ✕ Hand, Wrist, and Forearm Disorders ✕ ✕ ChronicAnkle and Pain Foot Disorders ✕ Cervical and Thoracic Spine Disorders Non-Exempt 133 ✕ ✕ Elbow Disorders Hydrocodone Bitartrate Zohydro ER, Hysingla ER Analgesics - Opioid ✕ Hand, Wrist, and Forearm Disorders ✕ Hip and Groin Disorders ✕ Knee Disorders Low Back Disorders ✓✕ Shoulder ✓✕ ✓✕ ChronicAnkle and Pain Foot Disorders ✓✕ Cervical and Thoracic Spine Disorders Non-Exempt 134 ✓✕ ✓ Elbow Disorders Hydrocodone/Acetaminophen 4 Days 4 Days Norco, Vicodin, Xodol Analgesics - Opioid ✓ Hand, Wrist, and Forearm Disorders ✓✕ Hip and Groin Disorders ✓✕ Knee Disorders Low Back Disorders ✕ Shoulder ✕ ✕ ChronicAnkle and Pain Foot Disorders ✕ Cervical and Thoracic Spine Disorders Vicoprofen Non-Exempt 135 ✕ ✕ Elbow Disorders Hydrocodone/Ibuprofen Analgesics - Opioid ✕ Hand, Wrist, and Forearm Disorders ✕ Hip and Groin Disorders ✕ Knee Disorders Low Back Disorders ✓✕ Shoulder ✓✕ ✓✕ ChronicAnkle and Pain Foot Disorders Cervical and Thoracic Spine Disorders Cortef Non-Exempt 136 ✓✕ ✕⦸ Elbow Disorders Hydrocortisone 4 Days Corticosteroids ⦸ Hand, Wrist, and Forearm Disorders ✓✕ Hip and Groin Disorders ⦸✓✕ Knee Disorders ⦸ Low Back Disorders 137 Non-Exempt ✓ ⦸ Shoulder

138 Hydrocortisone (Topical) Non-Exempt Dermatologicals ✓ Ankle and Foot Disorders

Hydrocortisone Valerate Westcort Dermatologicals Ankle and Foot Disorders

Effective January 1, 2018 10 of 21 MTUS Drug List ( 8 CCR § 9792.27.15)

145 Itraconazole Sporanox Non-Exempt Antifungals ✓Ankle and Foot Disorders

Ketoconazole Nizoral Dermatologicals ✓Ankle and Foot Disorders ✓ ✓ ⦸Chronic Ankle Painand Foot Disorders Cervical and Thoracic Spine Disorders Analgesics - Anti- ✓✕ Ketoprofen Exempt 146 ✓✕ ✓ ⦸ Elbow Disorders Oruvail Inflammatory (NSAID) ✓ ⦸ Hand, Wrist, and Forearm Disorders ✓⦸ Hip and Groin Disorders ✓⦸ Knee Disorders Low Back Disorders ✕ Shoulder ✕ ✕ ChronicAnkle and Pain Foot Disorders Cervical and Thoracic Spine Disorders Analgesics - Anti- ✕ 147 Ketorolac Tromethamine Non-Exempt ✕ ✕ Elbow Disorders Inflammatory (NSAID) ✕ Hand, Wrist, and Forearm Disorders ✕ Hip and Groin Disorders ✕ Knee Disorders Ophthalmic Agents Low Back Disorders 148 Ketorolac Tromethamine Ophthalmic Exempt ✓✕ Shoulder Eye Acular ✓ (NSAID) ✕ Lamotrigine Lamictal Non-Exempt 149 Cervical and Thoracic Spine Disorders ⦸ Chronic Pain Anticonvulsants ✕ ⦸ Low Back Disorders Shoulder

Effective January 1, 2018 11 of 21 MTUS Drug List ( 8 CCR § 9792.27.15)

Reference Brand Unique Drug Ingredient Exempt/Non-Exempt* Special Fill** Peri-Op*** Drug Class Reference in Guidelines Dosage Form Strength Pharmaceutical Name Identifier(s) ✓ ✓ ✓ Cervical and Thoracic Spine Disorders Exempt ✓ Elbow Disorders 150 Hand, Wrist, and Forearm Disorders Ulcer Drugs (Proton ✓ Lansoprazole Prevacid Hip and Groin Disorders pump inhibitor) ✓ ✓ Knee Disorders Low Back Disorders Shoulder Exempt ✓ 151 Antiasthmatic and Levalbuterol Xopenex Work Related Asthma Bronchodilator Agents ✕ Levetiracetam Keppra Non-Exempt 152 ✕⦸ Chronic Pain Anticonvulsants ✓⦸ Low Back Disorders Antibiotics ✓✕ Shoulder Levofloxacin Exempt 153 ✓ Ankle and Foot Disorders Hand, Wrist, and Forearm Disorders Levaquin (Fluoroquinolones)Ophthalmic Agents Hip and Groin Disorders Exempt 154 ✓✕ Eye Levofloxacin Ophthalmic Solution Quixin ✕ (Anti-bacterial) ✕ Chronic Pain ✕ Cervical and Thoracic Spine Disorders Levomilnacipran Non-Exempt 155 ✕ Antidepressants Hip and Groin Disorders Fetzima ✓ (SNRI) ✕ Knee Disorders ⦸ Low Back Disorders ✕ Shoulder ✕ ✕ ChronicAnkle and Pain Foot Disorders ✕ Cervical and Thoracic Spine Disorders Levorphanol Tartrate Non-Exempt ✕ 156 ✕ Elbow Disorders Levo-Dromoran Analgesics - Opioid ✕ Hand, Wrist, and Forearm Disorders ✕ Hip and Groin Disorders ✕ Knee Disorders Low Back Disorders ✓ Shoulder ✕ ✓⦸ Ankle and Foot Disorders Non-Exempt Cervical and Thoracic Spine Disorders 157 ✓⦸ Chronic Pain Lidocaine Lidoderm Dermatologicals ✕⦸ Elbow Disorders ✕ Hand, Wrist, and Forearm Disorders ⦸ Hip and Groin Disorders 158 Non-Exempt ✕⦸ Low Back Disorders

Lidocaine HCl Dermatologicals ✕ Cervical and Thoracic Spine Disorders ✕ ✓ Cervical and Thoracic Spine Disorders Emla Non-Exempt 159 ✕⦸ Chronic Pain Hand, Wrist, and Forearm Disorders Lidocaine/Prilocaine Dermatologicals ✕ ⦸ Hip and Groin Disorders Low Back Disorders Ativan Non-Exempt Antianxiety Agents ✓ 160 ⦸ Shoulder Ophthalmic Agents Lorazepam Alrex Non-Exempt Ankle and Foot Disorders 161 ✕ Eye Loteprednol Etabonate Ophthalmic ✕ (Steroid) ✓✕ Chronic Pain ✕ Cervical and Thoracic Spine Disorders Maprotiline HCL Non-Exempt 162 ✕ Antidepressants ⦸ Hip and Groin Disorders Ludiomil ✕ (TCAs) ✕⦸ Knee Disorders Low Back Disorders Shoulder

Effective January 1, 2018 12 of 21 MTUS Drug List ( 8 CCR § 9792.27.15)

Reference Brand Unique Drug Ingredient Exempt/Non-Exempt* Special Fill** Peri-Op*** Drug Class Reference in Guidelines Dosage Form Strength Pharmaceutical Name Identifier(s) ✓ ✓ ✓ ⦸Chronic Ankle Painand Foot Disorders Cervical and Thoracic Spine Disorders Analgesics - Anti- ✓✕ Meclomen Exempt 163 ✓✕ ✓ ⦸ Elbow Disorders Meclofenamate Sodium Inflammatory (NSAID) ✓ ⦸ Hand, Wrist, and Forearm Disorders ✓⦸ Hip and Groin Disorders ✓⦸ Knee Disorders Low Back Disorders ✓ Shoulder ✓ ✓ ⦸Chronic Ankle Painand Foot Disorders Cervical and Thoracic Spine Disorders Analgesics - Anti- ✓✕ Ponstel Exempt 164 ✓✕ ✓ ⦸ Elbow Disorders Mefenamic Acid Inflammatory (NSAID) ✓ ⦸ Hand, Wrist, and Forearm Disorders ✓⦸ Hip and Groin Disorders ✓⦸ Knee Disorders Low Back Disorders ✓ Shoulder ✓ ✓ ⦸Chronic Ankle Painand Foot Disorders Cervical and Thoracic Spine Disorders Analgesics - Anti- ✓✕ Meloxicam Mobic Exempt 165 ✓✕ ✓ ⦸ Elbow Disorders Inflammatory (NSAID) ✓ ⦸ Hand, Wrist, and Forearm Disorders ✓⦸ Hip and Groin Disorders ✓⦸ Knee Disorders Low Back Disorders Shoulder ✕ Chronic Pain Memantine HCL Non-Exempt PsychotherapeuticMisc. and 166 Neurological Agents - ✕ Namenda Low Back Disorders (NDMA Receptor Antagonist) ⦸ Ankle and Foot Disorders Menthol Non-Exempt ⦸ Cervical and Thoracic Spine Disorders 167 ✓ ✕⦸ Chronic Pain Bengay Ultra, Biofreeze Dermatologicals Hand, Wrist, and Forearm Disorders ⦸ Hip and Groin Disorders ⦸ Low Back Disorders ✕ ⦸ Shoulder ✕ ✕ ChronicAnkle and Pain Foot Disorders ✕ Cervical and Thoracic Spine Disorders Non-Exempt 168 ✕ ✕ Elbow Disorders Meperidine HCL Demerol Analgesics - Opioid ✕ Hand, Wrist, and Forearm Disorders ✕ Hip and Groin Disorders ✕ Knee Disorders Low Back Disorders ✕ Shoulder ✕ Chronic Pain ✕ Cervical and Thoracic Spine Disorders Metaxalone Non-Exempt Therapy Agents 169 Musculoskeletal ✕ Hip and Groin Disorders Skelaxin ✕ Knee Disorders (Muscle Relaxants) ✕ Low Back Disorders ✕ Shoulder ✕ ✕ ChronicAnkle and Pain Foot Disorders ✕ Cervical and Thoracic Spine Disorders Non-Exempt 170 ✕ ✕ Elbow Disorders Methadone HCL Dolophine Analgesics - Opioid ✕ Hand, Wrist, and Forearm Disorders ✕ Hip and Groin Disorders ✕ Knee Disorders Low Back Disorders Shoulder

Effective January 1, 2018 13 of 21 MTUS Drug List ( 8 CCR § 9792.27.15)

Reference Brand Unique Drug Ingredient Exempt/Non-Exempt* Special Fill** Peri-Op*** Drug Class Reference in Guidelines Dosage Form Strength Pharmaceutical Name Identifier(s) ✕ ✕ Chronic Pain ✕ Cervical and Thoracic Spine Disorders Methocarbamol Non-Exempt Therapy Agents 171 Musculoskeletal ✕ Hip and Groin Disorders Robaxin ✕ Knee Disorders (Muscle Relaxants) ✕ Low Back Disorders Shoulder ✓⦸ Cervical and Thoracic Spine Disorders Bengay Ultra Non-Exempt 172 ✕⦸ Chronic Pain Hand, Wrist, and Forearm Disorders Methyl Salicylate Dermatologicals ⦸ Hip and Groin Disorders ⦸ Low Back Disorders ⦸✓✕ Shoulder ✓✕ ✓✕ ChronicAnkle and Pain Foot Disorders Cervical and Thoracic Spine Disorders Non-Exempt 173 ✓ ✕⦸ Elbow Disorders Methylprednisolone 4 Days Medrol Corticosteroids ✓✕⦸ Hand, Wrist, and Forearm Disorders ✓✕ Hip and Groin Disorders ✓ ⦸ Low Back Disorders ⦸ Shoulder Chemicals (OTC Non-Exempt Work Related Asthma 174 ⦸ Hip and Groin Disorders Methylsulfonylmethane ⦸ Knee Disorders nutraceuticals) 175 Exempt ⦸✓ Shoulder

Metronidazole Anti-InfectiveDermatologicals Agents - Ankle and Foot Disorders Exempt ✓ 176 Misc. Metronidazole Oral Flagyl Hand, Wrist, and Forearm Disorders 177 Micatin Non-Exempt ✓

Miconazole Nitrate Dermatologicals ✕ Ankle and Foot Disorders ✕ Chronic Pain ✕ Cervical and Thoracic Spine Disorders Milnacipran Non-Exempt 178 PsychotherapeuticMisc. (Anti- and ✕ Neurological Agents - Hip and Groin Disorders Savella ✓ ✕ Knee Disorders depressant)Antibiotics ⦸ Low Back Disorders 179 Minocycline HCl Minocin Non-Exempt ✓ Shoulder ✓⦸ Ankle and Foot Disorders (Tetracyclines) ✓ ✓ Cervical and Thoracic Spine Disorders Misoprostol Cytotec Exempt ✓ Elbow Disorders 180 ✓ Hand, Wrist, and Forearm Disorders Ulcer Drugs ✓ Hip and Groin Disorders ✓ Knee Disorders Low Back Disorders 181 Elocon Non-Exempt ✓ Shoulder

Mometasone Furoate (Topical) Dermatologicals Ankle and Foot Disorders Asmanex Non-Exempt 182 Antiasthmatic and ✓ Mometasone Furoate Bronchodilator Agents Non-Exempt Work Related Asthma 183 Antiasthmatic and ✓ Montelukast Sodium Singluair Bronchodilator Agents ✓✕ Work Related Asthma ✓✕ ✓✕ ChronicAnkle and Pain Foot Disorders ✓✕ Cervical and Thoracic Spine Disorders Non-Exempt 184 ✓✕ ✓ Elbow Disorders Morphine Sulfate 4 Days 4 Days Analgesics - Opioid ✓ Hand, Wrist, and Forearm Disorders ✓✕ Hip and Groin Disorders ✓✕ Knee Disorders Low Back Disorders Shoulder

Effective January 1, 2018 14 of 21 MTUS Drug List ( 8 CCR § 9792.27.15)

189 Bactroban Exempt (Antibiotics) ✓ Mupirocin Dermatologicals ✓Ankle and Foot Disorders ✓ ✓ ⦸Chronic Ankle Painand Foot Disorders ✓✕ Cervical and Thoracic Spine Disorders Analgesics - Anti- Exempt ✓✕ 190 ✓ ⦸ Elbow Disorders Nabumetone Relafen ⦸ Hand, Wrist, and Forearm Disorders Inflammatory (NSAID) ✓ ✓⦸ Hip and Groin Disorders ✓⦸ Knee Disorders Low Back Disorders ✕ Shoulder ✓✕ Chronic Pain N-Acetyl-L-Cysteine NAC Non-Exempt 191 ✕ Cervical and Thoracic Spine Disorders Nutrients ✕ ⦸ Hip and Groin Disorders ✓ Low Back Disorders ✓✕ ✓ ⦸Chronic Ankle Painand Foot Disorders ✓✕ Cervical and Thoracic Spine Disorders Analgesics - Anti- Naproxen Exempt ✓✕ 192 ✓ ⦸ Elbow Disorders Aleve, Naprosyn ⦸ Hand, Wrist, and Forearm Disorders Inflammatory (NSAID) ✓ ✓⦸ Hip and Groin Disorders ✓⦸ Knee Disorders ⦸ Low Back Disorders Non-Exempt ⦸ Shoulder 193

194 Neomycin/PolymyxinNeomycin Sulfate B/Bacitracin Neosporin Exempt Dermatologicals ⦸✓ Hand, Wrist, and Forearm Disorders Ophthalmic Agents Neomycin/Bacitracin/Polymyxin B Ophthalmic Neosporin Exempt Dermatologicals Ankle and Foot Disorders 195 ✓✕ Eye Ophthalmic Agents Neosporin Exempt ✓ Eye 196 (Anti-bacterial) Ophthalmic Agents Neomycin/Polymyxin B/Gramicidin Ophthalmic Nevanac Exempt ✓✕ Eye 197 (Anti-bacterial) Nepafenac Ophthalmic Suspension Non-Exempt 198 (NSAID) ✓ Calcium Channel Nifedipine Procardia Antianginal Agents Non-Exempt Blockers ✓ Hand, Wrist, and Forearm Disorders 199 Nitroglycerin Transdermal Nitro-Dur (Glyceril trinitrate ⦸ Ankle and Foot Disorders patches) ⦸ Shoulder

Effective January 1, 2018 15 of 21 MTUS Drug List ( 8 CCR § 9792.27.15)

Reference Brand Unique Drug Ingredient Exempt/Non-Exempt* Special Fill** Peri-Op*** Drug Class Reference in Guidelines Dosage Form Strength Pharmaceutical Name Identifier(s) ✓ ✓ ✓ Cervical and Thoracic Spine Disorders Exempt ✓ Elbow Disorders 200 Hand, Wrist, and Forearm Disorders Ulcer Drugs (H2 ✓ Nizatidine Axid Hip and Groin Disorders receptor blocker) ✓ ✓ Knee Disorders ✓✕ Low Back Disorders ✓ ChronicShoulder Pain Cervical and Thoracic Spine Disorders Nortriptyline HCL Pamelor Non-Exempt 201 ✓✕ Antidepressants ✓⦸ Hip and Groin Disorders (TCAs) ✓✕⦸ Knee Disorders ⦸ Low Back Disorders 202 Nystatin/Triamcinolone Mycolog II Non-Exempt ✓ Shoulder Ophthalmic Agents Exempt Dermatologicals ✓✕Ankle Eye and Foot Disorders 203 Ofloxacin Ophthalmic Solution Ocuflox ✓ (Anti-bacterial) ✓ ✓ Cervical and Thoracic Spine Disorders Prilosec Exempt ✓ Elbow Disorders 204 Hand, Wrist, and Forearm Disorders Ulcer Drugs (Proton ✓ Omeprazole Hip and Groin Disorders pump inhibitor) ✓ ✓ Knee Disorders ✕ Low Back Disorders ✕ ShoulderChronic Pain ✕ Cervical and Thoracic Spine Disorders Norflex Non-Exempt Therapy Agents 205 Musculoskeletal ✕ Hip and Groin Disorders Orphenadrine Citrate ✕ Knee Disorders (Muscle Relaxants) ✕ Low Back Disorders ✓ Shoulder ✓ ✓ ⦸Chronic Ankle Painand Foot Disorders Cervical and Thoracic Spine Disorders Analgesics - Anti- ✓✕ Exempt 206 ✓✕ ✓ ⦸ Elbow Disorders Oxaprozin Daypro Inflammatory (NSAID) ✓ ⦸ Hand, Wrist, and Forearm Disorders ✓⦸ Hip and Groin Disorders ✓⦸ Knee Disorders ✓ Low Back Disorders ✕ Shoulder Trileptal Non-Exempt 207 Cervical and Thoracic Spine Disorders ⦸ Chronic Pain Oxcarbazepine Anticonvulsants ✕ ⦸ Low Back Disorders ✓✕ Shoulder ✓✕ ✓✕ ChronicAnkle and Pain Foot Disorders ✓✕ Cervical and Thoracic Spine Disorders Non-Exempt ✓✕ 208 ✓ Elbow Disorders Oxycodone HCL OxyContin, Roxicodone 4 Days 4 Days Analgesics - Opioid ✓ Hand, Wrist, and Forearm Disorders ✓✕ Hip and Groin Disorders ✓✕ Knee Disorders Low Back Disorders ✓✕ Shoulder ✓✕ ✓✕ ChronicAnkle and Pain Foot Disorders ✓✕ Cervical and Thoracic Spine Disorders Percocet Non-Exempt ✓✕ 209 ✓ Elbow Disorders Oxycodone/Acetaminophen 4 days 4 days Analgesics - Opioid ✓ Hand, Wrist, and Forearm Disorders ✓✕ Hip and Groin Disorders ✓✕ Knee Disorders Low Back Disorders Shoulder

Effective January 1, 2018 16 of 21 MTUS Drug List ( 8 CCR § 9792.27.15)

Reference Brand Unique Drug Ingredient Exempt/Non-Exempt* Special Fill** Peri-Op*** Drug Class Reference in Guidelines Dosage Form Strength Pharmaceutical Name Identifier(s) ✕ ✕ ✕ ChronicAnkle and Pain Foot Disorders ✕ Cervical and Thoracic Spine Disorders Non-Exempt 210 ✕ ✕ Elbow Disorders Oxycodone/Aspirin Percodan Analgesics - Opioid ✕ Hand, Wrist, and Forearm Disorders ✕ Hip and Groin Disorders ✕ Knee Disorders Low Back Disorders ✕ Shoulder ✕ ✕ ChronicAnkle and Pain Foot Disorders ✕ Cervical and Thoracic Spine Disorders Non-Exempt 211 ✕ ✕ Elbow Disorders Oxycodone/Ibuprofen Combunox Analgesics - Opioid ✕ Hand, Wrist, and Forearm Disorders ✕ Hip and Groin Disorders ✕ Knee Disorders Low Back Disorders ✕ Shoulder ✕ ✕ ChronicAnkle and Pain Foot Disorders ✕ Cervical and Thoracic Spine Disorders Oxymorphone HCL Non-Exempt 212 ✕ ✕ Elbow Disorders Opana, Opana ER Analgesics - Opioid ✕ Hand, Wrist, and Forearm Disorders ✕ Hip and Groin Disorders ✕ Knee Disorders Low Back Disorders ✓ Shoulder ✓ ✓ Cervical and Thoracic Spine Disorders Protonix Exempt ✓ Elbow Disorders 213 Hand, Wrist, and Forearm Disorders Ulcer Drugs (Proton ✓ Pantoprazole Sodium Hip and Groin Disorders pump inhibitor) ✓ ✓ Knee Disorders Low Back Disorders ✕ Shoulder ✕ ✕ Cervical and Thoracic Spine Disorders Paroxetine HCL Paxil Non-Exempt 214 ✓✕⦸ Chronic Pain Hip and Groin Disorders Antidepressants (SSRI) ✕ ✕ Knee Disorders Antibiotics Low Back Disorders Non-Exempt 215 ✕ Shoulder Penicillin V Potassium ✕ (Penicillins) Hand, Wrist, and Forearm Disorders ✕ ✕ ChronicAnkle and Pain Foot Disorders ✕ Cervical and Thoracic Spine Disorders Non-Exempt ✕ 216 ✕ Elbow Disorders Pentazocine/Naloxone HCL Talwin NX Analgesics - Opioid ✕ Hand, Wrist, and Forearm Disorders ✕ Hip and Groin Disorders ✕ Knee Disorders Low Back Disorders ✕ Shoulder Phenytoin Non-Exempt 217 ✕⦸ Chronic Pain Dilantin Anticonvulsants ⦸ Low Back Disorders ✕ Shoulder ✕ ✕ ChronicAnkle and Pain Foot Disorders Cervical and Thoracic Spine Disorders Analgesics - Anti- ✕ Piroxicam Non-Exempt 218 ✕ ✕ Elbow Disorders Feldene Inflammatory (NSAID) ✕ Hand, Wrist, and Forearm Disorders ✕ Hip and Groin Disorders ✕ Knee Disorders Ophthalmic Agents Low Back Disorders Polymyxin B-Trimethoprim Polytrim Exempt 219 ✓✕ Shoulder Eye

220 Non-Exempt (Anti-bacterial) ✓ Prednicarbate Dermatop Dermatologicals Ankle and Foot Disorders

Effective January 1, 2018 17 of 21 MTUS Drug List ( 8 CCR § 9792.27.15)

Reference Brand Unique Drug Ingredient Exempt/Non-Exempt* Special Fill** Peri-Op*** Drug Class Reference in Guidelines Dosage Form Strength Pharmaceutical Name Identifier(s) ✓✕ ✓✕ ✓✕ ChronicAnkle and Pain Foot Disorders Cervical and Thoracic Spine Disorders Non-Exempt 221 ✓ ✕⦸ Elbow Disorders Prednisolone 4 Days Orapred Corticosteroids ✓✕⦸ Hand, Wrist, and Forearm Disorders ✓✕ Hip and Groin Disorders ✓ ⦸ Low Back Disorders Ophthalmic Agents ⦸ Shoulder Non-Exempt 222 ✕ WorkEye Related Asthma Prednisolone Acetate Pred Forte, Pred Mild ✓✕ (Steroid) ✓✕ ✓✕ ChronicAnkle and Pain Foot Disorders Cervical and Thoracic Spine Disorders Non-Exempt 223 ✓ ✕⦸ Elbow Disorders Prednisone 4 Days Sterapred Corticosteroids ✓✕⦸ Hand, Wrist, and Forearm Disorders ✓✕ Hip and Groin Disorders ✓ ⦸ Low Back Disorders ⦸ Shoulder ✓✕ Work Related Asthma Pregabalin Lyrica Non-Exempt 224 ✓⦸ Cervical and Thoracic Spine Disorders ⦸ Chronic Pain Anticonvulsants ✓✕ Ophthalmic Agents ⦸ Low Back Disorders Proparacaine HCL Alcaine Exempt 225 ✓ Eye⦸ Shoulder ✓ Chronic Pain Protriptyline HCL Non-Exempt 226 (Anesthetic) ✕ Antidepressants ✓ (TCAs) Knee Disorders ✓ ✓ Cervical and Thoracic Spine Disorders Aciphex Exempt ✓ Elbow Disorders 227 Hand, Wrist, and Forearm Disorders Ulcer Drugs (Proton ✓ Rabeprazole Sodium Hip and Groin Disorders pump inhibitor) ✓ ✓ Knee Disorders ✓ Low Back Disorders ✓ Shoulder ✓ Cervical and Thoracic Spine Disorders Zantac Exempt ✓ Elbow Disorders 228 Hand, Wrist, and Forearm Disorders Ulcer Drugs (H2 ✓ Ranitidine HCL Hip and Groin Disorders receptor blocker) ✓ ✓ Knee Disorders Low Back Disorders ✕ Non-Exempt Shoulder 229 ✕ Ophthalmic Agents Ankle and Foot Disorders Regular Insulin HumulinVexol R Non-Exempt Antidiabetics 230 ✕ EyeHand, Wrist, and Forearm Disorders Rimexolone Ophthalmic ✓✕ Chronic Pain (Steroid) ✓ Metabolic Agents- Actonel Non-Exempt 231 EndocrineMisc. and ✕⦸ Hip and Groin Disorders Risedronate Sodium ⦸✓ Knee Disorders Low Back Disorders (Bisphosphonate) Non-Exempt ✓ Shoulder 232 ⦸ Ankle and Foot Disorders 14 Days ✓ Rivaroxaban Xarelto Anticoagulants Hip and Groin Disorders Non-Exempt ✓ Knee Disorders 233 Antiasthmatic and Salmeterol Serevent Work Related Asthma Bronchodilator Agents ✓ ✓ ✓ ⦸Chronic Ankle Painand Foot Disorders Cervical and Thoracic Spine Disorders Analgesics - ✓✕ Exempt 234 ✓✕ ✓ ⦸ Elbow Disorders Salsalate Disalcid NonNarcotic (NSAID) ✓ ⦸ Hand, Wrist, and Forearm Disorders ✓⦸ Hip and Groin Disorders ✓⦸ Knee Disorders Low Back Disorders Shoulder

Effective January 1, 2018 18 of 21 MTUS Drug List ( 8 CCR § 9792.27.15)

Reference Brand Unique Drug Ingredient Exempt/Non-Exempt* Special Fill** Peri-Op*** Drug Class Reference in Guidelines Dosage Form Strength Pharmaceutical Name Identifier(s) ✕ ✕ ✕ Cervical and Thoracic Spine Disorders Zoloft Non-Exempt 235 ✓✕⦸ Chronic Pain Hip and Groin Disorders Sertraline HCL Antidepressants (SSRI) ✕ ✕ Knee Disorders Low Back Disorders Non-Exempt 236 Shoulder Silver Sulfadiazine Silvadene Exempt OphthalmicDermatologicals Agents 237 e⦸✓ Ey Hand, Wrist, and Forearm Disorders Ophthalmic Agents Sodium Chloride Ophthalmic Bleph-10 Exempt ✓ Eye 238 Sodium Sulfacetamide ✓ (Anti-bacterial) ✓ ✓ Cervical and Thoracic Spine Disorders Carafate Exempt 239 ✓ Elbow Disorders Hip and Groin Disorders Sucralfate Ulcer Drugs ✓ ✓ Knee Disorders Ophthalmic Agents Low Back Disorders Non-Exempt (Anti- Shoulder 240 ✕ Eye Sulfacetamide Sodium/Prednisolone Blephamide ✓ Anti-Infective Agents - Bactrim Exempt bacterial/steroid) ✓✕ 241 Misc. ⦸ Ankle and Foot Disorders Sulfamethoxazole/Trimethoprim ⦸ Hand, Wrist, and Forearm Disorders ✓ ✓ ✓ ⦸Chronic Ankle Painand Foot Disorders Cervical and Thoracic Spine Disorders Analgesics - Anti- ✓✕ Clinoril Exempt 242 ✓✕ ✓ ⦸ Elbow Disorders Sulindac Inflammatory (NSAID) ✓ ⦸ Hand, Wrist, and Forearm Disorders ✓⦸ Hip and Groin Disorders ✓⦸ Knee Disorders Low Back Disorders 243 Protopic Non-Exempt ✓ Shoulder Tacrolimus Dermatologicals ✕ Ankle and Foot Disorders ✕ ✕ ChronicAnkle and Pain Foot Disorders ✕ Cervical and Thoracic Spine Disorders Non-Exempt 244 ✕ ✕ Elbow Disorders Tapentadol Nucynta Analgesics - Opioid ✕ Hand, Wrist, and Forearm Disorders ✕ Hip and Groin Disorders ✕ Knee Disorders Low Back Disorders 245 Terbinafine HCl Lamisil Non-Exempt ✓ Shoulder 246 Lamisil Non-Exempt Antifungals ✓ Ankle and Foot Disorders Ophthalmic Agents TerbinafineTetracaine HCl HCL(Topical) Tetcaine Exempt Dermatologicals 247 ✓ EyeAnkle and Foot Disorders Tetracycline HCL Exempt Tetracyclines ✓ Eye 248 (Anesthetic) ✕ Chronic Pain Non-Exempt 249 ✕ Thalidomide Thalomid Assorted Classes Theophylline Non-Exempt ✓ Low Back Disorders 250 Antiasthmatic and Theo-24, Theo-Dur Work Related Asthma Bronchodilator Agents ✕ Tiagabine HCL Non-Exempt 251 ✕⦸ Chronic Pain Gabitril Anticonvulsants ⦸ Low Back Disorders ✓✕ Shoulder ✓✕ Chronic Pain ✓✕ Cervical and Thoracic Spine Disorders Zanaflex Non-Exempt Therapy Agents 252 Musculoskeletal ✕ Tizanidine HCL 4 days ✓✕ Hip and Groin Disorders ⦸ Knee Disorders (Muscle Relaxants) ✓✕ Low Back Disorders Shoulder

Effective January 1, 2018 19 of 21 MTUS Drug List ( 8 CCR § 9792.27.15)

Reference Brand Unique Drug Ingredient Exempt/Non-Exempt* Special Fill** Peri-Op*** Drug Class Reference in Guidelines Dosage Form Strength Pharmaceutical Name Identifier(s) Ophthalmic Agents Tobramycin Ophthalmic Tobrex Exempt 253 ✓✕ Eye Ophthalmic Agents Non-Exempt (Anti-bacterial)(Anti- 254 ✕ Eye Tobramycin/Dexamethasone Tobradex 255 Tolnaftate Tinactin Non-Exempt bacterial/steroid) ✓ Dermatologicals ✓ Ankle and Foot Disorders ✓ ✓ ⦸Chronic Ankle Painand Foot Disorders Cervical and Thoracic Spine Disorders Analgesics - Anti- ✓✕ Tolectin Exempt 256 ✓✕ ✓ ⦸ Elbow Disorders Tolmetin Sodium Inflammatory (NSAID) ✓ ⦸ Hand, Wrist, and Forearm Disorders ✓⦸ Hip and Groin Disorders ✓⦸ Knee Disorders Low Back Disorders ✓✕ Shoulder ✕ ✕ Cervical and Thoracic Spine Disorders Topiramate Topamax Non-Exempt 257 ✕⦸ Chronic Pain ⦸ Hip and Groin Disorders Anticonvulsants ✓ ✕⦸ Knee Disorders ⦸ Low Back Disorders ✓✕ ⦸ Shoulder ✓✕ ✓✕ ChronicAnkle and Pain Foot Disorders ✓✕ Cervical and Thoracic Spine Disorders Non-Exempt 258 ✓✕ ✓ Elbow Disorders Tramadol HCL 4 Days 4 Days Ultram, Ultram ER Analgesics - Opioid ✓ Hand, Wrist, and Forearm Disorders ✓✕ Hip and Groin Disorders ✓✕ Knee Disorders Low Back Disorders ✓✕ Shoulder ✓✕ ✓✕ ChronicAnkle and Pain Foot Disorders ✓✕ Cervical and Thoracic Spine Disorders Ultracet Non-Exempt 259 ✓✕ ✓ Elbow Disorders Tramadol HCL/AC 4 Days 4 Days Analgesics - Opioid ✓ Hand, Wrist, and Forearm Disorders ✓✕ Hip and Groin Disorders ✓✕ Knee Disorders ✕ Low Back Disorders ✕ Chronic Shoulder Pain ✕ Cervical and Thoracic Spine Disorders Non-Exempt 260 ✕ Hip and Groin Disorders Trazodone HCL Desyrel, Oleptro Antidepressants (SSRI) ✕ ✕ Knee Disorders Low Back Disorders 261 Non-Exempt ✓ Shoulder Triamcinolone Acetonide I Arthricream Non-Exempt Dermatologicals ✓ 262 Ankle and Foot Disorders Ophthalmic Agents Trolamine Salicylate Exempt Dermatologicals Hand, Wrist, and Forearm Disorders 263 ✓✕ Eye Tropicamide Ophthalmic Mydriacyl Chemicals (Proteolytic Trypsin Non-Exempt (Anticholinergics) 264 ✕ enzyme) ✕ Non-Exempt Ankle and Foot Disorders 265 ⦸ Chronic Pain Depakote, Depakene, ✕ Valproic Acid Anticonvulsants ⦸ Low Back Disorders Depacon ✓✕ Shoulder ✓ Cervical and Thoracic Spine Disorders Venlafaxine HCL Effexor Non-Exempt 266 ✓✕⦸ Chronic Pain Antidepressants ✓⦸ Hip and Groin Disorders (SNRI) ✓✕⦸ Knee Disorders ⦸ Low Back Disorders Shoulder

Effective January 1, 2018 20 of 21 MTUS Drug List ( 8 CCR § 9792.27.15)

Reference Brand Unique Drug Ingredient Exempt/Non-Exempt* Special Fill** Peri-Op*** Drug Class Reference in Guidelines Dosage Form Strength Pharmaceutical Name Identifier(s) ✕ ✕ Chronic Pain ✕ Cervical and Thoracic Spine Disorders Non-Exempt 267 ✕ Hip and Groin Disorders Vilazodone Viibryd Antidepressants (SSRI) ✕ ✕ Knee Disorders Low Back Disorders Vitamin A Non-Exempt Vitamins 268 ✕ Shoulder ✕ Hematopoietic Agents Vitamin B-12 Non-Exempt Cervical and Thoracic Spine Disorders 269 Methylcobalamin Cervical and Thoracic Spine Disorders Cyanocobalamin, ✕ ⦸ Elbow Disorders (Vitamins) ✕ ✕ Low Back Disorders Vitamin B-6 Non-Exempt Vitamins 270 ✕⦸ Ankle and Foot Disorders Cervical and Thoracic Spine Disorders Pyridoxine ✕ ✕ Elbow Disorders Vitamin E Non-Exempt Vitamins ✕ Hand, Wrist, and Forearm Disorders 271 ✕⦸ Ankle and Foot Disorders Cervical and Thoracic Spine Disorders Non-Exempt ✓ Low Back Disorders 272 ⦸ Ankle and Foot Disorders 14 Days ✓ Warfarin Sodium Coumadin Anticoagulants Hip and Groin Disorders Accolate Non-Exempt Knee Disorders 273 Antiasthmatic and ✓ Zafirlukast Bronchodilator Agents Zyflo Non-Exempt Work Related Asthma 274 Antiasthmatic and ✓ Zileuton Bronchodilator Agents ✕ Zonegran Non-Exempt Work Related Asthma 275 ✕⦸ Chronic Pain Zonisamide Anticonvulsants ⦸ Low Back Disorders Shoulder

Effective January 1, 2018 21 of 21