MTUS Drug List v.3 (8 CCR § 9792.27.15)
DrugIngredient ReferenceBrandNameExempt/Non‐Exempt* SpecialFill** Peri‐Op*** DrugClass ReferenceinACOEMGuidelines* DosageForm Strength
UniquePharmaceuticalIdentifier(s)
Acetaminophen Tylenol Exempt Analgesics‐NonNarcotic
✓AnkleandFootDisorders✓CervicalandThoracicSpineDisorders✓ChronicPain✓✕ElbowDisorders✓✕Hand,Wrist,andForearmDisorders✓HipandGroinDisorders✓KneeDisorders✓LowBackDisorders✓Shoulder
AcetylL‐Carnitine Non‐ExemptPsychotherapeuticandNeurologicalAgents‐
Misc✕ChronicPain
Acyclovir Zovirax Non‐Exempt Antivirals ⦸ChronicPain
Adalimumab Humira Non‐ExemptAnalgesics‐Anti‐
Inflammatory(TNF‐alphablocker)
✕HipandGroinDisorders✕KneeDisorders✕LowBackDisorders
AlbuterolSulfate Proventil Exempt AntiasthmaticandBronchodilatorAgents ✓WorkRelatedAsthma
Alcaftadine Lastacaft Exempt Antihistamineand/ormastcellstabilization ✓Eye
AlclometasoneDipropionate Aclovate Non‐Exempt Dermatologicals ✓AnkleandFootDisorders
MTUSDrugListv.3(8CCR§9792.27.15)EFFECTIVEDATE:October1,2018
TheMTUSDrugListmustbeusedinconjunctionwith1)theMTUSGuidelines,whichcontainspecifictreatmentrecommendationsbasedonconditionandphaseoftreatmentand2)thedrugformularyrules.(See8CCR§9792.20‐§9792.27.23.)"ReferenceinACOEMGuidelines"indicatesguidelinetopic(s)whichdiscussthedrug.IneachguidelinetheremaybeconditionsforwhichthedrugisRecommended(✓),NotRecommended(✕),orNoRecommendation(⦸).Consultguidelinetodeterminetherecommendationfortheconditiontobetreatedandtoassureproperphaseofcareuse.*Exempt/Non‐Exempt"Exempt"indicatesdrugmaybeprescribed/dispensedwithoutseekingauthorizationthroughProspectiveReviewifinaccordancewithMTUS.1)Physiciandispensed"Exempt"drugslimitedtoone7‐daysupplyatinitialvisitwithinsevendaysofthedateofinjurywithoutProspectiveReview.2)Prescription/dispensingofBrandname"Exempt"drugwheregenericisavailablerequiresauthorizationthroughProspectiveReview."Non‐Exempt"or“Unlisted”drugrequiresauthorizationthroughProspectiveReviewpriortoprescribingordispensing.(See8CCR§9792.27.1through§9792.27.23forcompleterules.)**SpecialFill‐IndicatestheNon‐Exemptdrugmaybeprescribed/dispensedwithoutProspectiveReview:1)Rxatinitialvisitwithin7daysofinjury,and2)Supplynottoexceed#daysindicated,and3)isagenericorsinglesourcebrand,orbrandwherephysiciansubstantiatesmedicalnecessity,and4)ifinaccordwithMTUS.(See8CCR§9792.27.12.)***PerioperativeFill–IndicatestheNon‐Exemptdrugmaybeprescribed/dispensedwithoutProspectiveReview:1)Rxissuedduringtheperioperativeperiod(4daysbeforethrough4daysaftersurgery),and2)Supplynottoexceed#daysindicated,and3)isagenericorsinglesourcebrand,orbrandwherephysiciansubstantiatesmedicalnecessity,and4)isinaccordwithMTUS.(See8CCR§9792.27.13.)
*ACOEM Guidelines Copyright Reed Group Ltd.
Effective October 1, 2018 1 of 26
MTUS Drug List v.3 (8 CCR § 9792.27.15)
DrugIngredient ReferenceBrandNameExempt/Non‐Exempt* SpecialFill** Peri‐Op*** DrugClass ReferenceinACOEMGuidelines* DosageForm Strength
UniquePharmaceuticalIdentifier(s)
AlendronateSodium Fosamax Non‐Exempt
EndocrineandMetabolicAgents‐
Misc.(Bisphosphonate)
✓ChronicPain✓⦸HipandGroinDisorders⦸KneeDisorders✕LowBackDisorders✓Shoulder
AmantadineHCL Symmetrel Non‐ExemptAntiparkinsonAgents(NMDAreceptorantagonist)
✕ChronicPain✕LowBackDisorders
Amcinonide Cyclocort Non‐Exempt Dermatologicals ✓AnkleandFootDisorders
AmitriptylineHCL Elavil Non‐Exempt Antidepressants(TCAs)
✓✕CervicalandThoracicSpineDisorders✓✕ChronicPain✕⦸HipandGroinDisorders✓✕⦸KneeDisorders✓⦸LowBackDisorders✓✕Shoulder
AmlodipineBesylate Norvasc Non‐Exempt CalciumChannelBlockers ✓Hand,Wrist,andForearmDisorders
Amoxicillin/ClavulanateP Augmentin Exempt Antibiotics(Penicillins)
✓⦸AnkleandFootDisorders✓Hand,Wrist,andForearmDisorders✓LowBackDisorders
Anakinra Kineret Non‐Exempt Analgesics‐Anti‐inflammatory ✕KneeDisorders
Apixaban Eliquis Non‐Exempt 14Days Anticoagulants⦸AnkleandFootDisorders✓HipandGroinDisorders✓KneeDisorders
ArtificialTearOintments RefreshPM Exempt OphthalmicAgents(ArtificialTears) ✓Eye
AscorbicAcid VitaminC Non‐Exempt Vitamins
✕⦸AnkleandFootDisorders✕CervicalandThoracicSpineDisorders⦸ChronicPain✕LowBackDisorders
Aspirin Bayer Exempt Analgesics‐NonNarcotic
✓AnkleandFootDisorders✓CervicalandThoracicSpineDisorders✕ChronicPain✓ElbowDisorders✓✕⦸Hand,Wrist,andForearmDisorders✓HipandGroinDisorders✓KneeDisorders✓LowBackDisorders✓Shoulder
Aspirin/Caffeine/DihydrocodeineBitartrate Synalgos‐DC Non‐Exempt Analgesics‐Opioid
✕AnkleandFootDisorders✕CervicalandThoracicSpineDisorders✕ChronicPain✕ElbowDisorders✕Hand,Wrist,andForearmDisorders✕HipandGroinDisorders✕KneeDisorders✕LowBackDisorders✕Shoulder
AzelastineOphth Optivar Exempt Antihistamineand/ormastcellstabilization ✓Eye
AzithromycinOphth Azasite Exempt Antibiotics(Macrolides) ✓✕⦸Eye
Azithromycin Zithromax Non‐Exempt Antibiotics(Macrolides) ✕Hand,Wrist,andForearmDisorders
Bacitracin Exempt Anti‐InfectiveAgents‐Misc.
✓AnkleandFootDisorders⦸Hand,Wrist,andForearmDisorders
*ACOEM Guidelines Copyright Reed Group Ltd.
Effective October 1, 2018 2 of 26
MTUS Drug List v.3 (8 CCR § 9792.27.15)
DrugIngredient ReferenceBrandNameExempt/Non‐Exempt* SpecialFill** Peri‐Op*** DrugClass ReferenceinACOEMGuidelines* DosageForm Strength
UniquePharmaceuticalIdentifier(s)
Baclofen Lioresal Non‐Exempt 4Days 4DaysMusculoskeletalTherapyAgents
(MuscleRelaxants)
✓✕CervicalandThoracicSpineDisorders✓✕⦸ChronicPain✓✕HipandGroinDisorders✕⦸KneeDisorders✓✕LowBackDisorders✓✕Shoulder
Becaplermin Regranex Non‐Exempt Dermatologicals ✓AnkleandFootDisorders
BeclomethasoneDipropionate Qvar Non‐Exempt AntiasthmaticandBronchodilatorAgents ✓WorkRelatedAsthma
BepotastineOphth Bepreve Exempt Antihistamineand/ormastcellstabilization ✓Eye
BesifloxacinOphth Besivance Exempt Topicalantibiotic ✓✕⦸Eye
Betamethasone Celestone Non‐Exempt 4Days Corticosteroids
✓✕⦸ AnkleandFootDisorders✓✕CervicalandThoracicSpineDisorders✓ChronicPain✓⦸ElbowDisorders✓✕⦸Hand,Wrist,andForearmDisorders✓✕HipandGroinDisorders✓⦸KneeDisorders✓✕⦸LowBackDisorders✓✕⦸ Shoulder
BetamethasoneDipropionat Diprosone Non‐Exempt Dermatologicals ✓AnkleandFootDisorders
BetamethasoneValerate Valisone Non‐Exempt Dermatologicals ✓AnkleandFootDisorders
Bromfenac Prolensa Exempt OphthalmicAgents(NSAID) ✓✕Eye
Budesonide Pulmicort Non‐Exempt AntiasthmaticandBronchodilatorAgents ✓WorkRelatedAsthma
Budesonide/Formoterol Symbicort Non‐Exempt AntiasthmaticandBronchodilatorAgents ✓WorkRelatedAsthma
Buprenorphine(HCL) Butrans Non‐Exempt Analgesics‐Opioid
✕AnkleandFootDisorders✕CervicalandThoracicSpineDisorders✕ChronicPain✕ElbowDisorders✕Hand,Wrist,andForearmDisorders✕HipandGroinDisorders✕KneeDisorders✕LowBackDisorders✓Opioid✕Shoulder
BuprenorphineHCL/Naloxone Suboxone Non‐Exempt Analgesics‐Opioid
✕AnkleandFootDisorders✕CervicalandThoracicSpineDisorders✕ChronicPain✕ElbowDisorders✕Hand,Wrist,andForearmDisorders✕HipandGroinDisorders✕KneeDisorders✕LowBackDisorders✓Opioid✕Shoulder
*ACOEM Guidelines Copyright Reed Group Ltd.
Effective October 1, 2018 3 of 26
MTUS Drug List v.3 (8 CCR § 9792.27.15)
DrugIngredient ReferenceBrandNameExempt/Non‐Exempt* SpecialFill** Peri‐Op*** DrugClass ReferenceinACOEMGuidelines* DosageForm Strength
UniquePharmaceuticalIdentifier(s)
BupropionHCL Wellbutrin,WellbutrinXL,WellbutrinSR Non‐ExemptAntidepressants
(SSRI)
✕CervicalandThoracicSpineDisorders✓✕⦸ChronicPain✕HipandGroinDisorders✕KneeDisorders✕LowBackDisorders✕Shoulder
Butalbital/Apap/Caffeine Non‐Exempt Analgesics‐NonNarcotic ✕Hand,Wrist,andForearmDisorders
Butalbital/Asa/Caffeine Non‐Exempt Analgesics‐NonNarcotic ✕Hand,Wrist,andForearmDisorders
ButenafineHCl LotriminUltra Non‐Exempt Dermatologicals ✓AnkleandFootDisorders
ButorphanolTartrate Stadol Non‐Exempt Analgesics‐Opioid
✕AnkleandFootDisorders✕CervicalandThoracicSpineDisorders✕ChronicPain✕ElbowDisorders✕Hand,Wrist,andForearmDisorders✕HipandGroinDisorders✕KneeDisorders✕LowBackDisorders✕Shoulder
Calcitonin‐Salmon Fortical,Miacalcin Non‐Exempt
EndocrineandMetabolicAgents‐
Misc.(Bisphosphonate)
✕AnkleandFootDisorders✓✕ChronicPain✓⦸HipandGroinDisorders⦸KneeDisorders✕LowBackDisorders
CalciumPhosphateTribasic Non‐Exempt Minerals&Electrolytes ⦸AnkleandFootDisorders
Camphor BengayUltra Non‐Exempt Dermatologicals
⦸CervicalandThoracicSpineDisorders⦸ChronicPain✓Hand,Wrist,andForearmDisorders✕⦸HipandGroinDisorders⦸LowBackDisorders⦸Shoulder
Capsaicin Zostrix ExemptDermatologicals
(Topicalcreamsandointments)
✓CervicalandThoracicSpineDisorders✓⦸ChronicPain✓Hand,Wrist,andForearmDisorders✓HipandGroinDisorders✓LowBackDisorders✓⦸Shoulder
Carbamazepine Tegretol Non‐Exempt Anticonvulsants
✓CervicalandThoracicSpineDisorders✓ChronicPain⦸LowBackDisorders✓✕Shoulder
CarboxymethylcelluloseSodiumOphthalmic RefreshPlus Exempt OphthalmicAgents(ArtificialTears) ✓Eye
Carisoprodol Soma Non‐ExemptMusculoskeletalTherapyAgents
(MuscleRelaxants)
✕CervicalandThoracicSpineDisorders✕ChronicPain✕HipandGroinDisorders✕KneeDisorders✕LowBackDisorders✕Shoulder
CefuroximeAxetil Ceftin Exempt Antibiotics(Cephalosporins) ✓Hand,Wrist,andForearmDisorders
*ACOEM Guidelines Copyright Reed Group Ltd.
Effective October 1, 2018 4 of 26
MTUS Drug List v.3 (8 CCR § 9792.27.15)
DrugIngredient ReferenceBrandNameExempt/Non‐Exempt* SpecialFill** Peri‐Op*** DrugClass ReferenceinACOEMGuidelines* DosageForm Strength
UniquePharmaceuticalIdentifier(s)
Celecoxib Celebrex Exempt Analgesics‐Anti‐Inflammatory(NSAID)
✓AnkleandFootDisorders✓CervicalandThoracicSpineDisorders✓ChronicPain✓✕⦸ElbowDisorders✓✕⦸Hand,Wrist,andForearmDisorders✓⦸HipandGroinDisorders✓⦸KneeDisorders✓LowBackDisorders✓Shoulder
Cephalexin Keflex Exempt Antibiotics(Cephalosporins)
✓⦸AnkleandFootDisorders✕Hand,Wrist,andForearmDisorders
CertolizumabPegol Cimzia Non‐Exempt GastrointestinalAgents(TNFBlocker)
✕HipandGroinDisorders✕KneeDisorders✕LowBackDisorders
Chlorzoxazone Lorzone,ParafonForte Non‐ExemptMusculoskeletalTherapyAgents
(MuscleRelaxants)
✕CervicalandThoracicSpineDisorders✕ChronicPain✕HipandGroinDisorders✕KneeDisorders✕LowBackDisorders✕Shoulder
CholineMagnesiumTrisalicylate Trilisate Exempt Analgesics‐NonNarcotic(NSAID)
✓AnkleandFootDisorders✓CervicalandThoracicSpineDisorders✓ChronicPain✓✕⦸ElbowDisorders✓✕⦸Hand,Wrist,andForearmDisorders✓⦸HipandGroinDisorders✓⦸KneeDisorders✓LowBackDisorders✓Shoulder
ChondroitinSulfate Non‐Exempt AlternativeMedicines(OTCnutraceutical)
⦸Hand,Wrist,andForearmDisorders⦸HipandGroinDisorders⦸KneeDisorders⦸Shoulder
Ciclesonide Alvesco Non‐Exempt AntiasthmaticandBronchodilatorAgents ✓WorkRelatedAsthma
CiclopiroxOlamine Loprox Non‐Exempt Dermatologicals ✓AnkleandFootDisorders
Cimetidine Tagamet Exempt UlcerDrugs(H2receptorblocker)
✓CervicalandThoracicSpineDisorders✓ElbowDisorders✓Hand,Wrist,andForearmDisorders✓HipandGroinDisorders✓KneeDisorders✓LowBackDisorders✓Shoulder
Ciprofloxacin Cipro Exempt Antibiotics(Fluoroquinolones)
✓AnkleandFootDisorders✓Hand,Wrist,andForearmDisorders
CiprofloxacinHCLOphthalmic Ciloxan Exempt OphthalmicAgents(Antibiotics) ✓✕⦸Eye
CitalopramHydrobromide Celexa Non‐Exempt Antidepressants(SSRI)
✕CervicalandThoracicSpineDisorders✓✕ChronicPain✕HipandGroinDisorders✓✕KneeDisorders✕LowBackDisorders✕Shoulder
Clarithromycin Biaxin Non‐Exempt Antibiotics(Macrolides) ✕Hand,Wrist,andForearmDisorders
*ACOEM Guidelines Copyright Reed Group Ltd.
Effective October 1, 2018 5 of 26
MTUS Drug List v.3 (8 CCR § 9792.27.15)
DrugIngredient ReferenceBrandNameExempt/Non‐Exempt* SpecialFill** Peri‐Op*** DrugClass ReferenceinACOEMGuidelines* DosageForm Strength
UniquePharmaceuticalIdentifier(s)
ClindamycinHCL Cleocin Exempt Anti‐InfectiveAgents‐Misc.
✓⦸AnkleandFootDisorders✓✕⦸Hand,Wrist,andForearmDisorders✓HipandGroinDisorders✓KneeDisorders
ClomipramineHCL Anafranil Non‐Exempt Antidepressants(TCAs)
✕CervicalandThoracicSpineDisorders✓ChronicPain✕⦸HipandGroinDisorders✕⦸KneeDisorders✕LowBackDisorders✕Shoulder
Clonazepam Klonopin Non‐Exempt Anticonvulsants ⦸LowBackDisorders✕Shoulder
ClonidineHCL Catapres Non‐Exempt Analgesics‐NonNarcotic✓⦸ChronicPain✕⦸LowBackDisorders
ClotrimazoleAntifungal LotriminAF Non‐Exempt Dermatologicals ✓AnkleandFootDisorders
CodeinePhosphate Non‐Exempt Analgesics‐Opioid
✕AnkleandFootDisorders✕CervicalandThoracicSpineDisorders✕ChronicPain✕ElbowDisorders✕Hand,Wrist,andForearmDisorders✕HipandGroinDisorders✕KneeDisorders✕LowBackDisorders✕Shoulder
CodeineSulfate Non‐Exempt Analgesics‐Opioid
✕AnkleandFootDisorders✕CervicalandThoracicSpineDisorders✕ChronicPain✕ElbowDisorders✕Hand,Wrist,andForearmDisorders✕HipandGroinDisorders✕KneeDisorders✕LowBackDisorders✕Shoulder
Codeine/Acetaminophen Tylenol#3,Tylenol#4 Non‐Exempt Analgesics‐Opioid
✕AnkleandFootDisorders✕CervicalandThoracicSpineDisorders✕ChronicPain✕ElbowDisorders✕Hand,Wrist,andForearmDisorders✕HipandGroinDisorders✕KneeDisorders✕LowBackDisorders✕Shoulder
CoenzymeQ10 CoQ10 Non‐Exempt AlternativeMedicines ⦸ChronicPain
Colchicine Non‐Exempt GoutAgents ✕CervicalandThoracicSpineDisorders✕LowBackDisorders
*ACOEM Guidelines Copyright Reed Group Ltd.
Effective October 1, 2018 6 of 26
MTUS Drug List v.3 (8 CCR § 9792.27.15)
DrugIngredient ReferenceBrandNameExempt/Non‐Exempt* SpecialFill** Peri‐Op*** DrugClass ReferenceinACOEMGuidelines* DosageForm Strength
UniquePharmaceuticalIdentifier(s)
Cortisone Cortone Non‐Exempt 4Days Corticosteroids
✓✕⦸AnkleandFootDisorders✓✕CervicalandThoracicSpineDisorders✓✕ChronicPain⦸ElbowDisorders✓⦸Hand,Wrist,andForearmDisorders✕HipandGroinDisorders✓✕⦸LowBackDisorders✓✕⦸ Shoulder
CreatineMonohydrate Non‐Exempt Chemicals ⦸ChronicPain
CromolynSodium Intal Non‐Exempt AntiasthmaticandBronchodilatorAgents ✓WorkRelatedAsthma
CromolynSodium(Opthalmic) Opticrom Exempt Antihistamineand/ormastcellstabilization ✓Eye
CyclobenzaprineHCL Flexeril Non‐Exempt 4DaysMusculoskeletalTherapyAgents
(MuscleRelaxants)
✓✕CervicalandThoracicSpineDisorders✓✕⦸ChronicPain✕HipandGroinDisorders✕⦸KneeDisorders✓✕LowBackDisorders✓✕Shoulder
CyclopentolateHCL Cyclogyl Non‐Exempt OphthalmicAgents(Anticholinergics) ✕Eye
Dalteparin Fragmin Non‐Exempt Anticoagulants ⦸AnkleandFootDisorders
DantroleneSodium Dantrium Non‐ExemptMusculoskeletalTherapyAgents
(MuscleRelaxants)
✕CervicalandThoracicSpineDisorders✕ChronicPain✕HipandGroinDisorders✕KneeDisorders✕LowBackDisorders✕Shoulder
Dehydroepiandrosterone(DHEA) Non‐Exempt Chemicals ⦸ChronicPain
DesipramineHCL Norpramin Non‐Exempt Antidepressants(TCAs)
✓✕CervicalandThoracicSpineDisorders✓ChronicPain⦸HipandGroinDisorders✓✕⦸KneeDisorders✓⦸LowBackDisorders✓✕Shoulder
Desloratadine Clarinex Exempt Antihistamineand/ormastcellstabilization ✓Eye
Desonide Desowen Non‐Exempt Dermatologicals ✓AnkleandFootDisorders
Desoximetasone Topicort Non‐Exempt Dermatologicals ✓AnkleandFootDisorders
*ACOEM Guidelines Copyright Reed Group Ltd.
Effective October 1, 2018 7 of 26
MTUS Drug List v.3 (8 CCR § 9792.27.15)
DrugIngredient ReferenceBrandNameExempt/Non‐Exempt* SpecialFill** Peri‐Op*** DrugClass ReferenceinACOEMGuidelines* DosageForm Strength
UniquePharmaceuticalIdentifier(s)
DesvenlafaxineER Pristiq Non‐Exempt Antidepressants(SNRI)
✕CervicalandThoracicSpineDisorders✕ChronicPain✕HipandGroinDisorders✕KneeDisorders✕⦸LowBackDisorders✕Shoulder
Dexamethasone Decadron Non‐Exempt 4Days Corticosteroids
✓✕⦸ AnkleandFootDisorders✓✕CervicalandThoracicSpineDisorders✓✕ChronicPain✓⦸ElbowDisorders✓✕⦸Hand,Wrist,andForearmDisorders✕HipandGroinDisorders✓⦸KneeDisorders✓✕⦸LowBackDisorders✓✕⦸ Shoulder
DexamethasoneSodiumPhosphateOphthalmic Maxidex Non‐Exempt 4Days OphthalmicAgents(Steroid) ✓✕⦸Eye
Dexlansoprazole Dexilant Exempt UlcerDrugs(Protonpumpinhibitor)
✓CervicalandThoracicSpineDisorders✓ElbowDisorders✓Hand,Wrist,andForearmDisorders✓KneeDisorders✓Shoulder
Dextromethorphan Delsym Non‐ExemptCough/Cold/Allergy(NMDAReceptorAntagonist)
✓✕⦸ ChronicPain✕LowBackDisorders✓Shoulder
Diazepam Valium Non‐Exempt AntianxietyAgents(Musclerelaxant) ✕ChronicPain
DiclofenacPotassium Cataflam Exempt Analgesics‐Anti‐Inflammatory(NSAID)
✓AnkleandFootDisorders✓CervicalandThoracicSpineDisorders⦸ChronicPain✓✕⦸ElbowDisorders✓✕⦸Hand,Wrist,andForearmDisorders✓⦸HipandGroinDisorders✓⦸KneeDisorders✓LowBackDisorders✓Shoulder
DiclofenacSodium Voltaren Non‐Exempt Analgesics‐Antiinflammatory ⦸ChronicPain
DiclofenacSodium(Topical) Voltaren1%gel Exempt Dermatologicals
✓✕⦸ AnkleandFootDisorders⦸CervicalandThoracicSpineDisorders✓ChronicPain✓⦸ElbowDisorders✓Hand,Wrist,andForearmDisorders✕⦸HipandGroinDisorders⦸LowBackDisorders⦸Shoulder
DiclofenacSodiumOphthalmic Voltaren Exempt OphthalmicAgents(NSAID) ✓✕Eye
*ACOEM Guidelines Copyright Reed Group Ltd.
Effective October 1, 2018 8 of 26
MTUS Drug List v.3 (8 CCR § 9792.27.15)
DrugIngredient ReferenceBrandNameExempt/Non‐Exempt* SpecialFill** Peri‐Op*** DrugClass ReferenceinACOEMGuidelines* DosageForm Strength
UniquePharmaceuticalIdentifier(s)
DiclofenacSodium/Misoprostol Arthrotec ExemptAnalgesics‐Anti‐
Inflammatory(NSAID/Ulcerdrug)
✓⦸AnkleandFootDisorders✓CervicalandThoracicSpineDisorders✕ChronicPain✓ElbowDisorders✓Hand,Wrist,andForearmDisorders✓HipandGroinDisorders✓KneeDisorders✓LowBackDisorders✓Shoulder
DicloxacillinSodium Dynapen Exempt Antibiotics(Penicillins) ✓⦸AnkleandFootDisorders
Diflunisal Dolobid Exempt Analgesics‐Anti‐Inflammatory(NSAID)
✓AnkleandFootDisorders✓CervicalandThoracicSpineDisorders✓ChronicPain✓✕⦸ElbowDisorders✓✕⦸Hand,Wrist,andForearmDisorders✓⦸HipandGroinDisorders✓⦸KneeDisorders✓LowBackDisorders✓Shoulder
DimethylSulfoxide DMSO Non‐ExemptGenitourinary‐Misc.(Ointmentsandtopical
agents)
✕CervicalandThoracicSpineDisorders✓ChronicPain✕⦸HipandGroinDisorders✕LowBackDisorders
DolasetronMesylate Anzemet Non‐Exempt Antiemetics ⦸ChronicPain
DoxepinHCL Sinequan Non‐Exempt Antidepressants(TCAs)
✓✕CervicalandThoracicSpineDisorders✕ChronicPain⦸HipandGroinDisorders✕⦸KneeDisorders✓⦸LowBackDisorders✕Shoulder
Doxycycline Vibramycin Exempt Antibiotics(Tetracyclines)
✓⦸AnkleandFootDisorders✓Hand,Wrist,andForearmDisorders✓HipandGroinDisorders
DuloxetineHCL Cymbalta Non‐Exempt Antidepressants(SNRI)
✓✕CervicalandThoracicSpineDisorders✓ChronicPain⦸HipandGroinDisorders✓✕⦸KneeDisorders✓⦸LowBackDisorders✓✕⦸ Shoulder
EconazoleNitrate Spectazole Non‐Exempt Dermatologicals ✓AnkleandFootDisorders
EmedastineOphth Emadine Exempt Antihistamineand/ormastcellstabilization ✓Eye
EnoxaparinSodium Lovenox Non‐Exempt 14Days Anticoagulants⦸AnkleandFootDisorders✓HipandGroinDisorders✓KneeDisorders
EpinastineHCL Elestat Exempt Antihistamineand/ormastcellstabilization ✓Eye
Erythromycin Ery‐Tab Non‐Exempt Antibiotics(Macrolides) ✕Hand,Wrist,andForearmDisorders
ErythromycinOphthalmicOintment Ilotycin Exempt OphthalmicAgents(Antibiotics) ✓✕⦸Eye
EscitalopramOxalate Lexapro Non‐Exempt Antidepressants(SSRI)
✕CervicalandThoracicSpineDisorders✓✕ChronicPain✕HipandGroinDisorders
*ACOEM Guidelines Copyright Reed Group Ltd.
Effective October 1, 2018 9 of 26
MTUS Drug List v.3 (8 CCR § 9792.27.15)
DrugIngredient ReferenceBrandNameExempt/Non‐Exempt* SpecialFill** Peri‐Op*** DrugClass ReferenceinACOEMGuidelines* DosageForm Strength
UniquePharmaceuticalIdentifier(s)
EsomeprazoleMagnesium Nexium Exempt UlcerDrugs(Protonpumpinhibitor)
✓CervicalandThoracicSpineDisorders✓ElbowDisorders✓Hand,Wrist,andForearmDisorders✓HipandGroinDisorders✓KneeDisorders✓LowBackDisorders✓Shoulder
Esomeprazole/Naproxen Vimovo Non‐Exempt
Analgesics‐Anti‐Inflammatory(Proton
PumpInhibitor/NSAID)
✕AnkleandFootDisorders✕CervicalandThoracicSpineDisorders✕ChronicPain✕ElbowDisorders✕Hand,Wrist,andForearmDisorders✕HipandGroinDisorders✕KneeDisorders✕LowBackDisorders✕Shoulder
Estradiol Climara,Estraderm Non‐Exempt Estrogens ✕ChronicPain
Etanercept Enbrel Non‐ExemptAnalgesics‐Anti‐
Inflammatory(TNF‐alphablocker)
✕HipandGroinDisorders✕KneeDisorders✕LowBackDisorders
EtidronateDisodium Didronel Non‐Exempt
EndocrineandMetabolicAgents‐
Misc.(Bisphosphonate)
✓⦸HipandGroinDisorders⦸KneeDisorders✕LowBackDisorders✓Shoulder
Etodolac Lodine Exempt Analgesics‐Anti‐Inflammatory(NSAID)
✓AnkleandFootDisorders✓CervicalandThoracicSpineDisorders✓ChronicPain✓✕⦸ElbowDisorders✓✕⦸Hand,Wrist,andForearmDisorders✓⦸HipandGroinDisorders✓⦸KneeDisorders✓LowBackDisorders✓Shoulder
Famciclovir Famvir Non‐Exempt Antivirals ⦸ChronicPain
Famotidine Pepcid Exempt UlcerDrugs(H2receptorblocker)
✓CervicalandThoracicSpineDisorders✓ElbowDisorders✓Hand,Wrist,andForearmDisorders✓HipandGroinDisorders✓KneeDisorders✓LowBackDisorders✓Shoulder
*ACOEM Guidelines Copyright Reed Group Ltd.
Effective October 1, 2018 10 of 26
MTUS Drug List v.3 (8 CCR § 9792.27.15)
DrugIngredient ReferenceBrandNameExempt/Non‐Exempt* SpecialFill** Peri‐Op*** DrugClass ReferenceinACOEMGuidelines* DosageForm Strength
UniquePharmaceuticalIdentifier(s)
Famotidine/Ibuprofen Duexis Non‐Exempt
Analgesics‐Anti‐Inflammatory(H2ReceptorBlocker
/NSAID)
✕AnkleandFootDisorders✕CervicalandThoracicSpineDisorders✕ChronicPain✕ElbowDisorders✕Hand,Wrist,andForearmDisorders✕HipandGroinDisorders✕KneeDisorders✕LowBackDisorders✕Shoulder
FenoprofenCalcium Nalfon Exempt Analgesics‐Anti‐Inflammatory(NSAID)
✓AnkleandFootDisorders✓CervicalandThoracicSpineDisorders✓ChronicPain✓✕⦸ElbowDisorders✓✕⦸Hand,Wrist,andForearmDisorders✓⦸HipandGroinDisorders✓⦸KneeDisorders✓LowBackDisorders✓Shoulder
Fentanyl Duragesic Non‐Exempt Analgesics‐Opioid
✕AnkleandFootDisorders✕CervicalandThoracicSpineDisorders✕ChronicPain✕ElbowDisorders✕Hand,Wrist,andForearmDisorders✕HipandGroinDisorders✕KneeDisorders✕LowBackDisorders✕Shoulder
FentanylCitrateOralTransmucosal Actiq,Fentora Non‐Exempt Analgesics‐Opioid
✕AnkleandFootDisorders✕CervicalandThoracicSpineDisorders✕ChronicPain✕ElbowDisorders✕Hand,Wrist,andForearmDisorders✕HipandGroinDisorders✕KneeDisorders✕LowBackDisorders✕Shoulder
Fluconazole Diflucan Non‐Exempt Antifungals ✓AnkleandFootDisorders
Flunisolide AerospanHFA Non‐Exempt AntiasthmaticandBronchodilatorAgents ✓WorkRelatedAsthma
FluocinoloneAcetonide Synalar Non‐Exempt Dermatologicals ✓AnkleandFootDisorders
Fluocinonide Non‐Exempt Dermatologicals ✕⦸ElbowDisorders
Fluorometholone FML Non‐Exempt 4Days OphthalmicAgents ✓✕⦸Eye
FluoxetineHCL Prozac Non‐Exempt Antidepressants(SSRI)
✕CervicalandThoracicSpineDisorders✓✕ChronicPain✕HipandGroinDisorders✓✕KneeDisorders✕LowBackDisorders✕Shoulder
*ACOEM Guidelines Copyright Reed Group Ltd.
Effective October 1, 2018 11 of 26
MTUS Drug List v.3 (8 CCR § 9792.27.15)
DrugIngredient ReferenceBrandNameExempt/Non‐Exempt* SpecialFill** Peri‐Op*** DrugClass ReferenceinACOEMGuidelines* DosageForm Strength
UniquePharmaceuticalIdentifier(s)
Flurbiprofen Ansaid Exempt Analgesics‐Anti‐Inflammatory(NSAID)
✓AnkleandFootDisorders✓CervicalandThoracicSpineDisorders✓ChronicPain✓✕⦸ElbowDisorders✓✕⦸Hand,Wrist,andForearmDisorders✓⦸HipandGroinDisorders✓⦸KneeDisorders✓LowBackDisorders✓Shoulder
FlurbiprofenSodium Ocufen ExemptAnti‐Inflammatory(NSAID)Ophthalmic
Drops✓✕Eye
FluticasonePropionate Flovent Non‐Exempt AntiasthmaticandBronchodilatorAgents ✓WorkRelatedAsthma
FluticasoneProp(Topical) Cutivate Non‐Exempt Dermatologicals ✓AnkleandFootDisorders
Fluticasone‐Salmeterol Advair Non‐Exempt AntiasthmaticandBronchodilatorAgents ✓WorkRelatedAsthma
FluvoxamineMaleate Luvox Non‐Exempt Antidepressants(SSRI)
✕CervicalandThoracicSpineDisorders✓✕ChronicPain✕HipandGroinDisorders✕KneeDisorders✕LowBackDisorders✕Shoulder
FolicAcid Non‐Exempt HematopoieticAgents ✕CervicalandThoracicSpineDisorders
FondaparinuxSodium Arixtra Non‐Exempt 14Days Anticoagulants⦸AnkleandFootDisorders✓HipandGroinDisorders✓KneeDisorders
FormoterolFumarate Foradil Non‐Exempt AntiasthmaticandBronchodilatorAgents ✓WorkRelatedAsthma
Formoterol/Mometasone Dulera Non‐Exempt AntiasthmaticandBronchodilatorAgents ✓WorkRelatedAsthma
Gabapentin Neurontin Non‐Exempt 4Days Anticonvulsants
✓✕⦸ CervicalandThoracicSpineDisorders✓ChronicPain✓✕⦸HipandGroinDisorders✓✕⦸KneeDisorders✓⦸LowBackDisorders✓✕⦸ Shoulder
Gabapentin(Once‐daily) Gralise Non‐ExemptPsychotherapeuticandNeurologicalAgents‐
Misc✕ChronicPain
GabapentinEnacarbil Horizant Non‐ExemptPsychotherapeuticandNeurologicalAgents‐
Misc✓✕ChronicPain
Gatifloxacin Zymaxid Exempt OphthalmicAgents(Anti‐bacterial) ✓✕Eye
Gentamicin(Topical) Exempt Dermatologicals ✓AnkleandFootDisorders
*ACOEM Guidelines Copyright Reed Group Ltd.
Effective October 1, 2018 12 of 26
MTUS Drug List v.3 (8 CCR § 9792.27.15)
DrugIngredient ReferenceBrandNameExempt/Non‐Exempt* SpecialFill** Peri‐Op*** DrugClass ReferenceinACOEMGuidelines* DosageForm Strength
UniquePharmaceuticalIdentifier(s)
GentamicinSulfateOphthalmic Gentak Exempt OphthalmicAgents(Anti‐bacterial) ✓✕⦸Eye
GlucosamineSulfate Non‐Exempt AlternativeMedicines(OTCnutraceutical)
⦸Hand,Wrist,andForearmDisorders⦸HipandGroinDisorders✕KneeDisorders⦸Shoulder
Golimumab Simponi Non‐ExemptAnalgesics‐Anti‐
Inflammatory(TNF‐alphablocker)
✕HipandGroinDisorders✕KneeDisorders✕LowBackDisorders
HeparinSodium Non‐Exempt 14Days Anticoagulants✕⦸AnkleandFootDisorders✓HipandGroinDisorders✓KneeDisorders
HomatropineHBrOphthalmic IsoptoHomatropine Exempt OphthalmicAgents(Anticholinergics) ✕Eye
Hydrochlorothiazide Microzide Non‐Exempt Diuretics ✕AnkleandFootDisorders✕Hand,Wrist,andForearmDisorders
HydrocodoneBitartrate ZohydroER,HysinglaER Non‐Exempt Analgesics‐Opioid
✕AnkleandFootDisorders✕CervicalandThoracicSpineDisorders✕ChronicPain✕ElbowDisorders✕Hand,Wrist,andForearmDisorders✕HipandGroinDisorders✕KneeDisorders✕LowBackDisorders✕Shoulder
Hydrocodone/Acetaminophen Norco,Vicodin,Xodol Non‐Exempt 4Days 4Days Analgesics‐Opioid
✓✕AnkleandFootDisorders✓✕CervicalandThoracicSpineDisorders✓✕ChronicPain✓✕ElbowDisorders✓✕Hand,Wrist,andForearmDisorders✓HipandGroinDisorders✓KneeDisorders✓✕LowBackDisorders✓✕Shoulder
Hydrocodone/Ibuprofen Vicoprofen Non‐Exempt Analgesics‐Opioid
✕AnkleandFootDisorders✕CervicalandThoracicSpineDisorders✕ChronicPain✕ElbowDisorders✕Hand,Wrist,andForearmDisorders✕HipandGroinDisorders✕KneeDisorders✕LowBackDisorders✕Shoulder
Hydrocortisone Cortef Non‐Exempt 4Days Corticosteroids
✓✕AnkleandFootDisorders✓✕CervicalandThoracicSpineDisorders✓✕ChronicPain⦸ElbowDisorders✓✕⦸Hand,Wrist,andForearmDisorders✕HipandGroinDisorders⦸KneeDisorders✓✕⦸LowBackDisorders✓✕⦸ Shoulder
Hydrocortisone(Topical) Non‐Exempt Dermatologicals ✓AnkleandFootDisorders
HydrocortisoneValerate Westcort Non‐Exempt Dermatologicals ✓AnkleandFootDisorders
*ACOEM Guidelines Copyright Reed Group Ltd.
Effective October 1, 2018 13 of 26
MTUS Drug List v.3 (8 CCR § 9792.27.15)
DrugIngredient ReferenceBrandNameExempt/Non‐Exempt* SpecialFill** Peri‐Op*** DrugClass ReferenceinACOEMGuidelines* DosageForm Strength
UniquePharmaceuticalIdentifier(s)
HydromorphoneHCL Dilaudid Non‐Exempt Analgesics‐Opioid
✕AnkleandFootDisorders✕CervicalandThoracicSpineDisorders✕ChronicPain✕ElbowDisorders✕Hand,Wrist,andForearmDisorders✕HipandGroinDisorders✕KneeDisorders✕LowBackDisorders✕Shoulder
IbandronateSodium Boniva Non‐Exempt
EndocrineandMetabolicAgents‐
Misc.(Bisphosphonate)
✓⦸HipandGroinDisorders⦸KneeDisorders✕LowBackDisorders✓Shoulder
Ibuprofen Motrin Exempt Analgesics‐Anti‐Inflammatory(NSAID)
✓AnkleandFootDisorders✓CervicalandThoracicSpineDisorders✓ChronicPain✓✕⦸ElbowDisorders✓✕⦸Hand,Wrist,andForearmDisorders✓⦸HipandGroinDisorders✓✕⦸KneeDisorders✓LowBackDisorders✓Shoulder
ImipramineHCL Tofranil Non‐Exempt Antidepressants(TCAs)
✓✕CervicalandThoracicSpineDisorders✕ChronicPain⦸HipandGroinDisorders✕KneeDisorders✓⦸LowBackDisorders✕Shoulder
Indomethacin Indocin Exempt Analgesics‐Anti‐Inflammatory(NSAID)
✓AnkleandFootDisorders✓CervicalandThoracicSpineDisorders✓ChronicPain✓✕⦸ElbowDisorders✓✕⦸Hand,Wrist,andForearmDisorders✓⦸HipandGroinDisorders✓⦸KneeDisorders✓LowBackDisorders✓Shoulder
IrrigatingEyewash Exempt OphthalmicAgents ✓Eye
Itraconazole Sporanox Non‐Exempt Antifungals ✓AnkleandFootDisorders
Ketoconazole Nizoral Non‐Exempt Dermatologicals ✓AnkleandFootDisorders
Ketoprofen Oruvail Exempt Analgesics‐Anti‐Inflammatory(NSAID)
✓AnkleandFootDisorders✓CervicalandThoracicSpineDisorders✓ChronicPain✓✕⦸ElbowDisorders✓✕⦸Hand,Wrist,andForearmDisorders✓⦸HipandGroinDisorders✓⦸KneeDisorders✓LowBackDisorders✓Shoulder
*ACOEM Guidelines Copyright Reed Group Ltd.
Effective October 1, 2018 14 of 26
MTUS Drug List v.3 (8 CCR § 9792.27.15)
DrugIngredient ReferenceBrandNameExempt/Non‐Exempt* SpecialFill** Peri‐Op*** DrugClass ReferenceinACOEMGuidelines* DosageForm Strength
UniquePharmaceuticalIdentifier(s)
KetorolacTromethamine Non‐Exempt Analgesics‐Anti‐Inflammatory(NSAID)
✕AnkleandFootDisorders✕CervicalandThoracicSpineDisorders✕ChronicPain✕ElbowDisorders✕Hand,Wrist,andForearmDisorders✕HipandGroinDisorders✕KneeDisorders✕LowBackDisorders✕Shoulder
KetorolacTromethamineOphthalmic Acular Exempt OphthalmicAgents(NSAID) ✓✕Eye
KetotifenFumarate Zaditor Exempt OphthalmicAgents ✓Eye
Lamotrigine Lamictal Non‐Exempt Anticonvulsants
✓CervicalandThoracicSpineDisorders✓ChronicPain⦸LowBackDisorders✕Shoulder
Lansoprazole Prevacid Exempt UlcerDrugs(Protonpumpinhibitor)
✓CervicalandThoracicSpineDisorders✓ElbowDisorders✓Hand,Wrist,andForearmDisorders✓HipandGroinDisorders✓KneeDisorders✓LowBackDisorders✓Shoulder
Lenalidomide Revlimid Non‐Exempt MiscellaneousTherapeuticClasses ✕ChronicPain
Levalbuterol Xopenex Exempt AntiasthmaticandBronchodilatorAgents ✓WorkRelatedAsthma
Levetiracetam Keppra Non‐Exempt Anticonvulsants✕ChronicPain⦸LowBackDisorders✕Shoulder
Levofloxacin Levaquin Exempt Antibiotics(Fluoroquinolones)
✓AnkleandFootDisorders✓✕Hand,Wrist,andForearmDisorders✓HipandGroinDisorders
LevofloxacinOphthalmicSolution Quixin Exempt OphthalmicAgents(Anti‐bacterial) ✓✕⦸Eye
Levomilnacipran Fetzima Non‐Exempt Antidepressants(SNRI)
✕CervicalandThoracicSpineDisorders✕ChronicPain✕HipandGroinDisorders✕KneeDisorders✕LowBackDisorders✕Shoulder
LevorphanolTartrate Levo‐Dromoran Non‐Exempt Analgesics‐Opioid
✕AnkleandFootDisorders✕CervicalandThoracicSpineDisorders✕ChronicPain✕ElbowDisorders✕Hand,Wrist,andForearmDisorders✕HipandGroinDisorders✕KneeDisorders✕LowBackDisorders✕Shoulder
*ACOEM Guidelines Copyright Reed Group Ltd.
Effective October 1, 2018 15 of 26
MTUS Drug List v.3 (8 CCR § 9792.27.15)
DrugIngredient ReferenceBrandNameExempt/Non‐Exempt* SpecialFill** Peri‐Op*** DrugClass ReferenceinACOEMGuidelines* DosageForm Strength
UniquePharmaceuticalIdentifier(s)
Lidocaine Lidoderm Non‐Exempt Dermatologicals
✓⦸AnkleandFootDisorders✕CervicalandThoracicSpineDisorders✓⦸ChronicPain⦸ElbowDisorders✓Hand,Wrist,andForearmDisorders✕⦸HipandGroinDisorders✕⦸LowBackDisorders
LidocaineHCl Non‐Exempt Dermatologicals ✕CervicalandThoracicSpineDisorders
LidocaineHClOphth Akten Exempt OpthalmicAgents ✓Eye
Lidocaine/Prilocaine Emla Non‐Exempt Dermatologicals
✕CervicalandThoracicSpineDisorders⦸ChronicPain✓Hand,Wrist,andForearmDisorders✕⦸HipandGroinDisorders✕LowBackDisorders⦸Shoulder
LodoxamideOphth Alomide Exempt Antihistamineand/ormastcellstabilization ✓Eye
Loratadine Claritin Exempt Antihistamineand/ormastcellstabilization ✓Eye
Lorazepam Ativan Non‐Exempt AntianxietyAgents ✓AnkleandFootDisorders
LoteprednolEtabonateOphthalmic Alrex Non‐Exempt 4Days OphthalmicAgents(Steroid) ✓✕⦸Eye
Magnesium Non‐Exempt Minerals&Electrolytes ✕ChronicPain
MaprotilineHCL Ludiomil Non‐Exempt Antidepressants(TCAs)
✕CervicalandThoracicSpineDisorders✕ChronicPain✕⦸HipandGroinDisorders✕⦸KneeDisorders✕LowBackDisorders✕Shoulder
MeclofenamateSodium Meclomen Exempt Analgesics‐Anti‐Inflammatory(NSAID)
✓AnkleandFootDisorders✓CervicalandThoracicSpineDisorders✓ChronicPain✓✕⦸ElbowDisorders✓✕⦸Hand,Wrist,andForearmDisorders✓⦸HipandGroinDisorders✓⦸KneeDisorders✓LowBackDisorders✓Shoulder
MefenamicAcid Ponstel Exempt Analgesics‐Anti‐Inflammatory(NSAID)
✓AnkleandFootDisorders✓CervicalandThoracicSpineDisorders✓ChronicPain✓✕⦸ElbowDisorders✓✕⦸Hand,Wrist,andForearmDisorders✓⦸HipandGroinDisorders✓⦸KneeDisorders✓LowBackDisorders✓Shoulder
*ACOEM Guidelines Copyright Reed Group Ltd.
Effective October 1, 2018 16 of 26
MTUS Drug List v.3 (8 CCR § 9792.27.15)
DrugIngredient ReferenceBrandNameExempt/Non‐Exempt* SpecialFill** Peri‐Op*** DrugClass ReferenceinACOEMGuidelines* DosageForm Strength
UniquePharmaceuticalIdentifier(s)
Melatonin Non‐Exempt ✓ChronicPain
Meloxicam Mobic Exempt Analgesics‐Anti‐Inflammatory(NSAID)
✓AnkleandFootDisorders✓CervicalandThoracicSpineDisorders✓ChronicPain✓✕⦸ElbowDisorders✓✕⦸Hand,Wrist,andForearmDisorders✓⦸HipandGroinDisorders✓⦸KneeDisorders✓LowBackDisorders✓Shoulder
MemantineHCL Namenda Non‐Exempt
PsychotherapeuticandNeurologicalAgents‐
Misc.(NDMAReceptorAntagonist)
✕⦸ChronicPain✕LowBackDisorders
Menthol BengayUltra,Biofreeze Non‐Exempt Dermatologicals
⦸AnkleandFootDisorders⦸CervicalandThoracicSpineDisorders⦸ChronicPain✓Hand,Wrist,andForearmDisorders✕⦸HipandGroinDisorders⦸LowBackDisorders⦸Shoulder
MeperidineHCL Demerol Non‐Exempt Analgesics‐Opioid
✕AnkleandFootDisorders✕CervicalandThoracicSpineDisorders✕ChronicPain✕ElbowDisorders✕Hand,Wrist,andForearmDisorders✕HipandGroinDisorders✕KneeDisorders✕LowBackDisorders✕Shoulder
Metaxalone Skelaxin Non‐ExemptMusculoskeletalTherapyAgents
(MuscleRelaxants)
✕CervicalandThoracicSpineDisorders✕ChronicPain✕HipandGroinDisorders✕KneeDisorders✕LowBackDisorders✕Shoulder
MethadoneHCL Dolophine Non‐Exempt Analgesics‐Opioid
✕AnkleandFootDisorders✕CervicalandThoracicSpineDisorders✕ChronicPain✕ElbowDisorders✕Hand,Wrist,andForearmDisorders✕HipandGroinDisorders✕KneeDisorders✕LowBackDisorders✓Opioid✕Shoulder
Methocarbamol Robaxin Non‐ExemptMusculoskeletalTherapyAgents
(MuscleRelaxants)
✕CervicalandThoracicSpineDisorders✕ChronicPain✕HipandGroinDisorders✕KneeDisorders✕LowBackDisorders✕Shoulder
*ACOEM Guidelines Copyright Reed Group Ltd.
Effective October 1, 2018 17 of 26
MTUS Drug List v.3 (8 CCR § 9792.27.15)
DrugIngredient ReferenceBrandNameExempt/Non‐Exempt* SpecialFill** Peri‐Op*** DrugClass ReferenceinACOEMGuidelines* DosageForm Strength
UniquePharmaceuticalIdentifier(s)
MethylSalicylate BengayUltra Non‐Exempt Dermatologicals
⦸CervicalandThoracicSpineDisorders⦸ChronicPain✓Hand,Wrist,andForearmDisorders✕⦸HipandGroinDisorders⦸LowBackDisorders⦸Shoulder
Methylprednisolone Medrol Non‐Exempt 4Days Corticosteroids
✓✕AnkleandFootDisorders✓✕CervicalandThoracicSpineDisorders✓✕ChronicPain⦸ElbowDisorders✓⦸Hand,Wrist,andForearmDisorders✕HipandGroinDisorders✓✕⦸LowBackDisorders✓✕⦸Shoulder✓WorkRelatedAsthma
Methylsulfonylmethane Non‐Exempt Chemicals(OTCnutraceuticals)
⦸HipandGroinDisorders⦸KneeDisorders⦸Shoulder
Metronidazole Exempt Dermatologicals ✓AnkleandFootDisorders
MetronidazoleOral Flagyl Exempt Anti‐InfectiveAgents‐Misc. ✓Hand,Wrist,andForearmDisorders
MiconazoleNitrate Micatin Non‐Exempt Dermatologicals ✓AnkleandFootDisorders
Milnacipran Savella Non‐Exempt
PsychotherapeuticandNeurologicalAgents‐
Misc.(Anti‐depressant)
✕CervicalandThoracicSpineDisorders✓✕ChronicPain✕HipandGroinDisorders✕KneeDisorders✕LowBackDisorders✕Shoulder
MinocyclineHCl Minocin Non‐Exempt Antibiotics(Tetracyclines) ✓⦸AnkleandFootDisorders
Mirtazapine Remeron Non‐Exempt Antidepressants ✓ChronicPain
Misoprostol Cytotec Exempt UlcerDrugs
✓CervicalandThoracicSpineDisorders✓ElbowDisorders✓Hand,Wrist,andForearmDisorders✓HipandGroinDisorders✓KneeDisorders✓LowBackDisorders✓Shoulder
MometasoneFuroate(Topical) Elocon Non‐Exempt Dermatologicals ✓AnkleandFootDisorders
MometasoneFuroate Asmanex Non‐Exempt AntiasthmaticandBronchodilatorAgents ✓WorkRelatedAsthma
MontelukastSodium Singluair Non‐Exempt AntiasthmaticandBronchodilatorAgents ✓WorkRelatedAsthma
MorphineSulfate Non‐Exempt 4Days 4Days Analgesics‐Opioid
✓✕AnkleandFootDisorders✓✕CervicalandThoracicSpineDisorders✓✕ChronicPain✓✕ElbowDisorders✓✕Hand,Wrist,andForearmDisorders✓HipandGroinDisorders✓KneeDisorders✓✕LowBackDisorders✓✕Shoulder
*ACOEM Guidelines Copyright Reed Group Ltd.
Effective October 1, 2018 18 of 26
MTUS Drug List v.3 (8 CCR § 9792.27.15)
DrugIngredient ReferenceBrandNameExempt/Non‐Exempt* SpecialFill** Peri‐Op*** DrugClass ReferenceinACOEMGuidelines* DosageForm Strength
UniquePharmaceuticalIdentifier(s)
MorphineSulfateExtendedRelease MSContin,Kadian,Avinza Non‐Exempt Analgesics‐Opioid
✕AnkleandFootDisorders✕CervicalandThoracicSpineDisorders✓✕ChronicPain✕ElbowDisorders✓✕Hand,Wrist,andForearmDisorders✕HipandGroinDisorders✕KneeDisorders✕LowBackDisorders✕Shoulder
Morphine/Naltrexone Embeda Non‐Exempt Analgesics‐Opioid
✕AnkleandFootDisorders✕CervicalandThoracicSpineDisorders✕ChronicPain✕ElbowDisorders✕Hand,Wrist,andForearmDisorders✕HipandGroinDisorders✕KneeDisorders✕LowBackDisorders✕Shoulder
MoxifloxacinHCL Avelox Exempt Antibiotics(Fluoroquinolones)
✓AnkleandFootDisorders✓Hand,Wrist,andForearmDisorders
MoxifloxacinHCLOphthalmic Vigamox Exempt OphthalmicAgents(Antibiotics) ✓✕⦸Eye
Mupirocin Bactroban Exempt Dermatologicals ✓AnkleandFootDisorders
Nabumetone Relafen Exempt Analgesics‐Anti‐Inflammatory(NSAID)
✓AnkleandFootDisorders✓CervicalandThoracicSpineDisorders✓ChronicPain✓✕⦸ElbowDisorders✓✕⦸Hand,Wrist,andForearmDisorders✓⦸HipandGroinDisorders✓⦸KneeDisorders✓LowBackDisorders✓Shoulder
N‐Acetyl‐L‐Cysteine NAC Non‐Exempt Nutrients
✕CervicalandThoracicSpineDisorders✓✕ChronicPain✕⦸HipandGroinDisorders✕LowBackDisorders
NaloxoneHCL Evzio,Narcan Exempt AntidotesandSpecificAntagonists ✓Opioid
Naproxen Aleve,Naprosyn Exempt Analgesics‐Anti‐Inflammatory(NSAID)
✓⦸AnkleandFootDisorders✓✕CervicalandThoracicSpineDisorders✓ChronicPain✓✕⦸ElbowDisorders✓✕⦸Hand,Wrist,andForearmDisorders✓⦸HipandGroinDisorders✓⦸KneeDisorders✓⦸LowBackDisorders✓⦸Shoulder
NatamycinOphth Natacyn Exempt Antifungals ✓✕Eye
Nedocromil Alocril Exempt OphtalmicAgents ✓Eye
NeomycinSulfate Non‐Exempt Dermatologicals ⦸Hand,Wrist,andForearmDisorders
Neomycin/PolymyxinB/Bacitracin Neosporin Exempt Dermatologicals ✓AnkleandFootDisorders
*ACOEM Guidelines Copyright Reed Group Ltd.
Effective October 1, 2018 19 of 26
MTUS Drug List v.3 (8 CCR § 9792.27.15)
DrugIngredient ReferenceBrandNameExempt/Non‐Exempt* SpecialFill** Peri‐Op*** DrugClass ReferenceinACOEMGuidelines* DosageForm Strength
UniquePharmaceuticalIdentifier(s)
Nifedipine Procardia Non‐Exempt CalciumChannelBlockers ✓Hand,Wrist,andForearmDisorders
NitroglycerinTransdermal Nitro‐Dur Non‐ExemptAntianginalAgents(Glyceriltrinitrate
patches)
✓⦸AnkleandFootDisorders⦸Shoulder
Nizatidine Axid Exempt UlcerDrugs(H2receptorblocker)
✓CervicalandThoracicSpineDisorders✓ElbowDisorders✓Hand,Wrist,andForearmDisorders✓HipandGroinDisorders✓KneeDisorders✓LowBackDisorders✓Shoulder
NortriptylineHCL Pamelor Non‐Exempt Antidepressants(TCAs)
✓✕CervicalandThoracicSpineDisorders✓ChronicPain⦸HipandGroinDisorders✓✕⦸KneeDisorders✓⦸LowBackDisorders✓✕Shoulder
Nystatin/Triamcinolone MycologII Non‐Exempt Dermatologicals ✓AnkleandFootDisorders
OfloxacinOphthalmicSolution Ocuflox Exempt OphthalmicAgents(Anti‐bacterial) ✓✕⦸Eye
OlopatadineHCL Pataday,Patanol Exempt Antihistamineand/ormastcellstabilization ✓Eye
Omeprazole Prilosec Exempt UlcerDrugs(Protonpumpinhibitor)
✓CervicalandThoracicSpineDisorders✓ElbowDisorders✓Hand,Wrist,andForearmDisorders✓HipandGroinDisorders✓KneeDisorders✓LowBackDisorders✓Shoulder
Ondansetron Zofran Non‐Exempt Antiemetics ⦸ChronicPain
OrphenadrineCitrate Norflex Non‐ExemptMusculoskeletalTherapyAgents
(MuscleRelaxants)
✕CervicalandThoracicSpineDisorders✕ChronicPain✕HipandGroinDisorders✕KneeDisorders✕LowBackDisorders✕Shoulder
Oxaprozin Daypro Exempt Analgesics‐Anti‐Inflammatory(NSAID)
✓AnkleandFootDisorders✓CervicalandThoracicSpineDisorders✓ChronicPain✓✕⦸ElbowDisorders✓✕⦸Hand,Wrist,andForearmDisorders✓⦸HipandGroinDisorders✓⦸KneeDisorders✓LowBackDisorders✓Shoulder
Oxcarbazepine Trileptal Non‐Exempt Anticonvulsants
✓CervicalandThoracicSpineDisorders✓ChronicPain⦸LowBackDisorders✕Shoulder
*ACOEM Guidelines Copyright Reed Group Ltd.
Effective October 1, 2018 20 of 26
MTUS Drug List v.3 (8 CCR § 9792.27.15)
DrugIngredient ReferenceBrandNameExempt/Non‐Exempt* SpecialFill** Peri‐Op*** DrugClass ReferenceinACOEMGuidelines* DosageForm Strength
UniquePharmaceuticalIdentifier(s)
OxycodoneHCL OxyContin,Roxicodone Non‐Exempt 4Days 4Days Analgesics‐Opioid
✓✕AnkleandFootDisorders✓✕CervicalandThoracicSpineDisorders✓✕ChronicPain✓✕ElbowDisorders✓✕Hand,Wrist,andForearmDisorders✓HipandGroinDisorders✓KneeDisorders✓✕LowBackDisorders✓✕Shoulder
Oxycodone/Acetaminophen Percocet Non‐Exempt 4days 4days Analgesics‐Opioid
✓✕AnkleandFootDisorders✓✕CervicalandThoracicSpineDisorders✓✕ChronicPain✓✕ElbowDisorders✓✕Hand,Wrist,andForearmDisorders✓HipandGroinDisorders✓KneeDisorders✓✕LowBackDisorders✓✕Shoulder
Oxycodone/Aspirin Percodan Non‐Exempt Analgesics‐Opioid
✕AnkleandFootDisorders✕CervicalandThoracicSpineDisorders✕ChronicPain✕ElbowDisorders✕Hand,Wrist,andForearmDisorders✕HipandGroinDisorders✕KneeDisorders✕LowBackDisorders✕Shoulder
Oxycodone/Ibuprofen Combunox Non‐Exempt Analgesics‐Opioid
✕AnkleandFootDisorders✕CervicalandThoracicSpineDisorders✕ChronicPain✕ElbowDisorders✕Hand,Wrist,andForearmDisorders✕HipandGroinDisorders✕KneeDisorders✕LowBackDisorders✕Shoulder
OxymorphoneHCL Opana,OpanaER Non‐Exempt Analgesics‐Opioid
✕AnkleandFootDisorders✕CervicalandThoracicSpineDisorders✕ChronicPain✕ElbowDisorders✕Hand,Wrist,andForearmDisorders✕HipandGroinDisorders✕KneeDisorders✕LowBackDisorders✕Shoulder
Oxytocin Pitocin Non‐Exempt Oxytocics ✕ChronicPain
PantoprazoleSodium Protonix Exempt UlcerDrugs(Protonpumpinhibitor)
✓CervicalandThoracicSpineDisorders✓ElbowDisorders✓Hand,Wrist,andForearmDisorders✓HipandGroinDisorders✓KneeDisorders✓LowBackDisorders✓Shoulder
*ACOEM Guidelines Copyright Reed Group Ltd.
Effective October 1, 2018 21 of 26
MTUS Drug List v.3 (8 CCR § 9792.27.15)
DrugIngredient ReferenceBrandNameExempt/Non‐Exempt* SpecialFill** Peri‐Op*** DrugClass ReferenceinACOEMGuidelines* DosageForm Strength
UniquePharmaceuticalIdentifier(s)
ParoxetineHCL Paxil Non‐Exempt Antidepressants(SSRI)
✕CervicalandThoracicSpineDisorders✓✕ChronicPain✕HipandGroinDisorders✓✕KneeDisorders✕LowBackDisorders✕Shoulder
PenicillinVPotassium Non‐Exempt Antibiotics(Penicillins) ✕Hand,Wrist,andForearmDisorders
Pentazocine/NaloxoneHCL TalwinNX Non‐Exempt Analgesics‐Opioid
✕AnkleandFootDisorders✕CervicalandThoracicSpineDisorders✕ChronicPain✕ElbowDisorders✕Hand,Wrist,andForearmDisorders✕HipandGroinDisorders✕KneeDisorders✕LowBackDisorders✕Shoulder
Phenytoin Dilantin Non‐Exempt Anticonvulsants✕ChronicPain⦸LowBackDisorders✕Shoulder
Piroxicam Feldene Non‐Exempt Analgesics‐Anti‐Inflammatory(NSAID)
✕AnkleandFootDisorders✕CervicalandThoracicSpineDisorders✕ChronicPain✕ElbowDisorders✕Hand,Wrist,andForearmDisorders✕HipandGroinDisorders✕KneeDisorders✕LowBackDisorders✕Shoulder
PramipexoleDihydrochloride Mirapex Non‐ExemptAntiparkinsonandRelatedTherapy
Agents⦸ChronicPain
Prednicarbate Dermatop Non‐Exempt Dermatologicals ✓AnkleandFootDisorders
Prednisolone Orapred Non‐Exempt 4Days Corticosteroids
✓✕AnkleandFootDisorders✓✕CervicalandThoracicSpineDisorders✓✕ChronicPain⦸ElbowDisorders✓⦸Hand,Wrist,andForearmDisorders✕HipandGroinDisorders✓✕⦸LowBackDisorders✓✕⦸Shoulder✓WorkRelatedAsthma
PrednisoloneAcetate PredForte,PredMild Non‐Exempt OphthalmicAgents(Steroid) ✓✕⦸Eye
PrednisoloneSodiumOphth Omnipred Non‐Exempt 4Days OphthalmicAgents(Steroid) ✓✕⦸Eye
Prednisone Sterapred Non‐Exempt 4Days Corticosteroids
✓✕AnkleandFootDisorders✓✕CervicalandThoracicSpineDisorders✓✕ChronicPain⦸ElbowDisorders✓⦸Hand,Wrist,andForearmDisorders✕HipandGroinDisorders✓✕⦸LowBackDisorders✓✕⦸Shoulder✓WorkRelatedAsthma
*ACOEM Guidelines Copyright Reed Group Ltd.
Effective October 1, 2018 22 of 26
MTUS Drug List v.3 (8 CCR § 9792.27.15)
DrugIngredient ReferenceBrandNameExempt/Non‐Exempt* SpecialFill** Peri‐Op*** DrugClass ReferenceinACOEMGuidelines* DosageForm Strength
UniquePharmaceuticalIdentifier(s)
Pregabalin Lyrica Non‐Exempt Anticonvulsants
⦸CervicalandThoracicSpineDisorders✓ChronicPain✓⦸LowBackDisorders✓✕⦸ Shoulder
Pregabalin(Once‐daily) LyricaCR Non‐ExemptPsychotherapeuticandNeurologicalAgents‐
Misc✕ChronicPain
ProparacaineHCL Alcaine Exempt OphthalmicAgents(Anesthetic) ✓Eye
ProtriptylineHCL Non‐Exempt Antidepressants(TCAs)✕ChronicPain✕KneeDisorders
PyridostigmineBromide Mestinon Non‐Exempt Antimyasthenic/CholinergicAgents ✕ChronicPain
QuetiapineFumarate Seroquel Non‐Exempt Antipsychotics/AntimanicAgents ⦸ChronicPain
RabeprazoleSodium Aciphex Exempt UlcerDrugs(Protonpumpinhibitor)
✓CervicalandThoracicSpineDisorders✓ElbowDisorders✓Hand,Wrist,andForearmDisorders✓HipandGroinDisorders✓KneeDisorders✓LowBackDisorders✓Shoulder
RaloxifeneHydrochloride Evista Non‐ExemptEndocrineand
MetabolicAgents‐Misc.
✕ChronicPain
RanitidineHCL Zantac Exempt UlcerDrugs(H2receptorblocker)
✓CervicalandThoracicSpineDisorders✓ElbowDisorders✓Hand,Wrist,andForearmDisorders✓HipandGroinDisorders✓KneeDisorders✓LowBackDisorders✓Shoulder
RegularInsulin HumulinR Non‐Exempt Antidiabetics ✕AnkleandFootDisorders✕Hand,Wrist,andForearmDisorders
RisedronateSodium Actonel Non‐Exempt
EndocrineandMetabolicAgents‐
Misc.(Bisphosphonate)
✓⦸HipandGroinDisorders⦸KneeDisorders✕LowBackDisorders✓Shoulder
Rivaroxaban Xarelto Non‐Exempt 14Days Anticoagulants⦸AnkleandFootDisorders✓HipandGroinDisorders✓KneeDisorders
S‐Adenosylmethionine SAME Non‐Exempt AlternativeMedicines ✕ChronicPain
Salmeterol Serevent Non‐Exempt AntiasthmaticandBronchodilatorAgents ✓WorkRelatedAsthma
Salsalate Disalcid Exempt Analgesics‐NonNarcotic(NSAID)
✓AnkleandFootDisorders✓CervicalandThoracicSpineDisorders✓ChronicPain✓✕⦸ElbowDisorders✓✕⦸Hand,Wrist,andForearmDisorders✓⦸HipandGroinDisorders✓⦸KneeDisorders✓LowBackDisorders✓Shoulder
*ACOEM Guidelines Copyright Reed Group Ltd.
Effective October 1, 2018 23 of 26
MTUS Drug List v.3 (8 CCR § 9792.27.15)
DrugIngredient ReferenceBrandNameExempt/Non‐Exempt* SpecialFill** Peri‐Op*** DrugClass ReferenceinACOEMGuidelines* DosageForm Strength
UniquePharmaceuticalIdentifier(s)
SertralineHCL Zoloft Non‐Exempt Antidepressants(SSRI)
✕CervicalandThoracicSpineDisorders✓✕ChronicPain✕HipandGroinDisorders✓✕KneeDisorders✕LowBackDisorders✕Shoulder
SilverSulfadiazine Silvadene Non‐Exempt Dermatologicals ⦸Hand,Wrist,andForearmDisorders
SodiumChlorideOphthalmic Exempt OphthalmicAgents ✓Eye
SodiumOxybate Xyrem Non‐ExemptPsychotherapeuticandNeurologicalAgents‐
Misc.✓ChronicPain
Sucralfate Carafate Exempt UlcerDrugs
✓CervicalandThoracicSpineDisorders✓ElbowDisorders✓HipandGroinDisorders✓KneeDisorders✓LowBackDisorders✓Shoulder
Sulfamethoxazole/Trimethoprim Bactrim Exempt Anti‐InfectiveAgents‐Misc.
✓⦸AnkleandFootDisorders✓✕⦸Hand,Wrist,andForearmDisorders
Sulindac Clinoril Exempt Analgesics‐Anti‐Inflammatory(NSAID)
✓AnkleandFootDisorders✓CervicalandThoracicSpineDisorders✓ChronicPain✓✕⦸ElbowDisorders✓✕⦸Hand,Wrist,andForearmDisorders✓⦸HipandGroinDisorders✓⦸KneeDisorders✓LowBackDisorders✓Shoulder
Tacrolimus Protopic Non‐Exempt Dermatologicals ✓AnkleandFootDisorders
Tapentadol Nucynta Non‐Exempt Analgesics‐Opioid
✕AnkleandFootDisorders✕CervicalandThoracicSpineDisorders✕ChronicPain✕ElbowDisorders✕Hand,Wrist,andForearmDisorders✕HipandGroinDisorders✕KneeDisorders✕LowBackDisorders✕Shoulder
TerbinafineHCl Lamisil Non‐Exempt Antifungals ✓AnkleandFootDisorders
TerbinafineHCl(Topical) Lamisil Non‐Exempt Dermatologicals ✓AnkleandFootDisorders
TetracaineHCL Tetcaine Exempt OphthalmicAgents(Anesthetic) ✓Eye
TetracyclineHCL Exempt Tetracyclines ✓Eye
Thalidomide Thalomid Non‐Exempt AssortedClasses ✕ChronicPain✕LowBackDisorders
Theophylline Theo‐24,Theo‐Dur Non‐Exempt AntiasthmaticandBronchodilatorAgents ✓WorkRelatedAsthma
TiagabineHCL Gabitril Non‐Exempt Anticonvulsants✕ChronicPain⦸LowBackDisorders✕Shoulder
*ACOEM Guidelines Copyright Reed Group Ltd.
Effective October 1, 2018 24 of 26
MTUS Drug List v.3 (8 CCR § 9792.27.15)
DrugIngredient ReferenceBrandNameExempt/Non‐Exempt* SpecialFill** Peri‐Op*** DrugClass ReferenceinACOEMGuidelines* DosageForm Strength
UniquePharmaceuticalIdentifier(s)
TizanidineHCL Zanaflex Non‐Exempt 4daysMusculoskeletalTherapyAgents
(MuscleRelaxants)
✓✕CervicalandThoracicSpineDisorders✓✕⦸ChronicPain✓✕HipandGroinDisorders✕⦸KneeDisorders✓✕LowBackDisorders✓✕Shoulder
TobramycinOphthalmic Tobrex Exempt OphthalmicAgents(Anti‐bacterial) ✓✕⦸Eye
Tolnaftate Tinactin Non‐Exempt Dermatologicals ✓AnkleandFootDisorders
TolmetinSodium Tolectin Exempt Analgesics‐Anti‐Inflammatory(NSAID)
✓AnkleandFootDisorders✓CervicalandThoracicSpineDisorders✓ChronicPain✓✕⦸ElbowDisorders✓✕⦸Hand,Wrist,andForearmDisorders✓⦸HipandGroinDisorders✓⦸KneeDisorders✓LowBackDisorders✓Shoulder
Topiramate Topamax Non‐Exempt Anticonvulsants
✓✕CervicalandThoracicSpineDisorders✓ChronicPain✕⦸HipandGroinDisorders✕⦸KneeDisorders✓⦸LowBackDisorders✕⦸Shoulder
TramadolHCL Ultram,UltramER Non‐Exempt 4Days 4Days Analgesics‐Opioid
✓✕AnkleandFootDisorders✓✕CervicalandThoracicSpineDisorders✓✕ChronicPain✓✕ElbowDisorders✓✕Hand,Wrist,andForearmDisorders✓HipandGroinDisorders✓KneeDisorders✓✕LowBackDisorders✓✕Shoulder
TramadolHCL/AC Ultracet Non‐Exempt 4Days 4Days Analgesics‐Opioid
✓✕AnkleandFootDisorders✓✕CervicalandThoracicSpineDisorders✓✕ChronicPain✓✕ElbowDisorders✓✕Hand,Wrist,andForearmDisorders✓HipandGroinDisorders✓KneeDisorders✓✕LowBackDisorders✓✕Shoulder
TranexamicAcid Lysteda Exempt Hemostatics ✓Eye
TrazodoneHCL Desyrel,Oleptro Non‐Exempt Antidepressants(SSRI)
✕CervicalandThoracicSpineDisorders✓✕⦸ChronicPain✕HipandGroinDisorders✕KneeDisorders✕LowBackDisorders✕Shoulder
TriamcinoloneAcetonideI Non‐Exempt Dermatologicals ✓AnkleandFootDisorders
TrolamineSalicylate Arthricream Non‐Exempt Dermatologicals ✓Hand,Wrist,andForearmDisorders
TropicamideOphthalmic Mydriacyl Exempt OphthalmicAgents(Anticholinergics) ✕Eye
Trypsin Non‐Exempt Chemicals(Proteolyticenzyme) ✕AnkleandFootDisorders
*ACOEM Guidelines Copyright Reed Group Ltd.
Effective October 1, 2018 25 of 26
MTUS Drug List v.3 (8 CCR § 9792.27.15)
DrugIngredient ReferenceBrandNameExempt/Non‐Exempt* SpecialFill** Peri‐Op*** DrugClass ReferenceinACOEMGuidelines* DosageForm Strength
UniquePharmaceuticalIdentifier(s)
ValacyclovirHCL Valtrex Non‐Exempt Antivirals ✕⦸ChronicPain
ValproicAcid Depakote,Depakene,Depacon Non‐Exempt Anticonvulsants✕ChronicPain⦸LowBackDisorders✕Shoulder
VenlafaxineHCL Effexor Non‐Exempt Antidepressants(SNRI)
✓✕CervicalandThoracicSpineDisorders✓ChronicPain⦸HipandGroinDisorders✓✕⦸KneeDisorders✓⦸LowBackDisorders✓✕Shoulder
Vilazodone Viibryd Non‐Exempt Antidepressants(SSRI)
✕CervicalandThoracicSpineDisorders✕ChronicPain✕HipandGroinDisorders✕KneeDisorders✕LowBackDisorders✕Shoulder
VitaminA Non‐Exempt Vitamins ✕CervicalandThoracicSpineDisorders
VitaminB‐12 Cyanocobalamin,Methylcobalamin Non‐ExemptHematopoieticAgents
(Vitamins)
✕CervicalandThoracicSpineDisorders⦸ElbowDisorders✕LowBackDisorders
VitaminB‐6 Pyridoxine Non‐Exempt Vitamins
✕⦸AnkleandFootDisorders✕CervicalandThoracicSpineDisorders✕ElbowDisorders✕Hand,Wrist,andForearmDisorders
VitaminD3 Non‐Exempt Vitamins ✓ChronicPain
VitaminE Non‐Exempt Vitamins✕⦸AnkleandFootDisorders✕CervicalandThoracicSpineDisorders✕LowBackDisorders
WarfarinSodium Coumadin Non‐Exempt 14Days Anticoagulants⦸AnkleandFootDisorders✓HipandGroinDisorders✓KneeDisorders
Zafirlukast Accolate Non‐Exempt AntiasthmaticandBronchodilatorAgents ✓WorkRelatedAsthma
Zileuton Zyflo Non‐Exempt AntiasthmaticandBronchodilatorAgents ✓WorkRelatedAsthma
ZolpidemTartrate Ambien Non‐ExemptHypnotics/Sedatives/SleepDisorder
Agents✕ChronicPain
Zonisamide Zonegran Non‐Exempt Anticonvulsants✕ChronicPain⦸LowBackDisorders✕Shoulder
*ACOEM Guidelines Copyright Reed Group Ltd.
Effective October 1, 2018 26 of 26