[PROPOSED FOR ADOPTION] MTUS Drug List ( 8 CCR § 9792.27...

[MODIFIED PROPOSED NEW REGULATION FOR ADOPTION] MTUS Drug List ( 8 CCR § 9792.27.15)

[MODIFIED PROPOSED NEW REGULATION FOR ADOPTION 8 CCR section 9792.27.15 - 1st 15-Day Comment Period - July 2017] tolf

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Drug Ingredient Reference Brand Name

Preferred / Non-Preferred*

Exempt/Non-Exempt*Special Fill** Peri-Op*** Drug Class Reference in Guidelines Dosage Form Strength

Unique Product

Identifier(s)

1 Acetaminophen Tylenol Preferred ExemptAnalgesics - NonNarcotic

✓⦸ Ankle and Foot Disorders✓ Cervical and Thoracic Spine Disorders✓ Chronic Pain✓✕ Elbow Disorders✓ Eye✓✕ Hand, Wrist, and Forearm Disorders✓ Hip and Groin Disorders✓ Knee Disorders✓ Low Back Disorders✓ Shoulder

2 Adalimumab Humira Non-Preferred Non-Exempt

Analgesics - Anti-Inflammatory (TNF-

alpha blocker)

✕ Chronic Pain✕ Hip and Groin Disorders✕ Knee Disorders✕ Low Back Disorders

3 Albuterol Sulfate Proventil Preferred ExemptAntiasthmatic and

Bronchodilator Agents ✓ Work Related Asthma

4 Alclometasone Dipropionate Aclovate Non-Preferred Non-Exempt Dermatologicals ✓ Ankle and Foot Disorders

45 Alendronate Sodium Fosamax

Non-Preferred Non-Exempt

Endocrine and Metabolic Agents-

Misc. (Bisphosphonate)

✓✕ Chronic Pain✓⦸ Hip and Groin Disorders⦸ Knee Disorders✕ Low Back Disorders✓ Shoulder

56 Amantadine HCL Symmetrel


Antiparkinson Agents (NMDA receptor

antagonist)✕ Chronic Pain✕ Low Back Disorders

7 Amcinonide Cyclocort Non-Preferred Non-Exempt Dermatologicals ✓ Ankle and Foot Disorders

68 Amitriptyline HCL Elavil


Antidepressants (TCAs)

✓✕ Cervical and Thoracic Spine Disorders✓ Chronic Pain✕⦸ Hip and Groin Disorders✓✕⦸ Knee Disorders✓⦸ Low Back Disorders✓✕ Shoulder

79 Amlodipine Besylate Norvasc


Calcium Channel Blockers ✓ Hand, Wrist, and Forearm Disorders

810 Amoxicillin/Clavulanate P Augmentin

Preferred Exempt

Antibiotics (Penicillins)

✓⦸ Ankle and Foot Disorders✓ Hand, Wrist, and Forearm Disorders✓ Low Back Disorders

11 Anakinra Kineret Non-Preferred Non-ExemptAnalgesics - Anti-

inflammatory ✕ Knee Disorders

912 Apixaban Eliquis


14 Days 4 Days Anticoagulants

⦸ Ankle and Foot Disorders✓ Hip and Groin Disorders✓ Knee Disorders

1013 Artificial Tear Ointments Refresh PM

Preferred Exempt

Ophthalmic Agents (Artificial Tears) ✓ Eye

1114 Ascorbic Acid Vitamin C

Non-Preferred Non-Exempt Vitamins

✕⦸ Ankle and Foot Disorders✕ Cervical and Thoracic Spine Disorders✓✕ Chronic Pain✕ Low Back Disorders

[PROPOSED FOR ADOPTION] MTUS Drug List ( 8 CCR § 9792.27.14 §9792.27.15)The 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 - §9792.27.2123.) "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.* Preferred/Non-Preferred - "Preferred" * Exempt/Non-Exempt"Exempt" indicates drug may be prescribed/dispensed without seeking authorization through Prospective Review if in accordance with MTUS. 1) Physician dispensed "ExemptPreferred" 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"Preferred drug where generic is available requires authorization through Prospective Review. "Non-ExemptPreferred" or “Unlisted” drug requires authorization through Prospective Review prior to prescribing or dispensing. (See 8 CCR §9792.27.1 through §9792.27.2123 for complete rules.)** Special Fill - Indicates the Non-ExemptPreferred 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 § 9792.27.1112.)***Perioperative Fill – Indicates the Non-ExemptPreferred drug may be prescribed/dispensed without Prospective Review: 1) Rx issued during the perioperative period (2 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) if in accord with MTUS. (See 8 CCR § 9792.27.1213.)



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Unique Product

Identifier(s)

1215 Aspirin Bayer

Preferred Exempt

Analgesics - NonNarcotic

✓ Ankle and Foot Disorders✓ Cervical and Thoracic Spine Disorders✕ Chronic Pain✓ Elbow Disorders✓✕⦸ Hand, Wrist, and Forearm Disorders✓ Hip and Groin Disorders✓ Knee Disorders✓ Low Back Disorders✓ Shoulder

1316 Aspirin/Caffeine/Dihydrocodeine Bitartrate Synalgos-DC

Non-Preferred Non-Exempt Analgesics - Opioid

✕ Ankle and Foot Disorders ✕ Cervical and Thoracic Spine Disorders✕ Chronic Pain✕ Elbow Disorders✕ Hand, Wrist, and Forearm Disorders✕ Hip and Groin Disorders✕ Knee Disorders✕ Low Back Disorders✕ Shoulder

1417 Azithromycin Zithromax


Antibiotics (Macrolides) ✕ Hand, Wrist, and Forearm Disorders

1518 Bacitracin

Non-Preferred Exempt

Anti-Infective Agents - Misc.

✓ Ankle and Foot Disorders⦸ Hand, Wrist, and Forearm Disorders

1619 Bacitracin Ophthalmic AK-Tracin

Preferred Exempt

Ophthalmic Agents (Antibiotics) ✓ Eye

1720 Bacitracin-Polymyxin B Ophthalmic AK-Poly-Bac

Preferred Exempt

Ophthalmic Agents (Antibiotics) ✓ Eye

1821 Baclofen Lioresal

Non-Preferred Non-Exempt 4 Days 4 Days

Musculoskeletal Therapy Agents

(Muscle Relaxants)

✓✕ Cervical and Thoracic Spine Disorders✓✕⦸ Chronic Pain✓✕ Hip and Groin Disorders✕⦸ Knee Disorders✓✕ Low Back Disorders✓✕ Shoulder

22 Becaplermin Regranex Non-Preferred Non-Exempt Dermatologicals ✓Ankle and Foot Disorders

1923 Balanced Salt Solution BSS

Preferred Exempt Ophthalmic Agents ✓ Eye

2024 Beclomethasone Dipropionate Qvar


Antiasthmatic and Bronchodilator Agents ✓ Work Related Asthma

2125 Betamethasone Celestone

Non-Preferred Non-Exempt Corticosteroids

✓✕⦸ Ankle and Foot Disorders✓✕ Cervical and Thoracic Spine Disorders✓⦸ Elbow Disorders✓✕⦸ Hand, Wrist, and Forearm Disorders✓✕ Hip and Groin Disorders✓⦸ Knee Disorders✓✕⦸ Low Back Disorders✓✕⦸ Shoulder

26 Betamethasone Dipropionat Diprosone Non-Preferred Non-Exempt Dermatologicals ✓ Ankle and Foot Disorders

27 Betamethasone Valerate Valisone Non-Preferred Non-Exempt Dermatologicals ✓ Ankle and Foot Disorders

2228 Bromfenac Prolensa

Preferred Exempt

Ophthalmic Agents (NSAID) ✓✕ Eye

2329 Budesonide Pulmicort



2430 Budesonide/Formoterol Symbicort





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Unique Product

Identifier(s)

2531 Buprenorphine HCL Butrans


✕ Ankle and Foot Disorders✕ Cervical and Thoracic Spine Disorders✕ Chronic Pain✕ Elbow Disorders✕ Hand, Wrist, and Forearm Disorders✕ Hip and Groin Disorders✕ Knee Disorders✕ Low Back Disorders✕ Shoulder

2632 Buprenorphine HCL/Naloxone Suboxone



2733 Bupropion HCL

Wellbutrin, Wellbutrin XL, Wellbutrin SR


Antidepressants (SSRI)

✕ Cervical and Thoracic Spine Disorders✕⦸ Chronic Pain✕ Hip and Groin Disorders✕ Knee Disorders✕ Low Back Disorders✕ Shoulder

2834 Butalbital/Apap/Caffeine


Analgesics - NonNarcotic ✕ Hand, Wrist, and Forearm Disorders

2935 Butalbital/Asa/Caffeine


Analgesics - NonNarcotic ✕ Hand, Wrist, and Forearm Disorders

36 Butenafine HCl Lotrimin Ultra Non-Preferred Non-Exempt Dermatologicals ✓ Ankle and Foot Disorders

3037 Butorphanol Tartrate Stadol



3138 Calcitonin-Salmon Fortical, Miacalcin




✕ Ankle and Foot Disorders✓✕ Chronic Pain✓⦸ Hip and Groin Disorders⦸ Knee Disorders✕ Low Back Disorders

39 Calcium Phosphate Tribasic Non-Preferred Non-ExemptMinerals & Electrolytes ⦸ Ankle and Foot Disorders

3240 Camphor Bengay Ultra

Non-Preferred Non-Exempt Dermatologicals

⦸ Cervical and Thoracic Spine Disorders⦸ Chronic Pain✓ Hand, Wrist, and Forearm Disorders✕⦸ Hip and Groin Disorders⦸ Low Back Disorders⦸ Shoulder

3341 Capsaicin Zostrix

Preferred Exempt

Dermatologicals (Topical creams and

ointments)

✓ Cervical and Thoracic Spine Disorders✓⦸ Chronic Pain✓ Hand, Wrist, and Forearm Disorders✓ Hip and Groin Disorders✓ Low Back Disorders✓⦸ Shoulder

3442 Carbamazepine Tegretol

Non-Preferred Non-Exempt Anticonvulsants

✓ Cervical and Thoracic Spine Disorders✓✕⦸ Chronic Pain⦸ Low Back Disorders✓✕ Shoulder

3543 Carboxymethylcellulose Sodium Ophthalmic Refresh Plus

Preferred Exempt

Ophthalmic Agents (Artificial Tears) ✓ Eye



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Unique Product

Identifier(s)

3644 Carisoprodol Soma



(Muscle Relaxants)

✕ Cervical and Thoracic Spine Disorders✕ Chronic Pain✕ Hip and Groin Disorders✕ Knee Disorders✕ Low Back Disorders✕ Shoulder

3745 Cefuroxime Axetil Ceftin

Preferred Exempt

Antibiotics (Cephalosporins) ✓ Hand, Wrist, and Forearm Disorders

3846 Celecoxib Celebrex

Preferred Exempt

Analgesics - Anti-Inflammatory (NSAID)

✓⦸ Ankle and Foot Disorders✓ Cervical and Thoracic Spine Disorders✓ Chronic Pain✓✕⦸ Elbow Disorders✓✕⦸ Hand, Wrist, and Forearm Disorders✓⦸ Hip and Groin Disorders✓⦸ Knee Disorders✓ Low Back Disorders✓ Shoulder

3947 Cephalexin Keflex

Non-Preferred Exempt

Antibiotics (Cephalosporins)

✓⦸ Ankle and Foot Disorders✕ Hand, Wrist, and Forearm Disorders

4048 Certolizumab Pegol Cimzia


Gastrointestinal Agents (TNF Blocker)


4149 Chlorzoxazone Loxone, Parafon Forte



(Muscle Relaxants)


4250 Choline Magnesium Trisalicylate Trilisate

Preferred Exempt

Analgesics - NonNarcotic (NSAID)


4351 Chondroitin Sulfate


Alternative Medicines (OTC nutraceutical)

⦸ Hand, Wrist, and Forearm Disorders✕ Hip and Groin Disorders✕ Knee Disorders✕ Shoulder

4452 Ciclesonide Alvesco



53 Ciclopirox Olamine Loprox Non-Preferred Non-Exempt Dermatologicals ✓ Ankle and Foot Disorders

4554 Cimetidine Tagamet

Preferred Exempt

Ulcer Drugs (H2 receptor blocker)

✓ Cervical and Thoracic Spine Disorders✓ Elbow Disorders✓ Hand, Wrist, and Forearm Disorders✓ Hip and Groin Disorders✓ Knee Disorders✓ Low Back Disorders✓ Shoulder

4655 Ciprofloxacin Cipro

Preferred Exempt

Antibiotics (Fluoroquinolones)

✓ Ankle and Foot Disorders✓ Hand, Wrist, and Forearm Disorders

4756 Ciprofloxacin HCL Ophthalmic Ciloxan

Preferred Exempt

Ophthalmic Agents (Antibiotics) ✓✕ Eye

4857 Citalopram Hydrobromide Celexa



✕ Cervical and Thoracic Spine Disorders✕⦸ Chronic Pain✕ Hip and Groin Disorders✓✕ Knee Disorders✕ Low Back Disorders✕ Shoulder

4958 Clarithromycin Biaxin





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Unique Product

Identifier(s)

5059 Clindamycin HCL Cleocin

Preferred Exempt


✓ Ankle and Foot Disorders✓✕⦸ Hand, Wrist, and Forearm Disorders✓ Hip and Groin Disorders✓ Knee Disorders

5160 Clomipramine HCL Anafranil



✕ Cervical and Thoracic Spine Disorders✓✕ Chronic Pain✕⦸ Hip and Groin Disorders✕⦸ Knee Disorders✕ Low Back Disorders✕ Shoulder

5261 Clonazepam Klonopin


✕ Chronic Pain⦸ Low Back Disorders✕ Shoulder

5362 Clonidine HCL Catapres, Duraclon


Analgesics - NonNarcotic

✓✕ Chronic Pain✕⦸ Low Back Disorders

63 Clotrimazole Antifungal Lotrimin AF Non-Preferred Non-Exempt Dermatologicals ✓ Ankle and Foot Disorders

5464 Codeine Phosphate



5565 Codeine Sulfate



5666 Codeine/Acetaminophen Tylenol #3, Tylenol #4



5767 Colchicine

Non-Preferred Non-Exempt Gout Agents

✕ Cervical and Thoracic Spine Disorders✕ Low Back Disorders

5868 Cortisone Cortone

Non-Preferred Non-Exempt 4 Days Corticosteroids

✓✕ ⦸ Ankle and Foot Disorders✓✕ Cervical and Thoracic Spine Disorders✓✕ Chronic Pain⦸ Elbow Disorders✓⦸ Hand, Wrist, and Forearm Disorders✕ Hip and Groin Disorders✓✕⦸ Low Back Disorders✓✕⦸ Shoulder

5969 Cromolyn Sodium Intal



6070 Cyclobenzaprine HCL Flexeril

Non-Preferred Non-Exempt 4 Days


(Muscle Relaxants)

✓✕ Cervical and Thoracic Spine Disorders✕ Chronic Pain✕ Hip and Groin Disorders✕⦸ Knee Disorders✓✕ Low Back Disorders✓✕ Shoulder

6171 Cyclopentolate HCL Cyclogyl

Preferred Exempt

Ophthalmic Agents (Anticholinergics) ✓✕ Eye

6272 Dalteparin Fragmin

Non-Preferred Non-Exempt Anticoagulants ⦸ Ankle and Foot Disorders



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Unique Product

Identifier(s)

6373 Dantrolene Sodium Dantrium



(Muscle Relaxants)


6474 Desipramine HCL Norpramin



✓✕ Cervical and Thoracic Spine Disorders✓ Chronic Pain⦸ Hip and Groin Disorders✓✕⦸ Knee Disorders✓⦸ Low Back Disorders✓✕ Shoulder

75 Desonide Desowen Non-Preferred Non-Exempt Dermatologicals ✓ Ankle and Foot Disorders

76 Desoximetasone Topicort Non-Preferred Non-Exempt Dermatologicals ✓ Ankle and Foot Disorders

6577 Desvenlafaxine ER Pristiq


Antidepressants (SNRI)

✕ Cervical and Thoracic Spine Disorders✕ Chronic Pain✕ Hip and Groin Disorders✕ Knee Disorders✓⦸ Low Back Disorders✕ Shoulder

6678 Dexamethasone Decadron


✓✕⦸ Ankle and Foot Disorders✓✕ Cervical and Thoracic Spine Disorders✓✕ Chronic Pain✓⦸ Elbow Disorders✓✕⦸ Hand, Wrist, and Forearm Disorders✕ Hip and Groin Disorders✓⦸ Knee Disorders✓✕⦸ Low Back Disorders✓✕⦸ Shoulder

6779 Dexamethasone Sodium Phosphate Ophthalmic


Ophthalmic Agents (Steroid) ✕ Eye

6880 Dexlansoprazole Dexilant

Preferred Exempt

Ulcer Drugs (Proton pump inhibitor)

✓ Cervical and Thoracic Spine Disorders✓ Elbow Disorders✓ Hand, Wrist, and Forearm Disorders✓ Knee Disorders✓ Shoulder

6981 Dextromethorphan Delsym


Cough/Cold/Allergy (NMDA Receptor

Antagonist)

✓✕ Chronic Pain✕ Low Back Disorders✓ Shoulder

7082 Diazepam Valium


Antianxiety Agents (Muscle relaxant) ✕ Chronic Pain

7183 Diclofenac Potassium Cataflam, Voltaren

Preferred Exempt


✓⦸ Ankle and Foot Disorders✓ Cervical and Thoracic Spine Disorders✓⦸ Chronic Pain✓✕⦸ Elbow Disorders✓✕⦸ Hand, Wrist, and Forearm Disorders✓⦸ Hip and Groin Disorders✓⦸ Knee Disorders✓ Low Back Disorders✓ Shoulder

7284 Diclofenac Sodium Voltaren 1% gel

Preferred Exempt Dermatologicals

✓✕⦸ Ankle and Foot Disorders⦸ Cervical and Thoracic Spine Disorders✓⦸ Chronic Pain✓⦸ Elbow Disorders✓ Hand, Wrist, and Forearm Disorders✕⦸ Hip and Groin Disorders⦸ Low Back Disorders⦸ Shoulder

7385 Diclofenac Sodium Ophthalmic Voltaren

Preferred Exempt




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Unique Product

Identifier(s)

7486 Diclofenac Sodium/Misoprostol Arthrotec

Preferred Exempt

Analgesics - Anti-Inflammatory (NSAID/

Ulcer drug)


87 Dicloxacillin Sodium Dynapen Preferred ExemptAntibiotics

(Penicillins) ✓⦸ Ankle and Foot Disorders

7588 Diflunisal Dolobid

Preferred Exempt



7689 Dimethyl Sulfoxide DMSO


Genitourinary - Misc. (Ointments and topical

agents)

✕ Cervical and Thoracic Spine Disorders✓✕ Chronic Pain✕⦸ Hip and Groin Disorders✕ Low Back Disorders

7790 Doxepin HCL Sinequan



✓✕ Cervical and Thoracic Spine Disorders✕ Chronic Pain⦸ Hip and Groin Disorders✕⦸ Knee Disorders✓⦸ Low Back Disorders✕ Shoulder

7891 Doxycycline Vibramycin

Preferred Exempt

Antibiotics (Tetracyclines)

✓⦸ Ankle and Foot Disorders✓ Eye✓ Hand, Wrist, and Forearm Disorders✓ Hip and Groin Disorders

7992 Duloxetine HCL Cymbalta



✓✕ Cervical and Thoracic Spine Disorders✓⦸ Chronic Pain⦸ Hip and Groin Disorders✓✕⦸ Knee Disorders✓⦸ Low Back Disorders✓✕⦸ Shoulder

93 Econazole Nitrate Spectazole Non-Preferred Non-Exempt Dermatologicals ✓ Ankle and Foot Disorders

8094 Enoxaparin Sodium Lovenox




8195 Erythromycin Ery-Tab



8296 Erythromycin Ophthalmic Ointment Ilotycin

Preferred Exempt


8397 Escitalopram Oxalate Lexapro




8498 Esomeprazole Magnesium Nexium

Preferred Exempt





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Unique Product

Identifier(s)

8599 Esomeprazole/Naproxen Vimovo


Analgesics - Anti-Inflammatory (Proton

Pump Inhibitor /NSAID)


86100 Etanercept Enbrel



alpha blocker)


87101 Etidronate Disodium Didronel





88102 Etodolac Lodine

Preferred Exempt



89103 Famotidine Pepcid

Preferred Exempt



90104 Famotidine/Ibuprofen Duexis


Analgesics - Anti-Inflammatory (H2 Receptor Blocker

/NSAID)


91105 Fenoprofen Calcium Nalfon

Preferred Exempt



92106 Fentanyl Duragesic





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Unique Product

Identifier(s)

93107 Fentanyl Citrate Oral Transmucosal Actiq, Fentora



108 Fluconazole Diflucan Non-Preferred Non-Exempt Antifungals ✓ Ankle and Foot Disorders

94109 Flunisolide Anhydrous Aerospan HFA



110 Fluocinolone Acetonide Synalar Non-Preferred Non-Exempt Dermatologicals ✓Ankle and Foot Disorders

95111 Fluocinonide

Non-Preferred Non-Exempt Dermatologicals ✕⦸ Elbow Disorders

96112 Fluorometholone FML

Non-Preferred Non-Exempt Ophthalmic Agents ✕ Eye

97113 Fluoxetine HCL Prozac



✕ Cervical and Thoracic Spine Disorders✓✕ Chronic Pain✕ Hip and Groin Disorders✓✕ Knee Disorders✕ Low Back Disorders✕ Shoulder

98114 Flurbiprofen Ansaid

Preferred Exempt



99115 Fluticasone Propionate Flovent



116 Fluticasone Prop (Topical) Cutivate Non-Preferred Non-Exempt Dermatologicals ✓ Ankle and Foot Disorders

100117 Fluticasone-Salmeterol Advair



101118 Fluvoxamine Maleate Luvox



✕ Cervical and Thoracic Spine Disorders✕⦸ Chronic Pain✕ Hip and Groin Disorders✕ Knee Disorders✕ Low Back Disorders✕ Shoulder

102119 Folic Acid

Non-Preferred Non-Exempt Hematopoietic Agents ✕ Cervical and Thoracic Spine Disorders

103120 Fondaparinux Sodium Arixtra




104121 Formoterol Fumarate Foradil



105122 Formoterol/Mometasone Dulera



106123 Gabapentin Neurontin

Non-Preferred Non-Exempt 4 Days Anticonvulsants

✓✕⦸ Cervical and Thoracic Spine Disorders✓✕⦸ Chronic Pain✓✕⦸ Hip and Groin Disorders✓✕⦸ Knee Disorders✓⦸ Low Back Disorders✓✕⦸ Shoulder

107124 Gatifloxacin Zymaxid

Preferred Exempt

Ophthalmic Agents (Anti-bacterial) ✓✕ Eye



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Unique Product

Identifier(s)

125 Gentamicin (Topical) Preferred Exempt Dermatologicals ✓Ankle and Foot Disorders

108126 Gentamicin Sulfate Ophthalmic Gentak

Preferred Exempt


109127 Gentamicin-Prednisolone Ace Ophthalmic Pred-G


Ophthalmic Agents (Anti-

bacterial/steroid) ✕ Eye

110128 Glucosamine Sulfate


Alternative Medicines (OTC nutraceutical)

⦸ Hand, Wrist, and Forearm Disorders✕ Hip and Groin Disorders✕ Knee Disorders✕ Shoulder

111129 Golimumab Simponi



alpha blocker)


112130 Heparin Sodium



✕⦸ Ankle and Foot Disorders✓ Hip and Groin Disorders✓ Knee Disorders

113131 Homatropine HBr Ophthalmic Isopto Homatropine

Preferred Exempt


114132 Hydrochlorothiazide Microzide

Non-Preferred Non-Exempt Diuretics

✕ Ankle and Foot Disorders✕ Hand, Wrist, and Forearm Disorders

115133 Hydrocodone Bitartrate Zohydro ER, Hysingla ER



116134 Hydrocodone/Acetaminophen Norco, Vicodin, Xodol

Non-Preferred Non-Exempt 4 Days 4 Days Analgesics - Opioid

✓✕ Ankle and Foot Disorders✓✕ Cervical and Thoracic Spine Disorders✓✕ Chronic Pain✓✕ Elbow Disorders✓✕ Hand, Wrist, and Forearm Disorders✓ Hip and Groin Disorders✓ Knee Disorders✓✕ Low Back Disorders✓✕ Shoulder

117135 Hydrocodone/Ibuprofen Vicoprofen



118136 Hydrocortisone Cortef


✓✕ Ankle and Foot Disorders✓✕ Cervical and Thoracic Spine Disorders✓✕ Chronic Pain⦸ Elbow Disorders✓✕⦸ Hand, Wrist, and Forearm Disorders✕ Hip and Groin Disorders⦸ Knee Disorders✓✕⦸ Low Back Disorders✓✕⦸ Shoulder

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

138 Hydrocortisone Valerate Westcort Non-Preferred Non-Exempt Dermatologicals ✓ Ankle and Foot Disorders



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Unique Product

Identifier(s)

119139 Hydromorphone HCL Dilaudid



120140 Ibandronate Sodium Boniva





121141 Ibuprofen Motrin

Preferred Exempt


✓⦸ Ankle and Foot Disorders✓ Cervical and Thoracic Spine Disorders✓ Chronic Pain✓✕⦸ Elbow Disorders✓✕⦸ Hand, Wrist, and Forearm Disorders✓⦸ Hip and Groin Disorders✓✕⦸ Knee Disorders✓ Low Back Disorders✓ Shoulder

122142 Imipramine HCL Tofranil



✓✕ Cervical and Thoracic Spine Disorders✕ Chronic Pain⦸ Hip and Groin Disorders✕⦸ Knee Disorders✓⦸ Low Back Disorders✕ Shoulder

123143 Indomethacin Indocin

Preferred Exempt



144 Itraconazole Sporanox Non-Preferred Non-Exempt Antifungals ✓Ankle and Foot Disorders

145 Ketoconazole Nizoral Non-Preferred Non-Exempt Dermatologicals ✓Ankle and Foot Disorders

124146 Ketoprofen Oruvail

Preferred Exempt



125147 Ketorolac Tromethamine




126148 Ketorolac Tromethamine Ophthalmic Acular

Preferred Exempt


127149 Lamotrigine Lamictal


✓ Cervical and Thoracic Spine Disorders✕⦸ Chronic Pain⦸ Low Back Disorders✕ Shoulder



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Unique Product

Identifier(s)

128150 Lansoprazole Prevacid

Preferred Exempt



129151 Levalbuterol Xopenex

Preferred Exempt


130152 Levetiracetam Keppra


✕⦸ Chronic Pain⦸ Low Back Disorders✕ Shoulder

131153 Levofloxacin Levaquin

Preferred Exempt


✓ Ankle and Foot Disorders✓✕ Hand, Wrist, and Forearm Disorders✓ Hip and Groin Disorders

132154 Levofloxacin Ophthalmic Solution Quixin

Preferred Exempt


133155 Levomilnacipran Fetzima




134156 Levorphanol Tartrate Levo-Dromoran



135157 Lidocaine Lidoderm


✓✕⦸ Ankle and Foot Disorders✕ Cervical and Thoracic Spine Disorders✓⦸ Chronic Pain⦸ Elbow Disorders✓ Hand, Wrist, and Forearm Disorders✕⦸ Hip and Groin Disorders✕⦸ Low Back Disorders

158 Lidocaine HCl Non-Preferred Non-Exempt Dermatologicals ✕ Cervical and Thoracic Spine Disorders

136159 Lidocaine/Prilocaine Emla


✕ Cervical and Thoracic Spine Disorders✕⦸ Chronic Pain✓ Hand, Wrist, and Forearm Disorders✕⦸ Hip and Groin Disorders✕ Low Back Disorders⦸ Shoulder

137160 Lorazepam Ativan

Non-Preferred Non-Exempt Antianxiety Agents ✓ Ankle and Foot Disorders

138161 Loteprednol Etabonate Ophthalmic Alrex



139162 Maprotiline HCL Ludiomil



✕ Cervical and Thoracic Spine Disorders✓✕ Chronic Pain✕⦸ Hip and Groin Disorders✕⦸ Knee Disorders✕ Low Back Disorders✕ Shoulder

140163 Meclofenamate Sodium Meclomen

Preferred Exempt





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Unique Product

Identifier(s)

141164 Mefenamic Acid Ponstel

Preferred Exempt



142165 Meloxicam Mobic

Preferred Exempt



143166 Memantine HCL Namenda


Psychotherapeutic and Neurological Agents -

Misc.(NDMA Receptor

Antagonist)

✕ Chronic Pain✕ Low Back Disorders

144167 Menthol Bengay Ultra, Biofreeze


⦸ Ankle and Foot Disorders⦸ Cervical and Thoracic Spine Disorders⦸ Chronic Pain✓ Hand, Wrist, and Forearm Disorders✕⦸ Hip and Groin Disorders⦸ Low Back Disorders⦸ Shoulder

145168 Meperidine HCL Demerol



146169 Metaxalone Skelaxin



(Muscle Relaxants)


147170 Methadone HCL Dolophine



148171 Methocarbamol Robaxin



(Muscle Relaxants)


149172 Methyl Salicylate Bengay Ultra


⦸ Cervical and Thoracic Spine Disorders⦸ Chronic Pain✓ Hand, Wrist, and Forearm Disorders✕⦸ Hip and Groin Disorders⦸ Low Back Disorders⦸ Shoulder



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Unique Product

Identifier(s)

150173 Methylprednisolone Medrol

Non-Preferred Non-Exempt 4 Days 4 Days Corticosteroids

✓✕ Ankle and Foot Disorders✓✕ Cervical and Thoracic Spine Disorders✓✕ Chronic Pain⦸ Elbow Disorders✓⦸ Hand, Wrist, and Forearm Disorders✕ Hip and Groin Disorders✓✕⦸ Low Back Disorders✓✕⦸ Shoulder✓ Work Related Asthma

151174 Methylsulfonylmethane


Chemicals (OTC nutraceuticals)

⦸ Hip and Groin Disorders⦸ Knee Disorders⦸ Shoulder

175 Metronidazole Preferred Exempt Dermatologicals ✓ Ankle and Foot Disorders

152176 Metronidazole Oral Flagyl

Preferred Exempt

Anti-Infective Agents - Misc. ✓Hand, Wrist, and Forearm Disorders

177 Miconazole Nitrate Micatin Non-Preferred Non-Exempt Dermatologicals ✓ Ankle and Foot Disorders

153178 Milnacipran Savella


Psychotherapeutic and Neurological Agents -

Misc. (Anti-depressant)


179 Minocycline HCl Minocin Non-Preferred Non-ExemptAntibiotics

(Tetracyclines) ✓⦸ Ankle and Foot Disorders

154180 Misoprostol Cytotec

Preferred Exempt Ulcer Drugs


181 Mometasone Furoate (Topical) Elocon Non-Preferred Non-Exempt Dermatologicals ✓ Ankle and Foot Disorders

155182 Mometasone Furoate Asmanex



156183 Montelukast Sodium Singluair



157184 Morphine Sulfate



158185 Morphine Sulfate Extended Release MS Contin, Kadian, Avinza


✕ Ankle and Foot Disorders✕ Cervical and Thoracic Spine Disorders✓✕ Chronic Pain✕ Elbow Disorders✓✕ Hand, Wrist, and Forearm Disorders✕ Hip and Groin Disorders✕ Knee Disorders✕ Low Back Disorders✕ Shoulder



15 of 21




Unique Product

Identifier(s)

159186 Morphine/Naltrexone Embeda



160187 Moxifloxacin HCL Avelox

Preferred Exempt


✓ Ankle and Foot Disorders✓Hand, Wrist, and Forearm Disorders

161188 Moxifloxacin HCL Ophthalmic Vigamox

Preferred Exempt


189 Mupirocin Bactroban Preferred Exempt Dermatologicals ✓Ankle and Foot Disorders

162190 Nabumetone Relafen

Preferred Exempt



163191 N-Acetyl-L-Cysteine NAC

Non-Preferred Non-Exempt Nutrients

✕ Cervical and Thoracic Spine Disorders✓✕ Chronic Pain✕⦸ Hip and Groin Disorders✕ Low Back Disorders

164192 Naproxen Aleve, Naprosyn

Preferred Exempt


✓⦸ Ankle and Foot Disorders✓✕ Cervical and Thoracic Spine Disorders✓ Chronic Pain✓✕⦸ Elbow Disorders✓✕⦸ Hand, Wrist, and Forearm Disorders✓⦸ Hip and Groin Disorders✓⦸ Knee Disorders✓⦸ Low Back Disorders✓⦸ Shoulder

165193 Neomycin Sulfate

Non-Preferred Non-Exempt Dermatologicals ⦸ Hand, Wrist, and Forearm Disorders

194 Neomycin/Polymyxin B/Bacitracin Neosporin Preferred Exempt Dermatologicals ✓ Ankle and Foot Disorders

166195 Neomycin/Bacitracin/Polymyxin B Ophthalmic Neosporin

Preferred Exempt


167196 Neomycin/Polymyxin B/Gramicidin Ophthalmic Neosporin

Preferred Exempt

Ophthalmic Agents (Anti-bacterial) ✓ Eye

168197 Nepafenac Ophthalmic Suspension Nevanac

Preferred Exempt


169198 Nifedipine Procardia


Calcium Channel Blockers ✓ Hand, Wrist, and Forearm Disorders

170199 Nitroglycerin Transdermal Nitro-Dur


Antianginal Agents (Glyceril trinitrate

patches)✓⦸ Ankle and Foot Disorders⦸ Shoulder

171200 Nizatidine Axid

Preferred Exempt



172201 Nortriptyline HCL Pamelor



✓✕ Cervical and Thoracic Spine Disorders✓ Chronic Pain⦸ Hip and Groin Disorders✓✕⦸ Knee Disorders✓⦸ Low Back Disorders✓✕ Shoulder

202 Nystatin/Triamcinolone Mycolog II Non-Preferred Non-Exempt Dermatologicals ✓Ankle and Foot Disorders



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Unique Product

Identifier(s)

173203 Ofloxacin Ophthalmic Solution Ocuflox

Preferred Exempt


174204 Omeprazole Prilosec

Preferred Exempt



175205 Orphenadrine Citrate Norflex



(Muscle Relaxants)


176206 Oxaprozin Daypro

Preferred Exempt



177207 Oxcarbazepine Trileptal


✓ Cervical and Thoracic Spine Disorders✕⦸ Chronic Pain⦸ Low Back Disorders✕ Shoulder

178208 Oxycodone HCL OxyContin, Roxicodone



179209 Oxycodone/Acetaminophen Percocet

Non-Preferred Non-Exempt 4 days 4 days Analgesics - Opioid


180210 Oxycodone/Aspirin Percodan



181211 Oxycodone/Ibuprofen Combunox





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Unique Product

Identifier(s)

182212 Oxymorphone HCL Opana, Opana ER



183213 Pantoprazole Sodium Protonix

Preferred Exempt



184214 Paroxetine HCL Paxil




185215 Penicillin V Potassium


Antibiotics (Penicillins) ✕ Hand, Wrist, and Forearm Disorders

186216 Pentazocine/Naloxone HCL Talwin NX



187 Phenol Non-Preferred Antiseptics and Disinfectants

✕ Cervical and Thoracic Spine Disorders✕ Hand, Wrist, and Forearm Disorders✕ Hip and Groin Disorders✕ Knee Disorders✕ Low Back Disorders✕ Shoulder

188217 Phenytoin Dilantin



189218 Piroxicam Feldene




190219 Polymyxin B-Trimethoprim Polytrim

Preferred Exempt


220 Prednicarbate Dermatop Non-Preferred Non-Exempt Dermatologicals ✓ Ankle and Foot Disorders

191221 Prednisolone Orapred



192222 Prednisolone Acetate Pred Forte, Pred Mild





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Unique Product

Identifier(s)

193223 Prednisone Sterapred



194224 Pregabalin Lyrica


⦸ Cervical and Thoracic Spine Disorders✓✕⦸ Chronic Pain✓⦸ Low Back Disorders✓✕⦸ Shoulder

195225 Proparacaine HCL Alcaine

Preferred Exempt

Ophthalmic Agents (Anesthetic) ✓ Eye

196226 Protriptyline HCL



✓ Chronic Pain✕ Knee Disorders

197227 Rabeprazole Sodium Aciphex

Preferred Exempt



198228 Ranitidine HCL Zantac

Preferred Exempt



199229 Regular Insulin Humulin R

Non-Preferred Non-Exempt Antidiabetics

✕ Ankle and Foot Disorders✕ Hand, Wrist, and Forearm Disorders

200230 Rimexolone Ophthalmic Vexol



201231 Risedronate Sodium Actonel





202232 Rivaroxaban Xarelto




203233 Salmeterol Serevent



204234 Salsalate Disalcid

Preferred Exempt

Analgesics - NonNarcotic (NSAID)


205235 Sertraline HCL Zoloft




206236 Silver Sulfadiazine Silvadene

Non-Preferred Non-Exempt Dermatologicals ⦸ Hand, Wrist, and Forearm Disorders

207237 Sodium Chloride Ophthalmic

Preferred Exempt Ophthalmic Agents ✓ Eye

208238 Sodium Sulfacetamide Bleph-10

Preferred Exempt

Ophthalmic Agents (Anti-bacterial) ✓ Eye



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Unique Product

Identifier(s)

209239 Sucralfate Carafate

Preferred Exempt Ulcer Drugs

✓ Cervical and Thoracic Spine Disorders✓ Elbow Disorders✓ Hip and Groin Disorders✓ Knee Disorders✓ Low Back Disorders✓ Shoulder

210240 Sulfacetamide Sodium/Prednisolone Blephamide




211241 Sulfamethoxazole/Trimethoprim Bactrim

Preferred Exempt


✓⦸ Ankle and Foot Disorders✓✕⦸ Hand, Wrist, and Forearm Disorders

212 Sulfasalazine Azulfidine Preferred Gastrointestinal Agents - Misc.

✓⦸ Ankle and Foot Disorders✓ Chronic Pain✓✕⦸ Elbow Disorders✓✕⦸ Hand, Wrist, and Forearm Disorders✓⦸ Knee Disorders✓ Shoulder

213242 Sulindac Clinoril

Preferred Exempt



243 Tacrolimus Protopic Non-Preferred Non-Exempt Dermatologicals ✓Ankle and Foot Disorders

214244 Tapentadol Nucynta



245 Terbinafine HCl Lamisil Non-Preferred Non-Exempt Antifungals ✓Ankle and Foot Disorders

246 Terbinafine HCl (Topical) Lamisil Non-Preferred Non-Exempt Dermatologicals ✓ Ankle and Foot Disorders215247 Tetracaine HCL Tetcaine

Preferred Exempt

Ophthalmic Agents (Anesthetic) ✓ Eye

216248 Tetracycline HCL

Preferred Exempt Tetracyclines ✓ Eye

217249 Thalidomide Thalomid

Non-Preferred Non-Exempt Assorted Classes

✕ Chronic Pain✕ Low Back Disorders

218250 Theophylline Theo-24, Theo-Dur



219251 Tiagabine HCL Gabitril



220252 Tizanidine HCL Zanaflex

Non-Preferred Non-Exempt 4 days


(Muscle Relaxants)

✓✕ Cervical and Thoracic Spine Disorders✓✕ Chronic Pain✓✕ Hip and Groin Disorders✕⦸ Knee Disorders✓✕ Low Back Disorders✓✕ Shoulder

221253 Tobramycin Ophthalmic Tobrex

Preferred Exempt


222254 Tobramycin/Dexamethasone Tobradex




255 Tolnaftate Tinactin Non-Preferred Non-Exempt Dermatologicals ✓ Ankle and Foot Disorders



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Unique Product

Identifier(s)

223256 Tolmetin Sodium Tolectin

Preferred Exempt



224257 Topiramate Topamax


✓✕ Cervical and Thoracic Spine Disorders✕⦸ Chronic Pain✕⦸ Hip and Groin Disorders✕⦸ Knee Disorders✓⦸ Low Back Disorders✕⦸ Shoulder

225258 Tramadol HCL Ultram, Ultram ER



226259 Tramadol HCL/AC Ultracet



227260 Trazodone HCL Desyrel, Oleptro




261 Triamcinolone Acetonide I Non-Preferred Non-Exempt Dermatologicals ✓ Ankle and Foot Disorders

228 Triamcinolone Hexacetonide Aristopan Non-Preferred 4 Days Corticosteroids

✕ Ankle and Foot Disorders✕ Cervical and Thoracic Spine Disorders✓✕ Hand, Wrist, and Forearm Disorders✓✕ Hip and Groin Disorders✓ Knee Disorders✓✕⦸ Low Back Disorders

229262 Trolamine Salicylate Arthricream

Non-Preferred Non-Exempt Dermatologicals ✓ Hand, Wrist, and Forearm Disorders

230263 Tropicamide Ophthalmic Mydriacyl

Preferred Exempt


231264 Trypsin


Chemicals (Proteolytic enzyme) ✕ Ankle and Foot Disorders

232265 Valproic Acid

Depakote, Depakene, Depacon



233266 Venlafaxine HCL Effexor



✓✕ Cervical and Thoracic Spine Disorders✓⦸ Chronic Pain⦸ Hip and Groin Disorders✓✕⦸ Knee Disorders✓⦸ Low Back Disorders✓✕ Shoulder



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Unique Product

Identifier(s)

234267 Vilazodone Viibryd




235268 Vitamin A

Non-Preferred Non-Exempt Vitamins ✕ Cervical and Thoracic Spine Disorders

236269 Vitamin B-12

Cyanocobalamin, Methylcobalamin


Hematopoietic Agents (Vitamins)

✕ Cervical and Thoracic Spine Disorders⦸ Elbow Disorders✕ Low Back Disorders

237270 Vitamin B-6 Pyridoxine


✕⦸ Ankle and Foot Disorders✕ Cervical and Thoracic Spine Disorders✕ Elbow Disorders✕ Hand, Wrist, and Forearm Disorders

238271 Vitamin E


✕⦸ Ankle and Foot Disorders✕ Cervical and Thoracic Spine Disorders✕ Low Back Disorders

239272 Warfarin Sodium Coumadin




240273 Zafirlukast Accolate



241274 Zileuton Zyflo



242275 Zonisamide Zonegran



Drug List

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[PROPOSED FOR ADOPTION] MTUS Drug List ( 8 CCR § 9792.27...

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