Drug Class Generic Name Brand Name Gener Equiv StatusAnticoagulants Apixaban Eliquis® No YAnticoagulants Dabigatran Pradaxa® No YAnticoagulants Enoxaparin Lovenox® Yes YAnticoagulants Rivaroxaban Xarelto® No YAntidepressants Amitriptyline Elavil® Yes YAntidepressants Bupropion (mental) Wellbutrin® Yes YAntidepressants Bupropion (pain) Wellbutrin® Yes NAntidepressants Citalopram Celexa Yes NAntidepressants Desvenlafaxine Pristiq® Yes YAntidepressants Duloxetine Cymbalta® Yes YAntidepressants Escitalopram (mental) Lexapro® Yes YAntidepressants Escitalopram (pain) Lexapro® Yes NAntidepressants Fluoxetine (mental) Prozac® Yes YAntidepressants Fluoxetine (pain) Prozac® Yes NAntidepressants Fluvoxamine Luvox Yes NAntidepressants Milnacipran Savella/Ixel® Yes NAntidepressants Mirtazapine (pain) Remeron® Yes NAntidepressants Mirtazapine (mental) Remeron® Yes YAntidepressants Nortriptyline Pamelor™ Yes YAntidepressants Paroxetine (mental) Paxil Yes YAntidepressants Paroxetine (pain) Paxil Yes NAntidepressants Sertraline (mental) Zoloft® Yes YAntidepressants Sertraline (pain) Zoloft® Yes NAntidepressants Venlafaxine Effexor® Yes YAntidepressants Venlafaxine ER Effexor XR® Yes YAntidiabetics Acarbose Precose Yes NAntidiabetics Exenatide Byetta No NAntidiabetics Glimepiride Amaryl Yes NAntidiabetics Glipizide Glucotrol Yes NAntidiabetics Glyburide Glynase Yes NAntidiabetics Insulin Humalog No YAntidiabetics Insulin Humulin No NAntidiabetics Insulin Novolin No NAntidiabetics Insulin NovoLog No YAntidiabetics Metformin Glucophage Yes YAntidiabetics Miglitol Glyset Yes NAntidiabetics Nateglinide Starlix Yes NAntidiabetics Pioglitazone Actos Yes NAntidiabetics Repaglinide Prandin Yes NAntidiabetics Rosiglitazone Avandia Yes NAntidiabetics Saxagliptin Onglyza No NAntidiabetics Sitagliptin Januvia No N

ODG Workers’ Compensation Drug Formulary January 2019

Antiemetics Ondansetron Zofran® Yes NAntiemetics Ondansetron Zuplenz® No NAnti-epilepsy drugs (AEDs) Carbamazepine Tegretol® Yes YAnti-epilepsy drugs (AEDs) Gabapentin Neurontin®, Gabarone™ Yes YAnti-epilepsy drugs (AEDs) Gabapentin ER Gralise No NAnti-epilepsy drugs (AEDs) Gabapentin ER Horizant No NAnti-epilepsy drugs (AEDs) Lacosamide Vimpat® Yes NAnti-epilepsy drugs (AEDs) Lamotrigine Lamictal® Yes NAnti-epilepsy drugs (AEDs) Levetiracetam Keppra® Yes NAnti-epilepsy drugs (AEDs) Oxcarbazepine Trileptal® Yes YAnti-epilepsy drugs (AEDs) Phenytoin Dilantin® Yes NAnti-epilepsy drugs (AEDs) Pregabalin Lyrica® IR No YAnti-epilepsy drugs (AEDs) Pregabalin Lyrica® CR No NAnti-epilepsy drugs (AEDs) Tiagabine Gabitril® Yes NAnti-epilepsy drugs (AEDs) Topiramate Topamax® Yes NAnti-epilepsy drugs (AEDs) Zonisamide Zonegran® Yes NAntihypertensives Aliskiren Tekturna No NAntihypertensives Amlodipine Norvasc Yes YAntihypertensives Atenolol Tenormin Yes YAntihypertensives Benazepril Lotensin Yes YAntihypertensives Captopril Capoten Yes YAntihypertensives Clonidine Catapres Yes NAntihypertensives Doxazosin Cardura Yes NAntihypertensives Enalapril Vasotec Yes YAntihypertensives Hydralazine Apresoline Yes NAntihypertensives Hydrochlorothiazide HCTZ Yes YAntihypertensives Lisinopril Zestril Yes YAntihypertensives Losartan Cozaar Yes YAntihypertensives Metoprolol Lopressor Yes YAntihypertensives Minoxidil Loniten Yes NAntihypertensives Nadolol Corgard Yes YAntihypertensives Nicardipine Cardene Yes YAntihypertensives Nifedipine Procardia Yes YAntihypertensives Olmesartan Benicar Yes YAntihypertensives Prazosin Minipress Yes NAntihypertensives Propranolol Inderal Yes YAntihypertensives Ramipril Altace Yes YAntihypertensives Spironolactone Aldactone Yes NAntihypertensives Terazosin Hytrin Yes NAntihypertensives Valsartan Diovan Yes YAnti-infectives Amoxicillin Amoxil Yes YAnti-infectives Amoxicillin-Clavulanate Augmentin Yes YAnti-infectives Azithromycin Zithromax Yes YAnti-infectives Cefadroxil Duricef Yes YAnti-infectives Cefdinir Omnicef Yes Y

Anti-infectives Cefprozil Cefzil Yes YAnti-infectives Cefuroxime Ceftin Yes YAnti-infectives Cephalexin Keflex Yes YAnti-infectives Ciprofloxacin Cipro Yes YAnti-infectives Clarithromycin Biaxin Yes YAnti-infectives Clindamycin Cleocin Yes YAnti-infectives Dicloxacillin Dynapen Yes YAnti-infectives Doxycycline Vibramycin, Doryx Yes YAnti-infectives Levofloxacin Levaquin Yes YAnti-infectives Linezolid Zyvox Yes YAnti-infectives Metronidazole Flagyl Yes YAnti-infectives Minocycline Minocin, Dynacin Yes YAnti-infectives Moxifloxacin Avelox Yes YAnti-infectives Penicillin Veetids Yes YAnti-infectives Sulfamethoxazole-Trimethoprim Bactrim, Septra Yes YAsthma medications Albuterol inhalation Proventil®/ Ventolin® Yes (not metered) YAsthma medications Albuterol oral tablet Albuterol Yes NAsthma medications Albuterol/Ipratropium Combivent® Yes (not metered) YAsthma medications Beclomethasone Qvar® No YAsthma medications Budesonide inhalation Pulmicort® Yes (not metered) YAsthma medications Ciclesonide Alvesco® No YAsthma medications Cromolyn Cromolyn Yes NAsthma medications Fluticasone inhalation Flovent® No YAsthma medications Formoterol Foradil® No NAsthma medications Formoterol/Budesonide Symbicort® No YAsthma medications Formoterol/Mometasone Dulera® No YAsthma medications Indacaterol Arcapta® No NAsthma medications Ipratropium Atrovent® Yes (not metered) NAsthma medications Levalbuterol Xopenex® Yes (not metered) YAsthma medications Mometasone inhalation Asmanex® No YAsthma medications Montelukast Singulair® Yes NAsthma medications Omalizumab Xolair® No NAsthma medications Pirbuterol Maxair® No YAsthma medications Salmeterol Serevent® No NAsthma medications Salmeterol/Fluticasone Advair® No YAsthma medications Theophylline Slo-Bid® Yes NAsthma medications Zafirlukast Accolate® Yes NAsthma medications Zileuton Zyflo® No NAtypical antipsychotics Aripiprazole Abilify Yes NAtypical antipsychotics Quetiapine Seroquel Yes NAtypical antipsychotics Olanzapine Zyprexa Yes NAtypical antipsychotics Risperidone Risperdal Yes NBenzodiazepines Alprazolam Xanax Yes NBenzodiazepines Chlordiazepoxide Librium Yes NBenzodiazepines Clonazepam Klonopin Yes N

Benzodiazepines Clorazepate Tranxene Yes NBenzodiazepines Diazepam Valium Yes NBenzodiazepines Estazolam ProSom Yes NBenzodiazepines Flurazepam Dalmane Yes NBenzodiazepines Lorazepam Ativan Yes NBenzodiazepines Midazolam Versed Yes NBenzodiazepines Oxazepam Serax Yes NBenzodiazepines Quazepam Doral No NBenzodiazepines Temazepam Restoril Yes NBenzodiazepines Triazolam Halcion Yes NBisphosphonates Alendronate Fosamax® Yes YBisphosphonates Etidronate Didronel® Yes YBisphosphonates Ibandronate Boniva® Yes YBisphosphonates Risedronate Actonel®, Atelvia® Yes YBotulinum toxin Botulinum toxin Botox® No NBotulinum toxin Botulinum toxin Dysport No NBotulinum toxin Botulinum toxin Myobloc® No NBotulinum toxin Botulinum toxin Xeomin No NCannabinoids Marijuana/dronabinol Marinol® Yes NCannabinoids Nabilone Cesamet® No NCannabinoids Tetrahydrocannabinol THC/ dronabinol / Marino Yes NCentral adrenergic agonists Clonidine, intrathecal Duraclon® Yes NCompounding drugs N/A N/A No NDopamine agonists Amantadine Symmetrel Yes YDopamine agonists Carbidopa/Levodopa Sinemet® Yes YDopamine agonists Pramipexole Mirapex® Yes (not ER) NDopamine agonists Ropinirole Requip® Yes (not ER) NGout medications Colchicine Colchicine Yes NH2-receptor antagonists Cimetidine Tagamet® Y-OTC YH2-receptor antagonists Famotidine Pepcid® Y-OTC YH2-receptor antagonists Famotidine/ Ibuprofen Duexis® No NH2-receptor antagonists Ranitidine Zantac® Y-OTC YHIV Antiretrovirals Atazanavir Reyataz® Yes YHIV Antiretrovirals Darunavir Prezista® No YHIV Antiretrovirals Didanosine Videx No NHIV Antiretrovirals Didanosine ER Videx EC® Yes NHIV Antiretrovirals Emtricitabine Emtriva™ No YHIV Antiretrovirals Emtricitabine/ Tenofovir Truvada® Yes YHIV Antiretrovirals Etravirine Intelence® No YHIV Antiretrovirals Lamivudine Epivir® Yes YHIV Antiretrovirals Lamivudine/ Zidovudine Combivir® Yes YHIV Antiretrovirals Lopinavir/ Ritonavir Kaletra® Yes YHIV Antiretrovirals Nelfinavir Viracept® No NHIV Antiretrovirals Nevirapine Viramune® Yes NHIV Antiretrovirals Nevirapine ER Viramune XR Yes N

HIV Antiretrovirals Raltegravir Isentress® No YHIV Antiretrovirals Rilpivirine Edurant® No YHIV Antiretrovirals Ritonavir Norvir® Yes YHIV Antiretrovirals Tenofovir Viread® Yes YHIV Antiretrovirals Tipranavir Aptivus® No NHIV Antiretrovirals Zidovudine Retrovir™ Yes YHuman Immune globulins Hepatitis B Immune Globulin HepaGam B No YHuman Immune globulins Hepatitis B Immune Globulin Hyperhep B No YHuman Immune globulins Hepatitis B Immune Globulin Nabi-HB No YHuman Immune globulins Hepatitis B Immune Globulin HepaGam B NovaPlus No YLaxatives Lubiprostone Amitiza® No NLaxatives Methylnaltrexone Relistor® No NLaxatives Naloxegol Movantik® No NLaxatives OTC laxatives various Y-OTC YMuscle relaxants (Antispasticity drugs) Baclofen Lioresal® Yes YMuscle relaxants (Antispasmodics) Carisoprodol Soma® Yes N

Muscle relaxants (Antispasmodics)

Chlorzoxazone

Parafon Forte®, Paraflex®, Relax™DS,Remular S™

Yes Y

Muscle relaxants Chlorzoxazone Lorzone® No NMuscle relaxants (Antispasmodics) Cyclobenzaprine Flexeril®, Fexmid™ Yes YMuscle relaxants (Antispasmodics) Cyclobenzaprine ER Amrix® No NMuscle relaxants (Antispasticity drugs) Dantrolene Dantrium® Yes NMuscle relaxants Meprobamate Miltown Yes NMuscle relaxants (Antispasmodics) Metaxalone Skelaxin® Yes YMuscle relaxants (Antispasmodics) Methocarbamol Robaxin®, Relaxin™ Yes Y

Muscle relaxants (Antispasmodics)Orphenadrine

Norflex®, Banflex®, Antiflex™, Mio-Rel™, Orphenate

Yes N

Muscle relaxants (Antispasticity/ Antispasmodics) Tizanidine Zanaflex® Yes Y

Nonprescription analgesics Acetaminophen Tylenol® Y-OTC YNonprescription analgesics Aspirin Bayer® Y-OTC YNonprescription analgesics Ibuprofen Advil® Y-OTC YNonprescription analgesics Naproxen Aleve® Y-OTC YNSAIDs (non-steroidal anti-inflammatory druCelecoxib Celebrex® Yes YNSAIDs Diclofenac Zorvolex No NNSAIDs Diclofenac/ misoprostol Arthrotec® Yes NNSAIDs Diclofenac epolamine Flector patch No NNSAIDs Diclofenac Potassium Cataflam® Yes YNSAIDs Diclofenac Potassium Zipsor Yes NNSAIDs Diclofenac sodium Voltaren® Yes YNSAIDs Diclofenac sodium ER Voltaren-XR® Yes NNSAIDs Diclofenac sodium injection Dyloject No N

NSAIDs Diclofenac sodium topical Pennsaid® Yes NNSAIDs Diflunisal Dolobid® Yes YNSAIDs Etodolac Lodine® Yes YNSAIDs Etodolac ER Lodine XL® Yes YNSAIDs Fenoprofen Nalfon® Yes YNSAIDs Flurbiprofen Ansaid® Yes YNSAIDs Ibuprofen Advil® Y-OTC YNSAIDs Ibuprofen Motrin® Yes YNSAIDs Indomethacin Indocin® Yes NNSAIDs Indomethacin Tivorbex No NNSAIDs Indomethacin ER Indocin SR® Yes NNSAIDs Ketoprofen Ketoprofen Yes YNSAIDs Ketoprofen ER Ketoprofen ER Yes YNSAIDs Ketorolac Toradol® Yes NNSAIDs Ketorolac injection Toradol® Yes YNSAIDs Ketorolac nasal spray Sprix No NNSAIDs Mefenamic Acid Ponstel® Yes YNSAIDs Meloxicam Mobic® Yes YNSAIDs Meloxicam Vivlodex No NNSAIDs Nabumetone Relafen® Yes YNSAIDs Naproxen Aleve® Y-OTC YNSAIDs Naproxen Naprosyn® Yes YNSAIDs Naproxen ER EC-Naprosyn® Yes YNSAIDs Naproxen Anaprox® Yes YNSAIDs Naproxen Anaprox DS® Yes YNSAIDs Naproxen ER Naprelan® Yes NNSAIDs Oxaprozin Daypro® Yes YNSAIDs Piroxicam Feldene® Yes NNSAIDs Sulindac Clinoril® Yes YNSAIDs Tolmetin Tolectin® Yes YNSAIDs Tolmetin Tolectin DS Yes YOpioids & related entities Buprenorphine buccal film Belbuca™ No NOpioids Buprenorphine inj. for detox Buprenex® Yes Y Opioids Buprenorphine inj. for pain Buprenex® Yes N Opioids Buprenorphine implant Probuphine® No NOpioids Buprenorphine SL tab detox Bupren Yes Y Opioids Buprenorphine SL tab pain Bupren Yes N Opioids Buprenorphine transdermal Butrans™ No N Opioids Buprenorphine/Naloxone buccal film for detox Bunavail® No YOpioids Buprenorphine/Naloxone buccal film for pain Bunavail® No NOpioids Buprenorphine/Naloxone SL film for detox Suboxone® No YOpioids Buprenorphine/Naloxone SL film for pain Suboxone® No NOpioids Buprenorphine/Naloxone SL tab for detox Bupren/Nalox Yes Y Opioids Buprenorphine/Naloxone SL tab for pain Bupren/Nalox Yes N Opioids Buprenorphine/Naloxone SL tab for detox Zubsolv No Y

Opioids Buprenorphine/Naloxone SL tab for pain Zubsolv No NOpioids Butalbital combos (barbiturates) Fioricet® Yes NOpioids Codeine Codeine Yes YOpioids Codeine/acetamin Tylenol #3/4 Yes YOpioids Dihydrocodeine Trezix/ Synalgos-DC No NOpioids Sufentanil (Sub lingual) Dsuvia No NOpioids Fentanyl buccal Fentora® Yes NOpioids Fentanyl buccal film Onsolis™ No NOpioids Fentanyl lollipop Actiq® Yes NOpioids Fentanyl nasal spray Lazanda No NOpioids Fentanyl sublingual spray Subsys® No NOpioids Fentanyl transdermal Duragesic® Yes NOpioids Fentanyl transmucosal Abstral No NOpioids Hydrocodone ER Hysingla No NOpioids Hydrocodone ER Zohydro No NOpioids Hydrocodone/acetamin IR Vicodin® Yes YOpioids Hydrocodone/acetamin IR Lortab® Yes YOpioids Hydrocodone bitartrate Vantrela™ ER No NOpioids Hydrocodone/ibuprofen IR Vicoprofen® Yes NOpioids Hydromorphone IR Dilaudid® Yes YOpioids Hydromorphone ER Exalgo Yes NOpioids Levorphanol Levo-Dromoran® Yes NOpioids Meperidine Demerol® Yes NOpioids Methadone (link to rules) Methadose® Yes NOpioids Morphine IR Morphine Yes YOpioids Morphine ER Avinza® Yes NOpioids Morphine ER Kadian® Yes NOpioids Morphine ER MS-Contin Yes NOpioids Morphine ER / Naltrexone Embeda No NOpioids Morphine sulfate Arymo™ ER No NOpioids Morphine sulfate Morphabond™ ER No NOpioids Naloxone Injection device Evzio® No NOpioids Naloxone intranasal Narcan® No YOpioids Naloxone Injectable Naloxone Yes YOpioids Oxycodone IR OxyIR® Yes YOpioids Oxycodone IR Oxaydo No NOpioids Oxycodone ER OxyContin® No NOpioids Oxycodone ER/acetamin Xartemis XR No NOpioids Oxycodone ER/naloxone Targiniq ER® No NOpioids Oxycodone/acetaminophen IR Percocet® Yes YOpioids Oxycodone/aspirin IR Percodan® Yes NOpioids Oxycodone/ibuprofen IR Combunox Yes NOpioids Oxycodone/naltrexone Troxyca® ER No NOpioids Oxycodone HCL RoxyBond™ No NOpioids Oxymorphone IR Opana® Yes N

Opioids Oxymorphone ER Opana ER No NOpioids Pentazocine lactate Talwin Yes NOpioids Pentazocine/Naloxone Talwin NX Yes NOpioids Propoxyphene hcl Darvon® Yes NOpioids Propoxyphene/acetamin Darvocet® Yes NOpioids Propoxyphene napsylate Darvon-N® No NOpioids Tapentadol Nucynta™ No NOpioids Tramadol IR Ultram® Yes YOpioids Tramadol ER Ultram ER® Yes YOpioids Tramadol ER, biphasic ConZip / Ryzolt No NOpioids Tramadol/Acetaminophen IR Ultracet® Yes YOpioids & related entities Ziconotide (morphine pump) Prialt® No NOral corticosteroids Methylprednisolone Medrol Yes YOral corticosteroids Prednisone Prednisone Yes YPPI (Proton Pump Inhibitor) Dexlansoprazole Dexilant® No NPPI (Proton Pump Inhibitor) Esomeprazole Nexium® Y-OTC YPPI (Proton Pump Inhibitor) Esomeprazole/Naproxen Vimovo Yes NPPI (Proton Pump Inhibitor) Lansoprazole Prevacid® Y-OTC YPPI (Proton Pump Inhibitor) Omeprazole Prilosec® Y-OTC YPPI (Proton Pump Inhibitor) Pantoprazole Protonix® Yes NPPI (Proton Pump Inhibitor) Rabeprazole Aciphex® Yes NProstaglandins Misoprostol Cytotec® Yes YSedative-hypnotics Diphenhydramine for insomnia Benadryl Y-OTC NSedative-hypnotics Eszopiclone Lunesta™ Yes YSedative-hypnotics Promethazine Phenergan Yes NSedative-hypnotics Ramelteon Rozerem™ Yes YSedative-hypnotics Trazodone Desyrel Yes NSedative-hypnotics Zaleplon Sonata® Yes YSedative-hypnotics Zolpidem Ambien® Yes YSedative-hypnotics Zolpidem ER Ambien CR Yes NSedative-hypnotics Zolpidem Edluar SL Yes NStimulants (adjunctive pain medication) Armodafinil Nuvigil Yes NStimulants Modafinil Provigil® Yes NStimulants Sodium oxybate Xyrem Yes NTopical analgesics Capsaicin, topical Qutenza No NTopical analgesics Diclofenac Sodium Gel Voltaren® Gel Yes YTopical analgesics Dimethylsulfoxide DMSO Yes NTopical analgesics Ketamine, topical Ketamine Yes NTopical analgesics Lidocaine, topical Lidoderm® Yes NTopical analgesics Salicylate topicals Ben-Gay Y-OTC YTriptans Rizatriptan Maxalt® Yes YTriptans Sumatriptan Imitrex® Yes YTumor necrosis factor (TNF) modifiers Adalimumab Humira® Yes NTumor necrosis factor (TNF) modifiers Etanercept Enbrel® Yes NTumor necrosis factor (TNF) modifiers Infliximab Remicade® Yes N

© Copyright 2019 by the Work Loss Data Institute (WLDI). Commercial reproduction or other use beyond fair use prohibited without explicit WLDI permission.

Drug Class Generic Name Brand Name Gener Equiv StatusAnticoagulants Apixaban Eliquis® No YAnticoagulants Dabigatran Pradaxa® No YAnticoagulants Enoxaparin Lovenox® Yes YAnticoagulants Rivaroxaban Xarelto® No YAntidepressants Amitriptyline Elavil® Yes YAntidepressants Bupropion (mental) Wellbutrin® Yes YAntidepressants Bupropion (pain) Wellbutrin® Yes NAntidepressants Citalopram Celexa Yes NAntidepressants Desvenlafaxine Pristiq® Yes YAntidepressants Duloxetine Cymbalta® Yes YAntidepressants Escitalopram (mental) Lexapro® Yes YAntidepressants Escitalopram (pain) Lexapro® Yes NAntidepressants Fluoxetine (mental) Prozac® Yes YAntidepressants Fluoxetine (pain) Prozac® Yes NAntidepressants Fluvoxamine Luvox Yes NAntidepressants Milnacipran Savella/Ixel® Yes NAntidepressants Mirtazapine (pain) Remeron® Yes NAntidepressants Mirtazapine (mental) Remeron® Yes YAntidepressants Nortriptyline Pamelor™ Yes YAntidepressants Paroxetine (mental) Paxil Yes YAntidepressants Paroxetine (pain) Paxil Yes NAntidepressants Sertraline (mental) Zoloft® Yes YAntidepressants Sertraline (pain) Zoloft® Yes NAntidepressants Venlafaxine Effexor® Yes YAntidepressants Venlafaxine ER Effexor XR® Yes YAntidiabetics Acarbose Precose Yes NAntidiabetics Exenatide Byetta No NAntidiabetics Glimepiride Amaryl Yes NAntidiabetics Glipizide Glucotrol Yes NAntidiabetics Glyburide Glynase Yes NAntidiabetics Insulin Humalog No YAntidiabetics Insulin Humulin No NAntidiabetics Insulin Novolin No NAntidiabetics Insulin NovoLog No YAntidiabetics Metformin Glucophage Yes YAntidiabetics Miglitol Glyset Yes NAntidiabetics Nateglinide Starlix Yes NAntidiabetics Pioglitazone Actos Yes NAntidiabetics Repaglinide Prandin Yes NAntidiabetics Rosiglitazone Avandia Yes NAntidiabetics Saxagliptin Onglyza No NAntidiabetics Sitagliptin Januvia No N

ODG Workers’ Compensation Drug Formulary April 2019

Antiemetics Ondansetron Zofran® Yes NAntiemetics Ondansetron Zuplenz® No NAnti-epilepsy drugs (AEDs) Carbamazepine Tegretol® Yes YAnti-epilepsy drugs (AEDs) Gabapentin Neurontin®, Gabarone™ Yes YAnti-epilepsy drugs (AEDs) Gabapentin ER Gralise No NAnti-epilepsy drugs (AEDs) Gabapentin ER Horizant No NAnti-epilepsy drugs (AEDs) Lacosamide Vimpat® Yes NAnti-epilepsy drugs (AEDs) Lamotrigine Lamictal® Yes NAnti-epilepsy drugs (AEDs) Levetiracetam Keppra® Yes NAnti-epilepsy drugs (AEDs) Oxcarbazepine Trileptal® Yes YAnti-epilepsy drugs (AEDs) Phenytoin Dilantin® Yes NAnti-epilepsy drugs (AEDs) Pregabalin Lyrica® IR No YAnti-epilepsy drugs (AEDs) Pregabalin Lyrica® CR No NAnti-epilepsy drugs (AEDs) Tiagabine Gabitril® Yes NAnti-epilepsy drugs (AEDs) Topiramate Topamax® Yes NAnti-epilepsy drugs (AEDs) Zonisamide Zonegran® Yes NAntihypertensives Aliskiren Tekturna No NAntihypertensives Amlodipine Norvasc Yes YAntihypertensives Atenolol Tenormin Yes YAntihypertensives Benazepril Lotensin Yes YAntihypertensives Captopril Capoten Yes YAntihypertensives Clonidine Catapres Yes NAntihypertensives Doxazosin Cardura Yes NAntihypertensives Enalapril Vasotec Yes YAntihypertensives Hydralazine Apresoline Yes NAntihypertensives Hydrochlorothiazide HCTZ Yes YAntihypertensives Lisinopril Zestril Yes YAntihypertensives Losartan Cozaar Yes YAntihypertensives Metoprolol Lopressor Yes YAntihypertensives Minoxidil Loniten Yes NAntihypertensives Nadolol Corgard Yes YAntihypertensives Nicardipine Cardene Yes YAntihypertensives Nifedipine Procardia Yes YAntihypertensives Olmesartan Benicar Yes YAntihypertensives Prazosin Minipress Yes NAntihypertensives Propranolol Inderal Yes YAntihypertensives Ramipril Altace Yes YAntihypertensives Spironolactone Aldactone Yes NAntihypertensives Terazosin Hytrin Yes NAntihypertensives Valsartan Diovan Yes YAnti-infectives Amoxicillin Amoxil Yes YAnti-infectives Amoxicillin-Clavulanate Augmentin Yes YAnti-infectives Azithromycin Zithromax Yes YAnti-infectives Cefadroxil Duricef Yes YAnti-infectives Cefdinir Omnicef Yes Y

Anti-infectives Cefprozil Cefzil Yes YAnti-infectives Cefuroxime Ceftin Yes YAnti-infectives Cephalexin Keflex Yes YAnti-infectives Ciprofloxacin Cipro Yes YAnti-infectives Clarithromycin Biaxin Yes YAnti-infectives Clindamycin Cleocin Yes YAnti-infectives Dicloxacillin Dynapen Yes YAnti-infectives Doxycycline Vibramycin, Doryx Yes YAnti-infectives Levofloxacin Levaquin Yes YAnti-infectives Linezolid Zyvox Yes YAnti-infectives Metronidazole Flagyl Yes YAnti-infectives Minocycline Minocin, Dynacin Yes YAnti-infectives Moxifloxacin Avelox Yes YAnti-infectives Penicillin Veetids Yes YAnti-infectives Sulfamethoxazole-Trimethoprim Bactrim, Septra Yes YAsthma medications Albuterol inhalation Proventil®/ Ventolin® Yes (not metered) YAsthma medications Albuterol oral tablet Albuterol Yes NAsthma medications Albuterol/Ipratropium Combivent® Yes (not metered) YAsthma medications Beclomethasone Qvar® No YAsthma medications Budesonide inhalation Pulmicort® Yes (not metered) YAsthma medications Ciclesonide Alvesco® No YAsthma medications Cromolyn Cromolyn Yes NAsthma medications Fluticasone inhalation Flovent® No YAsthma medications Formoterol Foradil® No NAsthma medications Formoterol/Budesonide Symbicort® No YAsthma medications Formoterol/Mometasone Dulera® No YAsthma medications Indacaterol Arcapta® No NAsthma medications Ipratropium Atrovent® Yes (not metered) NAsthma medications Levalbuterol Xopenex® Yes (not metered) YAsthma medications Mometasone inhalation Asmanex® No YAsthma medications Montelukast Singulair® Yes NAsthma medications Omalizumab Xolair® No NAsthma medications Pirbuterol Maxair® No YAsthma medications Salmeterol Serevent® No NAsthma medications Salmeterol/Fluticasone Advair® No YAsthma medications Theophylline Slo-Bid® Yes NAsthma medications Zafirlukast Accolate® Yes NAsthma medications Zileuton Zyflo® No NAtypical antipsychotics Aripiprazole Abilify Yes NAtypical antipsychotics Quetiapine Seroquel Yes NAtypical antipsychotics Olanzapine Zyprexa Yes NAtypical antipsychotics Risperidone Risperdal Yes NBenzodiazepines Alprazolam Xanax Yes NBenzodiazepines Chlordiazepoxide Librium Yes NBenzodiazepines Clonazepam Klonopin Yes N

Benzodiazepines Clorazepate Tranxene Yes NBenzodiazepines Diazepam Valium Yes NBenzodiazepines Estazolam ProSom Yes NBenzodiazepines Flurazepam Dalmane Yes NBenzodiazepines Lorazepam Ativan Yes NBenzodiazepines Midazolam Versed Yes NBenzodiazepines Oxazepam Serax Yes NBenzodiazepines Quazepam Doral No NBenzodiazepines Temazepam Restoril Yes NBenzodiazepines Triazolam Halcion Yes NBisphosphonates Alendronate Fosamax® Yes YBisphosphonates Etidronate Didronel® Yes YBisphosphonates Ibandronate Boniva® Yes YBisphosphonates Risedronate Actonel®, Atelvia® Yes YBotulinum toxin Botulinum toxin Botox® No NBotulinum toxin Botulinum toxin Dysport No NBotulinum toxin Botulinum toxin Myobloc® No NBotulinum toxin Botulinum toxin Xeomin No NCalcitonin gene-related peptide receptor (CG Erenumab Aimovig No NCannabinoids Marijuana/dronabinol Marinol® Yes NCannabinoids Nabilone Cesamet® No NCannabinoids Tetrahydrocannabinol THC/ dronabinol / Marino Yes NCentral adrenergic agonists Clonidine, intrathecal Duraclon® Yes NCompounding drugs N/A N/A No NDopamine agonists Amantadine Symmetrel Yes YDopamine agonists Carbidopa/Levodopa Sinemet® Yes YDopamine agonists Pramipexole Mirapex® Yes (not ER) NDopamine agonists Ropinirole Requip® Yes (not ER) NGout medications Colchicine Colchicine Yes NH2-receptor antagonists Cimetidine Tagamet® Y-OTC YH2-receptor antagonists Famotidine Pepcid® Y-OTC YH2-receptor antagonists Famotidine/ Ibuprofen Duexis® No NH2-receptor antagonists Ranitidine Zantac® Y-OTC YHIV Antiretrovirals Atazanavir Reyataz® Yes YHIV Antiretrovirals Darunavir Prezista® No YHIV Antiretrovirals Didanosine Videx No NHIV Antiretrovirals Didanosine ER Videx EC® Yes NHIV Antiretrovirals Emtricitabine Emtriva™ No YHIV Antiretrovirals Emtricitabine/ Tenofovir Truvada® Yes YHIV Antiretrovirals Etravirine Intelence® No YHIV Antiretrovirals Lamivudine Epivir® Yes YHIV Antiretrovirals Lamivudine/ Zidovudine Combivir® Yes YHIV Antiretrovirals Lopinavir/ Ritonavir Kaletra® Yes YHIV Antiretrovirals Nelfinavir Viracept® No NHIV Antiretrovirals Nevirapine Viramune® Yes N

HIV Antiretrovirals Nevirapine ER Viramune XR Yes NHIV Antiretrovirals Raltegravir Isentress® No YHIV Antiretrovirals Rilpivirine Edurant® No YHIV Antiretrovirals Ritonavir Norvir® Yes YHIV Antiretrovirals Tenofovir Viread® Yes YHIV Antiretrovirals Tipranavir Aptivus® No NHIV Antiretrovirals Zidovudine Retrovir™ Yes YHuman Immune globulins Hepatitis B Immune Globulin HepaGam B No YHuman Immune globulins Hepatitis B Immune Globulin Hyperhep B No YHuman Immune globulins Hepatitis B Immune Globulin Nabi-HB No YHuman Immune globulins Hepatitis B Immune Globulin HepaGam B NovaPlus No YLaxatives Lubiprostone Amitiza® No NLaxatives Methylnaltrexone Relistor® No NLaxatives Naloxegol Movantik® No NLaxatives OTC laxatives various Y-OTC YMuscle relaxants (Antispasticity drugs) Baclofen Lioresal® Yes YMuscle relaxants (Antispasmodics) Carisoprodol Soma® Yes N

Muscle relaxants (Antispasmodics)

Chlorzoxazone

Parafon Forte®, Paraflex®, Relax™DS,Remular S™

Yes Y

Muscle relaxants Chlorzoxazone Lorzone® No NMuscle relaxants (Antispasmodics) Cyclobenzaprine Flexeril®, Fexmid™ Yes YMuscle relaxants (Antispasmodics) Cyclobenzaprine ER Amrix® No NMuscle relaxants (Antispasticity drugs) Dantrolene Dantrium® Yes NMuscle relaxants Meprobamate Miltown Yes NMuscle relaxants (Antispasmodics) Metaxalone Skelaxin® Yes YMuscle relaxants (Antispasmodics) Methocarbamol Robaxin®, Relaxin™ Yes Y

Muscle relaxants (Antispasmodics)Orphenadrine

Norflex®, Banflex®, Antiflex™, Mio-Rel™, Orphenate

Yes N

Muscle relaxants (Antispasticity/ Antispasmodics) Tizanidine Zanaflex® Yes Y

Nonprescription analgesics Acetaminophen Tylenol® Y-OTC YNonprescription analgesics Aspirin Bayer® Y-OTC YNonprescription analgesics Ibuprofen Advil® Y-OTC YNonprescription analgesics Naproxen Aleve® Y-OTC YNSAIDs (non-steroidal anti-inflammatory druCelecoxib Celebrex® Yes YNSAIDs Diclofenac Zorvolex No NNSAIDs Diclofenac/ misoprostol Arthrotec® Yes NNSAIDs Diclofenac epolamine Flector patch No NNSAIDs Diclofenac Potassium Cataflam® Yes YNSAIDs Diclofenac Potassium Zipsor Yes NNSAIDs Diclofenac sodium Voltaren® Yes YNSAIDs Diclofenac sodium ER Voltaren-XR® Yes N

NSAIDs Diclofenac sodium injection Dyloject No NNSAIDs Diclofenac sodium topical Pennsaid® Yes NNSAIDs Diflunisal Dolobid® Yes YNSAIDs Etodolac Lodine® Yes YNSAIDs Etodolac ER Lodine XL® Yes YNSAIDs Fenoprofen Nalfon® Yes YNSAIDs Flurbiprofen Ansaid® Yes YNSAIDs Ibuprofen Advil® Y-OTC YNSAIDs Ibuprofen Motrin® Yes YNSAIDs Indomethacin Indocin® Yes NNSAIDs Indomethacin Tivorbex No NNSAIDs Indomethacin ER Indocin SR® Yes NNSAIDs Ketoprofen Ketoprofen Yes YNSAIDs Ketoprofen ER Ketoprofen ER Yes YNSAIDs Ketorolac Toradol® Yes NNSAIDs Ketorolac injection Toradol® Yes YNSAIDs Ketorolac nasal spray Sprix No NNSAIDs Mefenamic Acid Ponstel® Yes YNSAIDs Meloxicam Mobic® Yes YNSAIDs Meloxicam Vivlodex No NNSAIDs Nabumetone Relafen® Yes YNSAIDs Naproxen Aleve® Y-OTC YNSAIDs Naproxen Naprosyn® Yes YNSAIDs Naproxen ER EC-Naprosyn® Yes YNSAIDs Naproxen Anaprox® Yes YNSAIDs Naproxen Anaprox DS® Yes YNSAIDs Naproxen ER Naprelan® Yes NNSAIDs Oxaprozin Daypro® Yes YNSAIDs Piroxicam Feldene® Yes NNSAIDs Sulindac Clinoril® Yes YNSAIDs Tolmetin Tolectin® Yes YNSAIDs Tolmetin Tolectin DS Yes YOpioids & related entities Buprenorphine buccal film Belbuca™ No NOpioids Buprenorphine inj. for detox Buprenex® Yes Y Opioids Buprenorphine inj. for pain Buprenex® Yes N Opioids Buprenorphine implant Probuphine® No NOpioids Buprenorphine SL tab detox Bupren Yes Y Opioids Buprenorphine SL tab pain Bupren Yes N Opioids Buprenorphine transdermal Butrans™ No N Opioids Buprenorphine/Naloxone buccal film for detox Bunavail® No YOpioids Buprenorphine/Naloxone buccal film for pain Bunavail® No NOpioids Buprenorphine/Naloxone SL film for detox Suboxone® No YOpioids Buprenorphine/Naloxone SL film for pain Suboxone® No NOpioids Buprenorphine/Naloxone SL tab for detox Bupren/Nalox Yes Y Opioids Buprenorphine/Naloxone SL tab for pain Bupren/Nalox Yes N

Opioids Buprenorphine/Naloxone SL tab for detox Zubsolv No Y Opioids Buprenorphine/Naloxone SL tab for pain Zubsolv No NOpioids Butalbital combos (barbiturates) Fioricet® Yes NOpioids Codeine Codeine Yes YOpioids Codeine/acetamin Tylenol #3/4 Yes YOpioids Dihydrocodeine Trezix/ Synalgos-DC No NOpioids Sufentanil (Sub lingual) Dsuvia No NOpioids Fentanyl buccal Fentora® Yes NOpioids Fentanyl buccal film Onsolis™ No NOpioids Fentanyl lollipop Actiq® Yes NOpioids Fentanyl nasal spray Lazanda No NOpioids Fentanyl sublingual spray Subsys® No NOpioids Fentanyl transdermal Duragesic® Yes NOpioids Fentanyl transmucosal Abstral No NOpioids Hydrocodone ER Hysingla No NOpioids Hydrocodone ER Zohydro No NOpioids Hydrocodone/acetamin IR Vicodin® Yes YOpioids Hydrocodone/acetamin IR Lortab® Yes YOpioids Hydrocodone bitartrate Vantrela™ ER No NOpioids Hydrocodone/ibuprofen IR Vicoprofen® Yes NOpioids Hydromorphone IR Dilaudid® Yes YOpioids Hydromorphone ER Exalgo Yes NOpioids Levorphanol Levo-Dromoran® Yes NOpioids Meperidine Demerol® Yes NOpioids Methadone (link to rules) Methadose® Yes NOpioids Morphine IR Morphine Yes YOpioids Morphine ER Avinza® Yes NOpioids Morphine ER Kadian® Yes NOpioids Morphine ER MS-Contin Yes NOpioids Morphine ER / Naltrexone Embeda No NOpioids Morphine sulfate Arymo™ ER No NOpioids Morphine sulfate Morphabond™ ER No NOpioids Naloxone Injection device Evzio® No NOpioids Naloxone intranasal Narcan® No YOpioids Naloxone Injectable Naloxone Yes YOpioids Oxycodone IR OxyIR® Yes YOpioids Oxycodone IR Oxaydo No NOpioids Oxycodone ER OxyContin® No NOpioids Oxycodone ER/acetamin Xartemis XR No NOpioids Oxycodone Xtampza ER No NOpioids Oxycodone ER/naloxone Targiniq ER® No NOpioids Oxycodone/acetaminophen IR Percocet® Yes YOpioids Oxycodone/aspirin IR Percodan® Yes NOpioids Oxycodone/ibuprofen IR Combunox Yes NOpioids Oxycodone/naltrexone Troxyca® ER No N

Opioids Oxycodone HCL RoxyBond™ No NOpioids Oxymorphone IR Opana® Yes NOpioids Oxymorphone ER Opana ER No NOpioids Pentazocine lactate Talwin Yes NOpioids Pentazocine/Naloxone Talwin NX Yes NOpioids Propoxyphene hcl Darvon® Yes NOpioids Propoxyphene/acetamin Darvocet® Yes NOpioids Propoxyphene napsylate Darvon-N® No NOpioids Tapentadol Nucynta™ No NOpioids Tramadol IR Ultram® Yes YOpioids Tramadol ER Ultram ER® Yes YOpioids Tramadol ER, biphasic ConZip / Ryzolt No NOpioids Tramadol/Acetaminophen IR Ultracet® Yes YOpioids & related entities Ziconotide (morphine pump) Prialt® No NOral corticosteroids Methylprednisolone Medrol Yes YOral corticosteroids Prednisone Prednisone Yes YPPI (Proton Pump Inhibitor) Dexlansoprazole Dexilant® No NPPI (Proton Pump Inhibitor) Esomeprazole Nexium® Y-OTC YPPI (Proton Pump Inhibitor) Esomeprazole/Naproxen Vimovo Yes NPPI (Proton Pump Inhibitor) Lansoprazole Prevacid® Y-OTC YPPI (Proton Pump Inhibitor) Omeprazole Prilosec® Y-OTC YPPI (Proton Pump Inhibitor) Pantoprazole Protonix® Yes NPPI (Proton Pump Inhibitor) Rabeprazole Aciphex® Yes NProstaglandins Misoprostol Cytotec® Yes YSedative-hypnotics Diphenhydramine for insomnia Benadryl Y-OTC NSedative-hypnotics Eszopiclone Lunesta™ Yes YSedative-hypnotics Promethazine Phenergan Yes NSedative-hypnotics Ramelteon Rozerem™ Yes YSedative-hypnotics Trazodone Desyrel Yes NSedative-hypnotics Zaleplon Sonata® Yes YSedative-hypnotics Zolpidem Ambien® Yes YSedative-hypnotics Zolpidem ER Ambien CR Yes NSedative-hypnotics Zolpidem Edluar SL Yes NStimulants (adjunctive pain medication) Armodafinil Nuvigil Yes NStimulants Modafinil Provigil® Yes NStimulants Sodium oxybate Xyrem Yes NTopical analgesics Capsaicin, topical Qutenza No NTopical analgesics Diclofenac Sodium Gel Voltaren® Gel Yes YTopical analgesics Dimethylsulfoxide DMSO Yes NTopical analgesics Ketamine, topical Ketamine Yes NTopical analgesics Lidocaine, topical Lidoderm® Yes NTopical analgesics Menthol Biofreeze gel Y-OTC YTopical analgesics Methyl salicylate Thera-Gesic Crème Y-OTC YTopical analgesics Salicylate topicals Ben-Gay Y-OTC YTriptans Rizatriptan Maxalt® Yes Y

Triptans Sumatriptan Imitrex® Yes YTumor necrosis factor (TNF) modifiers Adalimumab Humira® Yes NTumor necrosis factor (TNF) modifiers Etanercept Enbrel® Yes NTumor necrosis factor (TNF) modifiers Infliximab Remicade® Yes N© Copyright 2019 by the Work Loss Data Institute (WLDI). Commercial reproduction or other use beyond fair use prohibited without explicit WLDI permission.

Drug Class Generic Name Brand Name Gener Equiv StatusAnticoagulants Apixaban Eliquis® No YAnticoagulants Dabigatran Pradaxa® No YAnticoagulants Enoxaparin Lovenox® Yes YAnticoagulants Rivaroxaban Xarelto® No YAntidepressants Amitriptyline Elavil® Yes YAntidepressants Bupropion (mental) Wellbutrin® Yes YAntidepressants Bupropion (pain) Wellbutrin® Yes NAntidepressants Citalopram Celexa Yes NAntidepressants Desvenlafaxine Pristiq® Yes YAntidepressants Duloxetine Cymbalta® Yes YAntidepressants Escitalopram (mental) Lexapro® Yes YAntidepressants Escitalopram (pain) Lexapro® Yes NAntidepressants Esketamine Spravato™ No NAntidepressants Fluoxetine (mental) Prozac® Yes YAntidepressants Fluoxetine (pain) Prozac® Yes NAntidepressants Fluvoxamine Luvox Yes NAntidepressants Milnacipran Savella/Ixel® Yes NAntidepressants Mirtazapine (pain) Remeron® Yes NAntidepressants Mirtazapine (mental) Remeron® Yes YAntidepressants Nortriptyline Pamelor™ Yes YAntidepressants Paroxetine (mental) Paxil Yes YAntidepressants Paroxetine (pain) Paxil Yes NAntidepressants Sertraline (mental) Zoloft® Yes YAntidepressants Sertraline (pain) Zoloft® Yes NAntidepressants Venlafaxine Effexor® Yes YAntidepressants Venlafaxine ER Effexor XR® Yes YAntidiabetics Acarbose Precose Yes NAntidiabetics Exenatide Byetta No NAntidiabetics Glimepiride Amaryl Yes NAntidiabetics Glipizide Glucotrol Yes NAntidiabetics Glyburide Glynase Yes NAntidiabetics Insulin Humalog No YAntidiabetics Insulin Humulin No NAntidiabetics Insulin Novolin No NAntidiabetics Insulin NovoLog No YAntidiabetics Metformin Glucophage Yes YAntidiabetics Miglitol Glyset Yes NAntidiabetics Nateglinide Starlix Yes NAntidiabetics Pioglitazone Actos Yes NAntidiabetics Repaglinide Prandin Yes NAntidiabetics Rosiglitazone Avandia Yes NAntidiabetics Saxagliptin Onglyza No NAntidiabetics Sitagliptin Januvia No NAntiemetics Ondansetron Zofran® Yes N

ODG Workers’ Compensation Drug Formulary July 2019

Antiemetics Ondansetron Zuplenz® No NAnti-epilepsy drugs (AEDs) Carbamazepine Tegretol® Yes YAnti-epilepsy drugs (AEDs) Gabapentin Neurontin®, Gabarone™ Yes YAnti-epilepsy drugs (AEDs) Gabapentin ER Gralise No NAnti-epilepsy drugs (AEDs) Gabapentin ER Horizant No NAnti-epilepsy drugs (AEDs) Lacosamide Vimpat® Yes NAnti-epilepsy drugs (AEDs) Lamotrigine Lamictal® Yes NAnti-epilepsy drugs (AEDs) Levetiracetam Keppra® Yes NAnti-epilepsy drugs (AEDs) Oxcarbazepine Trileptal® Yes YAnti-epilepsy drugs (AEDs) Phenytoin Dilantin® Yes NAnti-epilepsy drugs (AEDs) Pregabalin Lyrica® IR No YAnti-epilepsy drugs (AEDs) Pregabalin Lyrica® CR No NAnti-epilepsy drugs (AEDs) Tiagabine Gabitril® Yes NAnti-epilepsy drugs (AEDs) Topiramate Topamax® Yes NAnti-epilepsy drugs (AEDs) Zonisamide Zonegran® Yes NAntihypertensives Aliskiren Tekturna No NAntihypertensives Amlodipine Norvasc Yes YAntihypertensives Atenolol Tenormin Yes YAntihypertensives Benazepril Lotensin Yes YAntihypertensives Captopril Capoten Yes YAntihypertensives Clonidine Catapres Yes NAntihypertensives Doxazosin Cardura Yes NAntihypertensives Enalapril Vasotec Yes YAntihypertensives Hydralazine Apresoline Yes NAntihypertensives Hydrochlorothiazide HCTZ Yes YAntihypertensives Lisinopril Zestril Yes YAntihypertensives Losartan Cozaar Yes YAntihypertensives Metoprolol Lopressor Yes YAntihypertensives Minoxidil Loniten Yes NAntihypertensives Nadolol Corgard Yes YAntihypertensives Nicardipine Cardene Yes YAntihypertensives Nifedipine Procardia Yes YAntihypertensives Olmesartan Benicar Yes YAntihypertensives Prazosin Minipress Yes NAntihypertensives Propranolol Inderal Yes YAntihypertensives Ramipril Altace Yes YAntihypertensives Spironolactone Aldactone Yes NAntihypertensives Terazosin Hytrin Yes NAntihypertensives Valsartan Diovan Yes YAnti-infectives Amoxicillin Amoxil Yes YAnti-infectives Amoxicillin-Clavulanate Augmentin Yes YAnti-infectives Azithromycin Zithromax Yes YAnti-infectives Cefadroxil Duricef Yes YAnti-infectives Cefdinir Omnicef Yes YAnti-infectives Cefprozil Cefzil Yes YAnti-infectives Cefuroxime Ceftin Yes YAnti-infectives Cephalexin Keflex Yes Y

Anti-infectives Ciprofloxacin Cipro Yes YAnti-infectives Clarithromycin Biaxin Yes YAnti-infectives Clindamycin Cleocin Yes YAnti-infectives Dicloxacillin Dynapen Yes YAnti-infectives Doxycycline Vibramycin, Doryx Yes YAnti-infectives Levofloxacin Levaquin Yes YAnti-infectives Linezolid Zyvox Yes YAnti-infectives Metronidazole Flagyl Yes YAnti-infectives Minocycline Minocin, Dynacin Yes YAnti-infectives Moxifloxacin Avelox Yes YAnti-infectives Penicillin Veetids Yes YAnti-infectives Sulfamethoxazole-Trimethoprim Bactrim, Septra Yes YAsthma medications Albuterol inhalation Proventil®/ Ventolin® Yes (not metered) YAsthma medications Albuterol oral tablet Albuterol Yes NAsthma medications Albuterol/Ipratropium Combivent® Yes (not metered) YAsthma medications Beclomethasone Qvar® No YAsthma medications Budesonide inhalation Pulmicort® Yes (not metered) YAsthma medications Ciclesonide Alvesco® No YAsthma medications Cromolyn Cromolyn Yes NAsthma medications Fluticasone inhalation Flovent® No YAsthma medications Formoterol Foradil® No NAsthma medications Formoterol/Budesonide Symbicort® No YAsthma medications Formoterol/Mometasone Dulera® No YAsthma medications Indacaterol Arcapta® No NAsthma medications Ipratropium Atrovent® Yes (not metered) NAsthma medications Levalbuterol Xopenex® Yes (not metered) YAsthma medications Mometasone inhalation Asmanex® No YAsthma medications Montelukast Singulair® Yes NAsthma medications Omalizumab Xolair® No NAsthma medications Pirbuterol Maxair® No YAsthma medications Salmeterol Serevent® No NAsthma medications Salmeterol/Fluticasone Advair® No YAsthma medications Theophylline Slo-Bid® Yes NAsthma medications Zafirlukast Accolate® Yes NAsthma medications Zileuton Zyflo® No NAtypical antipsychotics Aripiprazole Abilify Yes NAtypical antipsychotics Quetiapine Seroquel Yes NAtypical antipsychotics Olanzapine Zyprexa Yes NAtypical antipsychotics Risperidone Risperdal Yes NBenzodiazepines Alprazolam Xanax Yes NBenzodiazepines Chlordiazepoxide Librium Yes NBenzodiazepines Clonazepam Klonopin Yes NBenzodiazepines Clorazepate Tranxene Yes NBenzodiazepines Diazepam Valium Yes NBenzodiazepines Estazolam ProSom Yes NBenzodiazepines Flurazepam Dalmane Yes NBenzodiazepines Lorazepam Ativan Yes N

Benzodiazepines Midazolam Versed Yes NBenzodiazepines Oxazepam Serax Yes NBenzodiazepines Quazepam Doral No NBenzodiazepines Temazepam Restoril Yes NBenzodiazepines Triazolam Halcion Yes NBisphosphonates Alendronate Fosamax® Yes YBisphosphonates Etidronate Didronel® Yes YBisphosphonates Ibandronate Boniva® Yes YBisphosphonates Risedronate Actonel®, Atelvia® Yes YBotulinum toxin Botulinum toxin Botox® No NBotulinum toxin Botulinum toxin Dysport No NBotulinum toxin Botulinum toxin Myobloc® No NBotulinum toxin Botulinum toxin Xeomin No N

Calcitonin gene-related peptidereceptor (CGRP-R) antagonist Erenumab

Aimovig No N

Cannabinoids Marijuana/dronabinol Marinol® Yes NCannabinoids Nabilone Cesamet® No N

Cannabinoids TetrahydrocannabinolTHC/ dronabinol /Marinol Yes N

Central adrenergic agonists Clonidine, intrathecal Duraclon® Yes NCompounding drugs N/A N/A No NDopamine agonists Amantadine Symmetrel Yes YDopamine agonists Carbidopa/Levodopa Sinemet® Yes YDopamine agonists Pramipexole Mirapex® Yes (not ER) NDopamine agonists Ropinirole Requip® Yes (not ER) NGout medications Colchicine Colchicine Yes NH2-receptor antagonists Cimetidine Tagamet® Y-OTC YH2-receptor antagonists Famotidine Pepcid® Y-OTC YH2-receptor antagonists Famotidine/ Ibuprofen Duexis® No NH2-receptor antagonists Ranitidine Zantac® Y-OTC YHIV Antiretrovirals Atazanavir Reyataz® Yes YHIV Antiretrovirals Darunavir Prezista® No YHIV Antiretrovirals Didanosine Videx No NHIV Antiretrovirals Didanosine ER Videx EC® Yes NHIV Antiretrovirals Emtricitabine Emtriva™ No YHIV Antiretrovirals Emtricitabine/ Tenofovir Truvada® Yes YHIV Antiretrovirals Etravirine Intelence® No YHIV Antiretrovirals Lamivudine Epivir® Yes YHIV Antiretrovirals Lamivudine/ Zidovudine Combivir® Yes YHIV Antiretrovirals Lopinavir/ Ritonavir Kaletra® Yes YHIV Antiretrovirals Nelfinavir Viracept® No NHIV Antiretrovirals Nevirapine Viramune® Yes NHIV Antiretrovirals Nevirapine ER Viramune XR Yes NHIV Antiretrovirals Raltegravir Isentress® No YHIV Antiretrovirals Rilpivirine Edurant® No Y

HIV Antiretrovirals Ritonavir Norvir® Yes YHIV Antiretrovirals Tenofovir Viread® Yes YHIV Antiretrovirals Tipranavir Aptivus® No NHIV Antiretrovirals Zidovudine Retrovir™ Yes YHuman Immune globulins Hepatitis B Immune Globulin HepaGam B No YHuman Immune globulins Hepatitis B Immune Globulin Hyperhep B No YHuman Immune globulins Hepatitis B Immune Globulin Nabi-HB No YHuman Immune globulins Hepatitis B Immune Globulin HepaGam B NovaPlus No YLaxatives Lubiprostone Amitiza® No NLaxatives Methylnaltrexone Relistor® No NLaxatives Naloxegol Movantik® No NLaxatives OTC laxatives various Y-OTC YMuscle relaxants (Antispasticity drugs) Baclofen Lioresal® Yes YMuscle relaxants (Antispasmodics) Carisoprodol Soma® Yes N

Muscle relaxants (Antispasmodics)

Chlorzoxazone

Parafon Forte®, Paraflex®, Relax™DS,Remular S™

Yes Y

Muscle relaxants Chlorzoxazone Lorzone® No NMuscle relaxants (Antispasmodics) Cyclobenzaprine Flexeril®, Fexmid™ Yes YMuscle relaxants (Antispasmodics) Cyclobenzaprine ER Amrix® No NMuscle relaxants (Antispasticity drugs) Dantrolene Dantrium® Yes NMuscle relaxants Meprobamate Miltown Yes NMuscle relaxants (Antispasmodics) Metaxalone Skelaxin® Yes YMuscle relaxants (Antispasmodics) Methocarbamol Robaxin®, Relaxin™ Yes Y

Muscle relaxants (Antispasmodics)Orphenadrine

Norflex®, Banflex®, Antiflex™, Mio-Rel™, Orphenate

Yes N

Muscle relaxants (Antispasticity/ Antispasmodics) Tizanidine

Zanaflex® Yes Y

Nonprescription analgesics Acetaminophen Tylenol® Y-OTC YNonprescription analgesics Aspirin Bayer® Y-OTC YNonprescription analgesics Ibuprofen Advil® Y-OTC YNonprescription analgesics Naproxen Aleve® Y-OTC Y drugs) Celecoxib Celebrex® Yes YNSAIDs Diclofenac Zorvolex No NNSAIDs Diclofenac/ misoprostol Arthrotec® Yes NNSAIDs Diclofenac epolamine Flector patch No NNSAIDs Diclofenac Potassium Cataflam® Yes YNSAIDs Diclofenac Potassium Zipsor Yes NNSAIDs Diclofenac sodium Voltaren® Yes YNSAIDs Diclofenac sodium ER Voltaren-XR® Yes NNSAIDs Diclofenac sodium injection Dyloject No NNSAIDs Diclofenac sodium topical Pennsaid® Yes NNSAIDs Diflunisal Dolobid® Yes Y

NSAIDs Etodolac Lodine® Yes YNSAIDs Etodolac ER Lodine XL® Yes YNSAIDs Fenoprofen Nalfon® Yes YNSAIDs Flurbiprofen Ansaid® Yes YNSAIDs Ibuprofen Advil® Y-OTC YNSAIDs Ibuprofen Motrin® Yes YNSAIDs Indomethacin Indocin® Yes NNSAIDs Indomethacin Tivorbex No NNSAIDs Indomethacin ER Indocin SR® Yes NNSAIDs Ketoprofen Ketoprofen Yes YNSAIDs Ketoprofen ER Ketoprofen ER Yes YNSAIDs Ketorolac Toradol® Yes NNSAIDs Ketorolac injection Toradol® Yes YNSAIDs Ketorolac nasal spray Sprix No NNSAIDs Mefenamic Acid Ponstel® Yes YNSAIDs Meloxicam Mobic® Yes YNSAIDs Meloxicam Vivlodex No NNSAIDs Nabumetone Relafen® Yes YNSAIDs Naproxen Aleve® Y-OTC YNSAIDs Naproxen Naprosyn® Yes YNSAIDs Naproxen ER EC-Naprosyn® Yes YNSAIDs Naproxen Anaprox® Yes YNSAIDs Naproxen Anaprox DS® Yes YNSAIDs Naproxen ER Naprelan® Yes NNSAIDs Oxaprozin Daypro® Yes YNSAIDs Piroxicam Feldene® Yes NNSAIDs Sulindac Clinoril® Yes YNSAIDs Tolmetin Tolectin® Yes YNSAIDs Tolmetin Tolectin DS Yes YOpioids & related entities Buprenorphine buccal film Belbuca™ No NOpioids Buprenorphine inj. for detox Buprenex® Yes Y Opioids Buprenorphine inj. for pain Buprenex® Yes N Opioids Buprenorphine implant Probuphine® No NOpioids Buprenorphine SL tab detox Bupren Yes Y Opioids Buprenorphine SL tab pain Bupren Yes N Opioids Buprenorphine transdermal Butrans™ No N Opioids Buprenorphine/Naloxone buccal film for detox Bunavail® No YOpioids Buprenorphine/Naloxone buccal film for pain Bunavail® No NOpioids Buprenorphine/Naloxone SL film for detox Suboxone® No YOpioids Buprenorphine/Naloxone SL film for pain Suboxone® No NOpioids Buprenorphine/Naloxone SL tab for detox Bupren/Nalox Yes Y Opioids Buprenorphine/Naloxone SL tab for pain Bupren/Nalox Yes N Opioids Buprenorphine/Naloxone SL tab for detox Zubsolv No Y Opioids Buprenorphine/Naloxone SL tab for pain Zubsolv No NOpioids Butalbital combos (barbiturates) Fioricet® Yes NOpioids Codeine Codeine Yes YOpioids Codeine/acetamin Tylenol #3/4 Yes Y

Opioids Dihydrocodeine Trezix/ Synalgos-DC No NOpioids Sufentanil (Sub lingual) Dsuvia No NOpioids Fentanyl buccal Fentora® Yes NOpioids Fentanyl buccal film Onsolis™ No NOpioids Fentanyl lollipop Actiq® Yes NOpioids Fentanyl nasal spray Lazanda No NOpioids Fentanyl sublingual spray Subsys® No NOpioids Fentanyl transdermal Duragesic® Yes NOpioids Fentanyl transmucosal Abstral No NOpioids Hydrocodone ER Hysingla No NOpioids Hydrocodone ER Zohydro No NOpioids Hydrocodone/acetamin IR Vicodin® Yes YOpioids Hydrocodone/acetamin IR Lortab® Yes YOpioids Hydrocodone bitartrate Vantrela™ ER No NOpioids Hydrocodone/ibuprofen IR Vicoprofen® Yes NOpioids Hydromorphone IR Dilaudid® Yes YOpioids Hydromorphone ER Exalgo Yes NOpioids Levorphanol Levo-Dromoran® Yes NOpioids Meperidine Demerol® Yes NOpioids Methadone (link to rules) Methadose® Yes NOpioids Morphine IR Morphine Yes YOpioids Morphine ER Avinza® Yes NOpioids Morphine ER Kadian® Yes NOpioids Morphine ER MS-Contin Yes NOpioids Morphine ER / Naltrexone Embeda No NOpioids Morphine sulfate Arymo™ ER No NOpioids Morphine sulfate Morphabond™ ER No NOpioids Naloxone Injection device Evzio® No NOpioids Naloxone intranasal Narcan® No YOpioids Naloxone Injectable Naloxone Yes YOpioids Oxycodone IR OxyIR® Yes YOpioids Oxycodone IR Oxaydo No NOpioids Oxycodone ER OxyContin® No NOpioids Oxycodone ER/acetamin Xartemis XR No NOpioids Oxycodone Xtampza ER No NOpioids Oxycodone ER/naloxone Targiniq ER® No NOpioids Oxycodone/acetaminophen IR Percocet® Yes YOpioids Oxycodone/aspirin IR Percodan® Yes NOpioids Oxycodone/ibuprofen IR Combunox Yes NOpioids Oxycodone/naltrexone Troxyca® ER No NOpioids Oxycodone HCL RoxyBond™ No NOpioids Oxymorphone IR Opana® Yes NOpioids Oxymorphone ER Opana ER No NOpioids Pentazocine lactate Talwin Yes NOpioids Pentazocine/Naloxone Talwin NX Yes NOpioids Propoxyphene hcl Darvon® Yes NOpioids Propoxyphene/acetamin Darvocet® Yes N

Opioids Propoxyphene napsylate Darvon-N® No NOpioids Tapentadol Nucynta™ No NOpioids Tramadol IR Ultram® Yes YOpioids Tramadol ER Ultram ER® Yes YOpioids Tramadol ER, biphasic ConZip / Ryzolt No NOpioids Tramadol/Acetaminophen IR Ultracet® Yes YOpioids & related entities Ziconotide (morphine pump) Prialt® No NOral corticosteroids Methylprednisolone Medrol Yes YOral corticosteroids Prednisone Prednisone Yes YPPI (Proton Pump Inhibitor) Dexlansoprazole Dexilant® No NPPI (Proton Pump Inhibitor) Esomeprazole Nexium® Y-OTC YPPI (Proton Pump Inhibitor) Esomeprazole/Naproxen Vimovo Yes NPPI (Proton Pump Inhibitor) Lansoprazole Prevacid® Y-OTC YPPI (Proton Pump Inhibitor) Omeprazole Prilosec® Y-OTC YPPI (Proton Pump Inhibitor) Pantoprazole Protonix® Yes NPPI (Proton Pump Inhibitor) Rabeprazole Aciphex® Yes NProstaglandins Misoprostol Cytotec® Yes YSedative-hypnotics Diphenhydramine for insomnia Benadryl Y-OTC NSedative-hypnotics Eszopiclone Lunesta™ Yes YSedative-hypnotics Promethazine Phenergan Yes NSedative-hypnotics Ramelteon Rozerem™ Yes YSedative-hypnotics Trazodone Desyrel Yes NSedative-hypnotics Zaleplon Sonata® Yes YSedative-hypnotics Zolpidem Ambien® Yes YSedative-hypnotics Zolpidem ER Ambien CR Yes NSedative-hypnotics Zolpidem Edluar SL Yes NStimulants (adjunctive pain medication) Armodafinil Nuvigil Yes NStimulants Modafinil Provigil® Yes NStimulants Sodium oxybate Xyrem Yes NTopical analgesics Capsaicin, topical Qutenza No NTopical analgesics Diclofenac Sodium Gel Voltaren® Gel Yes YTopical analgesics Dimethylsulfoxide DMSO Yes NTopical analgesics Ketamine, topical Ketamine Yes NTopical analgesics Lidocaine, topical Lidoderm® Yes NTopical analgesics Menthol Biofreeze gel Y-OTC YTopical analgesics Methyl salicylate Thera-Gesic Crème Y-OTC YTopical analgesics Salicylate topicals Ben-Gay Y-OTC YTriptans Rizatriptan Maxalt® Yes YTriptans Sumatriptan Imitrex® Yes YTumor necrosis factor (TNF) modifiers Adalimumab Humira® Yes NTumor necrosis factor (TNF) modifiers Etanercept Enbrel® Yes NTumor necrosis factor (TNF) modifiers Infliximab Remicade® Yes N© Copyright 2019 by the Work Loss Data Institute (WLDI). Commercial reproduction or other use beyond fair use prohibited without explicit WLDI permission.

Drug Class Generic Name Brand Name Gener Equiv StatusAnticoagulants Apixaban Eliquis ® No YAnticoagulants Dabigatran Pradaxa ® No YAnticoagulants Enoxaparin Lovenox ® Yes YAnticoagulants Rivaroxaban Xarelto ® No YAntidepressants Amitriptyline Elavil ® Yes YAntidepressants Bupropion Wellbutrin ® Yes YAntidepressants Bupropion Wellbutrin ® Yes NAntidepressants Citalopram Celexa ® Yes NAntidepressants Desvenlafaxine Pristiq ® Yes YAntidepressants Duloxetine Cymbalta ® Yes YAntidepressants Duloxetine Cymbalta ® Yes YAntidepressants Escitalopram Lexapro ® Yes YAntidepressants Escitalopram Lexapro ® Yes NAntidepressants Esketamine Spravato™ No NAntidepressants Fluoxetine Prozac ® Yes YAntidepressants Fluoxetine Prozac ® Yes NAntidepressants Fluvoxamine Luvox ® Yes NAntidepressants Milnacipran Savella/Ixel ® Yes NAntidepressants Mirtazapine Remeron ® Yes NAntidepressants Mirtazapine Remeron ® Yes YAntidepressants Nortriptyline Pamelor ™ Yes YAntidepressants Paroxetine Paxil ® Yes YAntidepressants Paroxetine Paxil ® Yes NAntidepressants Sertraline Zoloft ® Yes YAntidepressants Sertraline Zoloft ® Yes NAntidepressants Venlafaxine Effexor ® Yes YAntidepressants Venlafaxine ER Effexor XR ® Yes YAntidiabetics Acarbose Precose Yes NAntidiabetics Exenatide Byetta No NAntidiabetics Glimepiride Amaryl Yes NAntidiabetics Glipizide Glucotrol Yes NAntidiabetics Glyburide Glynase Yes NAntidiabetics Insulin Humalog No YAntidiabetics Insulin Humulin No NAntidiabetics Insulin Novolin No NAntidiabetics Insulin NovoLog No YAntidiabetics Metformin Glucophage Yes YAntidiabetics Miglitol Glyset Yes NAntidiabetics Nateglinide Starlix Yes NAntidiabetics Pioglitazone Actos Yes NAntidiabetics Repaglinide Prandin Yes NAntidiabetics Rosiglitazone Avandia Yes NAntidiabetics Saxagliptin Onglyza No NAntidiabetics Sitagliptin Januvia No NAntiemetics Ondansetron Zofran ® Yes N

ODG Workers' Compensation Drug Formulary December 2019

Antiemetics Ondansetron Zuplenz ® No NAnti-epilepsy drugs (AEDs) Carbamazepine Tegretol ® Yes YAnti-epilepsy drugs (AEDs) Gabapentin Neurontin ®, Gabarone Yes YAnti-epilepsy drugs (AEDs) Gabapentin ER Gralise ® No NAnti-epilepsy drugs (AEDs) Gabapentin ER Horizant ® No NAnti-epilepsy drugs (AEDs) Lacosamide Vimpat ® Yes NAnti-epilepsy drugs (AEDs) Lamotrigine Lamictal ® Yes NAnti-epilepsy drugs (AEDs) Levetiracetam Keppra ® Yes NAnti-epilepsy drugs (AEDs) Oxcarbazepine Trileptal ® Yes YAnti-epilepsy drugs (AEDs) Phenytoin Dilantin ® Yes NAnti-epilepsy drugs (AEDs) Pregabalin Lyrica ® IR No YAnti-epilepsy drugs (AEDs) Pregabalin Lyrica® CR No NAnti-epilepsy drugs (AEDs) Tiagabine Gabitril ® Yes NAnti-epilepsy drugs (AEDs) Topiramate Topamax ® Yes NAnti-epilepsy drugs (AEDs) Zonisamide Zonegran ® Yes NAntihypertensives Aliskiren Tekturna No NAntihypertensives Amlodipine Norvasc Yes YAntihypertensives Atenolol Tenormin Yes YAntihypertensives Benazepril Lotensin Yes YAntihypertensives Captopril Capoten Yes YAntihypertensives Clonidine Catapres Yes NAntihypertensives Doxazosin Cardura Yes NAntihypertensives Enalapril Vasotec Yes YAntihypertensives Hydralazine Apresoline Yes NAntihypertensives Hydrochlorothiazide HCTZ Yes YAntihypertensives Lisinopril Zestril Yes YAntihypertensives Losartan Cozaar Yes YAntihypertensives Metoprolol Lopressor Yes YAntihypertensives Minoxidil Loniten Yes NAntihypertensives Nadolol Corgard Yes YAntihypertensives Nicardipine Cardene Yes YAntihypertensives Nifedipine Procardia Yes YAntihypertensives Olmesartan Benicar Yes YAntihypertensives Prazosin Minipress Yes NAntihypertensives Propranolol Inderal Yes YAntihypertensives Ramipril Altace Yes YAntihypertensives Spironolactone Aldactone Yes NAntihypertensives Terazosin Hytrin Yes NAntihypertensives Valsartan Diovan Yes YAnti-infectives Amoxicillin Amoxil Yes YAnti-infectives Amoxicillin-Clavulanate Augmentin Yes YAnti-infectives Azithromycin Zithromax Yes YAnti-infectives Cefadroxil Duricef Yes YAnti-infectives Cefdinir Omnicef Yes YAnti-infectives Cefprozil Cefzil Yes YAnti-infectives Cefuroxime Ceftin Yes YAnti-infectives Cephalexin Keflex Yes YAnti-infectives Ciprofloxacin Cipro Yes Y

Anti-infectives Clarithromycin Biaxin Yes YAnti-infectives Clindamycin Cleocin Yes YAnti-infectives Dicloxacillin Dynapen Yes YAnti-infectives Doxycycline Vibramycin, Doryx Yes YAnti-infectives Levofloxacin Levaquin Yes YAnti-infectives Linezolid Zyvox Yes YAnti-infectives Metronidazole Flagyl Yes YAnti-infectives Minocycline Minocin, Dynacin Yes YAnti-infectives Moxifloxacin Avelox Yes YAnti-infectives Penicillin Veetids Yes YAnti-infectives Sulfamethoxazole-Trimethoprim Bactrim, Septra Yes YAsthma medications Albuterol inhalation Proventil ®/Ventolin ® Yes YAsthma medications Albuterol oral tablet Albuterol Yes NAsthma medications Albuterol/Ipratropium Combivent ® Yes YAsthma medications Beclomethasone Qvar ® No YAsthma medications Budesonide Symbicort ® No YAsthma medications Budesonide inhalation Pulmicort ® Yes YAsthma medications Ciclesonide Alvesco ® No YAsthma medications Cromolyn Cromolyn ® Yes NAsthma medications Fluticasone inhalation Flovent ® No YAsthma medications Formoterol Foradil ® No NAsthma medications Indacaterol Arcapta ® No NAsthma medications Ipratropium Atrovent ® Yes NAsthma medications Levalbuterol Xopenex ® Yes YAsthma medications Mometasone Asmanex ® No YAsthma medications Mometasone Dulera ® No YAsthma medications Montelukast Singulair ® Yes NAsthma medications Omalizumab Xolair ® No NAsthma medications Pirbuterol Maxair No YAsthma medications Salmeterol Serevent ® No NAsthma medications Salmeterol/Fluticasone Advair ® No YAsthma medications Theophylline Slo-Bid ® Yes NAsthma medications Zafirlukast Accolate ® Yes NAsthma medications Zileuton Zyflo ® No NAtypical antipsychotics Aripiprazole Abilify Yes NAtypical antipsychotics Olanzapine Zyprexa Yes NAtypical antipsychotics Quetiapine Seroquel Yes NAtypical antipsychotics Risperidone Risperdal Yes NBenzodiazepines Alprazolam Xanax Yes NBenzodiazepines Chlordiazepoxide Librium Yes NBenzodiazepines Clonazepam Klonopin Yes NBenzodiazepines Clorazepate Tranxene Yes NBenzodiazepines Diazepam Valium Yes NBenzodiazepines Estazolam ProSom Yes NBenzodiazepines Flurazepam Dalmane Yes NBenzodiazepines Lorazepam Ativan Yes NBenzodiazepines Midazolam Versed Yes NBenzodiazepines Oxazepam Serax Yes N

Benzodiazepines Quazepam Doral No NBenzodiazepines Temazepam Restoril Yes NBenzodiazepines Triazolam Halcion Yes NBisphosphonates Alendronate Fosamax ® Yes YBisphosphonates Etidronate Didronel ® Yes YBisphosphonates Ibandronate Boniva ® Yes YBisphosphonates Risedronate Actonel ®, Atelvia ® Yes YBotulinum toxin Botulinum toxin Botox ® No NBotulinum toxin Botulinum toxin Dysport No NBotulinum toxin Botulinum toxin Myobloc ® No NBotulinum toxin Botulinum toxin Xeomin No NCalcitonin gene-related peptide receptor(CGRP-R) antagonist Erenumab

Aimovig No N

Calcitonin gene-related peptide receptor(CGRP-R) antagonist Fremanezumab-vfrm

Ajovy® No N

Calcitonin gene-related peptide receptor(CGRP-R) antagonist Galcanezumab-gnlm Emgality No N

Cannabinoids Marijuana/dronabinol Marinol ® Yes NCannabinoids Nabilone Cesamet ® No NCannabinoids Tetrahydrocannabinol THC dronabinol Marinol Yes NCentral adrenergic agonists Clonidine, intrathecal Duraclon ® Yes NCompound drugs N/A N/A No NDopamine agonists Amantadine Symmetrel Yes YDopamine agonists Carbidopa/Levodopa Sinemet ® Yes YDopamine agonists Pramipexole Mirapex ® Yes NDopamine agonists Ropinirole Requip ® Yes NGout medications Colchicine Colchicine Yes NH2-receptor antagonists ibuprofen and famotidine Duexis ® No NH2-receptor antagonists Cimetidine Tagamet ® Y-OTC YH2-receptor antagonists Famotidine Pepcid ® Y-OTC YH2-receptor antagonists Ranitidine Zantac ® Y-OTC YHIV Antiretrovirals Atazanavir Reyataz ® Yes YHIV Antiretrovirals Darunavir Prezista ® No YHIV Antiretrovirals Didanosine Videx ® No NHIV Antiretrovirals Didanosine ER Videx ® EC Yes NHIV Antiretrovirals Emtricitabine Emtriva ™ No YHIV Antiretrovirals Emtricitabine/Tenofovir Truvada ® Yes YHIV Antiretrovirals Etravirine Intelence ® No YHIV Antiretrovirals Lamivudine Epivir ® Yes YHIV Antiretrovirals Lamivudine/Zidovudine Combivir ® Yes YHIV Antiretrovirals Lopinavir/Ritonavir Kaletra ® Yes YHIV Antiretrovirals Nelfinavir Viracept ® No NHIV Antiretrovirals Nevirapine Viramune ® Yes NHIV Antiretrovirals Nevirapine ER Viramune XR Yes NHIV Antiretrovirals Raltegravir Isentress ® No YHIV Antiretrovirals Rilpivirine Edurant ® No Y

HIV Antiretrovirals Ritonavir Norvir ® Yes YHIV Antiretrovirals Tenofovir Viread ® Yes YHIV Antiretrovirals Tipranavir Aptivus ® No NHIV Antiretrovirals Zidovudine Retrovir ™ Yes YHuman Immune globulins Hepatitis B Immune Globulin HepaGam B No YHuman Immune globulins Hepatitis B Immune Globulin HepaGamB NovaPluss No YHuman Immune globulins Hepatitis B Immune Globulin Hyperhep B No YHuman Immune globulins Hepatitis B Immune Globulin Nabi-HB No YLaxatives Lubiprostone Amitiza ® No NLaxatives Methylnaltrexone Relistor ® No NLaxatives Naloxegol Movantik ® No NLaxatives OTC Laxatives various Y-OTC YMuscle relaxants Baclofen Lioresal ® Yes YMuscle relaxants Carisoprodol Soma ® Yes NMuscle relaxants Chlorzoxazone Lorzone ® No N

Muscle relaxants Chlorzoxazone

Parafon Forte ®, Paraflex ®, Relax™DS, Remular S™

Yes Y

Muscle relaxants Cyclobenzaprine Flexeril ®, Fexmid ™ Yes YMuscle relaxants Cyclobenzaprine ER Amrix ® No NMuscle relaxants Dantrolene Dantrium ® Yes NMuscle relaxants Meprobamate Miltown Yes NMuscle relaxants Metaxalone Skelaxin ® Yes YMuscle relaxants Methocarbamol Robaxin ®, Relaxin ™ Yes Y

Muscle relaxants

OrphenadrineNorflex®, Banflex®, Antiflex™, Mio-Rel™, Orphenate

Yes N

Muscle relaxants Tizanidine Zanaflex ® Yes YNonprescription analgesics Acetaminophen Tylenol ® Y-OTC YNonprescription analgesics Aspirin Bayer ® Y-OTC YNonprescription analgesics Ibuprofen Advil ® Y-OTC YNonprescription analgesics Naproxen Aleve ® Y-OTC YNSAIDs Celecoxib Celebrex ® Yes YNSAIDs Diclofenac Zorvolex ® No NNSAIDs Diclofenac epolamine Flector patch ® No NNSAIDs Diclofenac Potassium Cataflam ® Yes YNSAIDs Diclofenac Potassium Zipsor Yes NNSAIDs Diclofenac sodium Dyloject No NNSAIDs Diclofenac sodium Voltaren ® Yes YNSAIDs Diclofenac sodium ER Voltaren-XR ® Yes NNSAIDs Diclofenac sodium topical Pennsaid ® Yes NNSAIDs Diclofenac/ misoprostol Arthrotec ® Yes NNSAIDs Diflunisal Dolobid ® Yes YNSAIDs Esomeprazole/Naproxen Vimovo ® Yes NNSAIDs Etodolac Lodine ® Yes YNSAIDs Etodolac ER Lodine XL ® Yes Y

NSAIDs Fenoprofen Nalfon ® Yes YNSAIDs Flurbiprofen Ansaid ® Yes YNSAIDs Ibuprofen Advil ® Y-OTC YNSAIDs Ibuprofen Motrin ® Yes YNSAIDs Indomethacin Indocin ® Yes NNSAIDs Indomethacin Tivorbex No NNSAIDs Indomethacin ER Indocin SR ® Yes NNSAIDs Ketoprofen Ketoprofen Yes YNSAIDs Ketoprofen Ketoprofen ER Yes YNSAIDs Ketorolac Toradol ® Yes NNSAIDs Ketorolac injection Toradol ® Yes YNSAIDs Ketorolac nasal spray Sprix No NNSAIDs Mefenamic Acid Ponstel ® Yes YNSAIDs Meloxicam Mobic ® Yes YNSAIDs Meloxicam Vivlodex ® No NNSAIDs Nabumetone Relafen ® Yes YNSAIDs Naproxen Aleve ® Y-OTC YNSAIDs Naproxen Anaprox ® Yes YNSAIDs Naproxen Anaprox DS ® Yes YNSAIDs Naproxen Naprosyn ® Yes YNSAIDs Naproxen ER EC-Naprosyn ® Yes YNSAIDs Naproxen ER Naprelan ® Yes NNSAIDs Oxaprozin Daypro ® Yes YNSAIDs Piroxicam Feldene ® Yes NNSAIDs Sulindac Clinoril ® Yes YNSAIDs Tolmetin Tolectin ® Yes YNSAIDs Tolmetin Tolectin ®/Tolectin DS Yes YOpioids Buprenorphine buccal film Belbuca ™ No NOpioids Buprenorphine hydrochloride Buprenex ® Yes NOpioids Buprenorphine hydrochloride Bupren Yes YOpioids Buprenorphine hydrochloride Bupren Yes NOpioids Buprenorphine hydrochloride Buprenex ® Yes NOpioids Buprenorphine implant Probuphine No NOpioids Buprenorphine transdermal Butrans ™ No NOpioids Buprenorphine/Naloxone Bunavail ® No NOpioids Buprenorphine/Naloxone Bupren/Nalox Yes YOpioids Buprenorphine/Naloxone Bupren/Nalox Yes NOpioids Buprenorphine/Naloxone Suboxone ® Yes YOpioids Buprenorphine/Naloxone Zubsolv No YOpioids Buprenorphine/Naloxone Bunavail ® No YOpioids Buprenorphine/Naloxone Suboxone ® Yes NOpioids Buprenorphine/Naloxone Zubsolv No NOpioids Butalbital Fioricet ® Yes NOpioids Codeine Codeine Yes YOpioids Codeine/Acetamin Tylenol #3 4 Yes YOpioids Dihydrocodeine Trezix Synalgos-DC No NOpioids Fentanyl buccal Fentora ® Yes NOpioids Fentanyl buccal film Onsolis ™ No N

Opioids Fentanyl lollipop Actiq ® Yes NOpioids Fentanyl nasal spray Lazanda ® No NOpioids Fentanyl sublingual spray Subsys ® No NOpioids Fentanyl transdermal Duragesic ® Yes NOpioids Fentanyl transmucosal Abstral No NOpioids Hydrocodone bitartrate Vantrela ER ® No N

OpioidsHydrocodone bitartrate ER Hysingla® ER/ Zohydro

ERNo N

Opioids Hydrocodone/acetaminophen

Hycet®/ Lorcet®/ Lortab®/ Norco®/ Vicodin®/ Zamicet®

Yes Y

Opioids Hydrocodone/Ibuprofen Vicoprofen®/ Ibudone®/ Repraxain®/ Xylon® Yes N

Opioids Hydromorphone Dilaudid ® Yes YOpioids Hydromorphone ER Exalgo Yes NOpioids Levorphanol Levo-Dromoran ® Yes NOpioids Meperidine Demerol ® Yes NOpioids Methadone Methadose ® Yes NOpioids Morphine Morphine Yes YOpioids Morphine ER Avinza ® Yes NOpioids Morphine ER Kadian ® Yes NOpioids Morphine ER MS-Contin Yes NOpioids Morphine ER / Naltrexone Embeda No NOpioids Morphine sulfate Arymo ER ® No NOpioids Morphine sulfate Morphabond ER ® No NOpioids Naloxone Naloxone Yes YOpioids Naloxone Narcan ® No YOpioids Naloxone Evzio ® No NOpioids Oxycodone Oxaydo ® No NOpioids Oxycodone OxyIR ® Yes YOpioids Oxycodone Targiniq ER ® No NOpioids Oxycodone Troxyca ER ® No NOpioids Oxycodone Xartemis XR ® No NOpioids Oxycodone Xtampza ER No NOpioids Oxycodone ER OxyContin ® No NOpioids Oxycodone HCL RoxyBond ™ No NOpioids Oxycodone/acetaminophen Percocet ® Yes YOpioids Oxycodone/aspirin IR Percodan ® Yes NOpioids Oxycodone/ibuprofen IR Combunox Yes NOpioids Oxymorphone ER Opana ER No NOpioids Oxymorphone IR Opana ® Yes NOpioids Pentazocine lactate Talwin Yes NOpioids Pentazocine/Naloxone Talwin NX Yes NOpioids Propoxyphene hcl Darvon ® Yes NOpioids Propoxyphene napsylate Darvon-N ® No NOpioids Propoxyphene/acetamin Darvocet ® Yes N

Opioids Sufentanil Dsuvia No NOpioids Tapentadol Nucynta ™ No NOpioids Tramadol Ultram ® Yes YOpioids Tramadol ER Ultram ER ® Yes YOpioids Tramadol ER, biphasic ConZip/Ryzolt No NOpioids Tramadol/Acetaminophen Ultracet ® Yes YOpioids Ziconotide Prialt ® No NOral corticosteroids Methylprednisolone Medrol Yes YOral corticosteroids Prednisone Prednisone Yes YOTC (Over The Counter)PPI (Proton Pump Inhibitor) Dexlansoprazole Dexilant ® No NPPI (Proton Pump Inhibitor) Esomeprazole Nexium ® Y-OTC YPPI (Proton Pump Inhibitor) Lansoprazole Prevacid ® Y-OTC YPPI (Proton Pump Inhibitor) Omeprazole Prilosec ® Y-OTC YPPI (Proton Pump Inhibitor) Pantoprazole Protonix ® Yes NPPI (Proton Pump Inhibitor) Rabeprazole Aciphex ® Yes NProstaglandins Misoprostol Cytotec Yes YSedative-hypnotics Diphenhydramine Benadryl Y-OTC NSedative-hypnotics Eszopicolone Lunesta ™ Yes YSedative-hypnotics Promethazine Phenergan Yes NSedative-hypnotics Ramelteon Rozerem ™ Yes YSedative-hypnotics Trazodone Desyrel Yes NSedative-hypnotics Zaleplon Sonata ® Yes YSedative-hypnotics Zolpidem Ambien ® Yes YSedative-hypnotics Zolpidem Edluar SL Yes NSedative-hypnotics Zolpidem ER Ambien CR Yes NStimulants Armodafinil Nuvigil Yes NStimulants Modafinil Provigil ® Yes NStimulants Sodium oxybate Xyrem Yes NTopical analgesics Capsaicin Qutenza No NTopical analgesics Diclofenac sodium gel Voltaren ® Gel Yes YTopical analgesics Dimethylsulfoxide DMSO Yes NTopical analgesics Ketamine Ketamine Yes NTopical analgesics Lidocaine Lidoderm ® Yes NTopical analgesics Menthol Biofreeze gel Y-OTC YTopical analgesics Methyl salicylate Thera-Gesic Crème Y-OTC YTopical analgesics Salicylate Ben-Gay Y-OTC YTriptans Rizatriptan Maxalt ® Yes YTriptans Sumatriptan Imitrex ® Yes YTumor necrosis factor (TNF) modifiers Adalimumab Humira ® Yes NTumor necrosis factor (TNF) modifiers Etanercept Enbrel ® Yes NTumor necrosis factor (TNF) modifiers Infliximab Remicade ® Yes N

See Nonprescription analgesics.

© Copyright 2019 by the Work Loss Data Institute (WLDI). Commercial reproduction or other use beyond fair use prohibited without explicit WLDI permission.

Drug Class Generic Name Brand Name Gener Equiv StatusAnticoagulants Apixaban Eliquis ® No YAnticoagulants Dabigatran Pradaxa ® No YAnticoagulants Enoxaparin Lovenox ® Yes YAnticoagulants Rivaroxaban Xarelto ® No YAntidepressants Amitriptyline Elavil ® Yes YAntidepressants Bupropion Wellbutrin ® Yes YAntidepressants Bupropion Wellbutrin ® Yes NAntidepressants Citalopram Celexa ® Yes NAntidepressants Desvenlafaxine Pristiq ® Yes YAntidepressants Duloxetine Cymbalta ® Yes YAntidepressants Duloxetine Cymbalta ® Yes YAntidepressants Escitalopram Lexapro ® Yes YAntidepressants Escitalopram Lexapro ® Yes NAntidepressants Esketamine Spravato™ No NAntidepressants Fluoxetine Prozac ® Yes YAntidepressants Fluoxetine Prozac ® Yes NAntidepressants Fluvoxamine Luvox ® Yes NAntidepressants Milnacipran Savella/Ixel ® Yes NAntidepressants Mirtazapine Remeron ® Yes NAntidepressants Mirtazapine Remeron ® Yes YAntidepressants Nortriptyline Pamelor ™ Yes YAntidepressants Paroxetine Paxil ® Yes YAntidepressants Paroxetine Paxil ® Yes NAntidepressants Sertraline Zoloft ® Yes YAntidepressants Sertraline Zoloft ® Yes NAntidepressants Venlafaxine Effexor ® Yes YAntidepressants Venlafaxine ER Effexor XR ® Yes YAntidiabetics Acarbose Precose Yes NAntidiabetics Exenatide Byetta No NAntidiabetics Glimepiride Amaryl Yes NAntidiabetics Glipizide Glucotrol Yes NAntidiabetics Glyburide Glynase Yes NAntidiabetics Insulin Humalog No YAntidiabetics Insulin Humulin No NAntidiabetics Insulin Novolin No NAntidiabetics Insulin NovoLog No YAntidiabetics Metformin Glucophage Yes YAntidiabetics Miglitol Glyset Yes N

ODG Workers’ Compensation Drug Formulary May 2020

Antidiabetics Nateglinide Starlix Yes NAntidiabetics Pioglitazone Actos Yes NAntidiabetics Repaglinide Prandin Yes NAntidiabetics Rosiglitazone Avandia Yes NAntidiabetics Saxagliptin Onglyza No NAntidiabetics Sitagliptin Januvia No NAntiemetics Ondansetron Zofran ® Yes NAntiemetics Ondansetron Zuplenz ® No NAnti-epilepsy drugs (AEDs) Carbamazepine Tegretol ® Yes YAnti-epilepsy drugs (AEDs) Gabapentin Neurontin ®, Gabarone Yes YAnti-epilepsy drugs (AEDs) Gabapentin ER Gralise ® No NAnti-epilepsy drugs (AEDs) Gabapentin ER Horizant ® No NAnti-epilepsy drugs (AEDs) Lacosamide Vimpat ® Yes NAnti-epilepsy drugs (AEDs) Lamotrigine Lamictal ® Yes NAnti-epilepsy drugs (AEDs) Levetiracetam Keppra ® Yes NAnti-epilepsy drugs (AEDs) Oxcarbazepine Trileptal ® Yes YAnti-epilepsy drugs (AEDs) Phenytoin Dilantin ® Yes NAnti-epilepsy drugs (AEDs) Pregabalin Lyrica ® IR No YAnti-epilepsy drugs (AEDs) Pregabalin Lyrica® CR No NAnti-epilepsy drugs (AEDs) Tiagabine Gabitril ® Yes NAnti-epilepsy drugs (AEDs) Topiramate Topamax ® Yes NAnti-epilepsy drugs (AEDs) Zonisamide Zonegran ® Yes NAntihypertensives Aliskiren Tekturna No NAntihypertensives Amlodipine Norvasc Yes YAntihypertensives Atenolol Tenormin Yes YAntihypertensives Benazepril Lotensin Yes YAntihypertensives Captopril Capoten Yes YAntihypertensives Clonidine Catapres Yes NAntihypertensives Doxazosin Cardura Yes NAntihypertensives Enalapril Vasotec Yes YAntihypertensives Hydralazine Apresoline Yes NAntihypertensives Hydrochlorothiazide HCTZ Yes YAntihypertensives Lisinopril Zestril Yes YAntihypertensives Losartan Cozaar Yes YAntihypertensives Metoprolol Lopressor Yes YAntihypertensives Minoxidil Loniten Yes NAntihypertensives Nadolol Corgard Yes YAntihypertensives Nicardipine Cardene Yes YAntihypertensives Nifedipine Procardia Yes YAntihypertensives Olmesartan Benicar Yes YAntihypertensives Prazosin Minipress Yes N

Antihypertensives Prazosin Minipress Yes YAntihypertensives Propranolol Inderal Yes YAntihypertensives Ramipril Altace Yes YAntihypertensives Spironolactone Aldactone Yes NAntihypertensives Terazosin Hytrin Yes NAntihypertensives Valsartan Diovan Yes YAnti-infectives Amoxicillin Amoxil Yes YAnti-infectives Amoxicillin-Clavulanate Augmentin Yes YAnti-infectives Azithromycin Zithromax Yes YAnti-infectives Cefadroxil Duricef Yes YAnti-infectives Cefdinir Omnicef Yes YAnti-infectives Cefprozil Cefzil Yes YAnti-infectives Cefuroxime Ceftin Yes YAnti-infectives Cephalexin Keflex Yes YAnti-infectives Ciprofloxacin Cipro Yes YAnti-infectives Clarithromycin Biaxin Yes YAnti-infectives Clindamycin Cleocin Yes YAnti-infectives Dicloxacillin Dynapen Yes YAnti-infectives Doxycycline Vibramycin, Doryx Yes YAnti-infectives Levofloxacin Levaquin Yes YAnti-infectives Linezolid Zyvox Yes YAnti-infectives Metronidazole Flagyl Yes YAnti-infectives Minocycline Minocin, Dynacin Yes YAnti-infectives Moxifloxacin Avelox Yes YAnti-infectives Penicillin Veetids Yes YAnti-infectives Sulfamethoxazole-Trimethoprim Bactrim, Septra Yes YAsthma medications Albuterol inhalation Proventil ®/Ventolin ® Yes YAsthma medications Albuterol oral tablet Albuterol Yes NAsthma medications Albuterol/Ipratropium Combivent ® Yes YAsthma medications Beclomethasone Qvar ® No YAsthma medications Budesonide Symbicort ® No YAsthma medications Budesonide inhalation Pulmicort ® Yes YAsthma medications Ciclesonide Alvesco ® No YAsthma medications Cromolyn Cromolyn ® Yes NAsthma medications Fluticasone inhalation Flovent ® No YAsthma medications Formoterol Foradil ® No NAsthma medications Indacaterol Arcapta ® No NAsthma medications Ipratropium Atrovent ® Yes NAsthma medications Levalbuterol Xopenex ® Yes YAsthma medications Mometasone Asmanex ® No YAsthma medications Mometasone Dulera ® No Y

Asthma medications Montelukast Singulair ® Yes NAsthma medications Omalizumab Xolair ® No NAsthma medications Pirbuterol Maxair No YAsthma medications Salmeterol Serevent ® No NAsthma medications Salmeterol/Fluticasone Advair ® No YAsthma medications Theophylline Slo-Bid ® Yes NAsthma medications Zafirlukast Accolate ® Yes NAsthma medications Zileuton Zyflo ® No NAtypical antipsychotics Aripiprazole Abilify Yes NAtypical antipsychotics Olanzapine Zyprexa Yes NAtypical antipsychotics Quetiapine Seroquel Yes NAtypical antipsychotics Risperidone Risperdal Yes NBenzodiazepines Alprazolam Xanax Yes NBenzodiazepines Chlordiazepoxide Librium Yes NBenzodiazepines Clonazepam Klonopin Yes NBenzodiazepines Clorazepate Tranxene Yes NBenzodiazepines Diazepam Valium Yes NBenzodiazepines Estazolam ProSom Yes NBenzodiazepines Flurazepam Dalmane Yes NBenzodiazepines Lorazepam Ativan Yes NBenzodiazepines Midazolam Versed Yes NBenzodiazepines Oxazepam Serax Yes NBenzodiazepines Quazepam Doral No NBenzodiazepines Temazepam Restoril Yes NBenzodiazepines Triazolam Halcion Yes NBisphosphonates Alendronate Fosamax ® Yes YBisphosphonates Etidronate Didronel ® Yes YBisphosphonates Ibandronate Boniva ® Yes YBisphosphonates Risedronate Actonel ®, Atelvia ® Yes YBotulinum toxin Botulinum toxin Botox ® No NBotulinum toxin Botulinum toxin Dysport No NBotulinum toxin Botulinum toxin Myobloc ® No NBotulinum toxin Botulinum toxin Xeomin No NCalcitonin gene-related peptide receptor (CG Erenumab Aimovig No NCalcitonin gene-related peptide receptor (CG Fremanezumab-vfrm Ajovy® No NCalcitonin gene-related peptide receptor (CG Galcanezumab-gnlm Emgality No NCannabinoids Marijuana/dronabinol Marinol ® Yes NCannabinoids Nabilone Cesamet ® No NCannabinoids Tetrahydrocannabinol THC dronabinol Marinol Yes NCentral adrenergic agonists Clonidine, intrathecal Duraclon ® Yes NCompound drugs N/A N/A No N

Disease-modifying antirheumatic drug (DMA Hydroxychloroquine sulfate Plaquenil® Yes YDisease-modifying antirheumatic drug (DMA Hydroxychloroquine sulfate Plaquenil® Yes NDopamine agonists Amantadine Symmetrel Yes YDopamine agonists Carbidopa/Levodopa Sinemet ® Yes YDopamine agonists Pramipexole Mirapex ® Yes NDopamine agonists Ropinirole Requip ® Yes NGout medications Colchicine Colchicine Yes NH2-receptor antagonists ibuprofen and famotidine Duexis ® No NH2-receptor antagonists Cimetidine Tagamet ® Y-OTC YH2-receptor antagonists Famotidine Pepcid ® Y-OTC YH2-receptor antagonists Ranitidine Zantac ® Y-OTC YHIV Antiretrovirals Atazanavir Reyataz ® Yes YHIV Antiretrovirals Darunavir Prezista ® No YHIV Antiretrovirals Didanosine Videx ® No NHIV Antiretrovirals Didanosine ER Videx ® EC Yes NHIV Antiretrovirals Emtricitabine Emtriva ™ No YHIV Antiretrovirals Emtricitabine/Tenofovir Truvada ® Yes YHIV Antiretrovirals Etravirine Intelence ® No YHIV Antiretrovirals Lamivudine Epivir ® Yes YHIV Antiretrovirals Lamivudine/Zidovudine Combivir ® Yes YHIV Antiretrovirals Lopinavir/Ritonavir Kaletra ® Yes YHIV Antiretrovirals Lopinavir/Ritonavir Kaletra ® Yes NHIV Antiretrovirals Nelfinavir Viracept ® No NHIV Antiretrovirals Nevirapine Viramune ® Yes NHIV Antiretrovirals Nevirapine ER Viramune XR Yes NHIV Antiretrovirals Raltegravir Isentress ® No YHIV Antiretrovirals Rilpivirine Edurant ® No YHIV Antiretrovirals Ritonavir Norvir ® Yes YHIV Antiretrovirals Tenofovir Viread ® Yes YHIV Antiretrovirals Tipranavir Aptivus ® No NHIV Antiretrovirals Zidovudine Retrovir ™ Yes YHuman Immune globulins Hepatitis B Immune Globulin HepaGam B No YHuman Immune globulins Hepatitis B Immune Globulin HepaGamB NovaPluss No YHuman Immune globulins Hepatitis B Immune Globulin Hyperhep B No YHuman Immune globulins Hepatitis B Immune Globulin Nabi-HB No YLaxatives Lubiprostone Amitiza ® No NLaxatives Methylnaltrexone Relistor ® No NLaxatives Naloxegol Movantik ® No NLaxatives OTC Laxatives various Y-OTC YMuscle relaxants Baclofen Lioresal ® Yes YMuscle relaxants Carisoprodol Soma ® Yes N

Muscle relaxants Chlorzoxazone Lorzone ® No NMuscle relaxants Chlorzoxazone Parafon Forte ®, Yes YMuscle relaxants Cyclobenzaprine Flexeril ®, Fexmid ™ Yes YMuscle relaxants Cyclobenzaprine ER Amrix ® No NMuscle relaxants Dantrolene Dantrium ® Yes NMuscle relaxants Meprobamate Miltown Yes NMuscle relaxants Metaxalone Skelaxin ® Yes YMuscle relaxants Methocarbamol Robaxin ®, Relaxin ™ Yes YMuscle relaxants Orphenadrine Norflex®, Banflex®, Yes NMuscle relaxants Tizanidine Zanaflex ® Yes YNonprescription analgesics Acetaminophen Tylenol ® Y-OTC YNonprescription analgesics Aspirin Bayer ® Y-OTC YNonprescription analgesics Ibuprofen Advil ® Y-OTC YNonprescription analgesics Naproxen Aleve ® Y-OTC YNSAIDs Celecoxib Celebrex ® Yes YNSAIDs Diclofenac Zorvolex ® No NNSAIDs Diclofenac epolamine Flector patch ® No NNSAIDs Diclofenac Potassium Cataflam ® Yes YNSAIDs Diclofenac Potassium Zipsor Yes NNSAIDs Diclofenac sodium Dyloject No NNSAIDs Diclofenac sodium Voltaren ® Yes YNSAIDs Diclofenac sodium ER Voltaren-XR ® Yes NNSAIDs Diclofenac sodium topical Pennsaid ® Yes NNSAIDs Diclofenac/ misoprostol Arthrotec ® Yes NNSAIDs Diflunisal Dolobid ® Yes YNSAIDs Esomeprazole/Naproxen Vimovo ® Yes NNSAIDs Etodolac Lodine ® Yes YNSAIDs Etodolac ER Lodine XL ® Yes YNSAIDs Fenoprofen Nalfon ® Yes YNSAIDs Flurbiprofen Ansaid ® Yes YNSAIDs Ibuprofen Advil ® Y-OTC YNSAIDs Ibuprofen Motrin ® Yes YNSAIDs Indomethacin Indocin ® Yes NNSAIDs Indomethacin Tivorbex No NNSAIDs Indomethacin ER Indocin SR ® Yes NNSAIDs Ketoprofen Ketoprofen Yes YNSAIDs Ketoprofen Ketoprofen ER Yes YNSAIDs Ketorolac Toradol ® Yes NNSAIDs Ketorolac injection Toradol ® Yes YNSAIDs Ketorolac nasal spray Sprix No NNSAIDs Mefenamic Acid Ponstel ® Yes Y

NSAIDs Meloxicam Mobic ® Yes YNSAIDs Meloxicam Vivlodex ® No NNSAIDs Nabumetone Relafen ® Yes YNSAIDs Naproxen Aleve ® Y-OTC YNSAIDs Naproxen Anaprox ® Yes YNSAIDs Naproxen Anaprox DS ® Yes YNSAIDs Naproxen Naprosyn ® Yes YNSAIDs Naproxen ER EC-Naprosyn ® Yes YNSAIDs Naproxen ER Naprelan ® Yes NNSAIDs Oxaprozin Daypro ® Yes YNSAIDs Piroxicam Feldene ® Yes NNSAIDs Sulindac Clinoril ® Yes YNSAIDs Tolmetin Tolectin ® Yes YNSAIDs Tolmetin Tolectin ®/Tolectin DS Yes YOpioids Buprenorphine buccal film Belbuca ™ No NOpioids Buprenorphine hydrochloride Buprenex ® Yes NOpioids Buprenorphine hydrochloride Bupren Yes YOpioids Buprenorphine hydrochloride Bupren Yes NOpioids Buprenorphine hydrochloride Buprenex ® Yes NOpioids Buprenorphine implant Probuphine No NOpioids Buprenorphine transdermal Butrans ™ No NOpioids Buprenorphine/Naloxone Bunavail ® No NOpioids Buprenorphine/Naloxone Bupren/Nalox Yes YOpioids Buprenorphine/Naloxone Bupren/Nalox Yes NOpioids Buprenorphine/Naloxone Suboxone ® Yes YOpioids Buprenorphine/Naloxone Zubsolv No YOpioids Buprenorphine/Naloxone Bunavail ® No YOpioids Buprenorphine/Naloxone Suboxone ® Yes NOpioids Buprenorphine/Naloxone Zubsolv No NOpioids Butalbital Fioricet ® Yes NOpioids Codeine Codeine Yes YOpioids Codeine/Acetamin Tylenol #3 4 Yes YOpioids Dihydrocodeine Trezix Synalgos-DC No NOpioids Fentanyl buccal Fentora ® Yes NOpioids Fentanyl buccal film Onsolis ™ No NOpioids Fentanyl lollipop Actiq ® Yes NOpioids Fentanyl nasal spray Lazanda ® No NOpioids Fentanyl sublingual spray Subsys ® No NOpioids Fentanyl transdermal Duragesic ® Yes NOpioids Fentanyl transmucosal Abstral No NOpioids Hydrocodone bitartrate Vantrela ER ® No N

Opioids Hydrocodone bitartrate ER Hysingla® ER/ Zohydro No NOpioids Hydrocodone/acetaminophen Hycet®/ Lorcet®/ Yes YOpioids Hydrocodone/Ibuprofen Vicoprofen®/ Ibudone®/ Yes NOpioids Hydromorphone Dilaudid ® Yes YOpioids Hydromorphone ER Exalgo Yes NOpioids Levorphanol Levo-Dromoran ® Yes NOpioids Meperidine Demerol ® Yes NOpioids Methadone Methadose ® Yes NOpioids Morphine Morphine Yes YOpioids Morphine ER Avinza ® Yes NOpioids Morphine ER Kadian ® Yes NOpioids Morphine ER MS-Contin Yes NOpioids Morphine ER / Naltrexone Embeda No NOpioids Morphine sulfate Arymo ER ® No NOpioids Morphine sulfate Morphabond ER ® No NOpioids Naloxone Naloxone Yes YOpioids Naloxone Narcan ® No YOpioids Naloxone Evzio ® No NOpioids Oxycodone Oxaydo ® No NOpioids Oxycodone OxyIR ® Yes YOpioids Oxycodone Targiniq ER ® No NOpioids Oxycodone Troxyca ER ® No NOpioids Oxycodone Xartemis XR ® No NOpioids Oxycodone Xtampza ER No NOpioids Oxycodone ER OxyContin ® No NOpioids Oxycodone HCL RoxyBond ™ No NOpioids Oxycodone/acetaminophen Percocet ® Yes YOpioids Oxycodone/aspirin IR Percodan ® Yes NOpioids Oxycodone/ibuprofen IR Combunox Yes NOpioids Oxymorphone ER Opana ER No NOpioids Oxymorphone IR Opana ® Yes NOpioids Pentazocine lactate Talwin Yes NOpioids Pentazocine/Naloxone Talwin NX Yes NOpioids Propoxyphene hcl Darvon ® Yes NOpioids Propoxyphene napsylate Darvon-N ® No NOpioids Propoxyphene/acetamin Darvocet ® Yes NOpioids Sufentanil Dsuvia No NOpioids Tapentadol Nucynta ™ No NOpioids Tramadol Ultram ® Yes YOpioids Tramadol ER Ultram ER ® Yes YOpioids Tramadol ER, biphasic ConZip/Ryzolt No N

Opioids Tramadol/Acetaminophen Ultracet ® Yes YOpioids Ziconotide Prialt ® No NOral corticosteroids Methylprednisolone Medrol Yes YOral corticosteroids Prednisone Prednisone Yes YOTC (Over The Counter)PPI (Proton Pump Inhibitor) Dexlansoprazole Dexilant ® No NPPI (Proton Pump Inhibitor) Esomeprazole Nexium ® Y-OTC YPPI (Proton Pump Inhibitor) Lansoprazole Prevacid ® Y-OTC YPPI (Proton Pump Inhibitor) Omeprazole Prilosec ® Y-OTC YPPI (Proton Pump Inhibitor) Pantoprazole Protonix ® Yes NPPI (Proton Pump Inhibitor) Rabeprazole Aciphex ® Yes NProstaglandins Misoprostol Cytotec Yes YSedative-hypnotics Diphenhydramine Benadryl Y-OTC NSedative-hypnotics Eszopicolone Lunesta ™ Yes YSedative-hypnotics Promethazine Phenergan Yes NSedative-hypnotics Ramelteon Rozerem ™ Yes YSedative-hypnotics Trazodone Desyrel Yes NSedative-hypnotics Zaleplon Sonata ® Yes YSedative-hypnotics Zolpidem Ambien ® Yes YSedative-hypnotics Zolpidem Edluar SL Yes NSedative-hypnotics Zolpidem ER Ambien CR Yes NStimulants Armodafinil Nuvigil Yes NStimulants Modafinil Provigil ® Yes NStimulants Sodium oxybate Xyrem Yes NTopical analgesics Capsaicin Qutenza No NTopical analgesics Diclofenac sodium gel Voltaren ® Gel Yes YTopical analgesics Dimethylsulfoxide DMSO Yes NTopical analgesics Ketamine Ketamine Yes NTopical analgesics Lidocaine Lidoderm ® Yes NTopical analgesics Menthol Biofreeze gel Y-OTC YTopical analgesics Methyl salicylate Thera-Gesic Crème Y-OTC YTopical analgesics Salicylate Ben-Gay Y-OTC YTriptans Rizatriptan Maxalt ® Yes YTriptans Sumatriptan Imitrex ® Yes YTumor necrosis factor (TNF) modifiers Adalimumab Humira ® Yes NTumor necrosis factor (TNF) modifiers Etanercept Enbrel ® Yes NTumor necrosis factor (TNF) modifiers Infliximab Remicade ® Yes NCopyright © 2020 MCG Health, LLC.Commercial reproduction or other use beyond fair use prohibited without explicit WLDI permission.

See Nonprescription analgesics.