Pinnacol Custom Acute and Chronic Formularies
The formulary is split into acute and chronic portions. The acute period is defined with the time frame of 42 days or less from the date of injury (DOI).
The acute formulary is the list of medications that are available to the injured worker for the first six weeks following the injury. After the first six weeks,
the patient is moved into the chronic formulary which is tailored to long-lasting injuries.
GPI
Medication Class
Description
Typical products
Acute
Formulary (<42
days from DOI)
Chronic Formulary
(>42 days from DOI)
01
Penicillins
Penicillins are commonly used in prevention or
treatment of infection. From the data on timing of
penicillin prescription initiation, a majority begins
therapy within the first 30 days of therapy.
Penicillin,
Amoxicillin
Included
Excluded
02
Cephalosporins
Cephalexin,
Cefadroxil
Included
Excluded
03
Macrolides
Biaxin, Zithromax
Included
Excluded
04
Tetracyclines
Doxycycline
Included
Excluded
05
Fluoroquinolones
Cipro, Levaquin
Included
Excluded
12
Antivirals
Atripla, Valcyte
Misc antiinfectives
Excluded
Exceptions:
Anti-retrovirals
Included
Exceptions:
atovaquone
erythromycin - sulfisoxazole
linezolid
metronidazole
nitazoxanide
pentamidine isethionate
Excluded
16
Cephalosporins are commonly used in prevention or
treatment of infection. From the data on timing of
cephalosporin prescription initiation, a majority begins
therapy within the first 30 days of therapy.
Macrolides are commonly used in prevention or
treatment of infection, mainly those respiratory in
nature. From the data on timing of penicillin prescription
initiation, a majority begins therapy within the first 30
days of therapy.
Tetracyclines are commonly used in prevention or
treatment of infection. From the data on timing of
tetracycline prescription initiation, a majority begins
therapy within the first 30 days of therapy.
Fluoroquinolones are commonly used in prevention or
treatment of infection. From the data on timing of
Fluoroquinolones prescription initiation, a majority
begins therapy within the first 30 days of therapy.
These classes are used in prevention or treatment of
infection, but may require further evaluation for their
appropriate use related to the injury.
The miscellaneous antibiotics are generally those that
do not have multiple agents available within a class of
their own. Agents for multi-resistant infections are
excluded.
PMSI PROPRIETARY AND CONFIDENTIAL INFORMATION
PAGE 1 OF 8
LAST UPDATE October 24, 2012
Flagyl, Cleocin, Septra
Excluded
Pinnacol Custom Acute and Chronic Formularies
17-21
22
Vaccines, Toxoids,
Antisera, Misc
Biologicals,
Antineoplastics
Corticosteroids
23-26
Anabolic steroids,
Estrogens,
Contraceptives,
Progestins
27-30
Antidiabetics,
Thyroid, Oxytocics,
Misc Endocrine
3138
39,
40
Cardiotonics,
Antianginal agents,
Beta blockers,
Calcium blockers,
Antiarrythmic,
Antihypertensive,
Diuretics, Pressors
Antihyperlipidemics,
Misc Cardiovascular
41
Antihistamines
telithromycin
trimethoprim
vancomycin
Excluded
Excluded
These classes are biological preparations that improve
immunity to diseases, but may require further evaluation
for their appropriate use related to the injury.
All vaccines, Immune
Globulin, Venom,
Anticancer agents
Corticosteroids are mainly used in the treatment of
acute inflammation, as well as a host of other possible
used in this patient population (pain, spinal cord
compression, inflammation from chemical exposure,
etc).
These classes are primarily used to treat
hypogonadism, hormone replacement therapy, oral
contraception, amenorrhea, or abnormal uterine
bleeding. These agents may require further evaluation
for their appropriate use related to the injury.
These classes are primarily used for Type I and II
diabetes, hypo and hyperthyroidism, labor induction,
osteoporosis, and hormone deficiencies (e.g. growth
hormone, PTH). These agents may require further
evaluation for their appropriate use related to the injury.
These classes are primarily used to treat heart failure,
angina, hypertension, myocardial infarction, atrial
fibrillation or flutter, tremor, migraine, and heart failure.
These agents may require further evaluation for their
appropriate use related to the injury.
Prednisone, Decadron
Included (oral only)
Exceptions:
dexamethasone
fludricortisone
Included (oral only)
Exceptions:
dexamethasone
fludricortisone
Testosterone,
Estrogen, Ortho-TriCyclen, Progesterone
Excluded
Excluded
Insulin, oral diabetes
agents, Synthroid,
Oxytocin, Fosamax
Excluded
Excluded
Digoxin, Nitroglycerin,
Inderal, Cardizem,
Procainamide, Zestril,
Lasix, Dobutamine
Excluded
Excluded
These classes are primarily used to treat hyperlipidemia
and erectile dysfunction. These agents may require
further evaluation for their appropriate use related to the
injury.
Antihistamines are used in the treatment of histamine
induced inflammation, such as urticaria, or allergic
reactions to the environment or chemical exposure.
There are two general classes of antihistamines:
Sedating (Benadryl, chlorpheniramine, etc) and the nonsedating (Zyrtec, Claritin, etc). Phenergan has an
additional uses in the treatment of nausea and vomiting,
Lipitor, Viagra
Excluded
Excluded
Benadryl, Claritin
Phenergan, Zyrtec
Excluded
Excluded
PMSI PROPRIETARY AND CONFIDENTIAL INFORMATION
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LAST UPDATE October 24, 2012
Pinnacol Custom Acute and Chronic Formularies
42-45
46
Decongestants,
Cough/Cold,
Antiasthmatics, Misc
Respiratory
Laxatives
48
Antacids
49
Ulcer Medications
47,
50-52
57
Antidiarrheals,
Antiemetics,
Digestive aids, Misc
GI agents
Urinary AntiInfectives, Urinary
Antispasmodics,
Vaginal products,
Misc Genitourinary
products
Anxiolytics
58
Antidepressants
53-56
and is not typically used as an antihistamine, per se.
The use of non-sedating antihistamines may improve
daytime functionality over the sedating antihistamines,
allowing a quicker return to work
These classes are primarily used to treat the symptoms
of cough and cold, asthma/COPD, and cystic fibrosis.
These agents may require further evaluation for their
appropriate use related to the injury.
Laxatives are commonly used and prescribed in
patients using opioid analgesics (Percocet, Oxycontin,
etc) to maintain normal bowel function. It is appropriate
to allow these agents as available due to likely
association with opioid products.
Antacids are often used to treat the GI upset associated
with commonly used pain medications
Ulcer medications are often used to treat or prevent
ulcers associated with the use of anti-inflammatory
medications.
These classes are primarily used to treat gastric
indigestion, nausea/vomiting, ulcerative colitis and
digestion aids. These agents may require further
evaluation for their appropriate use related to the injury.
These classes are primarily used for suppression and
prophylaxis of frequently recurring urinary tract
infections, in the treatment of neurogenic bladder,
vaginal candidiasis, and nephrolithiasis. These agents
may require further evaluation for their appropriate use
related to the injury.
Anti-anxiety agents are commonly used in this patient
population. Diazepam is also utilized as a muscle
relaxant. Hydroxyzine (Atarax®, Vistaril®) is also
utilized as an antihistamine
Agents in this category are used both as
antidepressants and adjuvant medications for
neuropathic pain. These agents may enhance the
PMSI PROPRIETARY AND CONFIDENTIAL INFORMATION
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LAST UPDATE October 24, 2012
Cough and cold
products, Albuterol,
Theophylline,
Prolastin
Colace, Miralax,
Senokot
Excluded
Excluded
Included
Included
Tums, Maalox
Excluded
Excluded
Pepcid, Prilosec,
Nexium
Included
Exceptions:
hyoscyamine
dicyclomine
phenobarbital-belladona alkaloids
sucralfate
amoxicillin/clarithro/lansapraz
Proton Pump Inhibitors
Excluded
Included
Exceptions:
hyoscyamine
dicyclomine
phenobarbital-belladona alkaloids
sucralfate
amoxicillin/clarithro/lansapraz
Proton Pump Inhibitors
Excluded
Nitrofurantoin,
Ditropan, Metrogel,
Femring,
Phenazopyridine
Excluded
Excluded
Ativan, Atarax,
Valium, Vistaril
Included
Included
Amitriptyline,
Nortriptyline,
Cymbalta
Excluded
Included
Exceptions:
phenelzine
Scopolamine,
Pancrealipase,
Amitiza
Pinnacol Custom Acute and Chronic Formularies
59
Antipsychotics
60
Hypnotics
61,
62
Stimulants, Misc
psychotherapeutics
64
Non-opioid
analgesics
65
Short-acting opioid
analgesics
65
Long-acting opioid
analgesics
66
Antirheumatic agents
effects of opioids or NSAIDs and have independent
analgesic activity in certain situations. Depression is
also a common co-morbid disease state that often
presents in patients with chronic pain.
Antipsychotics are commonly used and prescribed in
patients with psychological disorders. These agents
may require further evaluation for their appropriate use
related to the injury.
Patients with acute and/or chronic pain may develop
insomnia. Insomnia is further related with daytime
drowsiness and impaired quality of life. Continuous
therapy is not recommended.
These classes are primarily used in the treatment of
ADHD and Alzheimer’s disease. These agents may
require further evaluation for their appropriate use
related to the injury.
The various combinations and single entity short-acting
agents listed are appropriate for patient specific
selection in acute pain management. Acetaminophen
(Tylenol®) alone and in combination represents the
largest selection of products used in this class.
Combination products including caffeine as an
ingredient are also commonly used in headache
treatment.
The various combinations and single entity agents listed
are appropriate for patient specific selection in acute
pain management. The oral fentanyl products (Actiq,
Fentora), Demerol, Subutex, and Suboxone are part of
these formularies.
Long-acting opioids are started only after determination
of need for chronic therapy and patient has been on
short-acting agents for extended duration.
The agents listed in the NSAID class are appropriate for
patient specific selection in acute pain and inflammation
PMSI PROPRIETARY AND CONFIDENTIAL INFORMATION
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LAST UPDATE October 24, 2012
tranylcypromine
Prochlorperazine,
Clozaril
Excluded
Excluded
Ambien, Lunesta,
Sonata
Excluded
Included
Adderall, Aricept
Excluded
Excluded
Tylenol
Included
Exceptions:
ziconotide
Included
Exceptions:
ziconotide
Lortab, Percocet,
Vicodin
Included
Exceptions:
Actiq
Fentora
Abstral
Lazanda
Onsolis
SUBSYS
Subutex
Suboxone
Oxymorphone
Included
Exceptions:
Oxymorphone ER
Included
Exceptions:
Included
Exceptions:
Actiq
Fentora
Abstral
Lazanda
Onsolis
SUBSYS
Subutex
Suboxone
Oxymorphone
Included
Exceptions:
Oxymorphone ER
Included
Exceptions:
Oxycontin, MS Contin,
Duragesic, Ultram ER,
Exalgo, Methadone
Celebrex, Ibuprofen,
naproxen, Mobic
Pinnacol Custom Acute and Chronic Formularies
management. There is great interpatient variability of
response to these agents. Patients requiring treatment
with NSAID-containing products may be an increased
risk for gastrointestinal ulcers and require prophylactic
treatment with a proton pump inhibitor
indomethacin
auranofin
methotrexate
anakinra
adalimumab
leflunomide
etanercept
Included
Exceptions:
almotriptan
APAP-isometheptene-dichloral
ergotamine tartrate
ergotamine-caffeine
ergotamine - PB - belladonna
sumatriptan succinate
Excluded
indomethacin
auranofin
methotrexate
anakinra
adalimumab
leflunomide
etanercept
Excluded
Included
Exceptions:
pregabalin
ethosuximide
ethotoin
felbamate
levetiracetam
zonisamide
Excluded
Included
Exceptions:
ethosuximide
ethotoin
felbamate
levetiracetam
zonisamide
Baclofen, Flexeril,
Skelaxin
Included
Exceptions:
Amrix
Included
Exceptions:
Amrix
Neostigmine,
Pyridostigmine
Excluded
Excluded
Vitamins,
Multivitamins, Amino
Excluded
Excluded
67
Migraine products
These classes are primarily used in the treatment of
migraine. These agents may require further evaluation
for their appropriate use related to the injury.
Imitrex
70
Gout products, Local
Anesthetics, General
Anesthetics
Colchicine, Lidocaine
(inj.), Ketamine (inj.)
72
Anticonvulsants
These classes are primarily used in the treatment of
gout and for anesthesia. These agents may require
further evaluation for their appropriate use related to the
injury.
Anticonvulsants are commonly used off-label in the
injured workers population for treatment of neuropathic
pain.
73,
74
Antiparkinsonian
agents,
Neuromuscular
blockers
Skeletal muscle
relaxants
These classes are primarily used in the treatment of
Parkinson’s disease and cervical dystonia. These
agents may require further evaluation for their
appropriate use related to the injury.
The agents listed are appropriate for use as skeletal
muscle relaxants. Patient response can vary
considerably between the agents as well as tolerance to
side effects.
These agents are used for the treatment of myasthenia
gravis. These agents may require further evaluation for
their appropriate use related to the injury.
These agents are used for the supplementation of
additional dietary needs. These agents may require
Sinemet, Botox
75
76
Musculoskeletal
agents
77-81
Vitamins,
Multivitamins,
PMSI PROPRIETARY AND CONFIDENTIAL INFORMATION
PAGE 5 OF 8
LAST UPDATE October 24, 2012
Gabapentin
(Neurontin),
Pregabalin (Lyrica)
Excluded
Excluded
Pinnacol Custom Acute and Chronic Formularies
further evaluation for their appropriate use related to the
injury.
acids, Herbals,
Hydration therapy
83
Minerals &
Electrolytes,
Nutrients, Dietary
products
Anticoagulants
These agents are used in the treatment of blood
disorders. These agents may require further evaluation
for their appropriate use related to the injury.
Warfarin, Lovenox
86
Ophthalmic products
The covered eye medications represent those used as
ophthalmic antibiotics or corticosteroids. Agents for
glaucoma and other non-injury associated products are
excluded.
Tobradex, Floxin, etc
87
Otic products
The covered otic medications represent those used as
antibiotics or corticosteroids.
Cortisporin otic, etc
PMSI PROPRIETARY AND CONFIDENTIAL INFORMATION
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LAST UPDATE October 24, 2012
Included
Exceptions:
enoxaparin sodium
fondaparinux sodium
tinzaparin sodium
warfarin sodium
Included
Exceptions:
acetazolamide
atropine sulfate
azelastine
betaxolol
brimonidine tartrate
carbachol
cyclosporine
dipivefrin
dorzolamide-timolol
ketorolac tromethamine
ketotifen
latanoprost
levobunolol
levocabastine
loteprednol-tobramycin methazolamide
moxifloxacin
naphazoline
natamycin
pemirolast
pilocarpine
sulfacetamide sod-pred
timolol
trifluridine
unoprostone
Included
Exceptions:
benzocaine - antipyrine
ciprofloxacin - HC
Included
Exceptions:
enoxaparin sodium
fondaparinux sodium
tinzaparin sodium
warfarin sodium
Excluded
Excluded
Pinnacol Custom Acute and Chronic Formularies
88
89
Oral rinses
Hemorrhoidal agents
90
Dermatologics
These agents are used for injuries in the mouth.
These agents are used in the treatment of injuries
needing rectal corticosteroids/anesthetic. These agents
may require further evaluation for their appropriate use
related to the injury.
Although there are multiple products within the
dermatologics (steroids, antibiotics, combination
products, etc), there are specific medications blocked
due to their use in cosmetic treatment, not due to
occupational injury.
Lidoderm patches are within this class, which are
effective in acute and chronic pain management.
PMSI PROPRIETARY AND CONFIDENTIAL INFORMATION
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LAST UPDATE October 24, 2012
Peridex, etc
Pramoxine,
Hydrocortisone
Lidocaine (Lidoderm)
neomycin-polymyxin-HC
triethanolamine oleate
Excluded
Excluded
Excluded
Excluded
Included
Exceptions:
acitretin
acyclovir topical
adapalene
alefacept
anthralin
azelaic acid
becaplermin
benzoyl peroxide
benzoyl peroxide - erythromycin
bexarotene
butenafine
calcipotriene
ciclopirox
clindamycin phosphate
clindamycin – benzoyl peroxide
clotrimazole
clotrimazole - betamethasone
crotamiton
econazole nitrate
efalizumab
erythromycin
fluorouracil
imiquimod
isotretinoin
lidocaine
lidocaine-prilocaine
lindane
methoxsalen
metronidazole
miconazole nitrate
neomycin-polymyxin-lidocaine
nitrofurazone
Included
Exceptions:
acitretin
acyclovir topical
adapalene
alefacept
anthralin
azelaic acid
becaplermin
benzoyl peroxide
benzoyl peroxide - erythromycin
bexarotene
butenafine
calcipotriene
ciclopirox
clindamycin phosphate
clindamycin – benzoyl peroxide
clotrimazole
clotrimazole - betamethasone
crotamiton
econazole nitrate
efalizumab
erythromycin
fluorouracil
imiquimod
isotretinoin
lidocaine
lidocaine-prilocaine
lindane
methoxsalen
metronidazole
miconazole nitrate
neomycin-polymyxin-lidocaine
nitrofurazone
Pinnacol Custom Acute and Chronic Formularies
92
Disinfectants
9398
Antidotes, Diagnostic
products, Herbal
products, Bulk
chemicals, Medical
devices,
Pharmaceutical
adjuvants
Immunosuppressives
99
This class represents topical skin and wound cleaning
products
These agents/products are used in the treatment of
overdose for various drugs and to diagnose or monitor
conditions. In addition, they are used in the
supplementation of additional dietary needs and to
compound medications. These products may require
further evaluation for their appropriate use related to the
injury.
This class represents immunosuppressives used in the
prophylaxis and treatment of transplant rejection.
PMSI PROPRIETARY AND CONFIDENTIAL INFORMATION
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LAST UPDATE October 24, 2012
Dakin’s solution
Naltrexone, Glucose
monitors and blood
strips, Herbal
products, Isopropyl
alcohol & powders,
Insulin syringes,
Petrolatum gel
Prograf, Rapamune
nystatin
nystatin-triamcinolone
oxiconazole nitrate
pimecrolimus
podofilox
pramoxine-HC
selenium sulfide
sulfacetamide sodium
tacrolimus
tretinoin
Excluded
nystatin
nystatin-triamcinolone
oxiconazole nitrate
pimecrolimus
podofilox
pramoxine-HC
selenium sulfide
sulfacetamide sodium
tacrolimus
tretinoin
Excluded
Excluded
Exceptions:
Bandages
Gauze pads & Dressings
Tape
Excluded
Exceptions:
Bandages
Gauze pads & Dressings
Tape
Excluded
Excluded