1. Healthcare

TennCare AutoExempt List
February 1, 2015
This is a current list of the drugs and supplies that do not count toward an enrollee’s monthly drug limit.
This list is subject to change. Go to the following link to see the most current version:
https://tenncare.magellanhealth.com/static/docs/Program_Information/TennCare_AutoExempt_List.pdf
CARDIOVASCULAR DISEASE (ORAL FORMULATIONS ONLY)
Note: Brand names in this category are provided for reference only. Only generic cardiovascular medications are exempt from the script limit. If classified
as a brand in Medispan, the product will not be exempt from the script limit.
acebutolol (Sectral)
felodipine ER
nifedipine ER/SA/XL
(Adalat CC, Procardia XL)
acetazolamide (Diamox)
fosinopril (Monopril)
nifedipine IR (Adalat, Procardia)
amiloride/hydrochlorothiazide
(Moduretic)
fosinopril/hydrochlorothiazide
(Monopril-HCT)
pindolol (Visken)
amiloride (Midamor)
furosemide (Lasix)
propranolol (Inderal)
amlodipine (Norvasc)
hydrochlorothiazide (Microzide, Oretic)
propranolol LA (Inderal LA)
atenolol (Tenormin)
indapamide
propranolol/hydrochlorothiazide
(Inderide)
atenolol/chlorthalidone (Tenoretic)
isradipine (DynaCirc)
quinapril (Accupril)
benazepril (Lotensin)
labetalol (Trandate)
quinapril/hydrochlorothiazide
(Accuretic)
benazepril/hydrochlorothiazide
(Lotensin HCT)
lisinopril (Prinivil, Zestril)
ramipril (Altace)
betaxolol (Kerlone)
lisinopril/hydrochlorothiazide
(Prinzide, Zestoretic)
sotalol (Betapace, Sorine)
bisoprolol fumarate (Zebeta)
losartan (Cozaar)
sotalol AF (Betapace AF)
bisoprolol/hydrochlorothiazide (Ziac)
losartan/HCTZ (Hyzaar)
spironolactone (Aldactone)
bumetanide (Bumex)
methyclothiazide (Enduron)
spironolactone/hydrochlorothiazide
(Aldactazide)
captopril (Capoten)
metolazone (Zaroxolyn)
telmisartan (Micardis)
captopril/hydrochlorothiazide
(Capozide)
metoprolol succinate (Toprol XL)
telmisartan/HCTZ (Micardis HCT)
carvedilol (Coreg)
metoprolol tartrate (Lopressor)
timolol maleate (Blocadren)
chlorothiazide (Diuril)
metoprolol/hydrochlorothiazide
(Lopressor HCT)
torsemide (Demadex)
chlorthalidone (Hygroton)
moexipril (Univasc)
trandolapril (Mavik)
diltiazem ER/SR/XR (Cardizem CD,
Cardizem LA, Cartia XT, Dilacor XR,
Dilt-CD, Taztia XT, Tiazac)
moexipril/hydrochlorothiazide
(Uniretic)
triamterene/hydrochlorothiazide
(Dyazide, Maxzide)
Proprietary & Confidential
© 2015, Magellan Health Services. All Rights Reserved.
CARDIOVASCULAR DISEASE (ORAL FORMULATIONS ONLY)
Note: Brand names in this category are provided for reference only. Only generic cardiovascular medications are exempt from the script limit. If classified
as a brand in Medispan, the product will not be exempt from the script limit.
diltiazem IR (Cardizem)
nadolol (Corgard)
valsartan (Diovan)
enalapril (Vasotec)
nadolol/bendroflumethiazide (Corzide)
verapamil ER
(Covera-HS, Isoptin SR, Verelan)
enalapril/hydrochlorothiazide
(Vasoretic)
nicardipine HCl (Cardene)
verapamil HCl (Calan, Isoptin)
DIABETES AGENTS – ORAL HYPOGLYCEMICS
Note: Brand names in this category are provided for reference only. Only generic oral hypoglycemic medications are exempt from the script limit. If
classified as a brand in Medispan the product will not be exempt from the script limit.
acarbose (Precose)
glipizide ER/XL (Glucotrol XL)
pioglitazone (Actos)
acetohexamide (Dymelor)
glyburide (Diabeta, Micronase)
pioglitazone glimepiride (DuetAct)
chlorpropamide (Diabinese)
glyburide, micronized
(Glynase, PresTab)
pioglitazole metformin
(ACTOplus Met)
glimepiride (Amaryl)
glyburide/metformin (Glucovance)
tolazamide (Tolinase)
glipizide/metformin (Metaglip)
metformin (Glucophage)
tolbutamide (Orinase)
glipizide (Glucotrol)
metformin ER (Glucophage XR)
DIABETES AGENTS – INSULINS
human insulin NPH (Humulin N, Novolin N®)
insulin detemir vials (Levemir® vials)
human insulin NPH/Regular
(Humulin 70/30, Novolin 70/30®)
insulin lispro (Humalog and Novolog – all dosage forms)
human insulin Regular
(Humulin R, Novolin R®, Humulin R U-500)
insulin lispro protamine/lispro
(Humalog and Novolog mix– all dosage forms)
insulin glargine (Lantus vials)
RESPIRATORY
Note: Brand names in this category, with the exception of Proventil HFA, are provided for reference only. Only generic respiratory medications are exempt
from the script limit. TennCare considers Proventil HFA a generic medication. All other medications classified as brand products in Medispan will not be
exempt from the script limit.
albuterol (Proventil HFA)
albuterol sulfate inhalation solution
(Accuneb, Proventil)
ipratropium inhalation solution
(Atrovent)
ANTINEOPLASTICS
abiraterone acetate (Zytiga)
dasatinib (Sprycel)
ixabepilone (Ixempra)
rituximab (Rituxan)
afatinib (Gilotrif)
daunorubicin (Cerubidine)
lapatinib (Tykerb)
romadepsin (Istodax)
anastrazole (Arimidex)
daunorubicin citrate
liposomal (DaunoXome)
lenalidomide (Revlimid)
ruxolitinib (Jakafi)
arsenic trioxide (Trisenox)
decitabine (Dacogen)
letrozole (Femara)
samarium SM 153
lexidronam (Quadramet)
asparaginase
(Elspar, Erwinaze)
degarelix (Firmagon)
leucovorin (Wellcovorin)
siltuximab (Sylvant)
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TennCare AutoExempt List
Effective Date: February 1, 2015
ANTINEOPLASTICS
axitinib (Inlyta)
denileukin diftitox (Ontak)
leuprolide (Eligard, Lupron,
Lupron Depot, Viadur)
sorafenib (Nexavar)
azacitidine (Vidaza)
dexrazoxane (Zinecard,
Totect)
lomustine (CeeNU)
streptozocin (Zanosar)
bcg vaccine
(TheraCys, TICE BCG)
docetaxel (Taxotere)
mechlorethamine
(Mustargen)
strontium-89 chloride
(Metastron)
bendamustine (Treanda)
doxorubicin (Adriamycin,
Rubex)
melphalan (L-PAM)
(Alkeran)
sunitinib (Sutent)
bevacizumab (Avastin)
doxorubicin, liposomal
(Doxil)
mercaptopurine (6-MP)
(Purinethol)
talc powder, sterile
(Sclerosol)
bexarotene (Targretin)
enzalutamide (Xtandi)
mesna (Mesnex)
regorafinib (Stivarga)
methotrexate
tamoxifen and oral solution
(Mexate, Trexall, Abitrexate,
(Nolvadex)
Folex, Otrexup)
bicalutamide (Casodex)
epirubicin (Ellence)
bleomycin (Blenoxane)
erlotinib (Tarceva)
mitomycin (MTC)
(Mutamycin)
temozolomide (Temodar)
bortezomib (Velcade)
estramustine phosphate
sodium (Emcyt)
mitotane (Lysodren)
temsirolimus (Torisel)
bosutinib (Bosulif)
etoposide (VP-16-213,
Toposar, VePesid,
Etopophos)
mitoxantrone (Novantrone)
teniposide (VM-26, Vumon)
brentuximab (Adcetris)
everolimus (Afinitor)
nelarabine (Arranon)
thalidomide (Thalomid)
busulfan (Busulfex, Myleran)
exemestane (Aromasin)
nilotinib (Tasigna)
thioguanine (TG, Tabloid)
cabazitaxel (Jevtana)
floxuridine (FUDR)
nintedanib (Ofev)
thiotepa (TSPA, Thioplex)
cabozantanib (Cometriq)
fludarabine phosphate
(Fludara, Oforta)
nilutamide (Nilandron)
topotecan (Hycamtin)
capecitabine (Xeloda)
fluorouracil (Adrucil,
Carac)
ofatumumab (Arzerra)
toremifene citrate (Fareston)
carboplatin (Paraplatin)
flutamide (Eulexin)
omacetaxine (Synribo)
tositumomab (Bexxar)
cafilzomib (Kyprolis)
fulvestrant (Faslodex)
oxaliplatin (Eloxatin)
trametinib (Mekinist )
Carmustine
(BCNU, BiCNU, Gliadel)
gallium nitrate (Ganite)
Paclitaxel
(Onxol, Abraxane, Taxol)
trastuzumab (Herceptin)
ceritinib (Zykadia)
gefitinib (Iressa)
panitumumab (Vectibix)
tretinoin
cetuximab (Erbitux)
gemcitabine (Gemzar)
pazopanib (Votrient)
triptorelin pamoate
(Trelstar)
chlorambucil (Leukeran)
gemtuzumab ozogamicin
(Mylotarg)
pegaspargase (Oncaspar)
uracil mustard
(Uracil Mustard)
cisplatin (Platinol)
goserelin (Zoladex)
pembrolizumab (Keytruda)
valrubicin (Valstar)
cladribine (CdA) (Leustatin)
Hydroxyurea
(Droxia, Hydrea, Mylocel)
pemetrexed (Alimta)
vandetanib (Caprelsa)
Effective Date: February 1, 2015
TennCare AutoExempt List
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ANTINEOPLASTICS
clofarabine (Clolar)
ibritumomab tiuxetan
(Zevalin)
pentostatin (DCF) (Nipent)
vemurafenib (Zelboraf)
crizotinib (Xalkori)
ibrutinib(Imbruvica)
pertuzumab (Perjeta)
vinblastine (Velban, Velsar)
Cyclophosphamide
(Cytoxan, Neosar)
idarubicin (Idamycin PFS)
plicamycin (Mithracin)
Vincristine
(Oncovin, Vincasar PFS)
cytarabine, conventional
(Cytosar-U, Tarabine PFS)
idelalisib (Zydelig)
pomalidomide (Pomalyst)
vinorelbine tartrate
(Navelbine)
cytarabine, liposomal
(DepoCyt)
ifosfamide (Ifex)
porfimer sodium (Photofrin)
vismodegib (Erivedge)
dabrafenib (Tafinlar)
imatinib mesylate
(Gleevec)
pralatrexate (Fotolyn)
vorinostat (Zolinza)
dacarbazine (DTIC-Dome)
ipilimumab (Yervoy)
procarbazine (Matulane)
ziv-aflibercept (Zaltrap)
dactinomycin (actinomycin D,
Cosmegen)
irinotecan (Camptosar)
ramucirumab (Cyramza)
ANTIPARKINSONIAN AGENT
benztropine (Cogentin)
carbidopa (Lodosyn)
ANTITUBERCULAR AGENTS
aminosalicylic acid
(PAS, Paser)
capreomycin
(Capastat Sulfate)
ethionamide (Trecator-SC)
rifampin (Rifadin)
streptomycin sulfate
isoniazid (INH, Isohydrazide,
rifampin/isoniazid (Rifamate)
Niazid, Nydrazid, Niazid-B6)
cycloserine
(Seromycin Pulvules)
Pyrazinamide
rifampin/pyrazinamide /
isoniazid (Rifater)
ethambutol (Myambutol)
rifabutin (Mycobutin)
rifapentine (Priftin)
ANTIVIRALS
abacavir/lamivudine (Epzicom)
emtricitabine/rilpivirine/tenofovir
(Complera)
nevirapine (Viramune, Viramune XR)
abacavir sulfate (Ziagen)
emtricitabine (Emtriva)
raltegravir (Isentress)
abacavir/lamivudine/zidovudine
(Trizivir)
emtricitabine/tenofovir (Truvada)
rilpivirine (Edurant)
adefovir (Hepsera)
enfuvirtide (Fuzeon)
ritonavir (Norvir)
amprenavir (Agenerase)
entecavir (Baraclude)
ritonavir/lopinavir (Kaletra)
atazanavir sulfate (Reyataz)
etravirine (Intelence)
saquinavir (Fortovase)
cidofovir (Vistide)
fomivirsen (Vitravene)
saquinavir mesylate (Invirase)
cobicistat/elvitegravir/emtricitabine/ten
ofovir (Stribild)
fosamprenavir calcium (Lexiva)
stavudine (d4T, Zerit)
darunavir ethanolate (Prezista)
foscarnet (Foscavir)
telbivudine (Tyzeka)
delavirdine mesylate (Rescriptor)
ganciclovir (DHPG, Cytovene IV)
tenofovir disoproxil fumarate (Viread)
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TennCare AutoExempt List
Effective Date: February 1, 2015
ANTIVIRALS
didanosine (ddl) (Videx)
indinavir sulfate (Crixivan)
tipranavir (Aptivus)
dolutegravir/abacavir/lamivudine
(Triumeq)
lamivudine (3TC, Epivir, Epivir HBV)
valganciclovir (Valcyte)
doutegravir (Tivicay)
lamivudine/zidovudine (Combivir)
zalcitabine (ddC, Hivid)
efavirenz (Sustiva)
maraviroc (Selzentry)
zidovudine (AZT, Retrovir)
efavirenz/emtricitabine/tenofovir
(Atripla)
nelfinavir mesylate (Viracept)
CONTRACEPTIVES
All oral contraceptives
All non-oral contraceptives
Intra-uterine Devices (IUDs):
Skyla, Mirena, Paragard
CLOTTING FACTORS
antihemophilic factor, human
(Alphanate, Hemofil-M, Humate-P, Koate, Melate, MonarcM, Monoclate-P, Nybcen, Profilate)
factor IX, human recombinant (Benefix)
antihemophilic factor, human recombinant
(Advate, Bioclate, Genarc, Helixate, Kogenate,
Recombinate, Refacto, Xyntha)
factor IX (Alphanine, Mononine)
antihemophilic factor/Von Willebrand factor complex
(Humate-P, Wilate)
factor IX complex, human
(Bebulin, Konyne, Profilnine, Proplex)
anti-inhibitor coagulant complex
(Autoplex T, Feiba VH Immuno)
factor IX, recombinant (Alprolix)
factor VIIa, recombinant (NovoSeven, NovoSeven RT)
factor XIII (Corifact)
factor VIII, recombinant (Obizur)
Fc fusion protein, recombinant (Eloctate)
DIALYSIS MEDICATIONS
calcium acetate (PhosLo, Eliphos)
ferric citrate
calcium acetate/ magnesium carbonate (MagneBind)
lanthanum carbonate (Fosrenol)
cinacalcet (Sensipar)
sevelamer (Renvela tablets, Renagel)
FA/vitamin B complex with C (B-Plex, Dialyvite, Folbee
Plus, Nephronex, renal caps, Renal Multivitamin Formula,
Renaphro)
sodium polystyrene sulfonate
(Kayexalate, Kionex, Marlexate, SPS)
FLU VACCINE – INJECTABLE FORMULATIONS ONLY
influenza (Fluvirin, Fluzone, Fluarix, Influenza A H1N1)
HEMATOPOIETIC AGENTS
darbepoetin alfa (Aranesp)
pegfilgrastim (Neulasta)
epoetin alfa, recombinant (Epogen, Procrit)
plerixafor (Mozobil)
filgrastim (Neupogen)
sargramostim (Leukine, Prokine)
oprelvekin (Neumega)
Effective Date: February 1, 2015
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HEPATITIS C
boceprevir (Victrelis)
interferon alfacon-1 (Infergen)
ribivirin / interferon alfa-2b (Rebetron)
dasabuvir/ombitasvir/paritaprevir/
ritonavir (Viekira)
peg-interferon alfa-2a (Pegasys)
simprevir (Olysio)
interferon alfa-2a (Roferon-A)
peg-interferon alfa-2b (PEG-Intron)
sofosbuvir (Sovaldi)
interferon alfa-2b (Intron A, Sylatron)
ribavirin (Copegus, Rebetol,
Ribasphere, Ribapak)
telaprevir (Incivek)
IMMUNOSUPPRESSIVES
azathioprine (Azasan, Imuran)
daclizumab (Zenapax)
sirolimus (Rapamune)
basiliximab (Simulect)
muromonab-CD3 (Orthoclone OKT3)
tacrolimus (FK506, Prograf, Hecoria,
Astagraf XL)
cyclosporine (Sandimmune, Gengraf,
Neoral, Sangcya)
mycophenolate (Cellcept, Myfortic)
IRON PREPARATIONS
iron dextran complex (DexFerrum,
Imferon, Infed, Proferdex)
iron sucrose complex (Venofer)
sodium ferric gluconate
complex/sucrose (Ferrlecit)
LONG-ACTING ANTIPSYCHOTICS
fluphenazine (Prolixin Decanoate)
haloperidol decanoate (Haldol Decanoate)
TRANSPLANT
hepatitis B immune globulin (Bayhep-B, H-Big, Hyperhep, NABI-HB, HepaGam B)
OTHER COVERED ITEMS
Antidiarrheals – Fulyzaq
Asthma Supplies – Spacers, Peak Flow Meters, and NaCl
for inhalation
Diabetic Supplies – Test strips; Lancets; Lancet Devices;
Acetone Urine Test (i.e., Ketostix®); Alcohol Pads; Glucose
Control Solution; Meters; Syringes: Pen Needles
Prenatal vitamins – Brands such as Prenate, Zenate, etc.
Large Volume Parenterals – IV fluids : quantities Products
≥ 50mL, (Generic Name: Dextrose; Lactated Ringers;
Sodium Chloride; Sterile Water)
Saline Flush – Coded up to 30mL vials
Total Parenteral Nutrition (TPN) – Coded by Amino Acid,
all additives will be covered Heplock 10u/mL or 100u/mL
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TennCare AutoExempt List
Effective Date: February 1, 2015