1. Healthcare

TennCare Preferred Drug List (PDL)
Effective February 1, 2015
PA – Prior Authorization required, subject to specific PA criteria, QL – Quantity Limit (PA and NP agents require a PA before dispensing)
Approval of NP agents requires trial and failure, contraindication or intolerance of 2 preferred agents, unless otherwise indicated.
Please note: With the exception of the “Branded Drugs Classified as Generics” list, TennCare is a mandatory generic program in accordance with state law (TCA 53-10-205).
Approval of a branded product when a generic is available requires documentation of a serious adverse reaction from the generic via a FDA MedWatch form OR
contraindication to an inactive ingredient in the AB-rated generic equivalent. Therapeutic Failure of an AB-rated generic equivalent may be considered for approval of
branded products in the following high-risk medication classes: Anticonvulsants, Atypical Antipsychotics, HIV antivirals, Immunosuppressants, and Oncology Agents.
Preferred Drugs
Non-Preferred Drugs
I. Analgesics
Agents for Opiate Detoxification
ReVia® PA
naltrexone PA
Buprenorphine and Buprenorphine/Naloxone
Suboxone® film PA, QL
Bunavail® PA, QL
Zubsolv® PA, QL
buprenorphine PA, QL
buprenorphine/naloxone
tablets PA, QL
COX-II Inhibitors Class PA
Celebrex® PA, QL
N/A
celecoxib PA, QL
Transmucosal Fentanyl Products
fentanyl lozenge PA, QL
Abstral® PA, QL
Fentora® PA, QL
Actiq® PA, QL
Subsys® PA, QL
Narcotics Agonist/Antagonists
butorphanol NS PA, QL
nalbuphine PA, QL
pentazocine/naloxone PA, QL
pentazocine/APAP PA, QL
Narcotics, Long Acting Narcotics
fentanyl patch PA, QL
morphine sulfate SA PA(≥100 mg), QL
Kadian® PA (≥100 mg), QL
Avinza® PA, QL
morphine sulfate SR 24hr PA, QL
Butrans® PA, QL
MS Contin® PA, QL
ConZipTM PA, QL
Nucynta® ER PA,QL
Dolophine® PA, QL
Opana ER® PA, QL
Duragesic® PA, QL
OxyContin® PA, QL
ExalgoTM PA, QL
oxymorphone ER PA, QL
hydromorphone ER PA, QL
oxycodone ER PA, QL
Hysingla® ER PA, QL
tramadol ER PA, QL
methadone PA, QL
tramadol ER 24 hr PA, QL
Methadose® PA, QL
Ultram ER® PA, QL
morphine sulfate ER capsules PA, QL Zohydro ER® PA, QL
Proprietary & Confidential
© 2015 Magellan Health Services
Preferred Drugs
Non-Preferred Drugs
I. Analgesics
Short-Acting Narcotics
codeine/APAP QL
morphine IR QL (excluding
suppositories)
butalbital/APAP/caff/codeine QL
Nucynta® QL
Endocet® QL
oxycodone QL
butalbital/ASA/caff/codeine QL
Opana® QL
hydrocodone/APAP QL
(excluding generic for Xodol)
oxycodone/APAP QL
Capital with Codeine® QL
Oxecta® QL
hydromorphone QL (excluding
suppositories)
tramadol QL
codeine QL
oxymorphone QL
Endodan® QL
oxycodone/ASA QL
Demerol® QL
oxycodone/IBU QL
dihydrocodeine/APAP/codeine QL
Panlor® SS QL
dihydrocodeine/ASA/codeine QL
Percocet® QL
Dilaudid® QL
Percodan® QL
Fioricet® with Codeine QL
Reprexain® QL
Fiorinal® with Codeine QL
Roxicet® QL
Hycet® QL
Roxicodone® QL
hydrocodone/APAP 5/300
Synalgos®-DC QL
hydrocodone/APAP 10/300
tramadol/APAP QL
hydrocodone/ibuprofen QL
Tylenol® with Codeine QL
hydromorphone suppositories
Tylox® QL
Levorphanol QL
Ultracet® QL
Lorcet® QL
Ultram® QL
Lortab® QL
Vicodin® QL
Maxidone® QL
Vicodin HP QL
Magnacet® QL
Vicoprofen® QL
meperidine QL
XartemisTM XR
Meperitab® QL
Xodol® QL
morphine suppositories QL
Zamicet® QL
Ibudone® QL
Norco® QL
NSAID/Anti-Ulcer Agents
N/A
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TennCare Preferred Drug List (PDL)
Arthrotec® PA
Duexis® PA
diclofenac/misoprostol PA
Vimovo® PA
Effective Date: February 1, 2015
QL
Preferred Drugs
Non-Preferred Drugs
I. Analgesics
Salicylates and Non-Narcotic Combination Agents
Be-Flex Plus® QL
Ed-Flex® QL
Acuflex® QL
Flextra DS® QL
choline mag trisalicylate QL
RhinoflexTM QL
Alpain® QL
Flextra-650® QL
diflunisal QL
salsalate QL
Anabar® QL
Lagesic® QL
Dologesic® QL
Tetra-Mag® QL
Cafgesic® QL
Levacet® QL
Cafgesic Forte® QL
MST 600® QL
Durabac® QL
Rhinoflex 650TM QL
Durabac Forte® QL
Zgesic® QL
Flextra® QL
Zorprin® QL
Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)
diclofenac potassium
ketorolac QL
Anaprox®
diclofenac sodium
meloxicam tablets
Anaprox DS
diclofenac sodium ER
nabumetone
CambiaTM
Motrin®
flurbiprofen
naproxen
Cataflam®
Nalfon®
ibuprofen
piroxicam
Clinoril®
Naprelan®
indomethacin
sulindac
Daypro®
naproxen sodium ER
diclofenac sodium 1.5%
Naprosyn®
EC-Naprosyn®
Pennsaid® PA
etodolac
Ponstel®
etodolac ER
oxaprozin
Feldene®
Sprix® PA
fenoprofen
tolmetin
Flector® PA, QL
Voltaren®
indomethacin ER
Voltaren® Gel PA
ketoprofen ER
Voltaren-XR®
meclofenamate
Zipsor®
mefenamic acid
Zorvolex® PA
ketoprofen
meloxicam suspension
Mobic®
®
Preferred Drugs
Non-Preferred Drugs
II. ANTI-INFECTIVES
Antibiotics: Cephalosporins First Generation
cefadroxil capsules
cephalexin capsules
cefadroxil tablets
cefadroxil suspension
cephalexin suspension
cephalexin tablets
Keflex®
Antibiotics: Cephalosporins Second Generation
cefaclor capsules
cefprozil
cefuroxime tabs PA
cefaclor suspension
Ceftin® suspension PA
cefaclor ER
Ceftin® tabs
Effective Date: February 1, 2015
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Preferred Drugs
Non-Preferred Drugs
II. ANTI-INFECTIVES
Antibiotics: Cephalosporins Third Generation
cefdinir
Suprax®
Cedax®
ceftibuten
Cefditoren
Spectracef®
cefpodoxime
Antibiotics: Ketolides
Ketek® PA
N/A
Antibiotics: Macrolides
azithromycin QL
erythromycin/sulfisoxazole
azithromycin suspension
Biaxin®
Biaxin XL
PA
erythromycin brand products
® QL
clarithromycin
clarithromycin ER/XL QL
erythromycin generic products
Dificid® PA, QL
Zithromax® QL
Zmax® QL
Antibiotics: Methenamine and Combo
all generic combinations of
methenamine, phenylsalicylate,
hyoscyamine, atropine, etc.
methenamine mandelate
methenamine hippurate
all brand combinations of
methenamine, phenylsalicylate,
hyoscyamine, atropine, etc.
Hiprex®
Uroqid Acid #2®
Antibiotics: Miscellaneous Agents for UTI
Monurol® QL, PA
N/A
Antibiotics: Non-Absorbable Rifamycin
Xifaxan® PA
N/A
Antibiotics: Oral Aminoglycosides
neomycin
N/A
Neo-Fradin®
Antibiotics: Oral Anti-Tuberculosis
ethambutol
pyrazinamide
cycloserine
Rifadin®
isoniazid
rifabutin PA
Isonarif® PA
Rifamate® PA
Mycobutin® PA
rifampin
Myambutol®
Rifater® PA
Paser®
Seromycin® Pulvules
Priftin®
Trecator®
Antibiotics: Oral Glycopeptides
vancomycin caps PA
N/A
Antibiotics: Oral Lincosamines
clindamycin caps
Cleocin®
Cleocin® Pediatric granules PA
clindamycin pediatric solution PA
Antibiotics: Oral Nitrofurans
nitrofurantoin capsules
nitrofurantoin suspension PA
Furadantin® PA
Macrobid®
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TennCare Preferred Drug List (PDL)
Effective Date: February 1, 2015
Macrodantin®
Preferred Drugs
Non-Preferred Drugs
II. ANTI-INFECTIVES
Antibiotics: Oxazolidinones
Zyvox® PA, QL
N/A
Antibiotics: Penicillins
amoxicillin
dicloxacillin
all brand penicillins
amoxicillin/clavulanate
penicillin
amoxicillin/clavulanic acid XR
amoxicillin ER
Antibiotics: Quinolones
ciprofloxacin
levofloxacin tabs
Avelox® PA
Levaquin® tabs
Avelox ABC Pack® PA
Levaquin® solution PA
Cipro® tablets
levofloxacin solution PA
Cipro® suspension PA
moxifloxacin PA
ciprofloxacin suspension PA
Noroxin® PA
ciprofloxacin ER QL
ofloxacin
Factive® PA
Antibiotics: Tetracyclines
doxycycline monohydrate 50 and 100 mg caps
Adoxa®
minocycline ER PA, QL
doxycycline hyclate 50 and 100mg
demeclocycline PA
minocycline tablets
minocycline capsules
minocycline capsules
Morgidox®
tetracycline
doxycycline hyclate DR particles
OcudoxTM Kit
doxycycline hyclate 20mg PA, QL
Oracea®
doxycycline monohydrate 75 mg
and 150 mg caps
Periostat® PA, QL
doxycycline monohydrate tabs
Solodyn® PA, QL
Doryx®
Vibramycin®
Dynacin®
Antibiotics: Sulfonamides, Folate Antagonist
sulfadiazine PA
trimethoprim (TMP)
TMP/sulfamethoxazole
Sulfatrim®
Bactrim®
Primsol®
Bactrim DS®
Septra DS®
Antifungals: Oral
clotrimazole troches
nystatin
Ancobon® PA
ketoconazole PA
fluconazole suspension PA
terbinafine PA, QL
Diflucan® suspension PA
Lamisil® PA, QL
fluconazole tablets QL
Diflucan® tablets QL
Noxafil® PA
griseofulvin suspension
flucytosine PA
Onmel® PA, QL
Gris-Peg®
Grifulvin V®
Sporanox® PA, QL
griseofulvin microsize
Terbinex® PA, QL
griseofulvin ultramicrosize
Vfend® PA
itraconazole PA, QL
voriconazole PA
Effective Date: February 1, 2015
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Preferred Drugs
Non-Preferred Drugs
II. ANTI-INFECTIVES
Antifungals: Vaginal
miconazole-3 kit
terconazole
nystatin
AVCTM cream
miconazole-3 vaginal supp
Gynazole-1
Terazol®
®
Anti-Infectives: Amebicides
N/A
paromomycin
Anti-Infectives: Antimalarials
atovaquone/proguanil
mefloquine
Aralen®
Malarone®
chloroquine
primaquine
Coartem®
Qualaquin®
dapsone
quinine sulfate
Daraprim
®
Anti-Infectives: Anthelmintics
Albenza®
N/A
Stromectol®
Biltricide®
Anti-Infectives: Miscellaneous Antiprotozoal Agents
metronidazole tabs
Alinia® PA
Flagyl® ER
atovaquone PA
Mepron® PA
Flagyl®
metronidazole caps
Anti-Infectives: Oral Nitroimidazoles
metronidazole tabs
Flagyl®
Tindamax®
Flagyl® ER
Tinidazole
metronidazole caps
Anti-Infectives: Vaginal Antibiotics
Cleocin® suppositories
metronidazole 0.75% gel
Cleocin® cream
clindamycin phos 2% cream
Vandazole®
Clindesse® vaginal cream
MetroGel® Vaginal
Antivirals: Cytomegalovirus Agents
valganciclovir
Valcyte®
Antivirals: Hepatitis B
Baraclude®
Epivir-HBV® QL
adefovir PA
lamivudine-HBV QL
entecavir
Tyzeka® PA
Hepsera® PA
Antivirals: Hepatitis C Non-Pegylated Interferons
Alferon® N
Intron-A®
Infergen® PA
Antivirals: Hepatitis C Pegylated Interferons
Pegasys® ProClick PA, QL
Pegasys Conv. Pack® PA, QL
Pegasys® syringes PA, QL
Pegasys® vials PA, QL
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TennCare Preferred Drug List (PDL)
PEG-Intron® QL
Effective Date: February 1, 2015
PEG-Intron Redipen® QL
Preferred Drugs
Non-Preferred Drugs
II. ANTI-INFECTIVES
Antivirals: Hepatitis C Antivirals
Harvoni® PA, QL
VictrelisTM PA, QL
Sovaldi® PA, QL
OlysioTM PA, QL
Antivirals: Hepatitis C Ribavirins
Ribasphere® 200 mg tablets
Copegus®
ribavirin tablets
Moderiba
ribavirin capsules
TM
dose pack
Ribapak®
Rebetol® capsules
Ribasphere® 200mg capsules
Rebetol® solution PA
Ribasphere® 400 & 600 mg tablets
Antivirals: Herpes
acyclovir
valacyclovir QL
famciclovir QL
Famvir® QL
Valtrex® QL
Sitavig® buccal tabs QL
Zovirax®
Antivirals: HIV CCR5 Antagonists
N/A
Selzentry® PA, QL
Antivirals: HIV Fusion Inhibitors
N/A
Fuzeon® PA, QL
Antivirals: HIV Integrase Inhibitors
Isentress® PA, QL
N/A
Tivicay® PA, QL
Antivirals: HIV NNRTIs
Edurant®
nevirapine QL
nevirapine ER QL
Viramune® QL
Intelence® PA, QL
Sustiva® QL
Rescriptor® QL
Viramune® XR QL
Antivirals: HIV NRTIs
abacavir QL
stavudine QL
Retrovir® QL
didanosine capsules QL
Videx® solution QL
Zerit® QL
Emtriva® QL
Viread® QL
Epivir® QL
Ziagen® QL
lamivudine QL
zidovudine QL
Videx® capsules QL
Antivirals: HIV NRTI Combos
abacavir/lamivudine/
zidovudine PA, QL
lamivudine/zidovudine QL
Atripla® QL
Stribild®
Combivir® QL
Triumeq® QL
Complera®
Trizivir® PA, QL
Epzicom® QL
Truvada® QL
N/A
Effective Date: February 1, 2015
TennCare Preferred Drug List (PDL)
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Preferred Drugs
Non-Preferred Drugs
II. ANTI-INFECTIVES
Antivirals: HIV Protease Inhibitors
Crixivan® QL
Aptivus® PA, QL
Prezista® QL
Invirase® QL
Prezista® QL
Kaletra® QL
Reyataz® caps and powderQL
Lexiva® QL
Viracept® QL
Norvir® QL
Antivirals: Influenza
Relenza® PA, QL
N/A
Preferred Drugs
Tamiflu® PA, QL
Non-Preferred Drugs
III. CARDIOVASCULAR
Alpha/Beta Blockers
labetalol
Coreg® QL
carvedilol QL
Trandate®
Coreg CR® QL
Alpha-Blockers
doxazosin
Cardura®
prazosin
Minipress®
terazosin
ACE Inhibitors
benazepril
lisinopril
Accupril®
perindopril QL
captopril
ramipril
Aceon
Prinivil®
® QL
QL
enalapril
Altace® QL
Quinapril
Epaned
trandolapril QL
fosinopril
Univasc® QL
Lotensin®
Vasotec®
Mavik
Zestril®
® PA
® QL
moexipril QL
ACEI + Calcium Channel Blocker Combo
N/A
benazepril/amlodipine QL, PA
Tarka® QL, PA
Lotrel® QL, PA
trandolapril/verapamil QL, PA
ACEI + Diuretic Combination
benazepril/HCTZ
enalapril/HCTZ
Accuretic®
quinapril/HCTZ
captopril/HCTZ
lisinopril/HCTZ
fosinopril/ HCTZ
Uniretic®
Lotensin HCT®
Vaseretic®
moexipril/HCTZ
Zestoretic®
Prinzide®
Angiotensin II Receptor Blockers
losartan
Page 8
Atacand® QL
QL
|
TennCare Preferred Drug List (PDL)
Effective Date: February 1, 2015
eprosartan
QL
Preferred Drugs
Non-Preferred Drugs
III. CARDIOVASCULAR
Avapro® QL
Benicar® QL
Cozaar® QL
candesartan® QL
Diovan® QL
EdarbiTM QL
irbesartan QL
Micardis® QL
telmisartan QL
Teveten® QL
valsartan QL
Angiotensin II Receptor Blockers + Calcium Channel Blocker Class PA, QL
Exforge® PA, QL
amlodipine/valsartan/HCTZ PA, QL
TribenzorTM PA, QL
Exforge HCT® PA, QL
Azor® PA, QL
Twynsta® PA, QL
telmisartan/amlodipine PA, QL
valsartan/amlodipine PA, QL
Angiotensin II Receptor Blockers + Diuretic
losartan/HCTZ® QL
Atacand HCT®
Hyzaar®
Avalide®
irbesartan/HCTZ
Benicar HCT® QL
Micardis HCT® QL
candesartan/HCTZ
QL
telmisartan/ HCTZ QL
Diovan HCT® QL
Teveten HCT®
Edarbyclor® QL
valsartan/ HCTZ QL
Anti-Anginal Agents: Miscellaneous
Ranexa® PA
N/A
Anti-Anginal Agents: Nitrates
Isochron®
nitroglycerin (excluding spray)
amyl nitrite
Monoket®
isosorbide dinitrate
(excluding 10 mg tabs
and SL tabs)
Nitrolingual®
Dilatrate-SR®
Nitro-Bid®
isosorbide mononitrate
Nitrostat®
Imdur®
Nitro-Dur®
Isordil®
nitroglycerin spray
Isosorbide dinitrate 10 mg tabs
NitroMistTM
Minitran®
isosorbide dinitrate, sublingual
Anti-Arrhythmics, Oral
amiodarone
quinidine sulfate
Betapace®
Pacerone®
disopyramide
sotalol
Betapace AF®
propafenone ER
flecainide
sotalol AF
Cordarone
Rythmol®
mexiletine
Tikosyn® QL
Multaq® PA
Rythmol SR®
propafenone
Norpace®
Sorine®
quinidine gluconate
Norpace CR®
Tambocor®
®
Anti-Hypertensives, Miscellaneous
Catapres®
NexiclonTM XR
clonidine
clonidine weekly TD patch QL
reserpine
guanfacine
Clorpres
Tenex®
Catapres-TTS® QL
methyldopa/HCTZ
Effective Date: February 1, 2015
®
TennCare Preferred Drug List (PDL)
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Preferred Drugs
Non-Preferred Drugs
III. CARDIOVASCULAR
hydralazine
guanabenz
methyldopa
minoxidil PA
Vecamyl® PA, QL
Beta Blockers
atenolol
propranolol (excluding solution)
acebutolol
metoprolol succinate PA, QL
metoprolol tartrate
sotalol
Betapace®
pindolol
betaxolol
propranolol solution PA
bisoprolol fumarate PA
propranolol ER
Bystolic®
Sectral®
Corgard®
Sorine®
Hemangeol TM PA
Tenormin®
Inderal LA®
timolol maleate
InnoPran XL® QL
Toprol XL® PA, QL
Levatol® QL
Zebeta®
nadolol
Lopressor®
Beta Blockers + Diuretic
Corzide®
nadolol/bendroflumethiazide
bisoprolol HCT
Dutoprol® PA, QL
Tenoretic®
metoprolol HCT
Lopressor HCT®
Ziac®
atenolol/chlorthalidone
propranolol HCT
Calcium Channel Blockers (DHP)
amlodipine QL
Adalat CC® QL
Norvasc® QL
felodipine ER
Cardene SR® QL
Nymalize® PA
nicardipine
isradipine QL
Procardia®
nifedipine ER/SA/XL QL
nifedipine IR
Procardia XL® QL
nimodipine PA
Sular® QL
nisoldipine QL
Calcium Channel Blockers (Non-DHP)
diltiazem ER/SR/XR
Calan®
diltiazem ER (generic for
Cardizem LA) QL
diltiazem IR
Calan SR®
Tiazac®
verapamil
Cardizem®
verapamil ER
verapamil ER PM
Cardizem CD
Verelan®
Cardizem LA® QL
Verelan PM®
®
QL
Dilacor XR®
Cardiac Glycosides
Lanoxin®
digoxin
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TennCare Preferred Drug List (PDL)
Effective Date: February 1, 2015
Preferred Drugs
Non-Preferred Drugs
III. CARDIOVASCULAR
Direct Renin Inhibitors Class PA
AmturnideTM PA, QL
N/A
Tekturna HCT® PA, QL
Tekamlo® PA, QL
Tekturna® PA, QL
Diuretics: Carbonic Anhydrase Inhibitors
acetazolamide
Diamox® Sequels
methazolamide
Diuretics: Combination Diuretics
amiloride/HCTZ
Aldactazide®
triamterene/HCTZ
Maxzide®
Dyazide®
spironolactone/HCTZ
Diuretics: Loop
bumetanide
furosemide
Demadex®
Edecrin®
torsemide
Lasix®
Diuretics: Potassium Sparing
amiloride
Aldactone®
spironolactone
Inspra® PA
eplerenone PA
Diuretics: Thiazide and Related Diuretics
chlorothiazide
indapamide
Diuril®
Microzide®
chlorthalidone
metolazone
hydrochlorothiazide 12.5mg tab PA
Thalitone®
methyclothiazide
Zaroxolyn®
hydrochlorothiazide
(excluding 12.5mg tab)
Hemostatics, Oral
aminocaproic acid
tranexamic acid PA, QL
Amicar®
Lysteda® PA, QL
Intermittent Claudication
cilostazol
Pletal®
pentoxifylline PA
Trental® PA
Lipotropics: Bile Acid Sequestrants
Colestid®
Questran Light®
cholestyramine light
colestipol
WelChol® packets PA
Prevalite®
Questran®
cholestyramine
WelChol® tablets
Lipotropics: Cholesterol Absorption Inhibitors
N/A
Zetia® PA, QL
Effective Date: February 1, 2015
TennCare Preferred Drug List (PDL) |
Page 11
Preferred Drugs
Non-Preferred Drugs
III. CARDIOVASCULAR
Lipotropics: Fibric Acid Derivatives
fenofibrate (excluding generic
for Antara®) PA
gemfibrozil
fenofibrate (generic
for TriCor®) PA
Antara® PA
Lipofen® PA
fenofibric acid PA
Lofibra® PA
Fenoglide® PA
Lopid®
fenofibrate (generic for
Antara®) PA
TriCor® PA
fenofibrate capsules (generic for
Lipofen®) PA
Triglide® PA
Fibricor® PA
TriLipix® PA
Lipotropics: Miscellaneous
Kynamro
Juxtapid® PA, QL
® PA, QL
Lipotropics: Niacin Derivatives Class PA
Niacor® PA
niacin ER PA
Niaspan® PA
Lipotropics: Omega-3 Fatty Acids Class PA
Lovaza® PA
N/A
Vascepa® PA
omega-3 acid ethyl esters PA
Lipotropics: Standard Potency Statins QL
lovastatin QL
simvastatin (5 mg, 10 mg, 20 mg,
40 mg) QL
pravastatin QL
Altoprev® QL
Livalo® QL
fluvastatin QL
Mevacor® QL
Lescol® QL
Pravachol® QL
Lescol XL® QL
Zocor® (5 mg, 10 mg, 20 mg, 40 mg)
Lipotropics: High Potency Statins
atorvastatin QL
simvastatin 80 mg PA, QL
QL
QL
Lipitor® QL
Zocor® 80 mg PA, QL
Crestor® QL
Lipotropics: Combination Antihyperlipidemics QL
N/A
Advicor® PA QL
Simcor® QL
Liptruzet PA
Vytorin® PA, QL
Lipotropics: Statin + CCB Combination
amlodipine/atorvastatin PA, QL
N/A
Caduet® PA, QL
Injectable Anticoagulants
fondaparinux
Lovenox®
Fragmin
heparin
®
Arixtra®
enoxaparin
Oral Anticoagulants
Coumadin®
Page 12
warfarin
|
TennCare Preferred Drug List (PDL)
Eliquis® PA, QL
Effective Date: February 1, 2015
Xarelto® PA, QL
Preferred Drugs
Non-Preferred Drugs
III. CARDIOVASCULAR
Pradaxa® PA, QL
Jantoven®
Oral Thrombopoietin Agonists
Promacta® PA, QL
N/A
Peripheral Vasodilators
ergoloid mesylates
Pheochromocytoma Agents
Demser® PA
N/A
Platelet Inhibitors
Aggrenox®
dipyridamole
Agrylin®
Persantine®
anagrelide
ticlopidine
Brilinta® PA, QL
Plavix®
cilostazol
clopidogrel 300 mg
Pletal®
clopidogrel 75 mg
Effient® PA
Pulmonary Arterial Hypertension Agents Class PA, QL
Adcirca® PA, QL
Tracleer® PA, QL
Adempas® PA, QL
Revatio® PA, QL
Letairis® PA, QL
Tyvaso® PA, QL
Opsumit® PA, QL
Revatio® suspension PA, QL
sildenafil PA, QL
Ventavis® PA, QL
Orenitram® ER PA, QL
Vasopressors
N/A
midodrine
Vasodilator/Nitrate Combinations
BiDil® PA
N/A
Preferred Drugs
Non-Preferred Drugs
IV. CENTRAL NERVOUS SYSTEM
Agents for Neuropathic Pain
gabapentin capsules QL
Cymbalta® PA, QL
lidocaine patch PA
duloxetine QL
Lidoderm® PA
gabapentin solution PA, QL
Lyrica® PA
gabapentin tablets QL
Neurontin® QL
Gralise® PA, QL
Neurontin® solution PA, QL
Horizant® PA, QL
Alzheimer’s: Cholinesterase Inhibitors
donepezil QL (excluding 23 mg)
Exelon® Patch QL
Aricept® ODT PA, QL
galantamine solution
donepezil ODT PA, QL
galantamine tablets
Aricept® QL
galantamine ER QL
Aricept® 23 mg tablet PA, QL
Razadyne®
donepezil 23 mg PA, QL
Razadyne ER® QL
Effective Date: February 1, 2015
TennCare Preferred Drug List (PDL) |
Page 13
Preferred Drugs
Non-Preferred Drugs
IV. CENTRAL NERVOUS SYSTEM
Exelon®
rivastigmine
Alzheimer’s: NMDA Receptor Antagonists
Namenda® PA, QL
N/A
Namenda XR® PA, QL
Antiparkinson’s Agents: Anticholinergics
benztropine
N/A
trihexyphenidyl
Antiparkinson’s Agents: Decarboxylase Inhibitors
Lodosyn®
carbidopa
Antiparkinson’s Agents: Dopamine Precursors/Decarboxylase Inhibitors
carbidopa/levodopa
carbidopa/levodopa ER/SR
Parcopa®
Sinemet® CR
Sinemet®
Antiparkinson’s Agents: COMT Inhibitors and Combos
carbidopa/levodopa/entacapone
Comtan®
Stalevo®
Tasmar®
entacapone
Antidepressants: SSRIs QL
citalopram QL
Brisdelle® PA
Paxil® QL
escitalopram QL
Celexa® QL
Paxil CR® QL
fluoxetine QL (excluding 20 mg and 60 mg tabs)
fluoxetine 20 mg and 60 mg tabs QL Pexeva® QL
fluvoxamine QL
fluoxetine (PMDD) QL
Prozac® QL
paroxetine QL
fluoxetine weekly PA, QL
Prozac Weekly® PA, QL
sertraline QL
fluvoxamine ER QL
Sarafem® QL
Lexapro® QL
Viibryd® QL
Luvox CR® QL
Zoloft® QL
paroxetine CR QL
Antidepressants: SSRI/SRMs
Brintellix® PA, QL
N/A
Antidepressants: SNRIs Class PA, QL
venlafaxine PA, QL
Cymbalta® PA, QL
Fetzima® PA, QL
venlafaxine ER caps QL
desvenlafaxine PA, QL
Khedezla® PA, QL
desvenlafaxine ER PA, QL
Pristiq® PA, QL
desvenlafaxine fumarate ER PA, QL
Savella® PA, QL
duloxetine QL
venlafaxine ER tabs PA, QL
Effexor XR® PA, QL
Antidepressants: New Generation
budeprion SR
mirtazapine
Aplenzin®
Remeron SolTab® PA
budeprion XL QL
mirtazapine rapdis PA
OleptroTM QL
trazodone 300 mg
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TennCare Preferred Drug List (PDL)
Effective Date: February 1, 2015
Preferred Drugs
Non-Preferred Drugs
IV. CENTRAL NERVOUS SYSTEM
Forfivo XL®
Wellbutrin®
bupropion XL QL
nefazodone
Wellbutrin SR®
maprotiline
Remeron®
Wellbutrin XL® QL
bupropion IR/SR
trazodone (excluding 300 mg)
Antidepressants: Tricyclics
amitriptyline
amoxapine
protriptyline
desipramine
Anafranil® PA
Surmontil®
doxepin
clomipramine PA
Tofranil®
imipramine HCl
imipramine pamoate
Tofranil-PM®
nortriptyline
Norpramin®
Vivactil®
Pamelor®
Antidepressants: MAOIs Class PA, QL
phenelzine PA, QL
Emsam® PA, QL
Parnate® PA, QL
Marplan® PA, QL
tranylcypromine PA, QL
Nardil® PA, QL
Antipsychotics: Typical
chlorpromazine
perphenazine
Haldol®
fluphenazine
thioridazine
Loxitane®
haloperidol
thiothixene
Moban®
loxapine
trifluoperazine
Navane®
Orap®
Antipsychotics: Atypical Class PA
Abilify® PA, QL
quetiapine PA, QL
Abilify MaintenaTM PA, QL
Risperdal® PA, QL
Abilify Discmelt® PA, QL
risperidone PA, QL
Clozaril® PA
Risperdal Consta® PA, QL
clozapine PA
risperidone ODT PA, QL
clozapine ODT PA
Risperdal M-tab® PA, QL
Fanapt® PA, QL
Saphris® PA, QL
FazaClo ODT® PA, QL
Zyprexa® PA, QL
Latuda® PA, QL
Seroquel® XR PA, QL
Geodon® PA, QL
Seroquel® PA, QL
olanzapine PA, QL
ziprasidone PA, QL
Invega® PA
Versacloz® suspension PA
Invega® SustennaTM PA, QL
olanzapine ODT PA, QL
Atypical Antipsychotic and SSRI Combinations
fluoxetine/olanzapine PA, QL
N/A
Zyprexa Zydis® PA, QL
Class PA
Symbyax® PA, QL
Anti-Migraine: Combination Agents
butalbital/APAP/caff QL
Cafergot®
butalbital/ASA/caff QL
Fiorinal® with codeine QL
Margesic® QL
butalbital/APAP/caff/codeine QL
isomethept/caffeine/APAP QL
butalbital/ASA/caff/codeine QL
Migergot®
Fioricet® with codeine QL
Effective Date: February 1, 2015
TennCare Preferred Drug List (PDL) |
Page 15
Preferred Drugs
Non-Preferred Drugs
IV. CENTRAL NERVOUS SYSTEM
Anti-Migraine: 5-HT1 Receptor Agonists QL
Imitrex Nasal® QL
rizatriptan QL
Alsuma® QL
naratriptan QL
Relpax® QL
rizatriptan ODT QL
Amerge® QL
sumatriptan kits QL
sumatriptan vials QL
Axert® PA, QL
sumatriptan nasal QL
sumatriptan tabs QL
Frova® QL
Sumavel® DoseProTM QL
Imitrex® Injectable QL
Treximet® QL
Imitrex® Kit QL
Zomig® QL
Imitrex® tablets QL
Zomig® Spray QL
Maxalt® QL
Zomig ZMT® QL
Maxalt MLT® QL
Anti-Migraine: Ergotamine Derivatives
Migranal® PA, QL
N/A
Antihyperkinesis: Stimulants
Adderall XR® QL
Methylin® tabs
Adderall® QL
Methylin® solution & chewables
amphetamine salt IR combo QL
methylphenidate
amphetamine salt ER combo QL
methylphenidate ER QL (generic for
Ritalin LA®)
dextroamphetamine QL
methylphenidate ER QL (excluding
generic for Ritalin LA®)
Concerta® QL
methylphenidate CR QL
dextroamphetamine solution QL
methylphenidate SA OSM QL
Daytrana® QL
methylphenidate solution
Focalin®
ProCentra® QL
Desoxyn® QL
methylphenidate SR 24hr QL
Focalin XR® QL
Quillivant XR® QL
dexmethylphenidate
Ritalin LA® QL
Metadate ER® QL
Ritalin ®
dexmethylphenidate XR QL
Ritalin SR®
methamphetamine QL
Vyvanse® QL
Dexedrine Spansule® QL
Zenzedi®
Methylin ER® QL
Antihyperkinesis: Non-Stimulants
Strattera
® QL
clonidine ER PA, QL
Intuniv® PA, QL
guanfacine ER PA, QL
KapvayTM PA, QL
Agents for Narcolepsy
modafinil PA, QL
Provigil® PA, QL
Nuvigil® PA, QL
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TennCare Preferred Drug List (PDL)
Effective Date: February 1, 2015
Xyrem® PA, QL
Preferred Drugs
Non-Preferred Drugs
IV. CENTRAL NERVOUS SYSTEM
Anticonvulsants
Aptiom® PA
Lamictal® ODT PA
carbamazepine ER (excluding generic lamotrigine chewable tabs
Carbatrol)
Banzel® PA
Lamictal® XR
Carbatrol®
levetiracetam
carbamazepine ER (generic for
Carbatrol® only)
lamotrigine ER
Diastat® PA, QL
levetiracetam ER
Celontin®
Lyrica® PA
Dilantin Kapseal® 30 mg
oxcarbazepine
clonazepam (tabs & ODT) PA, QL
Mysoline®
Dilantin® Infatabs®
phenobarbital PA
Depakene®
Neurontin® QL
divalproex
Phenytek®
Depakote®
Neurontin® solution PA, QL
divalproex DR sprinkles
phenytoin
Depakote® ER
Onfi®PA
divalproex extended release
primidone
Depakote® Sprinkles
Oxtellar XR®
Equetro®
topiramate
diazepam rectal gel PA, QL
Peganone®
ethosuximide
Tegretol-XR® 100mg
Dilantin-125®
Potiga® PA
gabapentin capsules QL
valproic acid
Dilantin Kapseal® 100 mg
QudexyTM XR PA, QL
Vimpat® PA
Epitol®
Sabril® PA
zonisamide
felbamate PA
Stavzor®
Felbatol® PA
Tegretol®
FycompaTM PA, QL
Tegretol-XR® (200 & 400mg)
gabapentin solution PA, QL
tiagabine
gabapentin tablets QL
Topamax®
Gabitril®
topiramate ER PA, QL
Keppra®
Trileptal®
Keppra® XR
Trokendi XR® PA, QL
Klonopin® PA, QL
Zarontin®
Lamictal® (tabs & chewable tabs)
Zonegran®
carbamazepine
lamotrigine tabs
Agents for RLS (Restless Leg Syndrome)
pramipexole QL
ropinirole
Horizant® PA, QL
Neupro® PA
Mirapex® QL
Requip®
Amyotrophic Lateral Sclerosis (ALS)
Rilutek®
riluzole
Effective Date: February 1, 2015
TennCare Preferred Drug List (PDL) |
Page 17
Preferred Drugs
Non-Preferred Drugs
IV. CENTRAL NERVOUS SYSTEM
Anti-Anxiety Agents
alprazolam PA, QL
diazepam PA, QL
alprazolam ER PA, QL
oxazepam PA, QL
buspirone (excluding 30 mg)
lorazepam PA, QL
alprazolam ODT PA, QL
Niravam PA, QL
chlordiazepoxide PA, QL
Ativan PA, QL
Tranxene-T PA, QL
clorazepate PA, QL
Buspar®
Valium PA, QL
buspirone 30 mg
Xanax PA, QL
Meprobamate
Xanax ER PA, QL
Cholinergic Muscle Stimulants
Mestinon® syrup
pyridostigmine 60 mg tab
Mytelase®
Prostigmin®
Mestinon® 60 mg tab
Mestinon® 180mg ER tab
Non-Ergot Dopamine Receptor Agonists
pramipexole QL
ropinirole
bromocriptine
Parlodel®
Cyloset®
Requip®
Mirapex® QL
Requip® XL
Mirapex® ER QL
ropinirole ER
Neupro® PA
MAOI-Bs
selegiline
Azilect®
N/A
Zelapar® PA
Eldepryl®
Miscellaneous CNS Agents
Nuedexta® PA, QL
N/A
Mood Stabilizers
carbamazepine
lithium citrate
Depakote®
Lamictal® XR
lamotrigine tabs
oxcarbazepine
Depakene®
lamotrigine ER
lamotrigine chewable tabs
valproic acid
Keppra
Stavzor®
®
levetiracetam
Lamictal® tabs
Tegretol®
lithium carbonate
Lamictal® chewable tabs
Trileptal®
lithium carbonate SA
Lamictal® ODT PA
Lithobid®
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TennCare Preferred Drug List (PDL)
Effective Date: February 1, 2015
Preferred Drugs
Non-Preferred Drugs
IV. CENTRAL NERVOUS SYSTEM
Sedative Hypnotic Agents QL
zaleplon QL
Ambien® QL
Lunesta® QL
zolpidem QL
Ambien CR® QL
Restoril® PA, QL
Belsomra® QL
Rozerem® QL
eszopiclone QL
Silenor® PA, QL
EdluarTM PA, QL
Sonata® QL
estazolam PA, QL
temazepam PA, QL
flurazepam PA, QL
triazolam PA, QL
Halcion® PA, QL
zolpidem ER QL
Hetlioz® PA, QL
Zolpimist® PA, QL
Intermezzo® QL
Skeletal Muscle Relaxants
baclofen
methocarbamol
Amrix® QL
orphenadrine
chlorzoxazone
orphenadrine/ASA/caffeine
carisoprodol PA, QL
Parafon Forte®
cyclobenzaprine
tizanidine tablets
carisoprodol/ASA PA, QL
Robaxin®
carisoprodol/ASA/codeine PA
Skelaxin®
cyclobenzaprine 7.5mg
Soma® PA, QL
Flexeril®
tizanidine capsules
Lorzone®
Zanaflex®
dantrolene
metaxalone
Preferred Drugs
Non-Preferred Drugs
V. DERMATOLOGICS
Topical Antipruritics/Antihistamines
Prudoxin® PA, QL
N/A
Zonalon® PA, QL
Topical Antivirals
acyclovir 5% ointment QL
Xerese® PA
Zovirax® ointment QL
Denavir® cream QL
Zovirax® cream QL
Topical Agents for Burns
silver sulfadiazine
Thermazene®
SSD®
mefanide
Sulfamylon®
Silvadene®
Effective Date: February 1, 2015
TennCare Preferred Drug List (PDL) |
Page 19
Preferred Drugs
Non-Preferred Drugs
V. DERMATOLOGICS
Antiseborrheic Agents
Mexar® wash
Carmol® 10% Scalp lotion
selenium sulfide/pyrithione zinc in
urea
selenium sulfide 2.5% lotion
Ovace®
SelenosTM
sulfacetamide sodium 10% wash
Ovace®Plus
Selsun®
Rosula® NS Pads
sodium sulfacetamide 10%
shampoo
Seb-PrevTM
sulfacetamide sodium/urea pads
selenium sulfide shampoo
TL TrisebTM
Topical Antibiotic Agents for Skin and Soft Tissue Infections
gentamicin
mupirocin ointment
Altabax®
Centany®
Bactroban® cream
mupirocin cream
Bactroban® ointment
Topical Antibiotic Agents for Acne (Covered for recipients < 21 years old only)
Azelex® 20% cream
clindamycin phosphate (excluding benzoyl peroxide (cleanser, gel, microspheres, towlettes, and all
foam and lotion)
strengths not listed as preferred)
benzoyl peroxide (2.5%, 5%,
10% excluding cleanser, gel,
microspheres, and towlettes)
erythromycin (excluding swab)
sodium sulfacetamide (excluding
suspension)
benzoyl peroxide kits and other dermatological kits PA
clindamycin phosphate foam and
lotion
clindamycin/benzoyl peroxide gel
erythromycin swab
erythromycin/benzoyl peroxide
sulfacetamide suspension
sodium sulfacetamide/sulfur
All branded single agent and combination products of: benzoyl peroxide,
clindamycin, erythromycin, and sodium sulfacetamide
Topical Agents for Rosacea (Covered for recipients < 21 years old only)
Finacea® Plus gel PA
MetroLotion® QL
metronidazole 0.75% cream QL
Metrocream® QL
Mirvaso®
metronidazole 0.75% gel QL
MetroGel® 1% QL
Noritate® 1% cream
metronidazole 0.75% lotion QL
MetroGel® 1% Kit
RosadanTM Kit
Finacea® 15% gel
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metronidazole gel 1% QL
TennCare Preferred Drug List (PDL)
Effective Date: February 1, 2015
Preferred Drugs
Non-Preferred Drugs
V. DERMATOLOGICS
Topical Antifungal Agents
Bensal HP®
Luzu® PA
ciclopirox
econazole
ciclopirox solution 8% PA
ketoconazole (shampoo and cream) Ciclodan® Kit PA
clotrimazole
nystatin
Loprox®
ciclopirox nail kit PA
Lotrisone®
clotrimazole/betamethasone
Mentax®
CNL 8 Nail Kit® PA
Naftin®
Ertaczo®
Nizoral®
Exelderm®
Nystatin/triamcinolone
Extina®
Oxistat®
Jublia® PA
Pediaderm® AF
Ketocon Kit PA
Pedipirox-4® Nail PA
ketoconazole foam
Penlac® PA
Ketodan® Kit PA
Vusion® PA
Lamisil®
Topical Antipsoriatics Class PA
calcipotriene ointment PA
Dovonex® Scalp Solution PA
calcipotriene scalp solution PA
calcitriol ointment PA
Sorilux® PA
Tazorac® PA
calcipotriene/betamethasone PA
Taclonex® PA
calcipotriene cream PA
Vectical® PA
Dovonex® PA
Genital Wart Agents
imiquimod
Aldara®
podofilox
Veregen®
Condylox®
Immunomodulators
Aldara®
imiquimod
Emollients
ammonium lactate
lactic acid
LacLotion®
lactic acid with vitamin E
Lac-Hydrin®
Retinoids, Oral
N/A
acitretin PA, QL
Myorisan® PA
Absorica® PA
Sotret® PA
Amnesteem® PA
Soriatane® QL
Claravis® PA
Zenatane® PA
Effective Date: February 1, 2015
TennCare Preferred Drug List (PDL) |
Page 21
Preferred Drugs
Non-Preferred Drugs
V. DERMATOLOGICS
Retinoids, Topical Class PA
Tazorac® PA
tretinoin PA
adapalene PA
Retin-A® PA
Atralin® PA
Retin-A Micro® PA
Differin® PA
tretinoin microsphere gel PA
Epiduo® PA
VeltinTM PA
FabiorTM
Pediculocides/Scabicides
NatrobaTM QL
Sklice® QL
permethrin QL
Ziana® PA
QL
Elimite® QL
Ovide® QL
Eurax® QL
spinosad QL
lindane PA, QL
UlesfiaTM QL
malathion QL
Keratolytic Agents
all generic urea products
all generic salicylic acid products
All brand urea products
All brand salicylic acid products
Enzyme Preps and Wound Healing
Regranex® PA
N/A
Santyl®
Topical Anesthetics
lidocaine QL
lidocaine viscous
All brand lidocaine products
Lidoderm® PA
lidocaine/hydrocortisone
lidocaine/prilocaine QL
EMLA® QL
Pliaglis®
lidocaine/hydrocortisone/aloe
Topical Antineoplastics
Carac®
Panretin®
diclofenac 3% gel
Picato®
Fluoroplex®
Solaraze®
Efudex®
Valchlor® PA
fluorouracil
Targretin
fluorouracil 5% cream
Zyclara®
®
Topical Steroids: Least Potent
hydrocortisone 1% cream and ointment
Alcortin® A
hydrocortisone 2.5% cream, lotion and ointment
Aqua Glycolic HC® Kit
hydrocortisone acetate-aloe vera 2% gel
Pediaderm HC® 2% Kit
Texacort® 2.5% solution
U-cort® 1% cream
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TennCare Preferred Drug List (PDL)
Effective Date: February 1, 2015
Preferred Drugs
Non-Preferred Drugs
V. DERMATOLOGICS
Topical Steroids: Mild
aclomethasone 0.05% cream and ointment
Derma-Smoothe/FS® Oil
betamethasone valerate 0.1% lotion
Desonate® 0.05% gel
desonide 0.05% cream
desonide 0.05% ointment
fluocinolone acetonide 0.01% cream, oil and solution
Synalar® 0.01% solution
Verdeso® 0.05% foam
Topical Steroids: Lower Mid-Strength
betamethasone dipropionate 0.05% lotion
Capex® shampoo
betamethasone valerate 0.1% cream
clocortolone 0.1% cream and pump
Derma-Top® 0.1% ointment
Cloderm® 0.1% cream
fluticasone proprionate 0.05% cream
Cutivate® 0.05% cream and lotion
hydrocortisone butyrate 0.1% solution
Derma-Top® 0.1% cream
desonide 0.05% lotion
Desowen® 0.05% lotion
Diprolene® 0.05% lotion
fluocinolone acetonide 0.01% shampoo
fluocinolone acetonide 0.025% cream
fluticasone proprionate 0.05% lotion
hydrocortisone butyrate 0.1% cream and ointment
hydrocortisone valerate 0.2% cream
Pandel® 0.1% cream
prednicarbate 0.1% cream and ointment
Topical Steroids: Mid-Strength
hydrocortisone valerate 0.2% ointment
Elocon® 0.1% cream and lotion
mometasone furoate 0.1% cream and solution (lotion)
fluocinolone acetonide 0.025% ointment
triamcinolone acetonide 0.1% cream
Kenalog® aerosol spray
Pediaderm TA® Kit
Effective Date: February 1, 2015
TennCare Preferred Drug List (PDL) |
Page 23
Preferred Drugs
Non-Preferred Drugs
V. DERMATOLOGICS
Topical Steroids: Upper Mid-Strength
fluocinonide 0.05% emulsified base cream
amcinonide 0.1% cream and lotion
fluticasone proprionate 0.005% ointment
betamethasone dipropionate 0.05% cream
triamcinolone acetonide 0.025% cream, lotion and ointment
betamethasone valerate 0.1% ointment
triamcinolone acetonide 0.1% lotion and ointment
betamethasone valerate 0.12% foam
triamcinolone acetonide 0.5% cream and ointment
desoximetasone 0.05% cream
Diprolene AF® 0.05% cream
Luxiq® 0.12% foam
Topicort® 0.05% cream
Trianex® 0.05% ointment
Topical Steroids: Potent
betamethasone dipropionate, augmented 0.05% cream
amcinonide 0.1% ointment
fluocinonide 0.05% cream, gel, ointment and solution
Apexicon E® 0.05% cream
mometasone furoate 0.1% ointment
betamethasone dipropionate, augmented 0.05% lotion
betamethasone dipropionate 0.05% ointment
desoximetasone 0.05% gel and ointment
desoximetasone 0.25% cream and ointment
diflorasone diactetate 0.05% cream and ointment
Elocon® 0.1% ointment
Halog® 0.1% ointment and cream
Topicort® 0.05% gel and ointment
Topicort® 0.25% cream and ointment
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TennCare Preferred Drug List (PDL)
Effective Date: February 1, 2015
Preferred Drugs
Non-Preferred Drugs
V. DERMATOLOGICS
Topical Steroids: Super Potent
clobetasol propionate 0.05% cream, gel, ointment, and solution
betamethasone dipropionate, augmented 0.05% gel, and ointment
clobetasol propionate emollient base 0.05% cream
clobetasol propionate 0.05% foam, lotion, shampoo, and spray
halobetasol propionate 0.05% cream and ointment
clobetasol propionate emollient base 0.05% foam
Clobex® 0.05% lotion and shampoo
Clobex® 0.05% spray
ClodanTM
ClodanTM Kit PA
Cordran® tape
Diprolene® 0.05% ointment
fluocinonide 0.1% cream
Olux® 0.05% aerosol
Olux-E® 0.05% aerosol
Temovate® 0.05% cream and ointment
Temovate E® 0.05% cream
Ultravate® 0.05% cream and ointment
Vanos® 0.1% cream
Preferred Drugs
Non-Preferred Drugs
VI. DIABETIC SUPPLIES
Diabetic Supplies: Blood Glucose Meters
Abbott Diabetes Care Products
AgaMatrix Products PA
LifeScan Products PA
(Covered Meters Include: Freestyle
InsuLinx Meter, FreeStyle Lite
Meter, FreeStyle Freedom Lite
Meter, Precision Xtra Meter)
Bayer Healthcare Products PA
Roche Diagnostics Products PA
Home Diagnostics Products PA
Diabetic Supplies: Blood Glucose Test Strips
Abbott Test Strips QL
AgaMatrix Products PA, QL
LifeScan Products PA, QL
(Covered Strips Include: Precision
Xtra Test Strips, FreeStyle Test
Strips, FreeStyle Lite Test Strips,
Freestyle InsuLinx Test Strips)
Bayer Healthcare Products PA, QL
Roche Diagnostics Products PA, QL
Home Diagnostics Products PA, QL
Preferred Drugs
Non-Preferred Drugs
VII. ENDOCRINE AND METABOLIC AGENTS
Agents for Gout
allopurinol
probenecid
Colcrys® PA
probenecid/colchicine
Uloric® PA
Effective Date: February 1, 2015
Zyloprim®
TennCare Preferred Drug List (PDL) |
Page 25
Preferred Drugs
Non-Preferred Drugs
VII. ENDOCRINE AND METABOLIC AGENTS
Anabolic Steroids Class PA
Anadrol-50® PA
N/A
Oxandrin® PA
oxandrolone PA
Androgens
Androgel® packets PA
Androderm® PA
Testred® PA
Androgel® pump PA
Android® PA
testosterone (generic Androgel®,
Fortesta®, Testim®) PA
Danazol
Axiron® PA
testosterone cypionate PA, QL
Depo-testosterone® PA, QL
(200 mg/mL 1 mL vial)
Androxy® PA
testosterone enanthate PA, QL
Delatestryl® PA, QL
Striant® PA
Depo-testosterone® PA, QL
(excluding 200 mg/mL
1 mL vial)
Testim® PA
Fortesta® PA
VogelxoTM PA
Methitest® PA
Antidiuretic/Vasopressor Agents
DDAVP
desmopressin tabs
Stimate® PA
desmopressin nasal spray
Bone: Bisphosphonates
Actonel® solution PA
Actonel® QL
Fosamax® QL
alendronate QL
Atelvia® QL
Fosamax Plus D® QL
Binosto® QL
ibandronate QL
Boniva® QL
risedronate QL
Didronel®
Skelid® QL
etidronate
Bone: Calcitonin Class PA, QL
calcitonin nasal spray
Fortical® PA, QL
PA, QL
Miacalcin® injection PA, QL
Miacalcin® nasal spray PA, QL
Bone: SERMs
Evista® QL
raloxifene QL
Bone: Parathyroid Hormone
Forteo® PA
N/A
Contraceptives, Non-Oral
Depo SubQ Provera® QL
Nuvaring® PA
medroxyprogesterone
acetate inj. QL
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TennCare Preferred Drug List (PDL)
Depo-Provera® QL
Ortho Evra® PA
Effective Date: February 1, 2015
Xulane TM PA
Preferred Drugs
Non-Preferred Drugs
VII. ENDOCRINE AND METABOLIC AGENTS
Contraceptives, Oral
Altavera®
Leena®
Ortho-Cept®
Balziva®
Seasonale®
Amethia Lo®
Lessina®
Ortho-Cyclen®
Generess FE®
Seasonique®
Apri®
levonorgestrel/ethinyl
estradiol
Ortho-Novum®
Jolessa®
Tilia FE®
Aranelle®
Levora®
Ovcon-50®
Kariva®
Tri-Legest® FE
Aviane®
Lo/Ovral®
Philith®
Lybrel®
Zenchent®
Beyaz®
Loestrin®
Plan B®
Ogestrel®
Brevicon®
Loestrin 24 FE®
Plan B® One-Step
Quasense®
Camila®
Lomedia 24 FE®
Portia®
Cesia®
Lo Loestrin FE®
Previfem®
Cryselle®
Low-Ogestrel®
Reclipsen®
Cyclessa®
Lutera®
Safyral®
DeblitaneTM
Microgestin®
Solia®
Desogen®
Microgestin FE®
Sprintec®
drosperinone/ ethinyl Mircette®
estradiol
Sronyx®
Elinest®
Modicon®
Tarina-FE®
Ella®
Mononessa®
Tri-Linyah®
Enpresse®
Necon®
Tri-Norinyl®
Errin®
Natazia®
Tri-Previfem®
estradiol
Next Choice®
Tri-Sprintec®
Estrostep FE®
Nikki®
Trinessa®
Femcon FE®
Nor-QD®
Trivora®
Gildagia®
Nora-BE®
Velivet®
Gildess®
Nordette®
Vesturna®
Heather®
norethindrone/ethinyl
estradiol - FE
Wymza Fe®
Jolivette®
Norinyl®
Yasmin®
Junel®
Nortrel®
YAZ®
Junel FE®
Ortho Micronor®
Zovia®
Kelnor 1/35®
Ortho Tri-Cyclen®
Kurvelo®
Ortho Tri-Cyclen Lo®
Effective Date: February 1, 2015
TennCare Preferred Drug List (PDL) |
Page 27
Preferred Drugs
Non-Preferred Drugs
VII. ENDOCRINE AND METABOLIC AGENTS
Diabetes: Alpha-Glucosidase Inhibitors
acarbose
Precose®
Glyset®
Diabetes: Amylin Analogs
Symlin® PA
N/A
Diabetes: Biguanides QL
metformin QL
Fortamet® QL
Glumetza® QL
metformin ER QL
Glucophage® QL
metformin ER osmotic QL
Glucophage XR® QL
Riomet® PA, QL
Diabetes: DPP-4 Inhibitors and Combinations Class PA, QL
Januvia® PA, QL
KombiglyzeTM XR PA, QL
Janumet XR® PA, QL
Nesina® PA, QL
Janumet® PA, QL
Onglyza® PA, QL
JentaduetoTM PA, QL
Oseni® PA, QL
Kazano® PA, QL
TradjentaTM PA, QL
Juvisync® PA, QL
Diabetes: GLP-2 Analogs
Gattex® PA
N/A
Diabetes: Incretin Mimetics Class PA, QL
Bydureon® vials PA, QL
Bydureon® Pen
Victoza® PA, QL
PA, QL
Trulicity® PA, QL
Tanzeum® PA, QL
Byetta® PA, QL
Diabetes: Insulins
Humalog® vials
Humulin 70/30® Pen PA
Apidra®
Humalog 75/25® vials
Lantus® vials
Apidra® Solostar PA
Humalog 50/50® vials
Levemir® vials
Lantus® OptiClick PA
Humalog® Kwikpen PA
Novolin N®
Lantus® Solostar PA
Humalog Mix 50/50® Kwikpen PA
Novolin R®
Levemir® FlexPen PA
Humalog Mix 75/25® Kwikpen PA
Novolin 70/30®
Humulin N®
Novolog® vials
Humulin N® Pen PA
Novolog® Flex Pen PA
Humulin R®
Novolog Mix 70/30® vials
Humulin® R U-500
Novolog Mix 70/30® Flex Pen PA
Humulin 70/30® vials
Diabetes: Meglitinides and CombinationQL
nateglinide QL
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TennCare Preferred Drug List (PDL)
Prandin® QL
repaglinide QL
PrandimetTM QL
Starlix® QL
Effective Date: February 1, 2015
Preferred Drugs
Non-Preferred Drugs
VII. ENDOCRINE AND METABOLIC AGENTS
Diabetes: Sulfonylureas and Combination
glimepiride QL
glyburide micronized
Amaryl® QL
Glucovance®
glipizide
glyburide/metformin
chlorpropamide
Glynase PresTab®
glipizide ER/XL
Diabeta®
Metaglip®
glipizide/metformin
Glucotrol®
tolazamide
glyburide
Glucotrol XL®
Diabetes: SGLT2 Inhibitors and Combinations
N/A
tolbutamide
Class PA
FarxigaTM PA, QL
Jardiance® PA, QL
InvokametTM PA, QL
Xigduo® XR PA, QL
InvokanaTM PA, QL
Diabetes: Thiazolidinediones Class PA, QL
Actos® PA, QL
pioglitazone PA, QL
Avandia® PA, QL
Diabetes: Thiazolidinedione Combinations Class PA, QL
pioglitazone-metformin PA, QL
ACTOplus Met® PA, QL
Avandaryl® PA, QL
ACTOplus Met® XR PA, QL
DuetAct® PA, QL
Avandamet® PA, QL
pioglitazone-glimepiride PA, QL
Disease Modifying Anti-Rheumatic Drugs
hydroxychloroquine
Ridaura®
Arava®
Depen®
leflunomide
sulfasalazine QL
Azulfidine® QL
Plaquenil®
methotrexate
sulfasalazine EC QL
Azulfidine EN® QL
Rheumatrex®
Cuprimine®
Trexall®
Note: Injectable agents for the treatment of RA are located under
Immunomodulators
Anti-Rheumatic: Kinase Inhibitors
XelJanz® PA, QL
N/A
Glucocorticoids, Oral
Celestone®
Orapred® ODT PA
cortisone
Cortef®
Pediapred®
dexamethasone
Dexpak®
prednisolone ODT PA
hydrocortisone
Medrol®
Rayos®
methylprednisolone
Millipred®
Veripred®
prednisolone
Orapred®
budesonide capsules PA
prednisone
Growth Hormone Agents Class PA
Genotropin® PA
Humatrope® PA
Saizen® PA
Norditropin® PA
Nutropin® PA
Serostim® PA
Nutropin AQ® PA
Tev-Tropin® PA
Omnitrope® PA
Zorbtive® PA
Effective Date: February 1, 2015
TennCare Preferred Drug List (PDL) |
Page 29
Preferred Drugs
Non-Preferred Drugs
VII. ENDOCRINE AND METABOLIC AGENTS
Hematopoietic Agents Class PA
Aranesp® PA
N/A
Procrit® PA
Epogen® PA
Hormones: Adrenocorticotropic
H.P. Acthar® PA, QL
N/A
Hormones: Anti-Thyroid
methimazole
Tapazole®
propylthiouracil
Hormones: LHRH
leuprolide PA
N/A
Synarel®
Hormones: Oral Estrogens
Cenestin®
estropipate
EnJuvia®
Femtrace®
estradiol
Premarin®
Estrace®
Menest®
Hormones: Oral Estrogen/Progestins
Activella®
PremPhase® QL
Angeliq®
JinteliTM
FemHRT® Low Dose
PremPro® QL
estradiol/norethindrone
LopreezaTM
FemHRT® 1/5
MimveyTM
PreFest®
Hormones: Oral Progestins
medroxyprogesterone
progesterone
megestrol QL
Aygestin®
Prometrium®
Megace® QL
Provera®
Megace ES® PA, QL
norethindrone acetate PA
Hormones: Thyroid
Cytomel®
liothyronine
Armour Thyroid®
Levothroid®
Synthroid®
Thyroid®
levothyroxine
Unithroid®
Thyrolar®
Tirosint®
Levoxyl®
Hormones: Transdermal Estrogens
Alora® QL
Divigel®
Estrasorb®
Climara® QL
Elestrin®
Evamist®
Vivelle-Dot® QL
Estraderm® QL
Menostar® QL
estradiol TDS QL
Hormones: Transdermal Estrogen/Progestins
Climara Pro® QL
Combipatch® QL
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Minivelle® QL
QL
TennCare Preferred Drug List (PDL)
Effective Date: February 1, 2015
Preferred Drugs
Non-Preferred Drugs
VII. ENDOCRINE AND METABOLIC AGENTS
Hormones: Vaginal Estrogens
Estring®
Estrace®
Vagifem®
Femring®
Premarin Vaginal Cream® QL
Insulin-Like Growth Factor-1 Class PA
N/A
Increlex® PA
Mineralocorticoids, Oral
N/A
fludrocortisone
Progesterone Receptor Antagonists
Korlym® PA
N/A
SERM/Estrogen Combinations
Duavee® PA
N/A
Somatostatic Agents
octreotide PA
Sandostatin® PA
Somatuline Depot®
Signifor® PA, QL
Somavert®
Preferred Drugs
Non-Preferred Drugs
VIII. GASTROINTESTINAL
5-ASA Derivatives, Oral QL
AprisoTM QL
Pentasa® QL
Asacol HD® QL
Dipentum® QL
Asacol® QL
sulfasalazine EC QL
Azulfidine® QL
Giazo® QL
balsalazide QL
sulfasalazine QL
Azulfidine EN® QL
Delzicol® QL
Sulfazine EC® QL
Colazal® QL
Lialda® QL
Sulfazine® QL
5-ASA Derivatives, Rectal
Canasa®
mesalamine enema
mesalamine kit
Rowasa®
Rowasa kit®
5HT-3 Receptor Antagonists (IBS) Class PA
Lotronex® PA, QL
N/A
Antidiarrheals
diphenoxylate with atropine
Lonox®
Lomotil®
opium tincture
Lofene®
loperamide
Motofen®
paregoric
Fulyzaq®PA
Anti-Emetics: A-9-THC Derivatives Class PA
N/A
Cesamet® PA
Marinol® PA
dronabinol PA
Effective Date: February 1, 2015
TennCare Preferred Drug List (PDL) |
Page 31
Preferred Drugs
Non-Preferred Drugs
VIII. GASTROINTESTINAL
Anti-Emetics: Anticholinergics
meclizine
trimethobenzamide
Antivert®
prochlorperazine
Transderm Scōp® PA, QL
Compro®
Tigan®
Phenergan ® PA
promethazine PA
Anti-Emetics: 5-HT3 Antagonists Class PA
ondansetron tabs and ODT PA, QL
Anzemet® PA, QL
Zofran ODT® PA, QL
granisetron PA, QL
Zofran® Solution PA
Kytril® PA, QL
Zofran® PA, QL
ondansetron oral soln PA
Zuplenz® PA, QL
Sancuso® PA, QL
Anti-Emetics: NK-1 Antagonists Class PA
Emend® PA, QL
N/A
Anti-Emetics: Miscellaneous
N/A
Diclegis® PA, QL
Antispasmodics/Anticholinergics
dicyclomine
Symax Fastabs®
Anaspaz®
methscopolamine
glycopyrrolate
Symax-SL
Bentyl
Pamine®
®
®
HyoMax®
Cantil®
Pamine Forte®
hyoscyamine
chlordiazepoxide/clidinium
Robinul®
Hyosyne®
Cuvposa® PA
Robinul Forte®
NuLev®
Levsin®
Sal-Tropine®
propantheline
Librax®
Combination Products for H. pylori Class PA
N/A
Helidac® PA
Prevpac® PA, QL
lansoprazole/amoxicillin/
clarithromycin PA, QL
Pylera® PA, QL
Omeclamox® PA
Gallstone Solubilizing Agents
ursodiol QL
Actigall® QL
Urso® QL
ChenodalTM
Urso Forte® QL
H2 Receptor Antagonists
Axid®
ranitidine capsules
famotidine
nizatidine
Zantac®
ranitidine tablets
Pepcid®
cimetidine
Page 32
ranitidine syrup
|
TennCare Preferred Drug List (PDL)
Effective Date: February 1, 2015
Preferred Drugs
Non-Preferred Drugs
VIII. GASTROINTESTINAL
Laxatives
Constulose®
PEG 3350 powder
CoLyte®
PEG 3350 with flavor packs
Enulose®
PEG 3350 electrolyte solution
GoLYTELY®
PEG 3350 solution
generlac
HalfLytely®
Prepopik®
lactulose
Kristalose®
Suclear®
MoviPrep®
Suprep®
NuLYTELY®
Trilyte®
OsmoPrep®
Visicol®
Miscellaneous Agents for Irritable Bowel Syndrome
Amitiza® PA, QL
N/A
Linzess® PA, QL
Miscellaneous Agents for Inflammatory Bowel Disease
Entocort® EC PA
N/A
Uceris® PA, QL
Motility Agents
Metozolv® ODT PA, QL
metoclopramide QL
Reglan® QL
Mucosal Protectants
misoprostol
sucralfate tablets
Carafate®
sucralfate suspension PA
Cytotec®
Pancreatic Enzymes
Creon® (all strengths)
ZenPep®
Pancreaze®
Ultresa®
PertzyeTM
Viokace®
pancrelipase (all strengths)
Proton Pump Inhibitors
pantoprazole QL
Aciphex® QL
Prevacid® QL
Protonix® suspension
Aciphex® sprinkles PA
Prevacid® SoluTabTM PA, QL
omeprazole® OL
Dexilant® QL
Prilosec® QL
esomeprazole QL
Protonix® QL
lansoprazole QL
rabeprazole QL
lansoprazole ODT PA, QL
Zegerid® QL
Nexium® QL
Saliva Stimulating Agents
pilocarpine PA, QL
cevimeline PA, QL
Salagen® PA, QL
Evoxac® PA, QL
Effective Date: February 1, 2015
TennCare Preferred Drug List (PDL) |
Page 33
Preferred Drugs
Non-Preferred Drugs
IX. IMMUNOLOGIC AGENTS
Anti-inflammatory: PDE-4 Inhibitors
Otezla® PA, QL
N/A
Immunomodulators Class PA, QL
Cimzia® PA, QL
Humira® PA, QL
Enbrel® PA, QL
Actemra® PA, QL
Simponi® PA, QL
Kineret® PA, QL
Stelara® PA, QL
Orencia® PA, QL
Immunosuppressants
azathioprine
Gengraf®
Astagraf XL® PA
mycophenolic acid PA
Cellcept® suspension
mycophenolate mofetil
Azasan® PA
Neoral® PA
cyclosporine
tacrolimus
Cellcept® (excluding suspension) PA Prograf® PA
cyclosporine microemulsion
Hecoria® PA
Rapamune® PA
Imuran® PA
Sandimmune® PA
Myfortic® PA
sirolimus PA
mycophenolatemofetil suspension
Zortress® PA
Multiple Sclerosis Agents QL
Avonex® QL
Copaxone®20 mg/mL QL
Avonex Administration Pack® QL
Rebif® QL
Copaxone® 40 mg/mL PA, QL
Extavia® QL
Betaseron® QL
Multiple Sclerosis Agents: Potassium Channel Blockers
N/A
Ampyra® QL
Multiple Sclerosis Agents: Oral Disease Modifying Agents
Aubagio® PA
N/A
Gilenya® PA, QL
Tecfidera® PA, QL
Topical Immunomodulators Class PA
Elidel® PA
tacrolimus ointment PA
Protopic® PA
Preferred Drugs
Non-Preferred Drugs
X. MISCELLANEOUS
Gaucher’s Disease Agents
CerdelgaTM QL
Zavesca®
Hereditary Tyrosinemia Agents
N/A
Orfadin®
Oral Iron Chelators Class PA
Exjade® PA
N/A
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TennCare Preferred Drug List (PDL)
Effective Date: February 1, 2015
Ferriprox® PA
Preferred Drugs
Non-Preferred Drugs
XI. ONCOLOGY AGENTS
Afinitor®
Inlyta®
Stivarga®
Afinitor Disperz® PA
Alkeran®
Iressa®
Tabloid®
Arimidex®
anastrozole
Jakafi®
Tafinlar®
Aromasin®
bicalutamide
leucovorin
tamoxifen
capicitabine
Bosulif
Leukeran
Tarceva
Casodex®
Caprelsa®
leuprolide PA
Targretin®
Femara®
Cometriq®
letrozole
Tasigna®
Hydrea®
cyclophosphamide
lomustine
temozolamide
Purinethol®
Droxia®
Lysodren®
Thalomid®
Purixan® PA
Eligard® PA
Matulane®
tretinoin
Temodar®
Emcyt®
Mekinist®
Tykerb®
Erivedge®
mercaptopurine
VotrientTM
etoposide
Mesna®
Xalkori®
exemestane
methotrexate
Xeloda®
Fareston®
Myleran®
Xtandi®
flutamide
Nexavar®
Zelboraf®
Gilotrif®
Nilandron®
Zolinza®
Gleevec®
OfortaTM
Zydelig®
Hexalen®
Pomalyst®
Zykadia®
Hycamtin®
Revlimid®
Zytiga®
hydroxyurea
Sprycel®
Imbruvica®
Sutent®
®
®
®
Effective March 1, 2014, the initial fill of oncology products will be limited to a 14 days supply. If the initial 14 days supply is tolerated, the
member is eligible to receive the remainder of the first months supply without additional copay by the pharmacy submitting a Submission
Clarification Code (NCPDP D.0 field 42Ø-DK) of 2. After the initial month, members may continue to receive up to a 31 days supply of oncology
products per fill.
Preferred Drugs
Non-Preferred Drugs
XII. OPHTHALMICS
Ophthalmic Antibiotic/Steroid Combinations
Blephamide®
TobraDex® ointment
neomycin/poly B/dexameth
Maxitrol®
TobraDex® suspension
sulfacetamide/prednisolone
neomycin/poly B/HC
TobraDex® ST suspension
Pred-G®
Poly-Pred®
Zylet® PA
neomycin/BAC/poly B/HC
tobramycin/dexamethasone
suspension
Effective Date: February 1, 2015
TennCare Preferred Drug List (PDL) |
Page 35
Preferred Drugs
Non-Preferred Drugs
XII. OPHTHALMICS
Ophthalmic Antibiotics
AK-Poly-BACTM
ofloxacin
AzaSite®
Ocuflox®
bacitracin/poly B
polymyxin B/TMP
bacitracin
Polysporin®
ciprofloxacin
Romycin®
Besivance®
Polytrim®
erythromycin
sulfacetamide sodium drops
Bleph-10®
sulfacetamide ointment
Gentak®
tobramycin
Ciloxan®
Tobrex® solution
gentamicin
Tobrasol®
Garamycin®
Zymaxid®
Moxeza®
Tobrex® ointment
gatifloxacin 0.5% solution
neomycin/bac/poly B
Vigamox®
levofloxacin 0.5% solution
Neosporin®
neomycin/poly B/gramicidin
Ophthalmic Antifungals
Natacyn® PA
N/A
Ophthalmic Antivirals
Viroptic®
trifluridine
Ophthalmic Antihistamines
BepreveTM QL
Pataday® QL
ketotifen QL
ZirganTM PA > 5yr old
QL
azelastine QL
LastacaftTM QL
Elestat® QL
Optivar® QL
Emadine® QL
Patanol® QL
epinastine QL
Zaditor® QL
Ophthalmic Alpha-2 Agonists
apraclonidine
brimonidine tartrate 0.15%
Alphagan P®
Iopidine®
brimonidine tartrate 0.2%
Ophthalmic Beta Blockers
carteolol
timolol maleate
levobunolol
Betagan®
OptiPranolol®
betaxolol
timolol gel solution
Betimol
Timoptic®
®
Betoptic-S®
Timpoptic Occudose®
Istalol®
Timoptic-XE®
metipranolol
Ophthalmic Carbonic Anhydrase Inhibitors QL
Azopt® QL
dorzolamide/timolol QL
Cosopt® QL
Trusopt® QL
Cosopt PF® QL
dorzolamide QL
Ophthalmic Decongestants
naphazoline
Neo-Synephrine®
phenylephrine
Ophthalmic Mast Cell Stabilizers
Alocril®
Page 36
cromolyn sodium
|
TennCare Preferred Drug List (PDL)
Alamast®
Effective Date: February 1, 2015
Alomide®
Preferred Drugs
Non-Preferred Drugs
XII. OPHTHALMICS
Mydriatics and Mydriatic Combos
atropine
AK-PentolateTM
Isopto® Homatropine
Atropine CareTM
Cyclogyl®
Isopto Hyoscine®
cyclopentolate
CyclomydrilTM
Mydriacyl®
tropicamide
Isopto Atropine®
Ophthalmic NSAIDs Class PA
diclofenac PA
Acular® PA
Ilevro® PA
flurbiprofen PA
Acular LS® PA
Nevanac® PA
ketorolac PA
AcuvailTM PA
Ocufen® PA
BromdayTM PA
Voltaren® PA
bromfenac PA
Ophthalmic Prostaglandin Agonists QL
latanoprost QL
Lumigan® QL
Rescula® QL
Xalatan® QL
Travatan Z® QL
Zioptan® QL
Travoprost QL
Ophthalmic Steroids
Alrex®
prednisolone acetate
dexamethasone
Lotemax® Ointment
fluorometholone
Pred Mild®
Durezol®
Maxidex®
FML® ointment
Flarex®
prednisolone sodium phosphate
Lotemax® Susp
FML Forte®
Pred Forte®
FML Liquifilm®
Vexol®
Lotemax® Gel
Glaucoma Direct Acting Miotics
Isopto® Carpine
pilocarpine
Pilopine HS®
phospholine iodide
Glaucoma Combinations
Simbrinza® PA
Combigan® PA
Ophthalmic Immunomodulators Class PA, QL
N/A
Restasis® PA, QL
Ophthalmic Vasoconstrictors
AK-Dilate® 2.5%, 10%
NeofrinTM 2.5%, 10%
Albalon®
naphazoline
phenylephrine 2.5%, 10%
Mydfrin®
Ophthalmic Lubricants and Artificial Tears
N/A
Lacrisert® PA
Effective Date: February 1, 2015
TennCare Preferred Drug List (PDL) |
Page 37
Preferred Drugs
Non-Preferred Drugs
XII. OPHTHALMICS
Miscellaneous Ophthalmics
Cystaran® PA
N/A
Preferred Drugs
Non-Preferred Drugs
XIII. OTICS
Otic Quinolones
CiproDex® QL
Cipro HC® QL
ofloxacin otic QL
ciprofloxacin otic
Otic Steroid/Antibiotic Combinations
Cortomycin® Otic
Cortisporin® Otic
HC/neomycin/polymyxinB
Cortisporin®-TC Otic
Coly-Mycin® S
Miscellaneous Otics
acetic acid
acetic acid/antipyrine/benzo/
polycosonal
RE Benzotic®
acetic acid/aluminum
Acetasol HC®
RE Chlorphenylcaine®
acetic acid/HC
Aurax
Treagan®
benzocaine/antipyrine
DermOtic®
TriOxin
chloroxylenol/pramoxine
fluocinolone acetonide
VoSol®
Neotic®
VoSol® HC
Otic Edge®
Zinotic®
Pramotic®
Zinotic ES®
PR Otic®
Preferred Drugs
Non-Preferred Drugs
XIV. RENAL AND GENITOURINARY
Alpha Blockers for BPH
doxazosin
tamsulosin QL
alfuzosin QL
Minipress®
prazosin
terazosin
Cardura®
Rapaflo®
Cardura XL® QL
Uroxatral® QL
Flomax® QL
Androgen Hormone Inhibitors
Avodart® QL
finasteride QL
Combination Agents for BPH
Jalyn®PA, QL
N/A
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TennCare Preferred Drug List (PDL)
Effective Date: February 1, 2015
Proscar® QL
Preferred Drugs
Non-Preferred Drugs
XIV. RENAL AND GENITOURINARY
Phosphorus Depleters
calcium acetate
Phoslyra®
ferric citrate
Renvela® powder for suspension PA
EliphosTM
Renvela® tablets
Fosrenol®
sevelamer
PhosLo®
Velphoro® PA
Renagel®
Urinary Tract Antispasmodics
oxybutynin
Toviaz® QL
Detrol® QL
oxybutynin ER QL
tolterodine QL
VESIcare® QL
Ditropan XL® QL
Oxytrol® QL
Detrol LA® QL
Sanctura XR® QL
Enablex® QL
tolterodine ER QL
flavoxate QL
trospium QL
GelniqueTM QL
trospium XR QL
Myrbetriq®
Urinary Alkalizing Agents
citric acid/sodium citrate
potassium citrate
Citrolith®
Tricitrates®
Cytra-K® solution
potassium citrate/citric acid
Cytra-K® crystals
Urocit-K®
Cytra-2®
Ora-Cit®
Virtrate-3®
Cytra-3®
Polycitra-K®
Urinary Acidifying Agents
Renacidin® PA
acetic acid
K-Phos MF®
K-Phos Original®
K-Phos Neutral®
K-Phos #2®
Phospha Neutral®
Urinary Analgesics
Phenazo®
phenazopyridine
Pyridium®
Urinary Interstitial Cystitis Agents
Elmiron®
RIMSO-50®
N/A
Vaginal Antiseptics
N/A
Fem pHTM
Preferred Drugs
Non-Preferred Drugs
XV. RESPIRATORY
Anaphylaxis Therapy Agents
Epipen® QL
Epipen, Jr.® QL
Adrenaclick® QL
epinephrine injectable QL
Auvi-QTM PA, QL
Effective Date: February 1, 2015
TennCare Preferred Drug List (PDL) |
Page 39
Preferred Drugs
Non-Preferred Drugs
XV. RESPIRATORY
Anticholinergics, Inhaled QL
albuterol/ipratropium QL
Combivent Respimat® QL
DuoNeb® QL
Spiriva Respimat® QL
Atrovent® HFA QL
ipratropium solutionQL
Incruse Ellipta® QL
Combivent MDI® QL
Spiriva® QL
Tudorza® QL
Anticholinergics, Nasal QL
Atrovent 0.3%, 0.6%® QL
ipratropium 0.3%, 0.6% QL
Antihistamines, First Generation (Covered for recipients < 21 years old only)
brompheniramine maleate
Dytuss syrup
all formulations of brompheniramine tannate
Bromspiro
hydroxyzine
all formulations of chlorpheniramine tannate
carbinoxamine maleate
LoHist-12
all formulations of diphenhydramine tannate
chlorpheniramine maleate
promethazine
Aldex AN®
Palgic®
clemastine
dexchlorpheniramine
Vazol®
cyproheptadine hydrochloride
Doxytex®
Vistaril®
diphenhydramine HCl
J-Tan PD
Antihistamines, Non-Sedating (Covered for recipients < 21 years old only)
cetirizine chewable PA, QL
Allegra® QL
Clarinex-D 24 Hr® QL
cetirizine tabs QL
Allegra-D 12 Hr® QL
desloratadine QL
cetirizine syrup
Allegra-D 24 Hr® QL
desloratadine ODT PA, QL
cetirizine/PSE QL
Allegra ODT® PA, QL
fexofenadine
loratadine QL
Claritin® QL
fexofenadine/PSE QL
loratadine RDT PA, QL
Claritin® chewable PA, QL
levocetirizine QL
loratadine/PSE QL
Claritin-D 12 Hr® QL
Semprex®-D QL
Claritin-D 24 Hr® QL
Xyzal® QL
Claritin RediTabs® PA, QL
Zyrtec® QL
Clarinex® QL
Zyrtec® chewable PA, QL
Clarinex RediTabs® PA, QL
Zyrtec® ODT PA, QL
Clarinex-D 12 Hr® QL
Zyrtec-D® QL
Antihistamines, Nasal
QL
Astepro® PA, QL
Patanase® QL
Dymista® PA, QL
azelastine PA, QL
Beta Agonists: Combination Products
olopatadine QL
Class PA, QL
Advair Diskus® PA, QL
Dulera® PA, QL
Anoro Ellipta® PA, QL
Advair HFA® PA, QL
Symbicort® PA, QL
Breo Ellipta® PA, QL
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TennCare Preferred Drug List (PDL)
QL
Effective Date: February 1, 2015
Preferred Drugs
Non-Preferred Drugs
XV. RESPIRATORY
Beta Agonists: Long Acting MDI Class PA, QL
Serevent Diskus® PA, QL
Foradil® PA, QL
Arcapta® QL
Striverdi ® Respimat QL
Beta Agonists: Nebulizer
albuterol inhalation solution QL
AccuNeb® QL
Perforomist® PA, QL
Brovana® PA, QL
Xopenex® PA, QL
levalbuterol PA, QL
Beta Agonists: Short Acting MDI QL
Proventil HFA® QL
Maxair Autohaler® QL
Ventolin HFA® QL
ProAir® HFA QL
Xopenex HFA® PA, QL
Beta Agonist: Oral
albuterol syrup
albuterol ER
terbutaline
albuterol tabs
VoSpire ER®
metaproterenol
Cystic Fibrosis Agents QL
Bethkis® PA,QL
Cayston® PA, QL
TOBI® Podhaler® and inhalation
solution PA, QL
Pulmozyme® PA, QL
Kalydeco® PA, QL
tobramycin solution
300mg/5mL PA, QL
Expectorants
SSKI
N/A
Leukotriene Receptor Antagonists QL
montelukast tabs
and chewables PA, QL
Accolate® QL
zafirlukast QL
montelukast granules PA, QL
Zyflo® QL
Singulair® tabs and
chewables PA, QL
Zyflo CR® QL
Singulair® granules PA, QL
Mast Cell Stabilizers
cromolyn QL
N/A
Mucolytics
acetylcysteine
N/A
Non-Narcotic Antitussives Class PA
benzonatate PA
Tessalon® PA
Zonatuss® PA
Tessalon Perles® PA
Effective Date: February 1, 2015
TennCare Preferred Drug List (PDL) |
Page 41
Preferred Drugs
Non-Preferred Drugs
XV. RESPIRATORY
Steroids, Orally Inhaled QL
Asmanex Twisthaler® QL
Aerospan® QL
budesonide respules PA, QL
Flovent HFA® QL
Alvesco® QL
Pulmicort Respules® PA, QL
Pulmicort Flexhaler® QL
Arnuity Ellipta® QL
Flovent Diskus® QL
QVAR® QL
Asmanex HFA® QL
Steroids, Intranasal QL
fluticasone propionate QL
Beconase AQ® QL
Omnaris® QL
Nasonex® QL
budesonide nasal spray QL
Rhinocort Aqua® QL
Qnasl® QL
Flonase® QL
triamcinolone acetonide QL
flunisolide QL
Veramyst® QL
Nasacort® AQ QL
Zetonna® QL
Xanthine Derivatives
aminophylline
Dyphylline GG®
Difil®-G
COPD
Elixophyllin®
Dilex-G
DG 200
Jay-Phyl
Lufyllin®-GG
Difil®-G Forte
Lufyllin®
Theochron®
Dy-G®
Theo-24®
Dylix®
theophylline ER
Phosphodiesterase 4 Inhibitor
Daliresp® PA
N/A
Vasoconstrictors, Intranasal
Adrenalin®
N/A
Tyzine®
Preferred Drugs
Non-Preferred Drugs
XVI. SMOKING CESSATION AGENTS
Smoking Cessation Agents QL
bupropion SR QL
nicotine polacrilex lozenge QL
Commit® QL
Nicotrol® inhaler QL
Chantix® QL
nicotine transdermal patch QL
Nicoderm® CQ QL
Nicotrol® nasal spray QL
Nicorette® gum QL
Zyban® QL
nicotine polacrilex gum QL
Preferred Drugs
Non-Preferred Drugs
XVII. VITAMINS AND ELECTROLYTES
Cystine Depleting Agent
Procysbi® PA
Cystagon®
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TennCare Preferred Drug List (PDL)
Effective Date: February 1, 2015
Preferred Drugs
Non-Preferred Drugs
XVII. VITAMINS AND ELECTROLYTES
Fluoride Products
Denta 5000®
Phos-flur®
Fluor-a-day® Chewable
Luride®
Dentagel®
Renaf®
Gel-Kam®
Prevident®
Epiflur®
SF
Fluor-a-day® drops
SF 5000 Plus
Fluoritab®
sodium fluoride
Ludent®
Folic Acid Preparations
folic acid
Deplin® PA
l-methylfolate PA
FalessaTM PA
Q-Tabs®
PA
Kidney Stone Agents
Lithostat®
N/A
Thiola®
Multivitamins with Fluoride (Covered for recipients < 21 years old only)
All brand prescription products (various manufacturers)
All generic prescription products (various manufacturers)
Multivitamins with Iron (Covered for recipients < 21 years old only)
All brand OTC and prescription products
All generic OTC and prescription products
Potassium Depletors
Kalexate
sodium polystyrene sulfonate
Kayexalate®
SPS®
Kionex®
Potassium Supplements
Effer-K®
K-Effervescent®
Epiklor®
Micro K®
Kaon-CL®
K-Vescent®
K-tabs®
potassium chloride caps
Klor-Con®
potassium bicarbonate
Klor-Con® powder
Klor-Con/EF®
potassium chloride tabs and
solution
Klor-Con M®
potassium chloride,
microencapsulated
Prenatal Vitamins
All generic OTC and prescription products (various manufacturers)
All brand OTC and prescription products (various manufacturers)
Renal Vitamins
All OTC and generic prescription products (various manufacturers)
All brand prescription products (various manufacturers)
Vitamin D / Vitamin D-Analogs
calcitriol
ergocalciferol
Vitamin D
doxercalciferol PA
paricalcitol PA
Drisdol®
Rocaltrol®
Hectorol® PA
Zemplar® PA
Effective Date: February 1, 2015
TennCare Preferred Drug List (PDL) |
Page 43
Preferred Drugs
Non-Preferred Drugs
XVII. VITAMINS AND ELECTROLYTES
Vitamin K Products
Mephyton®
N/A
Zinc Supplements
zinc sulfate
Page 44
Zincate®
|
TennCare Preferred Drug List (PDL)
Galzin® PA
Effective Date: February 1, 2015