TennCare Preferred Drug List (PDL)
Effective May 1, 2016
PA – Prior Authorization required, subject to specific PA criteria; QL – Quantity Limit (PA and NP agents require a PA before dispensing);
B – Budgetary Reduction Edit for utilization control (The standard NP PA criteria does not apply); ID – Class Prior Authorization criteria for patients
with Intellectual or Developmental Disability
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 5310-205). 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
naltrexone PA
Agents for Opiate Detoxification
ReVia® PA
Bunavail® PA, QL
Buprenorphine and Buprenorphine/Naloxone
buprenorphine PA, QL
Suboxone® film PA, QL
buprenorphine/naloxone tablets PA, QL Zubsolv® PA, QL
COX-II Inhibitors PA
Celebrex® PA, QL
N/A
celecoxib PA, QL
Transmucosal Fentanyl Products
Abstral® PA, QL
N/A
Fentora® PA, QL
® PA, QL
Actiq
Lazanda ® PA, QL
fentanyl lozenge PA, QL
Subsys® PA, QL
Narcotics Agonist/Antagonists
butorphanol NS PA, QL
nalbuphine PA, QL
pentazocine/naloxone PA, QL
pentazocine/APAP PA, QL
Embeda® PA≥100mg, QL
Kadian® PA (≥100 mg), QL
Narcotics, Long Acting Narcotics
Avinza® PA, QL
fentanyl patch (excluding
37.5mcg/hr, 62.5mcg/hr, and
87.5mcg/hr) PA, QL
morphine sulfate SA PA (≥100 mg), QL
® PA, QL
Belbuca
morphine sulfate SR 24hr PA, QL
Butrans® PA, QL
MS Contin® PA, QL
® PA, QL
ConZip
Nucynta® ER PA,QL
Dolophine® PA, QL
Opana ER® PA, QL
Duragesic® PA, QL
OxyContin® PA, QL
Exalgo
® PA, QL
oxymorphone ER PA, QL
oxycodone ER PA, QL
fentanyl patch (37.5mcg/hr,
PA, QL
62.5mcg/hr, and 87.5mcg/hr)
hydromorphone ER PA, QL
®
Hysingla ER
tramadol ER PA, QL
PA, QL
tramadol ER 24 hr PA, QL
methadone PA, QL
tramadol ER PA, QL (generic for
Conzip®)
Methadose® PA, QL
morphine sulfate ER capsules
* Note that agents not listed on PDL may be considered non-covered
Proprietary & Confidential
© 2016 Magellan Health Services
Ultram ER® PA, QL
PA, QL
Zohydro ER® PA, QL
Preferred Drugs
Non-Preferred Drugs
I. Analgesics
Short-Acting Narcotics
morphine IR
(excluding suppositories)
butalbital/APAP/caff/codeine QL
Opana® QL
Endocet® QL
oxycodone tabs QL
butalbital/ASA/caff/codeine QL
Oxaydo® QL
hydrocodone/APAP QL
(excluding generic for Xodol)
oxycodone/APAP QL
Capital with Codeine® QL
oxymorphone QL
hydromorphone QL
(excluding suppositories)
tramadol QL
codeine QL
oxycodone caps QL
Endodan® QL
oxycodone/ASA QL
codeine/APAP
QL
QL
hydrocodone/ibuprofen QL
Demerol® QL
oxycodone/IBU QL
dihydrocodeine/APAP/codeine
QL
Panlor® SS QL
dihydrocodeine/ASA/codeine QL
Percocet® QL
Dilaudid® QL
Percodan® QL
®
QL
Primlev® QL
®
QL
Reprexain
Fioricet with Codeine
Fiorinal with Codeine
® QL
Hycet® QL
Roxicet® QL
hydrocodone/APAP 5/300
QL
Roxicodone® QL
hydrocodone/APAP 10/300 QL
Synalgos®-DC QL
hydromorphone suppositories
tramadol/APAP QL
Ibudone
® QL
Tylenol® with Codeine QL
Levorphanol QL
Tylox® QL
Lorcet® QL
Ultracet® QL
® QL
Lortab
Ultram® QL
Maxidone® QL
Vicodin® QL
Magnacet® QL
Vicodin HP QL
meperidine
QL
Vicoprofen® QL
Meperitab® QL
Xartemis™ XR QL
morphine suppositories
QL
Norco® QL
Xodol® QL
Zamicet® QL
Nucynta® QL
NSAID/Anti-Ulcer Agents
N/A
Arthrotec® PA
Duexis® PA
diclofenac/misoprostol PA
Vimovo® PA
Salicylates and Non-Narcotic Combination Agents
Be-Flex Plus
® QL
choline mag trisalicylate QL
® QL
Dologesic
Rhinoflex
® QL
salsalate QL
Tetra-Mag
® QL
Ed-Flex® QL
Acuflex® QL
Flextra DS® QL
Alpain® QL
Flextra-650® QL
® QL
Anabar
Lagesic® QL
Cafgesic® QL
Levacet® QL
Cafgesic Forte® QL
MST 600® QL
diflunisal
QL
Rhinoflex 650®
Durabac® QL
Zgesic® QL
Durabac Forte® QL
Zorprin® QL
QL
® QL
Flextra
* Note that agents not listed on PDL may be considered non-covered
Effective Date: May 1, 2016
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Preferred Drugs
Non-Preferred Drugs
I. Analgesics
Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)
diclofenac potassium
ketorolac
Anaprox®
QL
diclofenac sodium
meloxicam tablets
Anaprox DS
diclofenac sodium ER
nabumetone
Cambia®
ibuprofen
naproxen
Cataflam
indomethacin
sulindac
Clinoril®
Daypro
Mobic®
®
Motrin®
Nalfon®
®
Naprelan®
naproxen sodium ER
®
Naprosyn®
diclofenac sodium 1.5%
PA
Naproxen® CR
® PA
diclofenac gel (generic for Voltaren® Pennsaid
PA
gel)
EC-Naprosyn®
piroxicam
etodolac
Ponstel®
etodolac ER
oxaprozin
Feldene
®
Sprix® PA,QL
fenoprofen
Tivorbex® PA
Flector® PA, QL
tolmetin
flurbiprofen
Toradol® QL
indomethacin ER
Voltaren®
ketoprofen
Voltaren® gel PA
ketoprofen ER
Voltaren-XR®
meclofenamate
Zipsor®
mefenamic acid
Zorvolex® PA
meloxicam suspension
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
cefuroxime tabs PA
cefprozil
cefaclor suspension
Ceftin® suspension PA
cefaclor ER
Ceftin® tabs
Antibiotics: Cephalosporins Third Generation
cefdinir
Suprax
®
Cedax®
cefpodoxime
cefditoren
ceftibuten
cefixime suspension
Spectracef®
Antibiotics: Ketolides
Ketek® PA
N/A
* Note that agents not listed on PDL may be considered non-covered
Effective Date: May 1, 2016
TennCare Preferred Drug List (PDL)
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Preferred Drugs
Non-Preferred Drugs
II. ANTI-INFECTIVES
Antibiotics: Macrolides
Biaxin®
erythromycin brand products
azithromycin suspension PA
Biaxin XL® QL
Zithromax® QL
clarithromycin
clarithromycin ER/XL QL
Zmax® QL
erythromycin generic products
Dificid® PA, QL
azithromycin QL
erythromycin/sulfisoxazole
Antibiotics: Methenamine and Combo
all generic combinations of
methenamine, phenylsalicylate,
hyoscyamine, atropine, etc.
methenamine mandelate
methenamine hippurate
all brand combinations of
methenamine, phenyl salicylate,
hyoscyamine, atropine, etc.
Hiprex®
Uroqid Acid #2®
Antibiotics: Miscellaneous Agents for UTI
Monurol® QL, PA
N/A
Antibiotics: Non-Absorbable Rifamycin
Xifaxan® PA, QL
N/A
Antibiotics: Oral Aminoglycosides
neomycin
Neo-Fradin
®
N/A
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®
clindamycin pediatric solution PA
Cleocin® Pediatric granules PA
Antibiotics: Oral Nitrofurans
nitrofurantoin capsules
nitrofurantoin suspension PA
Furadantin® PA
Macrodantin®
®
Macrobid
Antibiotics: Oxazolidinones
linezolid suspension
N/A
linezolid tabs
QL
PA, QL
Sivextro® PA, QL
Zyvox® PA, QL
Antibiotics: Penicillins
amoxicillin
dicloxacillin
all brand penicillins
amoxicillin/clavulanate
penicillin
amoxicillin/clavulanic acid XR
amoxicillin ER
* Note that agents not listed on PDL may be considered non-covered
Effective Date: May 1, 2016
TennCare Preferred Drug List (PDL)
|
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Preferred Drugs
Non-Preferred Drugs
II. ANTI-INFECTIVES
Antibiotics: Quinolones
ciprofloxacin
Avelox® PA
levofloxacin tabs
Levaquin® tabs
® PA
Avelox ABC Pack
Levaquin® solution PA
Cipro® tablets
levofloxacin solution PA
Cipro® suspension PA
ciprofloxacin suspension
moxifloxacin PA
PA
ciprofloxacin ER QL
Factive
Noroxin® PA
ofloxacin
® PA
Antibiotics: Tetracyclines
doxycycline monohydrate 50 and 100 mg caps
Adoxa®
minocycline ER PA, QL
doxycycline hyclate 50 and 100mg
demeclocycline PA
minocycline capsules and tablets
minocycline capsules
doxycycline hyclate DR particles
Morgidox®
tetracycline
doxycycline hyclate 20mg PA, QL
Ocudox® Kit
doxycycline monohydrate 75 mg
and 150 mg caps
Oracea®
doxycycline monohydrate powder
for suspension (generic for
Vibramycin®)
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
griseofulvin suspension
Ancobon® PA
ketoconazole PA
fluconazole suspension PA
nystatin
Cresemba® PA
Lamisil® PA, QL
fluconazole tablets QL
terbinafine PA, QL
Diflucan® suspension PA
®
Diflucan tablets
griseofulvin ultramicrosize
QL
Noxafil® PA
Onmel® PA, QL
flucytosine PA
Oravig® PA
Grifulvin V®
Sporanox® PA, QL
griseofulvin microsize
Terbinex® PA, QL
Gris-Peg®
Vfend® PA
itraconazole PA, QL
voriconazole PA
Antifungals: Vaginal
miconazole-3 kit
AVC® cream
terconazole
®
Gynazole-1
nystatin
miconazole-3 vaginal supp
Terazol®
Anti-Infectives: Amebicides
N/A
paromomycin
* Note that agents not listed on PDL may be considered non-covered
Effective Date: May 1, 2016
TennCare Preferred Drug List (PDL)
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Preferred Drugs
Non-Preferred Drugs
II. ANTI-INFECTIVES
Anti-Infectives: Antimalarials
atovaquone/proguanil
mefloquine
Aralen®
chloroquine
primaquine
Coartem®
dapsone
Malarone®
Daraprim
quinine sulfate
Qualaquin®
®
Anti-Infectives: Anthelmintics
Albenza
®
Biltricide
Emverm® PA
®
Stromectol
®
Anti-Infectives: Miscellaneous Antiprotozoal Agents
metronidazole tabs
Alinia® PA
Flagyl® ER
atovaquone PA
Mepron® PA
Flagyl®
metronidazole caps
Anti-Infectives: Oral Nitroimidazoles
Flagyl®
metronidazole tabs
Tindamax®
®
Flagyl ER
Tinidazole
metronidazole caps
Anti-Infectives: Vaginal Antibiotics
Cleocin suppositories
metronidazole 0.75% gel
Cleocin® cream
MetroGel® Vaginal
clindamycin phos 2% cream
Vandazole®
Clindesse® vaginal cream
Nuvessa®
®
Antivirals: Cytomegalovirus Agents
Valcyte
®
valganciclovir
Antivirals: Hepatitis B
Baraclude
®
® QL
Epivir-HBV
adefovir PA
lamivudine-HBV QL
entecavir
Tyzeka® PA
® PA
Hepsera
Antivirals: Hepatitis C Pegylated Interferons
®
Pegasys ProClick
PA>24 weeks, QL
Pegasys® syringes PA>24 weeks, QL
Pegasys Conv. Pack® PA>24 weeks, QL
PEG-Intron® QL
PEG-Intron Redipen® QL
Pegasys® vials PA>24 weeks, QL
Antivirals: Hepatitis C Antivirals
Daklinza
® PA, QL
®
Viekira Pak
PA, QL
Technivie® PA, QL
Harvoni® PA, QL
Sovaldi® PA, QL
Olysio®
Zepatier® PA, QL
PA, QL
Antivirals: Hepatitis C Ribavirins
®
Ribasphere 200 mg tablets
Copegus®
ribavirin tablets
ribavirin capsules
®
Moderiba dose pack
Ribapak®
Rebetol® capsules
Ribasphere® 200mg capsules
Rebetol® solution PA
Ribasphere® 400 and 600 mg tablets
Antivirals: Herpes
acyclovir caps and tabs
famciclovir
®
Zovirax suspension
acyclovir suspension
® QL
QL
Valtrex® QL
Zovirax® caps and tabs
Famvir
Sitavig® buccal tabs QL
valacyclovir QL
* Note that agents not listed on PDL may be considered non-covered
Effective Date: May 1, 2016
TennCare Preferred Drug List (PDL)
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Page 6
Preferred Drugs
Non-Preferred Drugs
II. ANTI-INFECTIVES
Antivirals: HIV CCR5 Antagonists
Selzentry
® PA, QL
N/A
Antivirals: Cytochrome P450 Inhibitors
Tybost®
N/A
Antivirals: HIV Fusion Inhibitors
Fuzeon
® PA, QL
N/A
Antivirals: HIV Integrase Inhibitors
® QL
Genvoya
Isentress
Tivicay
® PA, QL
® PA, QL
Vitekta
N/A
® PA, QL
Antivirals: HIV NNRTIs
®
Edurant
nevirapine
Intelence
® PA, QL
Sustiva
nevirapine ER QL
QL
® QL
® QL
Viramune® QL
Viramune® XR QL
Rescriptor
Antivirals: HIV NRTIs
abacavir
Descovy
QL
Emtriva
Odefsey
® QL
didanosine capsules
Retrovir® QL
® QL
stavudine
QL
® QL
®
Videx solution
Videx® capsules QL
® QL
QL
Zerit
QL
Viread® QL
Epivir® QL
Ziagen® QL
lamivudine QL
zidovudine QL
Antivirals: HIV NRTI Combos
abacavir/lamivudine/
zidovudine PA, QL
lamivudine/zidovudine QL
Atripla® QL
Stribild® QL
® QL
Combivir
Triumeq® QL
Complera® QL
Trizivir® PA, QL
Epzicom
® QL
N/A
Truvada® QL
Antivirals: HIV Protease Inhibitors
Aptivus® PA, QL
® QL
Evotaz
Invirase
Kaletra
® QL
® QL
Lexiva® QL
Crixivan® QL
Norvir® QL
Prezcobix
® QL
Prezista® QL
Reyataz® caps and powder QL
Viracept® QL
Antivirals: Influenza
Relenza® PA, QL
N/A
Tamiflu® PA, QL
Preferred Drugs
Non-Preferred Drugs
III. CARDIOVASCULAR
Alpha/Beta Blockers
labetalol
carvedilol
QL
Coreg® QL
Trandate®
Coreg CR® QL
* Note that agents not listed on PDL may be considered non-covered
Effective Date: May 1, 2016
TennCare Preferred Drug List (PDL)
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Preferred Drugs
Non-Preferred Drugs
III. CARDIOVASCULAR
Alpha-Blockers
doxazosin
Cardura®
prazosin
Minipress®
terazosin
ACE Inhibitors
benazepril
lisinopril
Accupril®
perindopril QL
captopril
ramipril QL
Aceon® QL
Prinivil®
Altace® QL
Quinapril
enalapril
® PA
Epaned
trandolapril QL
fosinopril
Univasc® QL
Lotensin®
Vasotec®
Mavik® QL
Zestril®
moexipril QL
ACEI + Calcium Channel Blocker Combo
benazepril/amlodipine
N/A
PA,QL
® PA, QL
Lotrel
Tarka® PA, QL
trandolapril/verapamil
PA,QL
Prestalia® PA, QL
ACEI + Diuretic Combination
captopril/HCTZ
lisinopril/HCTZ
enalapril/HCTZ
Accuretic®
Prinzide®
benazepril/HCTZ PA
quinapril/HCTZ
fosinopril/ HCTZ
Uniretic®
®
Lotensin HCT
Vaseretic®
moexipril/HCTZ
Zestoretic®
Angiotensin II Receptor Blockers
losartan QL
Atacand® QL
eprosartan
Avapro®
irbesartan
QL
® QL
Micardis
QL
telmisartan
candesartan® QL
Teveten®
® QL
QL
QL
valsartan QL
Diovan
Edarbi®
QL
® QL
Benicar
Cozaar®
QL
QL
Angiotensin II Receptor Blockers + Calcium Channel Blocker PA, QL
amlodipine /valsartan
PA, QL
amlodipine/valsartan/HCTZ PA, QL
Azor® PA, QL
telmisartan/amlodipine PA, QL
Exforge® PA, QL
Tribenzor® PA, QL
Exforge HCT® PA, QL
Twynsta® PA, QL
Angiotensin II Receptor Blockers + Diuretic
® QL
losartan/HCTZ
Atacand HCT®
Hyzaar®
Avalide®
irbesartan/HCTZ
Benicar HCT® QL
Micardis HCT® QL
candesartan/HCTZ
® QL
QL
telmisartan/ HCTZ
QL
®
Diovan HCT
Teveten HCT
Edarbyclor® QL
valsartan/ HCTZ QL
* Note that agents not listed on PDL may be considered non-covered
Effective Date: May 1, 2016
TennCare Preferred Drug List (PDL)
|
Page 8
Preferred Drugs
Non-Preferred Drugs
III. CARDIOVASCULAR
Angiotensin II Receptor Blockers + Neprilysin Inhibitor PA,QL
Entresto® PA, QL
Anti-Anginal Agents: Miscellaneous
Corlanor® PA, QL
N/A
Ranexa® PA
Anti-Anginal Agents: Nitrates
Isochron
®
nitroglycerin (excluding spray)
Nitrolingual®
isosorbide dinitrate
(excluding 10 mg tabs and SL tabs)
isosorbide mononitrate
Nitrostat®
Minitran®
amyl nitrite
Monoket®
Dilatrate-SR®
Nitro-Bid®
Imdur®
Nitro-Dur®
Isordil®
nitroglycerin spray
Isosorbide dinitrate 10 mg tabs
NitroMist®
isosorbide dinitrate, sublingual
Anti-Arrhythmics, Oral
amiodarone
quinidine sulfate
Betapace®
disopyramide
sotalol
Betapace AF®
flecainide
Cordarone
sotalol AF
Pacerone®
propafenone ER
®
Rythmol®
Multaq
Rythmol SR®
propafenone
Norpace®
Sorine®
quinidine gluconate
Norpace CR®
Tambocor®
mexiletine
Tikosyn
® PA
® QL
Anti-Hypertensives, Miscellaneous
Catapres-TTS
® QL
methyldopa/HCTZ
Catapres®
Nexiclon® XR
clonidine weekly TD patch
clonidine
®
Clorpres
hydralazine
guanabenz
minoxidil
reserpine
Tenex®
guanfacine
methyldopa
QL
Vecamyl® PA, QL
PA
* Note that agents not listed on PDL may be considered non-covered
Effective Date: May 1, 2016
TennCare Preferred Drug List (PDL)
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Page 9
Preferred Drugs
Non-Preferred Drugs
III. CARDIOVASCULAR
Beta Blockers
atenolol
propranolol (excluding solution)
metoprolol tartrate (excluding 37.5
and 75 mg)
Betapace
sotalol
metoprolol succinate PA, QL
acebutolol
®
metoprolol tartrate 37.5 & 75 mg
betaxolol
nadolol
pindolol
bisoprolol fumarate
PA
propranolol solution PA
®
propranolol ER
®
Sectral®
Bystolic
Corgard
Hemangeol®
PA
Sorine®
®
Sotylize® PA
Inderal XL®
Tenormin®
InnoPran XL® QL
timolol maleate
Levatol® QL
Toprol XL® PA, QL
Lopressor®
Zebeta®
Inderal LA
Beta Blockers + Diuretic
atenolol/chlorthalidone
Corzide®
propranolol HCT
nadolol/bendroflumethiazide
® PA, QL
Dutoprol
bisoprolol HCT
®
Lopressor HCT
metoprolol HCT
Tenoretic®
Ziac®
Calcium Channel Blockers (DHP)
amlodipine
QL
felodipine ER
nicardipine
nifedipine ER/SA/XL
QL
Adalat CC® QL
Norvasc® QL
Cardene SR® QL
Nymalize® PA
isradipine QL
Procardia®
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
QL
verapamil ER PM
®
Verelan®
® QL
Verelan PM®
PA, QL
Tekturna HCT® PA, QL
Cardizem CD
Cardizem LA
Dilacor XR®
Cardiac Glycosides
Lanoxin®
digoxin
Direct Renin Inhibitors PA
Amturnide®
N/A
Tekamlo® PA, QL
Tekturna® PA, QL
Diuretics: Potassium Sparing
acetazolamide
methazolamide
Diamox® Sequels
Keveyis® PA, QL
* Note that agents not listed on PDL may be considered non-covered
Effective Date: May 1, 2016
TennCare Preferred Drug List (PDL) |
Page 10
Preferred Drugs
Non-Preferred Drugs
III. CARDIOVASCULAR
Diuretics: Combination Diuretics
amiloride/HCTZ
Aldactazide®
triamterene/HCTZ
Dyazide
spironolactone/HCTZ
Maxzide®
®
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
PA
12.5mg tab
Thalitone®
methyclothiazide
Zaroxolyn®
hydrochlorothiazide
(excluding 12.5mg tab)
Hemostatics, Oral
®
Amicar
aminocaproic acid
Lysteda
® PA, QL
N/A
tranexamic acid
PA, QL
Intermittent Claudication
cilostazol
pentoxifylline
Pletal®
PA
Trental® PA
Lipotropics: Bile Acid Sequestrants
®
cholestyramine
Prevalite
cholestyramine light
WelChol® tablets
Colestid®
Questran Light®
Questran®
WelChol® packets PA
colestipol
Lipotropics: Cholesterol Absorption Inhibitors
Zetia® PA, QL
N/A
Lipotropics: Fibric Acid Derivatives
gemfibrozil
Antara® PA
Lipofen® PA
TriCor® PA
fenofibric acid PA
Lofibra® PA
TriLipix® PA
fenofibrate PA
Lopid®
Fenoglide
® PA
Triglide® PA
Fibricor® PA
Lipotropics: Miscellaneous
Juxtapid® PA, QL
Kynamro® PA, QL
Lipotropics: Niacin Derivatives PA
niacin ER PA
Niaspan® PA
Niacor® PA
Lipotropics: Omega-3 Fatty Acids PA
® PA
® PA
Lovaza
N/A
Vascepa
omega-3 acid ethyl esters PA
* Note that agents not listed on PDL may be considered non-covered
Effective Date: May 1, 2016
TennCare Preferred Drug List (PDL) |
Page 11
Preferred Drugs
Non-Preferred Drugs
III. CARDIOVASCULAR
Lipotropics: PCSK-9 Inhibitors
Praluent® PA, QL
Repatha® PA, QL
Lipotropics: Standard Potency Statins QL
lovastatin QL
simvastatin
QL
(5 mg, 10 mg, 20 mg, 40 mg)
Altoprev® QL
Livalo® QL
fluvastatin QL
pravastatin QL
Mevacor® QL
QL
fluvastatin ER
Lescol® QL
Pravachol® QL
Zocor® (5 mg, 10 mg, 20 mg, 40 mg) QL
Lescol XL® QL
Lipotropics: High Potency Statins QL
atorvastatin QL
Lipitor® QL
simvastatin 80 mg PA, QL
Zocor® 80 mg PA, QL
® QL
Crestor
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
heparin
Arixtra® QL
Fragmin®
Lovenox® QL
enoxaparin QL
Oral Anticoagulants
Coumadin
®
Jantoven®
warfarin
Eliquis® PA, QL
Savaysa® PA
Xarelto® PA, QL
Pradaxa® PA, QL
Oral Thrombopoietin Agonists
Promacta® PA, QL
N/A
Peripheral Vasodilators
ergoloid mesylates
Pheochromocytoma Agents
Demser® PA
N/A
dibenzyline
phenoxybenzamine PA, QL
PA, QL
Platelet Inhibitors
Aggrenox
clopidogrel 75 mg
Agrylin®
Persantine®
anagrelide
dipyridamole
aspirin/dipyridamole
Plavix®
Brilinta® PA, QL
ticlopidine
clopidogrel 300 mg
Pletal®
®
® PA, QL
Zontivity® PA, QL
Durlaza
cilostazol
Effient® PA
Pulmonary Arterial Hypertension Agents 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
Uptravi® PA, QL
* Note that agents not listed on PDL may be considered non-covered
Effective Date: May 1, 2016
TennCare Preferred Drug List (PDL) |
Page 12
Preferred Drugs
Non-Preferred Drugs
III. CARDIOVASCULAR
Pulmonary Fibrosis Agents
Esbriet® PA,QL
N/A
Ofev® PA,QL
Vasopressors
Northera® PA, QL
midodrine
Vasodilator/Nitrate Combinations
BiDil® PA
N/A
Preferred Drugs
Non-Preferred Drugs
IV. CENTRAL NERVOUS SYSTEM
Agents for Neuropathic Pain
duloxetine
PA, QL
gabapentin capsules QL
duloxetine caps
(generic for Irenka®) PA, QL
Irenka® PA, QL
Cymbalta® PA, QL
lidocaine patch PA
gabapentin solution PA, QL
Lidoderm® PA
gabapentin tablets PA, QL
Lyrica® PA
Gralise
® PA, QL
Neurontin® QL
Horizant® PA, QL
Neurontin® solution PA, QL
Alzheimer’s: Cholinesterase Inhibitors
donepezil
QL
(excluding 23 mg)
donepezil ODT PA, QL
®
Exelon patch
QL
galantamine tablets
Aricept® ODT PA, QL
galantamine ER QL
Aricept® QL
Razadyne®
®
Aricept 23 mg tablet
PA, QL
donepezil 23 mg PA, QL
®
Razadyne ER® QL
rivastigmine
rivastigmine patch QL
Exelon
galantamine solution
Alzheimer’s: NMDA Receptor Antagonists
memantine tablets
PA, QL
memantine solution PA, QL
Namenda XR® PA, QL
Namenda® PA, QL
Namzaric® PA, QL
Antiparkinson’s Agents: Anticholinergics
benztropine
trihexyphenidyl
N/A
Antiparkinson’s Agents: Decarboxylase Inhibitors
Lodosyn®
carbidopa
Antiparkinson’s Agents: Dopamine Precursors/Decarboxylase Inhibitors
carbidopa/levodopa
carbidopa/levodopa ER/SR
Parcopa®
Sinemet®
Rytary®
Sinemet® CR
Antiparkinson’s Agents: COMT Inhibitors and Combos
carbidopa/levodopa/entacapone
Stalevo
Comtan®
®
tolcapone
®
Tasmar
entacapone
* Note that agents not listed on PDL may be considered non-covered
Effective Date: May 1, 2016
TennCare Preferred Drug List (PDL) |
Page 13
Preferred Drugs
Non-Preferred Drugs
IV. CENTRAL NERVOUS SYSTEM
Antidepressants: SSRIs ID
Brisdelle® PA
paroxetine CR QL
Celexa® QL
Paxil® QL
escitalopram solution
Paxil CR® QL
fluvoxamine QL
fluoxetine tablets QL
Pexeva® QL
Lexapro®solution
fluoxetine (PMDD) QL
Prozac® QL
citalopram QL
escitalopram tabs QL
fluoxetine capsules
paroxetine
QL
QL
fluoxetine weekly
sertraline QL
PA, QL
Prozac Weekly® PA, QL
fluvoxamine ER QL
Sarafem® QL
Lexapro® tabs QL
Viibryd® QL
® QL
Zoloft® QL
Luvox CR
Antidepressants: SSRI/SRMs ID
Brintellix® PA, QL
N/A
Antidepressants: SNRIs ID
Cymbalta® PA, QL
duloxetine PA, QL
venlafaxine ER caps
QL
desvenlafaxine
Irenka® PA, QL
PA, QL
Khedezla® PA, QL
desvenlafaxine ER PA, QL
desvenlafaxine fumarate ER
Pristiq® PA, QL
PA, QL
Savella® PA, QL
duloxetine caps
(generic for Irenka®) PA, QL
venlafaxine PA, QL
Effexor XR® PA, QL
venlafaxine ER tabs PA, QL
® PA, QL
Fetzima
Antidepressants: New Generation ID
budeprion SR
mirtazapine
Aplenzin®
Remeron SolTab® PA
budeprion XL QL
mirtazapine rapdis PA
Forfivo XL®
trazodone 300 mg
bupropion IR/SR
trazodone (excluding 300 mg)
nefazodone
Wellbutrin®
bupropion XL
QL
Oleptro
® QL
Wellbutrin SR®
Remeron®
maprotiline
Wellbutrin XL® QL
Antidepressants: Tricyclics ID
amoxapine
amitriptyline
protriptyline
® PA
Surmontil®
Anafranil
desipramine
PA
Tofranil®
doxepin
clomipramine
imipramine
imipramine pamoate
Tofranil-PM®
nortriptyline
Norpramin®
Vivactil®
®
Pamelor
Antidepressants: MAOIs PA, QL, ID
phenelzine PA, QL
Emsam® PA, QL
Parnate® PA, QL
Marplan® PA, QL
tranylcypromine PA, QL
Nardil® PA, QL
* Note that agents not listed on PDL may be considered non-covered
Effective Date: May 1, 2016
TennCare Preferred Drug List (PDL) |
Page 14
Preferred Drugs
Non-Preferred Drugs
IV. CENTRAL NERVOUS SYSTEM
Antipsychotics: Typical ID
chlorpromazine
pimozide
molindone
fluphenazine
thioridazine
Orap®
haloperidol
thiothixene
loxapine
trifluoperazine
perphenazine
Antipsychotics: Atypical PA, ID
Abilify®tabs PA, QL
risperidone ODT PA, QL
Abilify® solution
aripiprazole ODT PA, QL
Saphris® PA, QL
Abilify Maintena®
aripiprazole solution PA, QL
Seroquel® XR PA, QL
aripiprazole tabs PA, QL
clozapine
PA
ziprasidone
PA, QL
Invega® Trinza®
PA, QL
paliperidone PA, QL
Rexulti® PA, QL
® PA
PA, QL
Latuda® PA, QL
olanzapine PA, QL
PA, QL
Aristada
Risperdal® PA, QL
Clozaril® PA
Risperdal Consta® PA, QL
clozapine ODT PA
Risperdal M-tab® PA, QL
Fanapt
Zyprexa® PA, QL
quetiapine PA, QL
FazaClo ODT® PA, QL
Seroquel® PA, QL
risperidone PA, QL
Geodon® PA, QL
Versacloz® suspension PA
olanzapine ODT
® PA, QL
PA, QL
® PA, QL
Vraylar® PA, QL
Invega
Invega® Sustenna®
PA, QL
Zyprexa Zydis® PA, QL
Atypical Antipsychotic and SSRI Combinations PA, ID
fluoxetine/olanzapine PA, QL
N/A
Symbyax® PA, QL
Anti-Migraine: Combination Agents
butalbital/APAP
QL
butalbital/APAP/caff QL
Cafergot®
butalbital/ASA/caff QL
Margesic® QL
butalbital/APAP/caff/codeine QL
butalbital/ASA/caff/codeine
Fiorinal® with codeine QL
QL
isomethept/caffeine/APAP QL
Migergot®
Fioricet® with codeine QL
Anti-Migraine: 5-HT1 Receptor Agonists QL
Imitrex Nasal® QL
rizatriptan QL
Relpax® QL
rizatriptan ODT QL
Alsuma® QL
naratriptan QL
almotriptan PA, QL
sumatriptan kits PA, QL
® QL
QL
Amerge
sumatriptan tabs QL
Axert® QL
sumatriptan vials
sumatriptan nasal QL
Sumavel® DosePro®
Frova® QL
Treximet® QL
frovatriptan
QL
Imitrex® Injectable QL
®
Imitrex Kit
PA, QL
PA, QL
Zecuity® PA, QL
Zembrace® Symtouch® PA, QL
Zomig® QL
Imitrex® tablets QL
Zomig® spray QL
Maxalt® QL
Zomig ZMT® QL
® QL
Maxalt MLT
zolmitriptan QL
Anti-Migraine: Ergotamine Derivatives
Migranal® PA, QL
N/A
* Note that agents not listed on PDL may be considered non-covered
Effective Date: May 1, 2016
TennCare Preferred Drug List (PDL) |
Page 15
Preferred Drugs
Non-Preferred Drugs
IV. CENTRAL NERVOUS SYSTEM
Antihyperkinesis: Stimulants PA ≥ 21 years old
Adderall XR® PA ≥ 21, QL
Adderall® PA ≥ 21, QL
methylphenidate PA ≥ 21
PA ≥ 21, QL
®
Evekeo® PA ≥ 21, QL
PA ≥ 21, QL
Metadate CD® PA ≥ 21, QL
amphetamine salt IR combo
methylphenidate ER (excluding
generic for Ritalin LA®) PA ≥ 21, QL
Adzenys XR ODT
dextroamphetamine PA ≥ 21, QL
methylphenidate SA OSM PA ≥ 21, QL
amphetamine salt ER comb PA ≥ 21, QL methamphetamine PA ≥ 21, QL
Focalin® PA ≥ 21
ProCentra® PA ≥ 21, QL
Aptensio®XR PA ≥ 21, QL
Methylin® soln and chewable PA ≥ 21
Focalin XR
Quillichew ER
Concerta
methylphenidate CR PA ≥ 21, QL
Metadate ER® PA ≥ 21, QL
Quillivant XR® PA ≥ 21, QL
Daytrana® PA ≥ 21, QL
methylphenidate ER (generic for
Ritalin LA®) PA ≥ 21, QL
Methylin ER® PA ≥ 21, QL
Vyvanse® PA ≥ 21, QL
Desoxyn® PA ≥ 21, QL
methylphenidate soln & chewables
(generic for Methylin®) PA ≥ 21
Dexedrine Spansule® PA ≥ 21, QL
methylphenidate SR 24 hr PA ≥ 21, QL
dexmethylphenidate PA ≥ 21
Ritalin® PA ≥ 21
® PA ≥ 21, QL
® PA ≥ 21, QL
® PA ≥ 21, QL
Methylin® tabs PA ≥ 21
dexmethylphenidate XR
PA ≥ 21, QL
dextroamphetamine soln
PA ≥ 21, QL
Ritalin LA
® PA ≥ 21, QL
® PA ≥ 21, QL
Zenzedi
Max cumulative amphetamine dose: Patients ≥ 21: 60 mg/day; Patients ≤ 20: 80 mg/day
Antihyperkinesis: Non-Stimulants
clonidine
guanfacine ER
guanfacine
Strattera® QL
clonidine ER PA, QL,B
QL
Kapvay® PA, QL, B
Intuniv® PA, QL
Agents for Narcolepsy
modafinil PA, QL
Provigil® PA, QL
Xyrem® PA, QL
Nuvigil® PA, QL
* Note that agents not listed on PDL may be considered non-covered
Effective Date: May 1, 2016
TennCare Preferred Drug List (PDL) |
Page 16
Preferred Drugs
Non-Preferred Drugs
IV. CENTRAL NERVOUS SYSTEM
Anticonvulsants
levetiracetam ER
Banzel® PA
Lamictal® ODT PA
carbamazepine (generic for
Carbatrol®)
oxcarbazepine
carbamazepine tabs and suspension
(generic for Tegretol®)
Lamictal® XR
Depakote® Sprinkles
phenobarbital PA
carbamazepine ER
lamotrigine ER
Aptiom
® PA
® PA, QL
PA (< 1 year, PA not
®
Carbatrol
lamotrigine ODT
Phenytek®
Celontin®
Lyrica® PA
Dilantin® Infatabs®
phenytoin
clonazepam tabs and ODT PA, QL
Mysoline®
divalproex
primidone
Depakene®
Neurontin® QL
Diastat
phenobarbital elixir
Dilantin Kapseal® 30 mg
required)
®
PA
Neurontin® solution PA, QL
divalproex extended release
topiramate
Depakote
divalproex DR sprinkles
Tegretol® (excluding chewables)
Depakote® ER
Onfi® PA
Equetro®
Tegretol-XR®
diazepam rectal gel PA, QL
Oxtellar XR®
®
®
ethosuximide
valproic acid
Dilantin-125
Peganone
gabapentin capsules QL
Vimpat® PA
Dilantin Kapseal® 100 mg
Potiga® PA
lamotrigine tabs
zonisamide
Qudexy® XR PA, QL
lamotrigine chewable tabs
felbamate PA
Sabril® PA
levetiracetam
Felbatol® PA
Stavzor®
® PA, QL
Tegretol®chewables
Fycompa
gabapentin solution PA, QL
gabapentin tablets
PA, QL
®
tiagabine
Topamax®
Gabitril
topiramate ER PA, QL
Keppra®
Trileptal®
Keppra® XR
Trokendi XR® PA, QL
® PA, QL
Klonopin
Zarontin®
Lamictal® tabs and chewable tabs
Zonegran®
Agents for RLS (Restless Leg Syndrome)
pramipexole
QL
ropinirole
Horizant® PA, QL
Neupro® PA
Mirapex® QL
Requip®
Amyotrophic Lateral Sclerosis (ALS)
®
riluzole
Rilutek
Anti-Anxiety Agents ID
alprazolam PA, QL
buspirone (excluding 30 mg)
alprazolam ER PA, QL
diazepam PA, QL
lorazepam
PA, QL
alprazolam ODT
PA, QL
oxazepam 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 XR PA, QL
®
Cholinergic Muscle Stimulants
®
Mestinon syrup
pyridostigmine 60 mg tab
Mytelase®
Prostigmin®
Mestinon® 60 mg tab
Mestinon® 180mg ER tab
* Note that agents not listed on PDL may be considered non-covered
Effective Date: May 1, 2016
TennCare Preferred Drug List (PDL) |
Page 17
Preferred Drugs
Non-Preferred Drugs
IV. CENTRAL NERVOUS SYSTEM
Non-Ergot Dopamine Receptor Agonists
pramipexole
QL
Parlodel®
bromocriptine
ropinirole
®
Cycloset
Requip®
Mirapex® QL
Requip® XL
Mirapex® ER QL
pramipexole ER QL
Neupro
® PA
ropinirole ER
MAOI-Bs
selegiline
Azilect®
N/A
Zelapar® PA
Eldepryl®
Miscellaneous CNS Agents
Nuedexta® PA, QL
N/A
Mood Stabilizers
®
lamotrigine tabs
lithium carbonate SA
carbamazepine tabs and suspension
Lamictal XR
lamotrigine chewable tabs
lithium citrate
Depakote®
lamotrigine ER
levetiracetam
oxcarbazepine
Depakene
®
lithium carbonate
valproic acid
Keppra®
Tegretol®
Lamictal® tabs
Trileptal®
Lamictal® chewable tabs
Lithobid®
Stavzor®
Lamictal® ODT PA
Sedative Hypnotic Agents QL, ID
zaleplon QL
Ambien® QL
Lunesta® QL
zolpidem QL
Ambien CR® QL
Restoril® PA, QL
® QL
Belsomra
Rozerem® QL
eszopiclone QL
Silenor® PA, QL
Edluar®
Sonata® QL
PA, QL
estazolam
PA, QL
temazepam PA, QL
flurazepam PA, QL
triazolam PA, QL
Halcion® PA, QL
zolpidem ER QL
® PA, QL
Hetlioz
zolpidem tartrate SL QL
Intermezzo® QL
Zolpimist® PA, QL
Skeletal Muscle Relaxants
baclofen
chlorzoxazone
cyclobenzaprine
methocarbamol
orphenadrine/ASA/caffeine
tizanidine tablets
dantrolene
Amrix® QL
carisoprodol
orphenadrine
PA, QL
carisoprodol/ASA
Parafon Forte®
PA, QL
Robaxin®
carisoprodol/ASA/codeine PA
Skelaxin®
cyclobenzaprine 7.5mg
Soma® PA, QL
®
Flexeril
Lorzone
®
tizanidine capsules
Zanaflex®
metaxalone
* Note that agents not listed on PDL may be considered non-covered
Effective Date: May 1, 2016
TennCare Preferred Drug List (PDL) |
Page 18
Preferred Drugs
Non-Preferred Drugs
V. DERMATOLOGICS
Topical Antipruritics/Antihistamines
doxepin cream PA, QL
N/A
Zonalon® PA, QL
® PA, QL
Prudoxin
Topical Antivirals
acyclovir 5% ointment
Xerese® PA
QL
Zovirax® ointment QL
Zovirax® cream QL
Denavir® cream QL
Topical Agents for Burns
®
silver sulfadiazine
Sulfamylon®
mefanide
SSD
Silvadene®
Thermazene®
Antiseborrheic Agents
Mexar wash
Carmol® 10% Scalp lotion
selenium sulfide/pyrithione zinc
in urea
selenium sulfide 2.5% lotion
Ovace®
Selenos®
®
®
sulfacetamide sodium 10% wash
Ovace Plus
Selsun®
Rosula® NS Pads
sodium sulfacetamide 10%
shampoo
Seb-Prev®
sulfacetamide sodium/urea pads
selenium sulfide shampoo
TL Triseb®
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 Aczone
foam and lotion)
benzoyl peroxide (2.5%, 5%,
10% excluding cleanser, gel,
microspheres, and towelettes)
erythromycin (excluding swab)
benzoyl peroxide (cleanser, gel, microspheres, towelettes, and all
strengths not listed as preferred)
benzoyl peroxide kits and other dermatological kits PA
sodium sulfacetamide (excluding
suspension)
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)
®
metronidazole gel 1% QL
Finacea 15% gel
metronidazole 0.75% cream
Finacea® 15% foam
®
QL
Finacea Plus gel
PA
MetroLotion® QL
Mirvaso®
metronidazole 0.75% gel QL
MetroCream® QL
Noritate® 1% cream
metronidazole 0.75% lotion QL
MetroGel® 1% QL
Rosadan® Kit
®
MetroGel 1% Kit
* Note that agents not listed on PDL may be considered non-covered
Effective Date: May 1, 2016
TennCare Preferred Drug List (PDL) |
Page 19
Preferred Drugs
Non-Preferred Drugs
V. DERMATOLOGICS
Topical Antifungal Agents
ciclopirox
ciclopirox solution 8%
Bensal HP®
econazole
PA
clotrimazole
®
Luzu® PA
PA
Loprox®
ketoconazole
(shampoo and cream)
Ciclodan Kit
nystatin
ciclopirox nail kit PA
Lotrisone®
clotrimazole/betamethasone
Mentax®
® PA
CNL 8 Nail Kit
Naftin®
Ertaczo®
Nizoral®
Exelderm®
Nystatin/triamcinolone
Extina®
oxiconazole
® PA
Jublia
Oxistat®
Ketocon Kit PA
Pediaderm® AF
ketoconazole foam
Pedipirox-4® Nail PA
Ketodan® Kit PA
Penlac® PA
Kerydin®
Vusion® PA
Lamisil®
Topical Antipsoriatics PA
calcipotriene cream PA
calcipotriene scalp solution
calcipotriene ointment PA
Vectical® PA
PA
calcitriol ointment
PA
calcipotriene/betamethasone PA
Tazorac® PA
Dovonex® Scalp Solution PA
Sorilux® PA
Taclonex® PA
Dovonex® PA
Antipsoriatics, Oral PA
methoxsalen capsules PA
N/A
Oxsoralen-Ultra® PA
Genital Wart Agents
imiquimod
Aldara®
podofilox
Veregen®
Condylox
®
Emollients
ammonium lactate
LacLotion
®
Lac-Hydrin®
lactic acid
lactic acid with vitamin E
Retinoids, Oral
acitretin PA, QL
N/A
Myorisan® PA
® PA
Absorica
Sotret® PA
Amnesteem® PA
Soriatane® QL
Claravis® PA
Zenatane® PA
Retinoids, Topical
PA
adapalene PA
Retin-A Micro® PA
Tazorac® PA
Atralin® PA
tretinoin gel
PA
® PA
Differin
® PA
tretinoin
Epiduo
tretinoin microsphere gel
Epiduo® Forte PA
® PA
Fabior
PA
Veltin®
PA
PA
® PA
Ziana
Retin-A® PA
* Note that agents not listed on PDL may be considered non-covered
Effective Date: May 1, 2016
TennCare Preferred Drug List (PDL) |
Page 20
Preferred Drugs
Non-Preferred Drugs
V. DERMATOLOGICS
Pediculocides/Scabicides QL
Natroba®
QL
permethrin
Elimite® QL
Sklice® QL
QL
Eurax
Ovide® QL
® QL
Soolantra® QL
lindane PA, QL
spinosad QL
malathion QL
Ulesfia®
QL
Keratolytic Agents
all generic urea products
PA
all generic salicylic acid products
All brand urea products
All brand salicylic acid products
Enzyme Preps and Wound Healing
Regranex
® PA
lidocaine
QL
®
N/A
Santyl
Topical Anesthetics
lidocaine/hydrocortisone
All brand lidocaine products
lidocaine viscous
lidocaine/prilocaine
QL
EMLA
® QL
lidocaine/hydrocortisone/aloe
Lidoderm® PA
®
hydrocortisone/pramoxine
Pliaglis
lidocaine patch PA
Pramsone® 2.5%–1% lotion
lidocaine/tetracaine
Topical Antineoplastics
Carac®
Panretin®
Efudex®
Valchlor® PA
diclofenac 3% gel
Targretin®
fluorouracil 5% cream
Zyclara®
Fluoroplex®
Picato®
fluorouracil
Solaraze®
Topical Steroids: Least Potent
hydrocortisone 1% cream and ointment
Alcortin® A
hydrocortisone 2.5% cream, lotion and ointment
Aqua Glycolic HC® Kit
Texacort® 2.5% solution
hydrocortisone acetate-aloe vera 2% gel
Pediaderm HC® 2% Kit
U-cort® 1% cream
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% ointment
desonide 0.05% cream
fluocinolone acetonide 0.01% cream, oil and solution
Synalar® 0.01% solution
Verdeso® 0.05% foam
* Note that agents not listed on PDL may be considered non-covered
Effective Date: May 1, 2016
TennCare Preferred Drug List (PDL) |
Page 21
Preferred Drugs
Non-Preferred Drugs
V. DERMATOLOGICS
Topical Steroids: Lower Mid-Strength
betamethasone dipropionate 0.05% lotion
Capex® shampoo
betamethasone valerate 0.1% cream
clocortolone 0.1% cream and pump
fluticasone propionate 0.05% cream
Cloderm® 0.1% cream
hydrocortisone butyrate 0.1% solution
Cutivate® 0.05% cream and lotion
prednicarbate 0.1% ointment
Derma-Top® 0.1% cream and ointment
desonide 0.05% lotion
Desowen® 0.05% lotion
Diprolene® 0.05% lotion
fluocinolone acetonide 0.01% shampoo
fluocinolone acetonide 0.025% cream
fluticasone propionate 0.05% lotion
hydrocortisone butyrate 0.1% cream and ointment
hydrocortisone valerate 0.2% cream
Pandel® 0.1% cream
prednicarbate 0.1% cream
Topical Steroids: Mid-Strength
Elocon® 0.1% cream and lotion
hydrocortisone valerate 0.2% ointment
mometasone furoate 0.1% cream and solution (lotion)
fluocinolone acetonide 0.025% ointment
triamcinolone acetonide 0.1% cream
Kenalog® aerosol spray
Pediaderm TA® Kit
triamcinolone spray
Topical Steroids: Upper Mid-Strength
betamethasone valerate 0.1% ointment
amcinonide 0.1% cream and lotion
fluticasone propionate 0.005% ointment
betamethasone dipropionate 0.05% cream
triamcinolone acetonide 0.025% cream, lotion and ointment
betamethasone valerate 0.12% foam
triamcinolone acetonide 0.1% lotion and ointment
desoximetasone 0.05% cream
triamcinolone acetonide 0.5% cream and ointment
Diprolene AF® 0.05% cream
fluocinonide 0.05% emulsified base cream
Luxiq® 0.12% foam
Sernivo®
Trianex® 0.05% ointment
* Note that agents not listed on PDL may be considered non-covered
Effective Date: May 1, 2016
TennCare Preferred Drug List (PDL) |
Page 22
Preferred Drugs
Non-Preferred Drugs
V. DERMATOLOGICS
Topical Steroids: Potent
betamethasone dipropionate, augmented 0.05% cream
amcinonide 0.1% ointment
fluocinonide 0.05% 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 diacetate 0.05% cream and ointment
Elocon® 0.1% ointment
fluocinonide 0.05% cream, gel, and ointment
Halog® 0.1% ointment and cream
Topicort® 0.05% gel and ointment
Topicort® 0.25% cream and ointment
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
Clodan®
Clodan® 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
* Note that agents not listed on PDL may be considered non-covered
Effective Date: May 1, 2016
TennCare Preferred Drug List (PDL) |
Page 23
Preferred Drugs
Non-Preferred Drugs
VI. DIABETIC SUPPLIES
Diabetic Supplies: Blood Glucose Meters QL
AgaMatrix Products PA, QL
Abbott Diabetes Care Products QL
(Covered Meters Include: Freestyle
InsuLinx Meter, FreeStyle Lite
Meter, FreeStyle Freedom Lite
Meter, Precision Xtra Meter)
LifeScan Products PA, QL
Bayer Healthcare Products
PA, QL
Roche Diagnostics Products PA, QL
Home Diagnostics Products PA, QL
Diabetic Supplies: Blood Glucose Test Strips
AgaMatrix Products PA, QL
QL
Abbott Test Strips
(Covered Strips Include: Precision
Xtra Test Strips, FreeStyle Test
Strips, FreeStyle Lite Test Strips,
Freestyle InsuLinx Test Strips)
LifeScan Products PA, QL
Bayer Healthcare Products PA, QL
Home Diagnostics Products
Preferred Drugs
Roche Diagnostics Products PA, QL
PA, QL
Non-Preferred Drugs
VII. ENDOCRINE AND METABOLIC AGENTS
Agents for Gout
allopurinol
probenecid
colchicine capsules (generic
® PA
Mitigare )
Uloric® PA
colchicine tablet PA
probenecid/colchicine
Colcrys® PA
Zyloprim®
Mitigare® PA
Anabolic Steroids PA
Anadrol-50® PA
N/A
oxandrolone
Oxandrin® PA
PA
Androgens
Androderm® PA
Natesto® nasal gel PA
Androgel® pump PA
Android® PA
Testred® PA
Danazol
Axiron® PA
testosterone (generic Androgel®,
Fortesta®, Testim®, Vogelxo®) PA
Depo-testosterone® PA, QL
(200 mg/mL 1 mL vial)
Androxy® PA
testosterone cypionate PA, QL
Delatestryl® PA, QL
testosterone enanthate PA, QL
Depo-testosterone® PA, QL
(excluding 200 mg/mL
1 mL vial)
Striant® PA
Fortesta® PA
Testim® PA
Methitest® PA
Vogelxo®
®
Androgel packets
PA
PA
methyltestosterone PA
Antidiuretic/Vasopressor Agents
Stimate® PA
DDAVP
desmopressin tabs
desmopressin nasal spray
* Note that agents not listed on PDL may be considered non-covered
Effective Date: May 1, 2016
TennCare Preferred Drug List (PDL) |
Page 24
Preferred Drugs
Non-Preferred Drugs
VII. ENDOCRINE AND METABOLIC AGENTS
Bone: Bisphosphonates
alendronate
Actonel® QL
QL
alendronate solution
Fosamax® QL
® QL
QL
Atelvia
Fosamax Plus D® QL
Binosto® QL
ibandronate QL
Boniva® QL
risedronate QL
®
Skelid® QL
Didronel
etidronate
Bone: Calcitonin PA, QL
calcitonin nasal spray
Fortical® PA, QL
PA, QL
Miacalcin® nasal spray PA, QL
Miacalcin® injection PA, QL
Bone: SERMs
raloxifene
Evista® QL
QL
Bone: Parathyroid Hormone
Forteo® PA
N/A
Natpara® PA
Contraceptives, Non-Oral
Depo SubQ Provera® QL
Nuvaring® PA
Depo-Provera® QL
Xulane ®
PA
Ortho Evra® PA
medroxyprogesterone
QL
acetate inj.
* Note that agents not listed on PDL may be considered non-covered
Effective Date: May 1, 2016
TennCare Preferred Drug List (PDL) |
Page 25
Preferred Drugs
Non-Preferred Drugs
VII. ENDOCRINE AND METABOLIC AGENTS
Contraceptives, Oral QL
Altavera® QL
Alyacen® QL
Amethia Lo
Amethyst
® QL
® QL
Kelnor 1/35® QL
Ortho-Cyclen® QL
Ashlyna® QL
Quasense® QL
Kimidess® QL
Ortho-Novum® QL
Balziva® QL
Seasonale® QL
Generess FE® QL
Seasonique® QL
Kurvelo
® QL
Ovcon-50
® QL
® QL
Larin 24
® QL
Philith
Jolessa
® QL
Tilia FE® QL
Apri® QL
Layolis FE® QL
Plan B® QL
Kariva® QL
Tri-Legest FE® QL
Aranelle® QL
Leena® QL
Plan B® One-Step QL
Lybrel® QL
Zenchent® QL
Aviane
® QL
® QL
®
Lessina
Portia
Bekyree® QL
levonorgestrel/
ethinyl estradiol QL
Previfem® QL
Beyaz® QL
Levora® QL
Quartette® QL
® QL
Blisovi FE
Lo/Ovral
Reclipsen® QL
Blisovi 24 FE® QL
Loestrin® QL
Safyral® QL
Brevicon® QL
Loestrin 24 FE® QL
Setlakin® QL
Camila® QL
Lomedia 24 FE®
Sharobel® QL
® QL
® QL
® QL
Cesia
Lo Loestrin FE
Solia® QL
Cryselle® QL
Low-Ogestrel® QL
Sprintec® QL
Cyclessa® QL
Lutera® QL
Sronyx® QL
® QL
Cyred
Lyza
Take Action® QL
Deblitane® QL
Microgestin® QL
Tarina-FE® QL
Desogen® QL
Microgestin FE® QL
Tri-Estarylla® QL
drosperinone/
ethinyl estradiol QL
Minastrin 24 FE® QL
Tri-Lo-Estarylla® QL
Econtra®EZ QL
Mircette® QL
Tri-Lo-Marzia® QL
Elinest® QL
Modicon® QL
Tri-Linyah® QL
Ella® QL
Mononessa® QL
Tri-Norinyl® QL
Enpresse
® QL
® QL
Myzilra®
QL
Tri-Previfem® QL
Errin® QL
Necon® QL
Tri-Sprintec® QL
estradiol QL
Natazia® QL
Trinessa® QL
Estrostep FE® QL
Next Choice® QL
Trinessa-Lo® QL
® QL
® QL
Trivora® QL
Femcon FE
Nikki
Gildagia® QL
Nor-QD® QL
Velivet® QL
Gildess® QL
Nora-BE® QL
Vesturna® QL
Gildess 24 FE® QL
Nordette® QL
Vienva® QL
Heather® QL
norethindrone/
ethinyl estradiol - FE QL
Wymza FE® QL
Jolivette® QL
Norinyl® QL
Yasmin® QL
Juleber® QL
Nortrel® QL
® QL
YAZ® QL
® QL
Junel
Ortho Micronor
Zeosa® QL
Junel FE® QL
Ortho Tri-Cyclen® QL
Zovia® QL
Junel FE 24® QL
Ortho Tri-Cyclen Lo® QL
® QL
Kaitlib-FE
Ogestrel
® QL
Ortho-Cept® QL
* Note that agents not listed on PDL may be considered non-covered
Effective Date: May 1, 2016
TennCare Preferred Drug List (PDL) |
Page 26
Preferred Drugs
Non-Preferred Drugs
VII. ENDOCRINE AND METABOLIC AGENTS
Diabetes: Alpha-Glucosidase Inhibitors
Precose®
®
acarbose
Glyset
Diabetes: Amylin Analogs
Symlin® PA
N/A
Diabetes: Biguanides QL
Fortamet® QL
metformin QL
metformin ER
QL
Glucophage
Glumetza® QL
® QL
metformin ER osmotic QL
Glucophage XR® QL
Riomet® PA, QL
Diabetes: DPP-4 Inhibitors and Combinations PA, QL
Januvia® PA, QL
Kombiglyze® XR PA, QL
alogliptin PA, QL
Janumet® PA, QL
Onglyza® PA, QL
alogliptin/metformin PA, QL
® PA, QL
Kazano® PA, QL
alogliptin/pioglitazone
Janumet XR
Jentadueto
PA, QL
® PA, QL
Nesina® PA, QL
Oseni® PA, QL
Tradjenta
® PA, QL
GLP-2 Analogs
Gattex® PA
N/A
Diabetes: Incretin Mimetics PA, QL
Bydureon® Pen & vials PA, QL
Tanzeum® PA, QL
Victoza® PA, QL
Trulicity® PA, QL
Byetta® PA, QL
Diabetes: Insulins
®
Humalog KwikPen
® PA
Humulin 70/30 vial
Afrezza® PA, QL
Novolog® FlexPen® PA
Humulin® N® vial
Apidra® Solostar®
Novolog® Mix 70/30® FlexPen® PA
®
Humalog® Mix 50/50® KwikPen® PA
®
Humulin R vial
Apidra vial
Novolog® Mix 70/30® vial
Humalog® Mix 50/50® vial
Humulin® R® U-500 vial
Humalog® U-200 KwikPen® PA
Novolog® vial
Humalog® Mix 75/25® vial
Lantus® Solostar®
Humulin® R® U-500 KwikPen® PA
Toujeo® Solostar® PA
®
®
Humalog Mix 75/25 KwikPen
®
® PA
®
®
®
®
®
®
Humalog vial
Lantus vial
Novolin 70/30
Humulin® 70/30® KwikPen® PA
Levemir® FlexTouch®
Novolin® N®
Humulin® N® KwikPen® PA
Levemir® vial
Novolin® R®
Tresiba® FlexTouch®
PA
Diabetes: Meglitinides and Combination QL
Prandin® QL
nateglinide QL
repaglinide
repaglinide/metformin
® QL
QL
Prandimet
Starlix
QL
® QL
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®
tolbutamide
Diabetes: SGLT2 Inhibitors and Combinations
Farxiga®
N/A
PA, QL
PA, QL
Jardiance® PA, QL
® PA, QL
Synjardy® PA, QL
Glyxambi
Invokamet®
Invokana®
PA, QL
Xigduo® XR PA, QL
PA, QL
* Note that agents not listed on PDL may be considered non-covered
Effective Date: May 1, 2016
TennCare Preferred Drug List (PDL) |
Page 27
Preferred Drugs
Non-Preferred Drugs
VII. ENDOCRINE AND METABOLIC AGENTS
Diabetes: Thiazolidinedione PA, QL
pioglitazone
Actos® PA, QL
PA, QL
Avandia® PA, QL
Diabetes: Thiazolidinedione Combinations PA, QL
ACTOplus Met® PA, QL
pioglitazone-metformin PA, QL
®
ACTOplus Met XR
PA, QL
Avandamet® PA, QL
Avandaryl® PA, QL
DuetAct® PA, QL
pioglitazone-glimepiride PA, QL
Disease Modifying Anti-Rheumatic Drugs
Arava®
®
hydroxychloroquine
Ridaura
leflunomide
sulfasalazine QL
methotrexate
sulfasalazine EC
Otrexup® PA
Azulfidine® QL
QL
Azulfidine EN
Plaquenil®
® QL
Rasuvo® PA
Cuprimine®
Rheumatrex®
Depen®
Trexall®
Injectable agents for the treatment of RA are located under Immunomodulators
Note:
Anti-Rheumatic: Kinase Inhibitors
XelJanz® PA, QL
N/A
Glucocorticoids, Oral
Celestone®
Orapred® ODT PA
cortisone
Cortef®
Pediapred®
dexamethasone
Dexpak®
budesonide capsules
PA
prednisone
prednisolone ODT PA
®
hydrocortisone
Medrol
Rayos®
methylprednisolone
Millipred®
Veripred®
prednisolone
Orapred®
Growth Hormone Agents PA
Humatrope® PA
Genotropin® PA
® PA
Saizen® PA
Norditropin
Serostim® PA
Nutropin® PA
Tev-Tropin® PA
Nutropin AQ® PA
Zomacton® PA
Omnitrope
® PA
Zorbtive® PA
Hematopoietic Agents PA
Aranesp® PA
Procrit® PA
N/A
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
®
estradiol
estropipate
EnJuvia®
Femtrace®
Premarin®
Estrace®
Menest®
* Note that agents not listed on PDL may be considered non-covered
Effective Date: May 1, 2016
TennCare Preferred Drug List (PDL) |
Page 28
Preferred Drugs
Non-Preferred Drugs
VII. ENDOCRINE AND METABOLIC AGENTS
Hormones: Oral Estrogen/Progestins
estradiol/norethindrone
Activella®
®
PreFest
®
FemHRT Low Dose
PremPhase
Mimvey®
PremPro® QL
Angeliq®
® QL
FemHRT® 1/5
Jinteli®
Lopreeza®
Hormones: Oral Progestins
medroxyprogesterone
Aygestin®
progesterone
norethindrone acetate PA
® QL
Prometrium®
megestrol acetate 40mg/ml
QL
suspension
Megace
megestrol acetate tabs
Megace ES® PA, QL
Provera®
megestrol acetate 625mg/5ml
QL
suspension
Hormones: Thyroid
®
Cytomel
Levothroid
Armour Thyroid®
liothyronine
®
Synthroid
Thyroid®
®
Thyrolar®
Unithroid®
levothyroxine
Tirosint®
Levoxyl®
Hormones: Transdermal Estrogens
Alora
Climara® QL
® QL
Estrasorb®
®
estradiol transdermal biweekly
patch QL
Divigel
Evamist®
Elestrin®
Menostar® QL
Estraderm® QL
Minivelle® QL
estradiol transdermal weekly
patch QL
Vivelle-Dot® QL
Hormones: Transdermal Estrogen/Progestins QL
Climara Pro® QL
Combipatch® QL
Hormones: Vaginal Estrogens
Estring®
Premarin Vaginal Cream
Estrace®
Vagifem®
Femring®
® QL
Insulin-Like Growth Factor-1 PA
Increlex® PA
N/A
Mineralocorticoids, Oral
N/A
fludrocortisone
Progesterone Receptor Antagonists
Korlym® PA
N/A
SERM/Estrogen Combinations
Duavee® PA
N/A
* Note that agents not listed on PDL may be considered non-covered
Effective Date: May 1, 2016
TennCare Preferred Drug List (PDL) |
Page 29
Preferred Drugs
Non-Preferred Drugs
VII. ENDOCRINE AND METABOLIC AGENTS
Somatostatic Agents
octreotide
Sandostatin® PA
PA
® PA, QL
Somatuline Depot®
Somavert®
Signifor
Preferred Drugs
Non-Preferred Drugs
VIII. GASTROINTESTINAL
5-ASA Derivatives, Oral QL
Sulfazine EC® QL
Asacol HD® QL
Dipentum® QL
Sulfazine® QL
Azulfidine® QL
Giazo® QL
Delzicol® QL
Azulfidine EN® QL
Lialda® QL
sulfasalazine QL
balsalazide QL
Pentasa® QL
sulfasalazine EC QL
Colazal® QL
Apriso®
QL
Asacol® QL
5-ASA Derivatives, Rectal
Canasa®
mesalamine kit
mesalamine enema
Rowasa®
Rowasa kit®
Agents for Irritable Bowel Syndrome (IBS) PA, QL
N/A
alosetron PA, QL
Lotronex® PA, QL
Amitiza® PA, QL
Viberzi® PA, QL
® PA, QL
Linzess
Agents for Opioid-Induced Constipation
Movantik® PA, QL
N/A
Antidiarrheals
diphenoxylate with atropine
Lofene
®
Lonox
®
loperamide
Lomotil®
opium tincture
Motofen®
paregoric
® PA
Fulyzaq
Anti-Emetics: A-9-THC Derivatives PA
Cesamet® PA
N/A
Marinol® PA
dronabinol PA
Anti-Emetics: Anticholinergics
meclizine
trimethobenzamide
prochlorperazine
promethazine
Transderm Scōp
® PA, QL
Antivert®
Compro
Tigan®
®
Phenergan ® PA
PA
Anti-Emetics: 5-HT3 Antagonists PA
Anzemet® PA, QL
granisetron PA, QL
Kytril® PA, QL
ondansetron oral soln PA
Sancuso® PA, QL
ondansetron tabs and ODT PA, QL
Zofran ODT® PA, QL
Zofran® Solution PA
Zofran® PA, QL
Zuplenz® PA, QL
* Note that agents not listed on PDL may be considered non-covered
Effective Date: May 1, 2016
TennCare Preferred Drug List (PDL) |
Page 30
Preferred Drugs
Non-Preferred Drugs
VIII. GASTROINTESTINAL
Anti-Emetics: NK-1 Antagonists PA
Akynzeo® PA, QL
N/A
Varubi® PA, QL
Emend® PA, QL
Anti-Emetics: Miscellaneous
Diclegis
® PA, QL
N/A
Antispasmodics/Anticholinergics
Anaspaz®
methscopolamine
Bentyl®
Pamine®
HyoMax®
Cantil®
Pamine Forte®
hyoscyamine
chlordiazepoxide/clidinium
dicyclomine
Symax Fastabs
®
®
glycopyrrolate
Symax-SL
Robinul®
Cuvposa
Robinul Forte®
NuLev®
Levsin®
Sal-Tropine®
propantheline
Librax®
Hyosyne
® PA
®
Combination Products for H. pylori PA
Pylera® PA, QL
Helidac® PA, QL
Omeclamox® PA, QL
lansoprazole/amoxicillin/
clarithromycin PA, QL
Prevpac® PA, QL
Gallstone Solubilizing Agents
ursodiol
QL
Actigall® QL
Urso® QL
Chenodal®
Urso Forte® QL
H2 Receptor Antagonists
cimetidine
Axid®
ranitidine syrup
ranitidine capsules
Zantac®
nizatidine
famotidine
®
Pepcid
ranitidine tablets
Laxatives
Constulose®
Enulose
®
PEG 3350 powder
CoLyte®
PEG 3350 electrolyte solution
GaviLYTE-H®/bisacodyl
PEG 3350 with flavor packs
PEG 3350 solution
®
HalfLytely
Prepopik®
Kristalose®
Suclear®
MoviPrep®
Suprep®
GoLYTELY
generlac
lactulose
PEG 3350 powder pack
®
®
NuLYTELY
Trilyte®
OsmoPrep®
Visicol®
Miscellaneous Agents for Inflammatory Bowel Disease
Entocort® EC PA
N/A
Uceris® PA, QL
Motility Agents
metoclopramide
metoclopramide ODT PA, QL
QL
Reglan® QL
Metozolv® ODT PA, QL
Mucosal Protectants
misoprostol
sucralfate tablets
Carafate®
sucralfate suspension PA
Cytotec®
* Note that agents not listed on PDL may be considered non-covered
Effective Date: May 1, 2016
TennCare Preferred Drug List (PDL) |
Page 31
Preferred Drugs
Non-Preferred Drugs
VIII. GASTROINTESTINAL
Pancreatic Enzymes
®
Creon (all strengths)
ZenPep
Pancreaze®
®
Pertzye
pancrelipase (all strengths)
Ultresa®
®
Viokace®
Proton Pump Inhibitors
pantoprazole
QL
Protonix® suspension
omeprazole
® OL
Aciphex® QL
Prevacid® QL
Aciphex® sprinkles PA
Prevacid® SoluTab®
® QL
® QL
Dexilant
Prilosec
esomeprazole QL
Protonix® QL
lansoprazole QL
lansoprazole ODT
PA, QL
rabeprazole QL
PA, QL
Zegerid® QL
Nexium® QL
Saliva Stimulating Agents
pilocarpine
cevimeline PA, QL
PA, QL
Salagen® PA, QL
Evoxac® PA, QL
Preferred Drugs
Non-Preferred Drugs
IX. IMMUNOLOGIC AGENTS
Anti-inflammatory: PDE-4 Inhibitors
Otezla® PA, QL
N/A
Immunomodulators PA, QL
Actemra® PA, QL
Enbrel® PA, QL
Humira
Orencia® PA, QL
® PA, QL
® PA, QL
Simponi® PA, QL
Cimzia
Cosentyx®Pen
PA, QL
Kineret® PA, QL
Stelara® PA, QL
Taltz® 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
®
Envarsus XR
cyclosporine microemulsion
QL
Prograf® PA
Rapamune® PA
Hecoria® PA
Sandimmune® PA
Imuran® PA
sirolimus PA
® PA
Zortress® PA
Myfortic
mycophenolate mofetil suspension
Multiple Sclerosis Agents QL
Avonex® QL
Copaxone® 20 mg/mL QL
® QL
Avonex Administration Pack
Rebif
Copaxone® 40 mg/mL PA, QL
Plegridy® PA, QL
® QL
® QL
Extavia
Glatopa® QL
® QL
Betaseron
Multiple Sclerosis Agents: Potassium Channel Blockers
Ampyra
® QL
N/A
* Note that agents not listed on PDL may be considered non-covered
Effective Date: May 1, 2016
TennCare Preferred Drug List (PDL) |
Page 32
Preferred Drugs
Non-Preferred Drugs
IX. IMMUNOLOGIC AGENTS
Multiple Sclerosis Agents: Oral Disease Modifying Agents
Gilenya
Aubagio® PA
® PA, QL
Tecfidera® PA, QL
Topical Immunomodulators PA
Protopic® PA
Elidel® PA
tacrolimus ointment PA
Preferred Drugs
Non-Preferred Drugs
X. MISCELLANEOUS
Gaucher’s Disease Agents
Zavesca
Cerdelga®
®
QL
Hereditary Angioedema (HAE) Agents
Firazyr® PA
® PA
Kalbitor
Hereditary Tyrosinemia Agents
Orfadin
®
N/A
Oral Iron Chelators PA
Exjade® PA
N/A
Jadenu® PA
Ferriprox® PA
* Note that agents not listed on PDL may be considered non-covered
Effective Date: May 1, 2016
TennCare Preferred Drug List (PDL) |
Page 33
Preferred Drugs
Non-Preferred Drugs
XI. ONCOLOGY AGENTS
Afinitor®
Iclusig®
Soltamox®
Afinitor Disperz® PA
Gleostine® (excluding 5mg)
Alkeran®
Imbruvica®
Sprycel®
Arimidex®
Hydrea®
Alecensa®
Inlyta®
Stivarga®
Aromasin®
imitanib
Sutent
capicitabine
Purinethol®
®
®
anastrozole
Iressa
bicalutamide
Jakafi® QL
Tabloid®
Casodex®
Purixan® PA
Bosulif®
Lenvima®
Tafinlar®
Femara®
Temodar®
Caprelsa
®
Cometriq
letrozole
®
Tagrisso
leucovorin
®
®
tamoxifen
®
Tarceva®
Cotellic
Leukeran
cyclophosphamide
leuprolide PA
Targretin®
Droxia®
lomustine
Tasigna®
Eligard
® PA
Lonsurf
® QL
temozolamide
Emcyt®
Lynparza® QL
Thalomid®
Erivedge®
Lysodren®
tretinoin
etoposide
Matulane®
Tykerb®
exemestane
Mekinist®
Votrient®
Fareston®
mercaptopurine
Xalkori®
®
Farydak
Mesna
®
Xeloda®
flutamide
methotrexate
Xtandi®
Gilotrif®
Myleran®
Zelboraf®
®
®
Gleevec
Gleostine® 5mg
QL
Zolinza®
Nilandron®
Zydelig®
Ninlaro
Zykadia®
Hycamtin®
Odomzo®
Zytiga®
hydroxyurea
Pomalyst®
Hexalen
Ibrance
®
Nexavar
®
®
Revlimid®
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 co-pay 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® ST suspension
sulfacetamide/prednisolone
neomycin/poly B/HC
tobramycin/dexamethasone
suspension
Pred-G®
Poly-Pred®
Zylet® PA
neomycin/BAC/poly B/HC
®
TobraDex suspension
* Note that agents not listed on PDL may be considered non-covered
Effective Date: May 1, 2016
TennCare Preferred Drug List (PDL) |
Page 34
Preferred Drugs
Non-Preferred Drugs
XII. OPHTHALMICS
Ophthalmic Antibiotics
AK-Poly-BAC
ofloxacin
AzaSite®
Neosporin®
bacitracin/poly B
polymyxin B/TMP
bacitracin
Ocuflox®
ciprofloxacin
Romycin®
Besivance®
Polysporin®
erythromycin (excluding
erythromycin base tabs)
sulfacetamide sodium drops
Bleph-10®
Polytrim®
Gentak®
tobramycin
Ciloxan®
sulfacetamide ointment
®
gentamicin
Tobrasol
erythromycin base tablets
Tobrex® solution
Moxeza®
Tobrex® ointment
Garamycin®
Zymaxid®
neomycin/bac/poly B
®
Vigamox
®
gatifloxacin 0.5% solution
levofloxacin 0.5% solution
neomycin/poly B/gramicidin
Ophthalmic Antifungals
Natacyn® PA
N/A
Ophthalmic Antivirals
Viroptic®
trifluridine
Zirgan®
PA > 5yr old
Ophthalmic Antihistamines QL
Bepreve®
QL
ketotifen QL
Pataday
® QL
azelastine QL
olopatadine QL
Elestat® QL
Optivar® QL
Emadine
® QL
Patanol® QL
epinastine QL
Pazeo® QL
Lastacaft®
Zaditor® QL
QL
Ophthalmic Alpha-2 Agonists
apraclonidine
Alphagan P®
brimonidine tartrate 0.15%
Iopidine®
brimonidine tartrate 0.2%
Ophthalmic Beta Blockers
carteolol
timolol maleate
levobunolol
Betagan®
OptiPranolol®
betaxolol
timolol gel solution
Betimol®
Timoptic®
Betoptic-S®
Timoptic Ocudose®
®
Timoptic-XE®
Istalol
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
cromolyn sodium
Alamast®
Alomide®
* Note that agents not listed on PDL may be considered non-covered
Effective Date: May 1, 2016
TennCare Preferred Drug List (PDL) |
Page 35
Preferred Drugs
Non-Preferred Drugs
XII. OPHTHALMICS
Mydriatics and Mydriatic Combos
AK-Pentolate®
atropine
®
Isopto® Homatropine
Cyclogyl
Isopto Hyoscine®
cyclopentolate
Cyclomydril®
Mydriacyl®
tropicamide
Isopto Atropine®
Paremyd®
Atropine Care
®
Ophthalmic NSAIDs PA
Acular® PA
diclofenac PA
flurbiprofen
PA
Acular LS
Ilevro® PA
® PA
Nevanac® PA
Acuvail® PA
ketorolac PA
Bromday®
Prolensa® PA
PA
bromfenac
Ocufen® PA
PA
Voltaren® PA
Ophthalmic Prostaglandin Agonists QL
latanoprost QL
bimatoprost 0.03% QL
Travoprost QL
Lumigan® 0.01% QL
Rescula® QL
Xalatan® QL
Travatan Z® QL
Zioptan® QL
Ophthalmic Steroids
Alrex
®
dexamethasone
prednisolone acetate
®
®
Maxidex®
Durezol
Flarex
fluorometholone
FML Forte®
®
FML Liquifilm
FML ointment
Pred Mild
prednisolone sodium phosphate
®
®
®
Lotemax® Ointment
Pred Forte®
Vexol®
Lotemax Gel
Glaucoma Direct Acting Miotics
Isopto® Carpine
pilocarpine
Pilopine HS®
phospholine iodide
Glaucoma Combinations
Combigan
Simbrinza® PA
® PA
Ophthalmic Immunomodulators PA, QL
Restasis® PA, QL
N/A
Ophthalmic Vasoconstrictors
AK-Dilate 2.5%, 10%
Neofrin 2.5%, 10%
Albalon®
naphazoline
phenylephrine 2.5%, 10%
Mydfrin®
®
®
Ophthalmic Lubricants and Artificial Tears
Lacrisert® PA
N/A
Miscellaneous Ophthalmics
Cystaran® PA
N/A
* Note that agents not listed on PDL may be considered non-covered
Effective Date: May 1, 2016
TennCare Preferred Drug List (PDL) |
Page 36
Preferred Drugs
Non-Preferred Drugs
XIII. OTICS
Otic Quinolones
® QL
CiproDex
Cipro HC® QL
ciprofloxacin otic
ofloxacin otic QL
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®
chloroxylenol/pramoxine
DermOtic®
TriOxin
fluocinolone acetonide
VoSol®
®
VoSol® HC
Neotic
Otic Edge
®
®
Zinotic
Pramotic®
Zinotic ES®
®
PR Otic
Preferred Drugs
Non-Preferred Drugs
XIV. RENAL AND GENITOURINARY
Alpha Blockers for BPH
alfuzosin QL
tamsulosin QL
Cardura®
Minipress®
doxazosin
terazosin
Cardura XL® QL
Rapaflo®
Flomax
prazosin
® QL
Uroxatral® QL
Androgen Hormone Inhibitors
finasteride
Avodart® QL
QL
Proscar® QL
dutasteride QL
Combination Agents for BPH
dutasteride/tamsulosin
N/A
PA, QL
Jalyn® PA, QL
Phosphorus Depleters
calcium acetate
Eliphos
®
Phoslyra
Auryxia®
®
®
Renvela tablets
Renagel®
®
QL
Fosrenol
Renvela® powder for suspensionPA,QL
Fosrenol®powder pack PA
sevelamer QL
PhosLo®
Velphoro® PA
Urinary Tract Antispasmodics
oxybutynin
Toviaz
darifenacin QL
oxybutynin ER QL
VESIcare® QL
Detrol® QL
Oxytrol® QL
® QL
Ditropan XL® QL
Detrol LA
® QL
Enablex® QL
flavoxate
Gelnique®
QL
QL
Sanctura XR® QL
tolterodine QL
tolterodine ER QL
trospium QL
trospium XR QL
Myrbetriq®
* Note that agents not listed on PDL may be considered non-covered
Effective Date: May 1, 2016
TennCare Preferred Drug List (PDL) |
Page 37
Preferred Drugs
Non-Preferred Drugs
XIV. RENAL AND GENITOURINARY
Urinary Alkalizing Agents
citric acid/sodium citrate
potassium citrate/citric acid
Ora-Cit®
Urocit-K®
®
Virtrate-3®
Tricitrates
potassium citrate
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 (Rx and OTC)
Pyridium®
Urinary Interstitial Cystitis Agents
Elmiron
®
®
N/A
RIMSO-50
Preferred Drugs
Non-Preferred Drugs
XV. RESPIRATORY
Anaphylaxis Therapy Agents
epinephrine injectable
Epipen®
QL
Epipen, Jr.®
Auvi-Q® QL
QL
QL
Antiallergens, Oral
Grastek® PA, QL
N/A
Ragwitek® PA, QL
Oralair® PA, QL
Anticholinergics, Inhaled QL
albuterol/ipratropium QL
ipratropium solution QL
Anoro Ellipta® PA, QL
Stiolto Respimat® PA, QL
Atrovent® HFA QL
Spiriva® QL
Incruse Ellipta® QL
Tudorza® QL
Combivent MDI
® PA, QL
® QL
Seebri Neohaler
Utibron Neohaler® PA, QL
Spiriva Respimat® QL
Combivent Respimat® 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)
®
Bromspiro
hydroxyzine
®
all formulations of brompheniramine tannate
carbinoxamine maleate
LoHist-12
all formulations of chlorpheniramine tannate
chlorpheniramine maleate
promethazine
all formulations of diphenhydramine tannate
clemastine
Aldex AN®
J-Tan PD
cyproheptadine hydrochloride
dexchlorpheniramine
Palgic®
®
diphenhydramine HCl
Doxytex
Dytuss® syrup
Karbinal® ER
Vazol®
Vistaril®
* Note that agents not listed on PDL may be considered non-covered
Effective Date: May 1, 2016
TennCare Preferred Drug List (PDL) |
Page 38
Preferred Drugs
Non-Preferred Drugs
XV. RESPIRATORY
Antihistamines, Non-Sedating (Covered for recipients < 21 years old only)
Allegra® QL
cetirizine 5mg/5ml solution
cetirizine 1mg/1ml solution
Allegra-D 12 Hr® QL
desloratadine QL
cetirizine syrup
Allegra-D 24 Hr® QL
desloratadine ODT PA, QL
cetirizine tabs QL
Allegra ODT® PA, QL
fexofenadine
cetirizine chewable
PA, QL
cetirizine/PSE
® QL
QL
loratadine QL
loratadine RDT PA, QL
loratadine/PSE
Claritin
fexofenadine/PSE QL
Claritin® chewable PA, QL
levocetirizine QL
Claritin-D 12 Hr® QL
Semprex®-D QL
® QL
QL
QL
Claritin-D 24 Hr
Xyzal® QL
Claritin RediTabs® PA, QL
Zyrtec® QL
Clarinex® QL
Zyrtec® chewable PA, QL
® PA, QL
Clarinex RediTabs
Zyrtec® ODT PA, QL
Clarinex-D 12 Hr® QL
Zyrtec-D® QL
Clarinex-D 24 Hr
® QL
Antihistamines, Nasal QL
Astepro® PA, QL
Patanase® QL
azelastine
Dymista® PA, QL
PA, QL
olopatadine QL
Beta Agonists: Combination Products PA, QL
Advair Diskus® PA, QL
Dulera® PA, QL
Advair HFA® PA, QL
Symbicort® PA, QL
Breo Ellipta® PA, QL
Beta Agonists: Long Acting MDI PA, QL
Serevent Diskus® PA, QL
Arcapta® QL
Foradil® PA, QL
Striverdi® Respimat QL
Beta Agonists: Nebulizer
albuterol inhalation solution
AccuNeb® QL
QL
Perforomist® PA, QL
Brovana® PA, QL
levalbuterol
Xopenex® PA, QL
PA, QL
Beta Agonists: Short Acting MDI QL
Proventil® HFA QL
Maxair Autohaler® QL
Ventolin® HFA PA, QL
ProAir® HFA PA, QL
Xopenex® HFAPA, QL
ProAir Respiclick® PA, QL
Beta Agonist: Oral
albuterol syrup
albuterol tabs
terbutaline
VoSpire ER®
metaproterenol
albuterol ER
Cystic Fibrosis Agents
Bethkis® PA,QL
Pulmozyme® PA, QL
Cayston® PA, QL
tobramycin nebulizer
Kitabis® PA
tobramycin vial
TOBI® Podhaler® and inhalation
solution PA, QL
tobramycin solution
300mg/5mL PA, QL
PA
Cystic Fibrosis Agents: CFTR Potentiators
Kalydeco® PA, QL
N/A
Orkambi® PA, QL
* Note that agents not listed on PDL may be considered non-covered
Effective Date: May 1, 2016
TennCare Preferred Drug List (PDL) |
Page 39
Preferred Drugs
Non-Preferred Drugs
XV. RESPIRATORY
Expectorants
N/A
SSKI
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
QL
cromolyn
N/A
Mucolytics
N/A
acetylcysteine
Non-Narcotic Antitussives PA
Tessalon® PA
benzonatate PA
Zonatuss® PA
Tessalon Perles® PA
Steroids, Orally Inhaled QL
Aerospan® QL
Asmanex Twisthaler® QL
Flovent HFA
® QL
Alvesco
QVAR® QL
budesonide respules QL
® QL
Pulmicort Flexhaler® QL
Arnuity Ellipta® QL
Pulmicort Respules® PA, QL
Asmanex HFA® QL
Flovent Diskus® QL
Steroids, Intranasal QL
Beconase AQ® QL
fluticasone propionate QL
®
Omnaris® QL
Nasacort OTC
budesonide nasal spray
Nasonex® QL
Flonase® QL
QL
Qnasl® QL
Rhinocort Aqua® QL
flunisolide QL
triamcinolone acetonide QL
mometasone furoate
Nasacort® AQ QL
QL
Veramyst® QL
Zetonna® QL
Xanthine Derivatives
aminophylline
Elixophyllin
®
N/A
®
Theo-24
Phosphodiesterase 4 Inhibitor
Daliresp® PA
N/A
Vasoconstrictors, Intranasal
Adrenalin
®
Tyzine
®
N/A
* Note that agents not listed on PDL may be considered non-covered
Effective Date: May 1, 2016
TennCare Preferred Drug List (PDL) |
Page 40
Preferred Drugs
Non-Preferred Drugs
XVI. SMOKING CESSATION AGENTS
Smoking Cessation Agents QL
bupropion SR QL
Chantix
® QL
nicotine polacrilex lozenge QL
Commit® QL
QL
®
nicotine transdermal patch
Nicotrol® inhaler QL
Nicoderm CQ
QL
Nicotrol® nasal spray QL
Nicorette® gum QL
nicotine polacrilex gum QL
Preferred Drugs
Zyban® QL
Non-Preferred Drugs
XVII. VITAMINS AND ELECTROLYTES
Cystine Depleting Agent
Cystagon
Procysbi® PA
®
Fluoride Products
®
Denta 5000
®
Dentagel
Phos-flur
Renaf
Epiflur®
Fluor-a-day® Chewable
®
®
Gel-Kam
®
Luride®
Prevident®
SF
®
Fluor-a-day drops
Fluoritab
®
SF 5000 Plus
sodium fluoride
Ludent®
Folic Acid Preparations
folic acid
Deplin® PA
l-methylfolate PA
Falessa®
Q-Tabs®
PA
PA
Kidney Stone Agents
®
Lithostat
Thiola
®
N/A
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®
Veltassa® QL
SPS®
Kionex®
Potassium Supplements
®
®
Effer-K
K-Effervescent
®
®
Epiklor®
Micro K®
®
K-Vescent
K-tabs
Klor-Con®
potassium bicarbonate
Klor-Con® powder
Klor-Con/EF®
potassium chloride tabs and
solution
Klor-Con M®
potassium chloride,
microencapsulated
Kaon-CL
potassium chloride caps
* Note that agents not listed on PDL may be considered non-covered
Effective Date: May 1, 2016
TennCare Preferred Drug List (PDL) |
Page 41
Preferred Drugs
Non-Preferred Drugs
XVII. VITAMINS AND ELECTROLYTES
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 K Products
Mephyton
® QL
N/A
Zinc Supplements
zinc sulfate
Zincate
Galzin® PA
®
* Note that agents not listed on PDL may be considered non-covered
Effective Date: May 1, 2016
TennCare Preferred Drug List (PDL) |
Page 42