TennCare AutoExempt List November 1, 2014 This is a current list of the drugs and supplies that do not count toward an enrollee’s monthly drug limit. This list is subject to change. Go to the following link to see the most current version: https://tenncare.magellanhealth.com/static/docs/Program_Information/TennCare_AutoExempt_List.pdf CARDIOVASCULAR DISEASE (ORAL FORMULATIONS ONLY) Note: Brand names in this category are provided for reference only. Only generic cardiovascular medications are exempt from the script limit. If classified as a brand in Medispan, the product will not be exempt from the script limit. acebutolol (Sectral) felodipine ER nifedipine ER/SA/XL (Adalat CC, Procardia XL) acetazolamide (Diamox) fosinopril (Monopril) nifedipine IR (Adalat, Procardia) amiloride/hydrochlorothiazide (Moduretic) fosinopril/hydrochlorothiazide (MonoprilHCT) pindolol (Visken) amiloride (Midamor) furosemide (Lasix) propranolol (Inderal) amlodipine (Norvasc) hydrochlorothiazide (Microzide, Oretic) propranolol LA (Inderal LA) atenolol (Tenormin) indapamide propranolol/hydrochlorothiazide (Inderide) atenolol/chlorthalidone (Tenoretic) isradipine (DynaCirc) quinapril (Accupril) benazepril (Lotensin) labetalol (Trandate) quinapril/hydrochlorothiazide (Accuretic) benazepril/hydrochlorothiazide (Lotensin HCT) lisinopril (Prinivil, Zestril) ramipril (Altace) betaxolol (Kerlone) lisinopril/hydrochlorothiazide (Prinzide, Zestoretic) sotalol (Betapace, Sorine) bisoprolol fumarate (Zebeta) losartan (Cozaar) sotalol AF (Betapace AF) bisoprolol/hydrochlorothiazide (Ziac) losartan/HCTZ (Hyzaar) spironolactone (Aldactone) bumetanide (Bumex) methyclothiazide (Enduron) spironolactone/hydrochlorothiazide (Aldactazide) captopril (Capoten) metolazone (Zaroxolyn) telmisartan (Micardis) captopril/hydrochlorothiazide (Capozide) metoprolol succinate (Toprol XL) telmisartan/HCTZ (Micardis HCT) carvedilol (Coreg) metoprolol tartrate (Lopressor) timolol maleate (Blocadren) chlorothiazide (Diuril) metoprolol/hydrochlorothiazide (Lopressor HCT) torsemide (Demadex) chlorthalidone (Hygroton) moexipril (Univasc) trandolapril (Mavik) diltiazem ER/SR/XR (Cardizem CD, Cardizem LA, Cartia XT, Dilacor XR, DiltCD, Taztia XT, Tiazac) moexipril/hydrochlorothiazide (Uniretic) triamterene/hydrochlorothiazide (Dyazide, Maxzide) diltiazem IR (Cardizem) nadolol (Corgard) valsartan (Diovan) enalapril (Vasotec) nadolol/bendroflumethiazide (Corzide) verapamil ER (Covera-HS, Isoptin SR, Verelan) enalapril/hydrochlorothiazide (Vasoretic) nicardipine HCl (Cardene) verapamil HCl (Calan, Isoptin) Proprietary & Confidential © 2014, Magellan Health Services, Inc. All Rights Reserved. Magellan Health Services TennCare AutoExempt List DIABETES AGENTS – ORAL HYPOGLYCEMICS Note: Brand names in this category are provided for reference only. Only generic oral hypoglycemic medications are exempt from the script limit. If classified as a brand in Medispan the product will not be exempt from the script limit. acarbose (Precose) glipizide ER/XL (Glucotrol XL) pioglitazone (Actos) acetohexamide (Dymelor) glyburide (Diabeta, Micronase) pioglitazone glimepiride (DuetAct) chlorpropamide (Diabinese) glyburide, micronized (Glynase, PresTab) pioglitazole metformin (ACTOplus Met) glimepiride (Amaryl) glyburide/metformin (Glucovance) tolazamide (Tolinase) glipizide/metformin (Metaglip) metformin (Glucophage) tolbutamide (Orinase) glipizide (Glucotrol) metformin ER (Glucophage XR) DIABETES AGENTS – INSULINS human insulin NPH (Humulin N, Novolin N®) insulin detemir vials (Levemir® vials) human insulin NPH/Regular (Humulin 70/30, Novolin 70/30®) insulin lispro (Humalog and Novolog – all dosage forms) human insulin Regular (Humulin R, Novolin R®, Humulin R U-500) insulin lispro protamine/lispro (Humalog and Novolog mix– all dosage forms) insulin glargine (Lantus vials) RESPIRATORY Note: Brand names in this category, with the exception of Proventil HFA, are provided for reference only. Only generic respiratory medications are exempt from the script limit. TennCare considers Proventil HFA a generic medication. All other medications classified as brand products in Medispan will not be exempt from the script limit. albuterol (Proventil HFA) albuterol sulfate inhalation solution (Accuneb, Proventil) ipratropium inhalation solution (Atrovent) ANTINEOPLASTICS abiraterone acetate (Zytiga) dasatinib (Sprycel) ixabepilone (Ixempra) rituximab (Rituxan) afatinib (Gilotrif) daunorubicin (Cerubidine) lapatinib (Tykerb) romadepsin (Istodax) anastrazole (Arimidex) daunorubicin citrate liposomal (DaunoXome) lenalidomide (Revlimid) ruxolitinib (Jakafi) arsenic trioxide (Trisenox) decitabine (Dacogen) letrozole (Femara) samarium SM 153 lexidronam (Quadramet) asparaginase (Elspar, Erwinaze) degarelix (Firmagon) leucovorin (Wellcovorin) siltuximab (Sylvant) axitinib (Inlyta) denileukin diftitox (Ontak) leuprolide (Eligard, Lupron, Lupron Depot, Viadur) sorafenib (Nexavar) azacitidine (Vidaza) dexrazoxane (Zinecard, Totect) lomustine (CeeNU) streptozocin (Zanosar) bcg vaccine (TheraCys, TICE BCG) docetaxel (Taxotere) mechlorethamine (Mustargen) strontium-89 chloride (Metastron) bendamustine (Treanda) doxorubicin (Adriamycin, Rubex) melphalan (L-PAM) (Alkeran) sunitinib (Sutent) bevacizumab (Avastin) doxorubicin, liposomal (Doxil) mercaptopurine (6-MP) (Purinethol) talc powder, sterile (Sclerosol) Proprietary & Confidential Page 2 Revision Date: November 1, 2014 Magellan Health Services TennCare AutoExempt List ANTINEOPLASTICS bexarotene (Targretin) enzalutamide (Xtandi) mesna (Mesnex) tamoxifen and oral solution (Nolvadex) bicalutamide (Casodex) epirubicin (Ellence) methotrexate (Mexate, Trexall, Abitrexate, Folex, Otrexup) temozolomide (Temodar) bleomycin (Blenoxane) erlotinib (Tarceva) mitomycin (MTC) (Mutamycin) temsirolimus (Torisel) bortezomib (Velcade) estramustine phosphate sodium (Emcyt) mitotane (Lysodren) teniposide (VM-26, Vumon) bosutinib (Bosulif) etoposide (VP-16-213, Toposar, VePesid, Etopophos) mitoxantrone (Novantrone) thalidomide (Thalomid) brentuximab (Adcetris) everolimus (Afinitor) nelarabine (Arranon) thioguanine (TG, Tabloid) busulfan (Busulfex, Myleran) exemestane (Aromasin) nilotinib (Tasigna) thiotepa (TSPA, Thioplex) cabazitaxel (Jevtana) floxuridine (FUDR) nilutamide (Nilandron) topotecan (Hycamtin) cabozantanib (Cometriq) fludarabine phosphate (Fludara, Oforta) ofatumumab (Arzerra) toremifene citrate (Fareston) capecitabine (Xeloda) fluorouracil (Adrucil) omacetaxine (Synribo) tositumomab (Bexxar) carboplatin (Paraplatin) flutamide (Eulexin) oxaliplatin (Eloxatin) trametinib (Mekinist ) cafilzomib (Kyprolis) fulvestrant (Faslodex) paclitaxel (Onxol, Abraxane, Taxol) trastuzumab (Herceptin) carmustine (BCNU, BiCNU, Gliadel) gallium nitrate (Ganite) panitumumab (Vectibix) tretinoin ceritinib (Zykadia) gefitinib (Iressa) pazopanib (Votrient) triptorelin pamoate (Trelstar) cetuximab (Erbitux) gemcitabine (Gemzar) pegaspargase (Oncaspar) uracil mustard (Uracil Mustard) chlorambucil (Leukeran) gemtuzumab ozogamicin (Mylotarg) pembrolizumab (Keytruda) valrubicin (Valstar) cisplatin (Platinol) goserelin (Zoladex) pemetrexed (Alimta) vandetanib (Caprelsa) cladribine (CdA) (Leustatin) hydroxyurea (Droxia, Hydrea, Mylocel) pentostatin (DCF) (Nipent) vemurafenib (Zelboraf) clofarabine (Clolar) ibritumomab tiuxetan (Zevalin) pertuzumab (Perjeta) vinblastine (Velban, Velsar) crizotinib (Xalkori) ibrutinib(Imbruvica) plicamycin (Mithracin) vincristine (Oncovin, Vincasar PFS) cyclophosphamide (Cytoxan, Neosar) idarubicin (Idamycin PFS) pomalidomide (Pomalyst) vinorelbine tartrate (Navelbine) cytarabine, conventional (Cytosar-U, Tarabine PFS) idelalisib (Zydelig) porfimer sodium (Photofrin) vismodegib (Erivedge) cytarabine, liposomal (DepoCyt) ifosfamide (Ifex) pralatrexate (Fotolyn) vorinostat (Zolinza) dabrafenib (Tafinlar) imatinib mesylate (Gleevec) procarbazine (Matulane) ziv-aflibercept (Zaltrap) dacarbazine (DTIC-Dome) ipilimumab (Yervoy) ramucirumab (Cyramza) dactinomycin (actinomycin D, irinotecan (Camptosar) regorafinib (Stivarga) Proprietary & Confidential Page 3 Revision Date: November 1, 2014 Magellan Health Services TennCare AutoExempt List ANTINEOPLASTICS Cosmegen) ANTIPARKINSONIAN AGENT benztropine (Cogentin) carbidopa (Lodosyn) ANTITUBERCULAR AGENTS aminosalicylic acid (PAS, Paser) ethionamide (Trecator-SC) rifampin (Rifadin) streptomycin sulfate capreomycin (Capastat Sulfate) isoniazid (INH, Isohydrazide, Niazid, Nydrazid, Niazid-B6) rifampin/isoniazid (Rifamate) cycloserine (Seromycin Pulvules) Pyrazinamide rifampin/pyrazinamide / isoniazid (Rifater) ethambutol (Myambutol) rifabutin (Mycobutin) rifapentine (Priftin) ANTIVIRALS abacavir/lamivudine (Epzicom) emtricitabine/rilpivirine/tenofovir (Complera) nevirapine (Viramune, Viramune XR) abacavir sulfate (Ziagen) emtricitabine (Emtriva) raltegravir (Isentress) abacavir/lamivudine/zidovudine (Trizivir) emtricitabine/tenofovir (Truvada) rilpivirine (Edurant) adefovir (Hepsera) enfuvirtide (Fuzeon) ritonavir (Norvir) amprenavir (Agenerase) entecavir (Baraclude) ritonavir/lopinavir (Kaletra) atazanavir sulfate (Reyataz) etravirine (Intelence) saquinavir (Fortovase) cidofovir (Vistide) fomivirsen (Vitravene) saquinavir mesylate (Invirase) cobicistat/elvitegravir/emtricitabine/teno fovir (Stribild) fosamprenavir calcium (Lexiva) stavudine (d4T, Zerit) darunavir ethanolate (Prezista) foscarnet (Foscavir) telbivudine (Tyzeka) delavirdine mesylate (Rescriptor) ganciclovir (DHPG, Cytovene IV) tenofovir disoproxil fumarate (Viread) didanosine (ddl) (Videx) indinavir sulfate (Crixivan) tipranavir (Aptivus) dolutegravir/abacavir/lamivudine (Triumeq) lamivudine (3TC, Epivir, Epivir HBV) valganciclovir (Valcyte) doutegravir (Tivicay) lamivudine/zidovudine (Combivir) zalcitabine (ddC, Hivid) efavirenz (Sustiva) maraviroc (Selzentry) zidovudine (AZT, Retrovir) efavirenz/emtricitabine/tenofovir (Atripla) nelfinavir mesylate (Viracept) CONTRACEPTIVES All oral contraceptives Proprietary & Confidential All non-oral contraceptives Intra-uterine Devices (IUDs): Skyla, Mirena, Paragard Page 4 Revision Date: November 1, 2014 Magellan Health Services TennCare AutoExempt List CLOTTING FACTORS antihemophilic factor, human (Alphanate, Hemofil-M, Humate-P, Koate, Melate, Monarc-M, Monoclate-P, Nybcen, Profilate) factor IX (Alphanine, Mononine) antihemophilic factor, human recombinant (Advate, Bioclate, Genarc, Helixate, Kogenate, Recombinate, Refacto, Xyntha) factor IX complex, human (Bebulin, Konyne, Profilnine, Proplex) antihemophilic factor/Von Willebrand factor complex (HumateP, Wilate) factor IX, recombinant (Alprolix) anti-inhibitor coagulant complex (Autoplex T, Feiba VH Immuno) factor XIII (Corifact) factor VIIa, recombinant (NovoSeven, NovoSeven RT) Fc fusion protein, recombinant (Eloctate) factor IX, human recombinant (Benefix) DIALYSIS MEDICATIONS calcium acetate (PhosLo, Eliphos) lanthanum carbonate (Fosrenol) calcium acetate/ magnesium carbonate (MagneBind) sevelamer (Renvela tablets, Renagel) cinacalcet (Sensipar) sodium polystyrene sulfonate (Kayexalate, Kionex, Marlexate, SPS) FA/vitamin B complex with C (B-Plex, Dialyvite, Folbee Plus, Nephronex, renal caps, Renal Multivitamin Formula, Renaphro) FLU VACCINE – INJECTABLE FORMULATIONS ONLY influenza (Fluvirin, Fluzone, Fluarix, Influenza A H1N1) HEMATOPOIETIC AGENTS darbepoetin alfa (Aranesp) pegfilgrastim (Neulasta) epoetin alfa, recombinant (Epogen, Procrit) plerixafor (Mozobil) filgrastim (Neupogen) sargramostim (Leukine, Prokine) oprelvekin (Neumega) HEPATITIS C boceprevir (Victrelis) peg-interferon alfa-2a (Pegasys) simprevir (Olysio) interferon alfa-2a (Roferon-A) peg-interferon alfa-2b (PEG-Intron) sofosbuvir (Sovaldi) interferon alfa-2b (Intron A, Sylatron) ribavirin (Copegus, Rebetol, Ribasphere, Ribapak) telaprevir (Incivek) interferon alfacon-1 (Infergen) ribivirin / interferon alfa-2b (Rebetron) IMMUNOSUPPRESSIVES azathioprine (Azasan, Imuran) daclizumab (Zenapax) sirolimus (Rapamune) basiliximab (Simulect) muromonab-CD3 (Orthoclone OKT3) tacrolimus (FK506, Prograf, Hecoria, Astagraf XL) cyclosporine (Sandimmune, Gengraf, Neoral, Sangcya) mycophenolate (Cellcept, Myfortic) Proprietary & Confidential Page 5 Revision Date: November 1, 2014 Magellan Health Services TennCare AutoExempt List IRON PREPARATIONS iron dextran complex (DexFerrum, Imferon, Infed, Proferdex) iron sucrose complex (Venofer) sodium ferric gluconate complex/sucrose (Ferrlecit) LONG-ACTING ANTIPSYCHOTICS fluphenazine (Prolixin Decanoate) haloperidol decanoate (Haldol Decanoate) TRANSPLANT hepatitis B immune globulin (Bayhep-B, H-Big, Hyperhep, NABI-HB, HepaGam B) OTHER COVERED ITEMS Antidiarrheals – Fulyzaq Asthma Supplies – Spacers, Peak Flow Meters, and NaCl for inhalation Diabetic Supplies – Test strips; Lancets; Lancet Devices; Acetone Urine Test (i.e., Ketostix®); Alcohol Pads; Glucose Control Solution; Meters; Syringes: Pen Needles Prenatal vitamins – Brands such as Prenate, Zenate, etc. Large Volume Parenterals – IV fluids : quantities Products ≥ 50mL, (Generic Name: Dextrose; Lactated Ringers; Sodium Chloride; Sterile Water) Saline Flush – Coded up to 30mL vials Total Parenteral Nutrition (TPN) – Coded by Amino Acid, all additives will be covered Heplock 10u/mL or 100u/mL Proprietary & Confidential Page 6 Revision Date: November 1, 2014