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TennCare Attestation List
November 1, 2014
To initiate an attestation request for any agent on the attestation list, the prescribing physician or the
prescribing physician’s agent must call the Magellan Health Services Call Center at 1-866-434-5524.
Medications on this list can be approved for patients currently at their monthly prescription limit (greater
than 5 prescriptions or greater than 2 brand medications), who are at a high risk for adverse health
consequences and could be hospitalized, institutionalized, or die within the next 90 days without the
requested drug(s). This list is independent of the preferred drug list (PDL) and other criteria. All drugs on
this list are still subject to existing TennCare edits, including non-preferred status on the PDL, clinical
criteria, step therapy criteria, and quantity limits.*
ANTI-INFECTIVES
Aminoglycosides
amikacin (Amikin)
paromomycin
gentamicin (Garamycin)
streptomycin
kanamycin
tobramycin (Nebcin, Tobi)
neomycin (Neo-Fradin)
Cephalosporins, First Generation
cefadroxil (Duricef)
cephalexin (Keflex)
cefazolin (Ancef)
Cephalosporins, Second Generation
cefaclor (Ceclor)
cefprozil (Cefzil)
cefoxitin (Mefoxin)
cefuroxime (Ceftin, Zinacef)
Cephalosporins, Third Generation
cefdinir
ceftazidime (Fortaz, Tazicef)
cefditoren (Spectracef)
ceftibuten (Cedax)
cefixime (Suprax)
ceftizoxime (Cefizox)
cefotaxime (Claforan)
ceftriaxone (Rocephin)
cefpodoxime (Vantin)
Cephalosporins, Fourth Generation
cefepime (Maxipime)
Ketolides
telithromycin (Ketek)
Lincosamides
clindamycin (Cleocin)
Proprietary & Confidential
© 2014, Magellan Health Services, Inc. All Rights Reserved.
lincomycin (Lincocin)
Magellan Health Services
TennCare Attestation List
ANTI-INFECTIVES
Macrolides
azithromycin (Zithromax, Zmax)
erythromycin (E.E.S., Eryc, Ery-Tab, EryPed)
clarithromycin (Biaxin, Biaxin XL)
erythromycin/sulfisoxazole (Eryzole, Pediazole)
Nitrofurans
nitrofurantoin (Furadantin, Macrodantin, Macrobid)
Nitroimidazoles
metronidazole HCl (Flagyl)
tinidazole (Tindamax)
Oxazolidinones
linezolid (Zyvox)
Penicillins
amoxicillin/potassium clavulanate (Augmentin)
oxacillin
amoxicillin
penicillin G (Bicillin C-R, Bicillin L-A, Permapen)
ampicillin
penicillin V potassium (Veetids)
ampicillin/sulbactam (Unasyn)
piperacillin
dicloxacillin
piperacillin/tazobactam (Zosyn)
nafcillin
ticarcillin/potassium clavulanate (Timentin)
Quinolones
ciprofloxacin (Cipro, Cipro XR, Proquin XR)
moxifloxacin (Avelox)
gemifloxacin (Factive)
norfloxacin (Noroxin)
levofloxacin (Levaquin)
ofloxacin (Floxin)
Sulfonamides
sulfadiazine
sulfasalazine (Azulfidine)
sulfamethoxazole/trimethoprim (Bactrim, Septra)
trimethoprim
Tetracyclines
demeclocycline
minocycline (Arestin, Dynacin, Minocin, Myrac)
doxycycline (Adoxa, Atridox, Doryx, Monodox, Oracea,
Oraxyl, Periostat, Vibramycin)
tetracycline (Sumycin)
Vancomycin and Derivatives
vancomycin (Vancocin)
Miscellaneous Antibiotics
fosfomycin (Monurol)
Proprietary & Confidential
methenamine (Hiprex, Urex)
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TennCare Attestation List
ANTI-INFECTIVES
Antifungals
amphotericin B (Abelcet, Ambisome, Amphocin,
Amphotec)
itraconazole (Sporanox)
anidulafungin (Cancidas)
micafungin (Mycamine)
caspofungin (Eraxis)
miconazole (Monistat)
fluconazole (Diflucan)
posaconazole (Noxafil)
flucytosine (Ancobon)
voriconazole (Vfend)
griseofulvin (Fulvicin U/F, Gris-Peg, Grifulvin V)
Antiparasitics
albendazole (Albenza)
mefloquine
artemether/lumefantrine (Coartem)
nitazoxanide (Alinia)
atovaqu one/proguanil (Malarone)
paromomycin
atovaquone (Mepron)
pentamidine (Nebupent, Pentam 300)
chloroquine (Aralen)
praziquantel (Biltricide)
dapsone
primaquine
iodoquinol (Yodoxin)
pyrantel (Pin-X, Reese Pinworm)
ivermectin (Stromectol)
pyrimethamine (Daraprim)
mebendazole
quinine (Qualaquin)
Antivirals
acyclovir (Zovirax)
penciclovir (Denavir)
famciclovir (Famvir)
valacyclovir (Valtrex)
oseltamivir (Tamiflu)
zanamivir (Relenza)
CARDIOVASCULAR
Anti-Anginal Agents, Miscellaneous
ranolazine (Ranexa)
Proprietary & Confidential
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TennCare Attestation List
CARDIOVASCULAR
Antiarryhthmics
adenosine (Adenocard)
lidocaine (Xylocaine)
amiodarone (Cordarone, Pacerone)
mexiletine (Mexitil)
bretylium
procainamide
disopyramide IR/SA (Norpace/Norpace CR)
propafenone (Rythmol/Rythmol SR)
dofetilide (Tikosyn)
quinidine gluconate
dronedarone (Multaq)
quinidine sulfate (Quinidex)
flecainide (Tambocor)
sotalol/sotalol af (Betapace/Betapace AF)
ibutilide (Corvert)
Anticoagulants
apixaban (Eliquis)
heparin (Heparin)
dalteparin (Fragmin)
rivaroxaban (Xarelto)
dabigatran Etexilate (Pradaxa)
tinzaparin (Innohep)
enoxaparin (Lovenox)
warfarin (Coumadin, Jantoven)
fondaparinux (Arixtra)
Antifibrinolytics
aminocaproic acid (Amicar)
tranexamic acid (Cyklokapron, Lysteda)
aprotinin (Trasylol)
Cardiac Glycosides
digoxin (Lanoxin)
Diuretics, Loop
ethacrynic acid (Edecrin)
Hyperkalemia Agents
sodium polystyrene sulfonate (Kayexalate, Kionex, SPS)
Hypotensives, ACE Inhibitors
perindopril (Aceon)
Proprietary & Confidential
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TennCare Attestation List
CARDIOVASCULAR
Hypotensives, Angiotensin Receptor Blockers
azilsartan (Edarbi)
olmesartan/HCTZ (Benicar HCT)
candesartan (Atacand)
telmisartan (Micardis)
candesartan/HCTZ (Atacand HCT)
telmisartan/HCTZ (Micardis HCT)
eprosartan (Teveten)
valsartan (Diovan)
eprosartan/HCTZ (Teveten HCT)
valsartan/HCTZ (Diovan HCT)
irbesartan (Avapro)
irbesartan/HCTZ (Avalide)
olmesartan (Benicar)
Hypotensives, Direct Renin Inhibitors
aliskiren/valsartan (Valturna)
aliskiren/HCTZ (Tekturna HC)
aliskiren (Tekturna)
Hypotensives, Sympatholytics
clonidine (Catapres, Catapres TTS, Nexiclon XR)
methyldopa/HCTZ
guanabenz
methyldopate
guanfacine (Tenex)
reserpine
methyldopa (Aldomet)
Hypotensives, Vasodilators
diazoxide (Hyperstat I.V.)
hydralazine HCl (Apresoline)
fenoldopam mesylate (Corlopam)
minoxidil (Minoxidil)
Oral Thrombopoietic Agonists
eltrombopag (Promacta)
Pheochromocytoma Agents
metyrosine (Demser)
Platelet Aggregation Inhibitors/Intermittent Claudication
abciximab (Reopro)
pentoxifylline (Trental)
aspirin/dipyridamole (Aggrenox)
prasugrel (Effient)
cilostazol (Pletal)
ticagrelor (Brilinta)
clopidogrel (Plavix)
ticlopidine (Ticlid)
dipyridamole (Persantine)
tirofiban (Aggrastat)
eptifibatide (Integrilin)
vorapaxar (Zontivity)
Proprietary & Confidential
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Magellan Health Services
TennCare Attestation List
CARDIOVASCULAR
Pulmonary Hypertension Agents
ambrisentan (Letairis)
riociguat (Adempas)
bosentan (Tracleer)
sildenafil (Revatio)
epoprostenol (Flolan)
tadalafil (Adcirca)
iloprost (Ventavis)
treprostinil (Remodulin, Tyvaso, Orenitram)
macitentan (Opsumit)
Vasodilators
amyl nitrite
isosorbide mononitrate (Imdur, Monoket)
isosorbide dinitrate (Dilatrate-SR, Isochron, Isordil)
nitroglycerin (Minitran, Nitrek, Nitro-Bid, Nitro-Dur,
Nitrolingual, Nitroquick, Nitrostat, Nitrotab, NitroTime, Nitromist)
Vasopressors
midodrine
CNS
Anticonsulvants
carbamazepine (Tegretol, Tegretol XR)
lacosamide (Vimpat)
clobazam (Onfi)
methsuximide (Celontin)
clonazepam (Klonopin)
oxcarbazepine (Trileptal)
clonazepam ODT (Klonopin Wafer)
perampanel (Fycompa)
diazepam rectal gel (Diastat)
phenobarbital
divalproex sodium (Depakote, Depakote ER, Depakote
Sprinkles)
phenytoin (Dilantin, Dilantin Kapseals, Phenytek)
eslicarbazepine (Aptiom)
pregabalin (Lyrica)
ethosuximide (Zarontin)
primidone (Mysoline)
ethotoin (Peganone)
rufinamide (Banzel)
ezogabine (Potiga)
tiagabine (Gabitril)
felbamate (Felbatol)
topiramate (Topamax, Qudexy XR)
fosphenytoin (Cerebyx)
valproate sodium (Depacon)
gabapentin (Neurontin)
valproic acid (Depakene, Stavzor)
lamotrigine (Lamictal, Lamictal XR)
vigabatrin (Sabril)
levetiracetam (Keppra, Keppra XR)
zonisamide (Zonegran)
Proprietary & Confidential
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Magellan Health Services
TennCare Attestation List
CNS
Antidepressants, New Generation
bupropion HCl (Wellbutrin, Wellbutrin SR,
Wellbutrin XL)
nefazodone (Serzone)
maprotiline
trazodone (Oleptro)
mirtazapine (Remeron, Remeron SolTab)
vilazodone (Viibryd)
Antidepressants, SNRIs and SSRIs
citalopram (Celexa)
fluvoxamine
desvenlafaxine (Pristiq, Khedezla)
milnacipran (Savella)
duloxetine (Cymbalta)
paroxetine (Paxil, Paxil CR, Pexeva)
escitalopram (Lexapro)
sertraline HCl (Zoloft)
fluoxetine (Prozac, Prozac Weekly, Sarafem)
venlafaxine (Effexor XR)
Anti-Parkinson Agents
apomorphine (Apokyn)
rasagiline (Azilect)
bromocriptine (Parlodel)
ropinirole (Requip, Requip XL)
carbidopa/levodopa (Sinemet, Sinemet CR)
selegiline (Zelapar, Eldepryl)
carbidopa/levodopa/entacapone (Stalevo)
tolcapone (Tasmar)
pramipexole (Mirapex, Mirapex ER)
entacapone (Comtan)
Antipsychotics
chlorpromazine (Thorazine)
perphenazine
droperidol (Inapsine)
pimozide (Orap)
fluphenazine
prochlorperazine (Compazine)
haloperidol (Haldol)
thioridazine
loxapine (Loxitane)
thiothixene (Navane)
molindone (Moban)
trifluoperazine
Antipsychotics, Atypical
aripiprazole (Abilify, Abilify Discmelt, Abilify Maintena)
olanzapine (Zyprexa, Zyprexa Zydis, Zyprexa Relprevv)
asenapine (Saphris)
paliperidone (Invega, Invega Sustenna)
clozapine (Clozaril, FazaClo)
quetiapine (Seroquel, Seroquel XR)
iloperidone (Fanapt)
risperidone (Risperdal, Risperdal Consta)
lurasidone (Latuda)
ziprasidone (Geodon)
MAOIs
isocarboxazide (Marplan)
selegiline (Eldepryl, Emsam, Zelapar)
phenelzine (Nardil)
tranylcypromine (Parnate)
Proprietary & Confidential
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TennCare Attestation List
CNS
Mood Stabilizers
lithium carbonate (Lithobid)
lithium citrate
lithium carbonate ER
SSRI/Antipsychotic Combos
olanzapine/fluoxetine (Symbyax)
TCAs
amitriptyline
imipramine (Tofranil, Tofranil-PM)
amoxapine
nortriptyline (Pamelor)
clomipramine (Anafranil)
protriptyline (Vivactil)
desipramine (Norpramin)
trimipramine (Surmontil)
doxepin
ENDOCRINE AGENTS
Glucocorticoids, Oral
cortisone
hydrocortisone (Cortef)
betamethasone solution (Celestone)
methylprednisolone (Medrol)
budesonide (Entocort EC)
prednisolone (Millipred, Orapred, Pediapred, Prelone)
dexamethasone (Dexpak, Dekpak Jr.)
prednisone
GASTROINTESTINAL AGENTS
Pancreatic Enzymes
6,000 L/19,000 P/30,000 A (Creon L 6,000 units)
24,000 L/76,000 P/120,000 A (Creon L 24,000 units)
12,000 L/38,000 P/60,000 A (Creon L 12,000 units)
Pancreatic Enzymes
Pancreaze
Viokace
Pertyze
ZenPep
Ultresa
Anti-Emetics
ondansetron (tabs, ODT, solution)
Kytril®
Zofran® (tabs, ODT, solution)
Sancuso®
Anzemet®
Zuplenz®
granisetron
Proprietary & Confidential
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TennCare Attestation List
IMMUNOGOLOGIC AGENTS
Immunomodulators
anakinra (Kineret)
golimumab (Simponi)
adalimumab (Humira)
tocilizumab (Actemra)
etanercept (Enbrel)
ustekinumab (Stelara)
certolizumab pegol (Cimzia)
Immune Globulins
Gammagard
Hizentra
Gamunex-C
Vivaglobin
Multiple Sclerosis
Fingolimod (Gilenya)
interferon beta-1b (Betaseron, Extavia)
glatiramer acetate (Copaxone)
teriflunomide (Aubagio)
interferon beta-1a (Avonex, Avonex Administration Pack,
Rebif)
MISCELLANEOUS
epinephrine (TwinJect, EpiPen, EpiPen Jr., Adrenaclick)
naloxone (Evzio)
OPHTHALMICS
Antibiotic/Corticoid Combinations
gentamicin/prednisolone (Pred-G)
neomycin/polymyxin B/prednisolone (Poly-Pred)
neomycin/bacitracin/polymyxin/hydrocortisone
(Cortisporin)
tobramycin/dexamethasone (Tobradex ointment)
neomycin/polymyxin B/dexamethasone (Maxitrol)
tobramycin/loteprednol (Zylet)
neomycin/polymyxin B/hydrocortisone (Cortisporin)
Antibiotics
azithromycin (AzaSite)
levofloxacin (Iquix, Quixin)
bacitracin
moxifloxacin (Vigamox)
bacitracin/polymyxin B (AK-Poly-BAC, Polycin-B,
Polysporin)
neomycin/ polymyxin B/bacitracin (Neosporin)
besifloxacin (Besivance)
neomycin/polymyxin B/gramicidin (Neosporin Eye
Drops)
chloramphenicol (Chloromycetin)
ofloxacin (Ocuflox)
ciprofloxacin (Ciloxan)
polymyxin B/trimethoprim (Polytrim)
erythromycin (Ilotycin, Romycin)
sulfacetamide sodium (Bleph-10)
gatifloxacin (Zymar)
tobramycin (AK-Tob, Tobrasol, Tobrex)
Proprietary & Confidential
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TennCare Attestation List
OPHTHALMICS
gentamicin (Garamycin, Genoptic, Gentak, Gentasol)
Antifungals
natamycin (Natacyn)
Antivirals
ganciclovir (Zirgan)
trifluridine (Viroptic)
Anti-inflammatory Agents
bromfenac (Xibrom)
ketorolac (Acular, Acular LS, Acular PF)
diclofenac (Voltaren)
loteprednol (Alrex, Lotemax)
fluorometholone (Flarex, FML Forte, FML Liquifilm, FML
S.O.P.)
nepafenac (Nevanac)
flurbiprofen (Ocufen)
rimexolone (Vexol)
Miotics/IOP Reducers
acetylcholine chloride (Miochol-E)
dorzolamide (Trusopt)
apraclonidine (Iopidine)
latanoprost (Xalatan)
betaxolol (Betoptic-S)
levobunolol (Betagan)
bimatoprost (Lumigan)
metipranolol (OptiPranolol)
brimonidine (Alphagan P)
pilocarpine (Isopto Carpine, Pilopine HS, Piloptic)
brinzolamide (Azopt)
timolol (Betimol, Istalol, Timoptic, Timoptic-XE GFS)
carbachol (Isopto Carbachol, Miostat)
timolol/dorzolamide (Cosopt)
carteolol
travoprost (Travatan Z)
Sulfonamides
sodium sulfacetamide/prednisolone (Blephamide S.O.P.)
sulfacetamide sodium (Bleph-10, Ocusulf-10, Sulfac,
Sulfamide)
OTICS
Antibiotics/Anti-inflammatory Agents
ciprofloxacin/dexamethasone (Ciprodex)
neomycin/polymixin B/hydrocortisone (Cortisporin Otic)
ciprofloxacin/hydrocortisone (Cipro HC Otic)
Antibiotics/Anti-inflammatory Agents
neomycin/colistin/hydrocortisone/thonzonium
(Cortisporin-TC Otic)
ofloxacin
neomycin/colistin/hydrocortisone (Colymycin-S)
Proprietary & Confidential
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TennCare Attestation List
RESPIRATORY
Anticholinergics
ipratropium (Atrovent HFA)
tiotropium (Spiriva)
Beta Agonist: Short-Acting
albuterol (ProAir HFA)
levalbuterol (Xopenex, Xopenex HFA)
Beta Agonist/Anticholinergic Combinations
albuterol/ipratropium (Combivent, Combivent Respimat) vilanterol/umeclidinium (Anoro Ellipta)
Beta Agonists: Other
formoterol (Foradil, Perforomist)
pirbuterol (Maxair Autohaler)
indacaterol (Arcapta)
salmeterol (Serevent)
metaproterenol
terbutaline (Brethine)
olodaterol (Striverdi)
Beta Agonist/Corticosteroid Combinations
budesonide/formoterol (Symbicort)
mometasone/formoterol (Dulera)
fluticasone/salmeterol (Advair)
fluticasone/vilanterol (Breo Ellipta)
Inhaled Corticosteroids
beclomethasone (QVAR)
fluticasone (Flovent Diskus, Flovent HFA)
budesonide (Pulmicort Respules, Pulmicort Flexhaler)
mometasone (Asmanex Twisthaler)
flunisolide (Aerospan)
Monoclonal Antibody
omalizumab (Xolair)
Mucolytics
acetylcysteine
dornase alfa (Pulmozyme)
Xanthines
aminophylline
dyphylline (Dylix, Lufyllin)
caffeine citrated (Cafcit)
theophylline anhydrous (Theo-24, Theochron, Uniphyl)
caffeine/sodium benzoate
VITAMINS AND ELECTROLYTES
Potassium Supplements (Rx ONLY)
potassium chloride (Epiklor, Kaon-CL, Klor-Con, K-tabs,
K-Vescent, Micro K)
Proprietary & Confidential
potassium chloride, microencapsulated (Klor-Con M)
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