TennCare Preferred Drug List (PDL)
TennCare Preferred Drug List (PDL) Effective November 1, 2014 PA – Prior Authorization required, subject to specific PA criteria, QL – Quantity Limit (PA and NP agents require a PA before dispensing) Approval of NP agents requires trial and failure, contraindication or intolerance of 2 preferred agents, unless otherwise indicated. Please note: With the exception of the “Branded Drugs Classified as Generics” list, TennCare is a mandatory generic program in accordance with state law (TCA 53-10-205). Approval of a branded product when a generic is available requires documentation of a serious adverse reaction from the generic via a FDA MedWatch form OR contraindication to an inactive ingredient in the AB-rated generic equivalent. Therapeutic Failure of an AB-rated generic equivalent may be considered for approval of branded products in the following high-risk medication classes: Anticonvulsants, Atypical Antipsychotics, HIV antivirals, Immunosuppressants, and Oncology Agents. Preferred Drugs Non-Preferred Drugs I. Analgesics Agents for Opiate Detoxification ReVia® PA naltrexone PA Suboxone® film Zubsolv® PA, QL Buprenorphine and Buprenorphine/Naloxone buprenorphine PA, QL PA, QL buprenorphine/naloxone tablets PA, QL COX-II Inhibitors Class PA Celebrex® PA, QL N/A Transmucosal Fentanyl Products fentanyl lozenge PA, QL Abstral® PA, QL Fentora® PA, QL Actiq® PA, QL Subsys® PA, QL Narcotics Agonist/Antagonists butorphanol NS PA, QL nalbuphine PA, QL pentazocine/naloxone PA, QL pentazocine/APAP PA, QL Narcotics, Long Acting Narcotics fentanyl patch PA, QL morphine sulfate SA PA(≥100 mg), QL Kadian® PA (≥100 mg), QL Avinza® PA, QL morphine sulfate SR 24hr PA, QL Butrans® PA, QL MS Contin® PA, QL ConZipTM PA, QL Nucynta® ER PA,QL Dolophine® PA, QL Opana ER® PA, QL Duragesic® PA, QL OxyContin® PA, QL ExalgoTM PA, QL oxymorphone ER PA, QL hydromorphone ER PA, QL tramadol ER PA, QL methadone PA, QL tramadol ER 24 hr PA, QL Methadose® PA, QL Ultram ER® PA, QL morphine sulfate ER capsules PA, QL Zohydro ER® PA, QL * Note that Covered agents not listed on PDL may be considered non-preferred Proprietary & Confidential © 2014, Magellan Health Services, Inc. All Rights Reserved. Effective Date: November 1, 2014 Magellan Health Services Preferred Drugs TennCare Preferred Drug List Non-Preferred Drugs I. Analgesics Short-Acting Narcotics codeine/APAP QL morphine IR QL (excluding suppositories) butalbital/APAP/caff/codeine QL Norco® QL butalbital/ASA/caff/codeine QL Nucynta® QL hydrocodone/APAP QL (excluding generic for Xodol) oxycodone QL oxycodone/APAP QL Capital with Codeine® QL Opana® QL tramadol QL codeine QL Oxecta® QL Endodan® QL oxymorphone QL Demerol® QL oxycodone/ASA QL dihydrocodeine/APAP/codeine QL oxycodone/IBU QL dihydrocodeine/ASA/codeine QL Panlor® SS QL Dilaudid® QL Percocet® QL Fioricet® with Codeine QL Percodan® QL Fiorinal® with Codeine QL Roxicet® QL Hycet® QL Roxicodone® QL hydrocodone/APAP 5/300 Synalgos®-DC QL hydrocodone/APAP 10/300 tramadol/APAP QL Endocet® QL hydrocodone/ibuprofen 5/200 mg QL hydromorphone QL (excluding suppositories) Ibudone® QL hydrocodone/ibuprofen (excluding Tylenol® with Codeine QL 5/200 mg) QL hydromorphone suppositories Tylox® QL Levorphanol QL Ultracet® QL Lorcet® QL Ultram® QL Lortab® QL Vicodin® QL Maxidone® QL Vicodin HP QL Magnacet® QL Vicoprofen® QL meperidine QL XartemisTM XR Meperitab® QL Xodol® QL morphine suppositories QL Zamicet® QL QL NSAID/Anti-Ulcer Agents N/A Arthrotec® PA Duexis® PA diclofenac/misoprostol PA Vimovo® PA Proprietary & Confidential * Note that Covered agents not listed on PDL may be considered non-preferred Page 2 Revision Date: November 1, 2014 Effective Date: November 1, 2014 Magellan Health Services Preferred Drugs TennCare Preferred Drug List Non-Preferred Drugs I. Analgesics Salicylates and Non-Narcotic Combination Agents Be-Flex Plus® QL Ed-Flex® QL Acuflex® QL Flextra DS® QL Alpain® QL Flextra-650® QL diflunisal QL RhinoflexTM QL salsalate QL Anabar® QL Lagesic® QL Tetra-Mag® QL Cafgesic® QL Levacet® QL Cafgesic Forte® QL MST 600® QL Durabac® QL Rhinoflex 650TM QL Durabac Forte® QL Zgesic® QL Flextra® QL Zorprin® QL choline mag trisalicylate QL Dologesic® QL Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) diclofenac potassium ketorolac QL Anaprox® meloxicam suspension Anaprox DS® Mobic® diclofenac sodium ER meloxicam tablets nabumetone CambiaTM Motrin® naproxen Cataflam® Nalfon® piroxicam Clinoril® Naprelan® sulindac Daypro® naproxen sodium ER diclofenac sodium 1.5% Naprosyn® EC-Naprosyn® Pennsaid® PA etodolac Ponstel® etodolac ER oxaprozin Feldene® Sprix® PA fenoprofen tolmetin Flector® PA, QL Voltaren® indomethacin ER Voltaren® Gel PA ketoprofen ER Voltaren-XR® meclofenamate Zipsor® mefenamic acid Zorvolex® PA diclofenac sodium flurbiprofen ibuprofen indomethacin ketoprofen Preferred Drugs Non-Preferred Drugs II. ANTI-INFECTIVES Antibiotics: Cephalosporins First Generation cefadroxil capsules cefadroxil suspension cephalexin capsules cephalexin suspension cefadroxil tablets Keflex® cephalexin tablets Proprietary & Confidential * Note that Covered agents not listed on PDL may be considered non-preferred Page 3 Revision Date: November 1, 2014 Effective Date: November 1, 2014 Magellan Health Services Preferred Drugs TennCare Preferred Drug List Non-Preferred Drugs II. ANTI-INFECTIVES 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® ceftibuten Cefditoren Spectracef® cefpodoxime Antibiotics: Ketolides Ketek® PA N/A azithromycin QL azithromycin suspension clarithromycin Antibiotics: Macrolides PA erythromycin/sulfisoxazole Biaxin XL® QL clarithromycin ER/XL QL erythromycin brand products Zithromax® QL Zmax® QL Dificid® PA, QL erythromycin generic products all generic combinations of methenamine, phenylsalicylate, hyoscyamine, atropine, etc. Biaxin® Antibiotics: Methenamine and Combo methenamine mandelate methenamine hippurate all brand combinations of methenamine, phenylsalicylate, hyoscyamine, atropine, etc. Hiprex® Uroqid Acid #2® Antibiotics: Miscellaneous Agents for UTI Monurol® QL, PA N/A Antibiotics: Non-Absorbable Rifamycin Xifaxan® PA N/A Antibiotics: Oral Aminoglycosides N/A neomycin Neo-Fradin® ethambutol pyrazinamide cycloserine Rifadin® Isonarif® PA Rifamate® PA Mycobutin® PA rifampin Myambutol® Rifater® PA Paser® Seromycin® Pulvules Priftin® Trecator® isoniazid rifabutin PA Antibiotics: Oral Anti-Tuberculosis Antibiotics: Oral Glycopeptides N/A clindamycin caps Cleocin® Pediatric granules PA vancomycin caps PA Antibiotics: Oral Lincosamines Cleocin® clindamycin pediatric solution PA Proprietary & Confidential * Note that Covered agents not listed on PDL may be considered non-preferred Page 4 Revision Date: November 1, 2014 Effective Date: November 1, 2014 Magellan Health Services Preferred Drugs TennCare Preferred Drug List Non-Preferred Drugs II. ANTI-INFECTIVES Antibiotics: Oral Nitrofurans nitrofurantoin capsules nitrofurantoin suspension PA Furadantin® PA Macrodantin® Macrobid® Antibiotics: Oxazolidinones Zyvox® PA, QL N/A amoxicillin amoxicillin/clavulanate ciprofloxacin Antibiotics: Penicillins all brand penicillins dicloxacillin penicillin amoxicillin ER amoxicillin/clavulanic acid XR Antibiotics: Quinolones levofloxacin tabs Avelox® PA Levaquin® tabs Avelox ABC Pack® PA Levaquin® solution PA Cipro® tablets levofloxacin solution PA Cipro® suspension PA moxifloxacin PA ciprofloxacin suspension PA Noroxin® PA ciprofloxacin ER QL ofloxacin Factive® PA Antibiotics: Tetracyclines doxycycline monohydrate 50 and 100 mg caps Adoxa® minocycline ER PA, QL doxycycline hyclate 50 and 100mg demeclocycline PA minocycline tablets minocycline capsules minocycline capsules Morgidox® tetracycline doxycycline hyclate DR particles OcudoxTM Kit doxycycline hyclate 20mg PA, QL Oracea® doxycycline monohydrate 75 mg and 150 mg caps Periostat® PA, QL doxycycline monohydrate tabs Solodyn® PA, QL Doryx® Vibramycin® Dynacin® Antibiotics: Sulfonamides, Folate Antagonist sulfadiazine PA trimethoprim (TMP) TMP/sulfamethoxazole Bactrim® Primsol® Bactrim DS® Septra DS® Proprietary & Confidential * Note that Covered agents not listed on PDL may be considered non-preferred Page 5 Revision Date: November 1, 2014 Effective Date: November 1, 2014 Magellan Health Services Preferred Drugs TennCare Preferred Drug List Non-Preferred Drugs II. ANTI-INFECTIVES Antifungals: Oral clotrimazole troches fluconazole suspension PA fluconazole tablets QL nystatin terbinafine PA, QL griseofulvin suspension Gris-Peg® Ancobon® PA ketoconazole PA Diflucan® suspension PA Lamisil® PA, QL Diflucan® tablets QL Noxafil® PA flucytosine PA Onmel® PA, QL Grifulvin V® Sporanox® PA, QL griseofulvin microsize Terbinex® PA, QL griseofulvin ultramicrosize Vfend® PA itraconazole PA, QL voriconazole PA Antifungals: Vaginal miconazole-3 kit nystatin terconazole AVCTM cream miconazole-3 vaginal supp Gynazole-1® Terazol® Anti-Infectives: Amebicides N/A paromomycin Anti-Infectives: Antimalarials atovaquone/proguanil mefloquine dapsone quinine sulfate chloroquine Daraprim® Albenza® Biltricide® primaquine Aralen® Malarone® Coartem® Qualaquin® Anti-Infectives: Anthelmintics N/A Stromectol® Anti-Infectives: Miscellaneous Antiprotozoal Agents metronidazole tabs Alinia® PA Flagyl® ER atovaquone PA Mepron® PA Flagyl® metronidazole caps Anti-Infectives: Oral Nitroimidazoles metronidazole tabs Flagyl® Tindamax® Flagyl® ER Tinidazole metronidazole caps Anti-Infectives: Vaginal Antibiotics Cleocin® suppositories clindamycin phos 2% cream metronidazole 0.75% gel Vandazole® Cleocin® cream MetroGel® Vaginal Clindesse® vaginal cream Proprietary & Confidential * Note that Covered agents not listed on PDL may be considered non-preferred Page 6 Revision Date: November 1, 2014 Effective Date: November 1, 2014 Magellan Health Services Preferred Drugs TennCare Preferred Drug List Non-Preferred Drugs II. ANTI-INFECTIVES Antivirals: Cytomegalovirus Agents N/A Valcyte® Baraclude® Antivirals: Hepatitis B Epivir-HBV® QL adefovir PA lamivudine-HBV QL entecavir Tyzeka® PA Hepsera® PA Antivirals: Hepatitis C Non-Pegylated Interferons Intron-A® Pegasys® ProClick PA, QL Pegasys® syringes PA, QL Alferon® N Infergen® PA Antivirals: Hepatitis C Pegylated Interferons Pegasys Conv. Pack® PA, QL PEG-Intron® QL PEG-Intron Redipen® QL Pegasys® vials PA, QL Antivirals: Hepatitis C Antivirals OlysioTM PA, QL IncivekTM PA, QL VictrelisTM PA, QL Ribasphere® 200 mg tablets ribavirin tablets Sovaldi® PA, QL Antivirals: Hepatitis C Ribavirins Copegus® ribavirin capsules ModeribaTM dose pack Ribapak® Rebetol® capsules Ribasphere® 200mg capsules Rebetol® solution PA Ribasphere® 400 & 600 mg tablets Antivirals: Herpes acyclovir famciclovir QL valacyclovir QL Valtrex® QL Sitavig® buccal tabs QL Zovirax® Antivirals: HIV CCR5 Antagonists N/A Selzentry® PA, QL Antivirals: HIV Fusion Inhibitors N/A Fuzeon® PA, QL Antivirals: HIV Integrase Inhibitors Isentress® PA, QL Tivicay® PA, QL Edurant® nevirapine Intelence® PA, QL Famvir® QL Sustiva® QL QL N/A Antivirals: HIV NNRTIs nevirapine ER QL Viramune® QL Rescriptor® QL Viramune® XR QL Proprietary & Confidential * Note that Covered agents not listed on PDL may be considered non-preferred Page 7 Revision Date: November 1, 2014 Effective Date: November 1, 2014 Magellan Health Services Preferred Drugs TennCare Preferred Drug List Non-Preferred Drugs II. ANTI-INFECTIVES Antivirals: HIV NRTIs abacavir QL stavudine QL Emtriva® QL Viread® QL didanosine capsules QL Epivir® QL lamivudine QL Retrovir® QL Zerit® QL Videx® solution QL Ziagen® QL zidovudine QL Antivirals: HIV NRTI Combos abacavir/lamivudine/ zidovudine PA, QL lamivudine/zidovudine QL Combivir® QL Triumeq® QL Atripla® QL Complera® Epzicom® QL Trizivir® PA, QL Truvada® QL Prezista® QL Kaletra® QL Reyataz® QL Lexiva® QL Norvir® QL N/A N/A Stribild® Aptivus® PA, QL Invirase® QL Videx® capsules QL Antivirals: HIV Protease Inhibitors Crixivan® QL Prezista® QL Viracept® QL Antivirals: Influenza Relenza® PA, QL Preferred Drugs Tamiflu® PA, QL Non-Preferred Drugs III. CARDIOVASCULAR Alpha/Beta Blockers labetalol carvedilol QL Coreg® QL Trandate® Coreg CR® QL Alpha-Blockers doxazosin terazosin prazosin Cardura® Proprietary & Confidential * Note that Covered agents not listed on PDL may be considered non-preferred Minipress® Page 8 Revision Date: November 1, 2014 Effective Date: November 1, 2014 Magellan Health Services TennCare Preferred Drug List Preferred Drugs Non-Preferred Drugs III. CARDIOVASCULAR ACE Inhibitors benazepril captopril enalapril lisinopril ramipril QL Accupril® perindopril QL Aceon® QL Prinivil® Altace® QL Quinapril Epaned® PA trandolapril QL fosinopril Univasc® QL Lotensin® Vasotec® Mavik® QL Zestril® moexipril QL ACEI + Calcium Channel Blocker Combo N/A benazepril/amlodipine QL, PA Tarka® QL, PA Lotrel® QL, PA trandolapril/verapamil QL, PA ACEI + Diuretic Combination benazepril/HCTZ captopril/HCTZ enalapril/HCTZ lisinopril/HCTZ Accuretic® quinapril/HCTZ fosinopril/ HCTZ Uniretic® Lotensin HCT® Vaseretic® moexipril/HCTZ Zestoretic® Prinzide® Angiotensin II Receptor Blockers losartan QL Atacand® QL Avapro® QL Benicar® QL Cozaar® QL candesartan® QL Diovan® QL EdarbiTM QL eprosartan QL irbesartan QL Micardis® QL telmisartan QL Teveten® QL valsartan QL Angiotensin II Receptor Blockers + Calcium Channel Blocker Class PA, QL Exforge® PA, QL Exforge HCT® PA, QL losartan/HCTZ® QL Azor® PA, QL TribenzorTM PA, QL telmisartan/amlodipine PA, QL Twynsta® PA, QL Angiotensin II Receptor Blockers + Diuretic Atacand HCT® Hyzaar® Avalide® irbesartan/HCTZ Benicar HCT® QL candesartan/HCTZ Micardis HCT® QL QL telmisartan/ HCTZ QL Diovan HCT® QL Teveten HCT® Edarbyclor® QL valsartan/ HCTZ QL Proprietary & Confidential * Note that Covered agents not listed on PDL may be considered non-preferred Page 9 Revision Date: November 1, 2014 Effective Date: November 1, 2014 Magellan Health Services Preferred Drugs TennCare Preferred Drug List Non-Preferred Drugs III. CARDIOVASCULAR Anti-Anginal Agents: Miscellaneous Ranexa® PA N/A Anti-Anginal Agents: Nitrates Isochron® nitroglycerin (excluding spray) amyl nitrite Monoket® Nitrolingual® Dilatrate-SR® Nitro-Bid® isosorbide mononitrate Nitrostat® Imdur® Nitro-Dur® Isordil® nitroglycerin spray Isosorbide dinitrate 10 mg tabs NitroMistTM isosorbide dinitrate (excluding 10 mg tabs and SL tabs) Minitran® isosorbide dinitrate, sublingual Anti-Arrhythmics, Oral amiodarone quinidine sulfate Betapace® Pacerone® Betapace AF® propafenone ER flecainide sotalol sotalol AF Cordarone® Rythmol® Tikosyn® QL Multaq® PA Rythmol SR® Norpace® Sorine® Norpace CR® Tambocor® disopyramide mexiletine propafenone quinidine gluconate Anti-Hypertensives, Miscellaneous Catapres® NexiclonTM XR clonidine weekly TD patch QL reserpine guanfacine Clorpres® Tenex® guanabenz Vecamyl® PA, QL methyldopa minoxidil PA Catapres-TTS® QL clonidine hydralazine methyldopa/HCTZ Proprietary & Confidential * Note that Covered agents not listed on PDL may be considered non-preferred Page 10 Revision Date: November 1, 2014 Effective Date: November 1, 2014 Magellan Health Services Preferred Drugs TennCare Preferred Drug List Non-Preferred Drugs III. CARDIOVASCULAR Beta Blockers atenolol metoprolol tartrate nadolol propranolol (excluding solution) sotalol acebutolol Lopressor® Betapace® metoprolol succinate PA, QL betaxolol pindolol bisoprolol fumarate PA propranolol solution PA Bystolic® propranolol ER Cartrol® Sectral® Corgard® Sorine® Inderal LA® Tenormin® InnoPran XL® QL timolol maleate Kerlone® Toprol XL® PA, QL Levatol® QL Zebeta® Beta Blockers + Diuretic atenolol/chlorthalidone bisoprolol HCT metoprolol HCT propranolol HCT Corzide® nadolol/bendroflumethiazide Dutoprol® PA, QL Tenoretic® Lopressor HCT® Ziac® Calcium Channel Blockers (DHP) amlodipine QL Adalat CC® QL Norvasc® QL felodipine ER Cardene SR® QL Nymalize® PA nicardipine isradipine QL Procardia® nifedipine ER/SA/XL QL nifedipine IR Procardia XL® QL nimodipine PA Sular® QL nisoldipine QL Calcium Channel Blockers (Non-DHP) diltiazem ER/SR/XR Calan® diltiazem ER (generic for Cardizem LA) QL diltiazem IR Calan SR® Tiazac® verapamil Cardizem® verapamil ER PM verapamil ER QL Cardizem CD® Verelan® Cardizem LA® QL Verelan PM® Dilacor XR® Cardiac Glycosides digoxin Lanoxin® Proprietary & Confidential * Note that Covered agents not listed on PDL may be considered non-preferred Page 11 Revision Date: November 1, 2014 Effective Date: November 1, 2014 Magellan Health Services Preferred Drugs TennCare Preferred Drug List Non-Preferred Drugs III. CARDIOVASCULAR Direct Renin Inhibitors Class PA AmturnideTM PA, QL N/A Tekturna HCT® PA, QL Tekamlo® PA, QL Tekturna® PA, QL Diuretics: Carbonic Anhydrase Inhibitors Diamox® Sequels acetazolamide methazolamide amiloride/HCTZ triamterene/HCTZ spironolactone/HCTZ bumetanide Edecrin® amiloride Diuretics: Combination Diuretics Aldactazide® Maxzide® Dyazide® Diuretics: Loop Demadex® furosemide Lasix® torsemide Diuretics: Potassium Sparing Aldactone® spironolactone Inspra® PA eplerenone PA Diuretics: Thiazide and Related Diuretics chlorothiazide chlorthalidone hydrochlorothiazide (excluding 12.5mg tab) aminocaproic acid Lysteda® PA, QL Diuril® indapamide Microzide® hydrochlorothiazide 12.5mg tab PA Thalitone® metolazone methyclothiazide Zaroxolyn® Hemostatics, Oral tranexamic acid PA, QL Amicar® Intermittent Claudication cilostazol pentoxifylline PA Pletal® cholestyramine WelChol® tablets Colestid® Questran Light® colestipol WelChol® packets PA cholestyramine light Prevalite® N/A Trental® PA Lipotropics: Bile Acid Sequestrants Questran® Lipotropics: Cholesterol Absorption Inhibitors Zetia® PA, QL Proprietary & Confidential * Note that Covered agents not listed on PDL may be considered non-preferred Page 12 Revision Date: November 1, 2014 Effective Date: November 1, 2014 Magellan Health Services Preferred Drugs TennCare Preferred Drug List Non-Preferred Drugs III. CARDIOVASCULAR Lipotropics: Fibric Acid Derivatives fenofibrate (excluding generic for Antara®) PA fenofibrate (generic for TriCor®) PA gemfibrozil Antara® PA Lipofen® PA fenofibric acid PA Lofibra® PA Fenoglide® PA Lopid® fenofibrate (generic for Antara®) PA TriCor® PA fenofibrate capsules (generic for Lipofen®) PA Triglide® PA Fibricor® PA TriLipix® PA Lipotropics: Miscellaneous Juxtapid® PA, QL Kynamro® PA, QL Lipotropics: Niacin Derivatives Class PA Niacor® PA Niaspan® PA Lipotropics: Omega-3 Fatty Acids Class PA Lovaza® PA N/A niacin ER PA Vascepa® PA omega-3 acid ethyl esters PA Lipotropics: Standard Potency Statins QL lovastatin QL pravastatin QL simvastatin (5 mg, 10 mg, 20 mg, Altoprev® QL 40 mg) QL Livalo® QL fluvastatin QL Mevacor® QL Lescol® QL Pravachol® QL Lescol XL® QL Zocor® (5 mg, 10 mg, 20 mg, 40 mg) QL Lipotropics: High Potency Statins QL atorvastatin QL Crestor® QL simvastatin 80 mg PA, QL Lipitor® QL Zocor® 80 mg PA, QL Lipotropics: Combination Antihyperlipidemics QL N/A Advicor® PA QL Simcor® QL Liptruzet PA Vytorin® PA, QL Lipotropics: Statin + CCB Combination amlodipine/atorvastatin PA, QL N/A fondaparinux Fragmin® Caduet® PA, QL Injectable Anticoagulants Lovenox® Arixtra® enoxaparin heparin Proprietary & Confidential * Note that Covered agents not listed on PDL may be considered non-preferred Page 13 Revision Date: November 1, 2014 Effective Date: November 1, 2014 Magellan Health Services Preferred Drugs TennCare Preferred Drug List Non-Preferred Drugs III. CARDIOVASCULAR Oral Anticoagulants Coumadin® Jantoven® Eliquis® PA warfarin Pradaxa® PA Oral Thrombopoietin Agonists Promacta® PA, QL N/A Peripheral Vasodilators ergoloid mesylates Pheochromocytoma Agents Demser® PA N/A Aggrenox® anagrelide cilostazol clopidogrel 75 mg Platelet Inhibitors dipyridamole ticlopidine Agrylin® Persantine® Brilinta® PA, QL Plavix® clopidogrel 300 mg Pletal® Effient® PA Pulmonary Arterial Hypertension Agents Class PA, QL Adcirca® PA, QL Tracleer® PA, QL Adempas® PA, QL Orenitram® PA, QL Ventavis® PA, QL Revatio® PA, QL Letairis® PA, QL sildenafil PA, QL Tyvaso® PA, QL Opsumit® PA, QL Revatio® suspension PA, QL Vasopressors N/A midodrine N/A Xarelto® PA, QL Vasodilator/Nitrate Combinations BiDil® PA Preferred Drugs Non-Preferred Drugs IV. CENTRAL NERVOUS SYSTEM Agents for Neuropathic Pain gabapentin capsules QL Cymbalta® PA, QL lidocaine patch PA duloxetine QL Lidoderm® PA gabapentin solution PA, QL Lyrica® PA gabapentin tablets QL Neurontin® QL Gralise® PA, QL Neurontin® solution PA, QL Horizant® PA, QL Proprietary & Confidential * Note that Covered agents not listed on PDL may be considered non-preferred Page 14 Revision Date: November 1, 2014 Effective Date: November 1, 2014 Magellan Health Services Preferred Drugs TennCare Preferred Drug List Non-Preferred Drugs IV. CENTRAL NERVOUS SYSTEM Alzheimer’s: Cholinesterase Inhibitors donepezil QL (excluding 23 mg) donepezil ODT PA, QL Exelon® Patch QL galantamine tablets Aricept® ODT PA, QL galantamine solution Aricept® QL galantamine ER QL Aricept® 23 mg tablet PA, QL Razadyne® donepezil 23 mg PA, QL Razadyne ER® QL Exelon® rivastigmine Alzheimer’s: NMDA Receptor Antagonists Namenda® PA, QL N/A Namenda XR® PA, QL Antiparkinson’s Agents: Anticholinergics benztropine carbidopa carbidopa/levodopa N/A trihexyphenidyl Antiparkinson’s Agents: Decarboxylase Inhibitors Lodosyn® Antiparkinson’s Agents: Dopamine Precursors/Decarboxylase Inhibitors carbidopa/levodopa ER/SR Parcopa® Sinemet® CR Sinemet® Antiparkinson’s Agents: COMT Inhibitors and Combos carbidopa/levodopa/entacapone Stalevo® entacapone Comtan® Tasmar® Antidepressants: SSRIs QL citalopram QL Brisdelle® PA Paxil® QL escitalopram QL Celexa® QL Paxil CR® QL fluoxetine QL (excluding 20 mg and 60 mg tabs) fluoxetine 20 mg and 60 mg tabs QL Pexeva® QL fluvoxamine QL fluoxetine (PMDD) QL Prozac® QL paroxetine QL fluoxetine weekly PA, QL Prozac Weekly® PA, QL sertraline QL fluvoxamine ER QL Sarafem® QL Lexapro® QL Viibryd® QL Luvox CR® QL Zoloft® QL paroxetine CR QL Antidepressants: SSRI/SRMs N/A Brintellix® PA, QL Proprietary & Confidential * Note that Covered agents not listed on PDL may be considered non-preferred Page 15 Revision Date: November 1, 2014 Effective Date: November 1, 2014 Magellan Health Services Preferred Drugs TennCare Preferred Drug List Non-Preferred Drugs IV. CENTRAL NERVOUS SYSTEM Antidepressants: SNRIs Class PA, QL venlafaxine PA, QL venlafaxine ER caps QL Cymbalta® PA, QL Fetzima® PA, QL desvenlafaxine PA, QL Khedezla® PA, QL desvenlafaxine ER PA, QL Pristiq® PA, QL desvenlafaxine fumarate ER PA, QL Savella® PA, QL duloxetine QL venlafaxine ER tabs PA, QL Effexor XR® PA, QL Antidepressants: New Generation budeprion SR mirtazapine Aplenzin® Remeron SolTab® PA OleptroTM QL trazodone 300 mg bupropion IR/SR trazodone (excluding 300 mg) Forfivo XL® Wellbutrin® nefazodone Wellbutrin SR® Remeron® Wellbutrin XL® QL budeprion XL QL bupropion XL QL mirtazapine rapdis PA maprotiline Antidepressants: Tricyclics amitriptyline amoxapine protriptyline desipramine Anafranil® PA Surmontil® doxepin clomipramine PA Tofranil® imipramine HCl imipramine pamoate Tofranil-PM® nortriptyline Norpramin® Vivactil® Pamelor® Antidepressants: MAOIs Class PA, QL phenelzine PA, QL Emsam® PA, QL Parnate® PA, QL Marplan® PA, QL tranylcypromine PA, QL Nardil® PA, QL Antipsychotics: Typical chlorpromazine perphenazine Haldol® haloperidol thiothixene Moban® fluphenazine loxapine Orap® thioridazine Loxitane® trifluoperazine Navane® Proprietary & Confidential * Note that Covered agents not listed on PDL may be considered non-preferred Page 16 Revision Date: November 1, 2014 Effective Date: November 1, 2014 Magellan Health Services Preferred Drugs TennCare Preferred Drug List Non-Preferred Drugs IV. CENTRAL NERVOUS SYSTEM Antipsychotics: Atypical Class PA Abilify® PA, QL quetiapine PA, QL Abilify MaintenaTM PA, QL Risperdal® PA, QL Clozaril® PA Risperdal Consta® PA, QL clozapine PA risperidone PA, QL risperidone ODT PA, QL clozapine ODT PA Risperdal M-tab® PA, QL Saphris® PA, QL FazaClo ODT® PA, QL Zyprexa® PA, QL Seroquel® XR PA, QL Geodon® PA, QL Seroquel® PA, QL ziprasidone PA, QL Invega® PA Versacloz® suspension PA Abilify Discmelt® PA, QL Fanapt® PA, QL Latuda® PA, QL olanzapine PA, QL olanzapine ODT PA, QL Atypical Antipsychotic and SSRI Combinations butalbital/ASA/caff/codeine QL butalbital/APAP/caff QL Imitrex Nasal® QL Relpax® QL Zyprexa Zydis® PA, QL Class PA fluoxetine/olanzapine PA, QL N/A butalbital/APAP/caff/codeine QL Invega® SustennaTM PA, QL Symbyax® PA, QL Anti-Migraine: Combination Agents Cafergot® Margesic® QL butalbital/ASA/caff QL isomethept/caffeine/APAP QL Fioricet® with codeine QL Migergot® Fiorinal® with codeine QL Anti-Migraine: 5-HT1 Receptor Agonists QL rizatriptan QL Alsuma® QL naratriptan QL rizatriptan ODT QL Amerge® QL sumatriptan kits QL sumatriptan vials QL Axert® PA, QL sumatriptan nasal QL sumatriptan tabs QL Frova® QL Sumavel® DoseProTM QL Imitrex® Injectable QL Treximet® QL Imitrex® Kit QL Zomig® QL Imitrex® tablets QL Zomig® Spray QL Maxalt® QL Zomig ZMT® QL Maxalt MLT® QL Anti-Migraine: Ergotamine Derivatives N/A Migranal® PA, QL Proprietary & Confidential * Note that Covered agents not listed on PDL may be considered non-preferred Page 17 Revision Date: November 1, 2014 Effective Date: November 1, 2014 Magellan Health Services Preferred Drugs TennCare Preferred Drug List Non-Preferred Drugs IV. CENTRAL NERVOUS SYSTEM Antihyperkinesis: Stimulants Adderall® QL Methylin® solution & chewables methylphenidate amphetamine salt ER combo QL methylphenidate ER QL (generic for Ritalin LA®) methylphenidate SA OSM QL Daytrana® QL methylphenidate solution ProCentra® QL Desoxyn® QL methylphenidate SR 24hr QL Quillivant XR® QL dexmethylphenidate Ritalin LA® QL Ritalin ® dexmethylphenidate XR QL Ritalin SR® Vyvanse® QL Dexedrine Spansule® QL Zenzedi® Adderall XR® QL Methylin® tabs dextroamphetamine QL methylphenidate ER QL (excluding Concerta® QL generic for Ritalin LA®) amphetamine salt IR combo QL dextroamphetamine solution QL Focalin® Focalin XR® QL Metadate ER® QL methamphetamine QL Methylin ER® QL Strattera® QL methylphenidate CR QL Antihyperkinesis: Non-Stimulants clonidine ER PA, QL KapvayTM PA, QL Intuniv® PA, QL Agents for Narcolepsy Provigil® PA, QL modafinil PA, QL Xyrem® PA, QL Nuvigil® PA, QL Proprietary & Confidential * Note that Covered agents not listed on PDL may be considered non-preferred Page 18 Revision Date: November 1, 2014 Effective Date: November 1, 2014 Magellan Health Services TennCare Preferred Drug List Preferred Drugs Non-Preferred Drugs IV. CENTRAL NERVOUS SYSTEM Anticonvulsants carbamazepine lamotrigine tabs Aptiom® PA Lamictal® (tabs & chewable tabs) Banzel® PA Lamictal® ODT PA Carbatrol® lamotrigine chewable tabs levetiracetam carbamazepine ER (generic for Carbatrol® only) Lamictal® XR levetiracetam ER Celontin® lamotrigine ER oxcarbazepine clonazepam (tabs & ODT) PA, QL Lyrica® PA phenobarbital PA Depakene® Mysoline® Phenytek® Depakote® Neurontin® QL phenytoin Depakote® ER Neurontin® solutionPA, QL primidone Depakote® Sprinkles Onfi®PA topiramate diazepam rectal gel PA, QL Oxtellar XR® Tegretol-XR® 100mg Dilantin-125® Peganone® valproic acid Dilantin Kapseal® 100 mg Potiga® PA Vimpat® PA Epitol® Sabril® PA zonisamide felbamate PA Felbatol® PA Stavzor® FycompaTM PA, QL Tegretol-XR® (200 & 400mg) carbamazepine ER (excluding generic Carbatrol) Diastat® PA, QL Dilantin Kapseal® 30 mg Dilantin® Infatabs® divalproex divalproex DR sprinkles divalproex extended release Equetro® ethosuximide gabapentin capsules QL Tegretol® gabapentin solution PA, QL tiagabine gabapentin tablets Topamax® QL Gabitril® Trileptal® Keppra® Trokendi XR® PA Keppra® XR Zarontin® Klonopin® PA, QL Zonegran® Agents for RLS (Restless Leg Syndrome) pramipexole QL ropinirole Horizant® PA, QL Neupro® PA Mirapex® QL Requip® Amyotrophic Lateral Sclerosis (ALS) Rilutek® riluzole Proprietary & Confidential * Note that Covered agents not listed on PDL may be considered non-preferred Page 19 Revision Date: November 1, 2014 Effective Date: November 1, 2014 Magellan Health Services Preferred Drugs TennCare Preferred Drug List Non-Preferred Drugs IV. CENTRAL NERVOUS SYSTEM Anti-Anxiety Agents alprazolam PA, QL buspirone (excluding 30 mg) chlordiazepoxide PA, QL diazepam PA, QL lorazepam PA, QL clorazepate PA, QL alprazolam ER PA, QL oxazepam PA, QL alprazolam ODT PA, QL Niravam PA, QL Ativan PA, QL Tranxene-T PA, QL Buspar® Valium PA, QL buspirone 30 mg Xanax PA, QL Meprobamate Xanax ER PA, QL Cholinergic Muscle Stimulants Mestinon® syrup Mestinon® 180mg ER tab pramipexole QL pyridostigmine 60 mg tab Mytelase® Prostigmin® Mestinon® 60 mg tab Non-Ergot Dopamine Receptor Agonists ropinirole bromocriptine Parlodel® Cyloset® Requip® Mirapex® QL Requip® XL Mirapex® ER QL ropinirole ER Neupro® PA MAOI-Bs selegiline N/A Azilect® Zelapar® PA Eldepryl® Miscellaneous CNS Agents Nuedexta® PA, QL N/A Mood Stabilizers carbamazepine lithium citrate Depakote® Lamictal® XR Depakene® lamotrigine ER lamotrigine chewable tabs valproic acid Keppra® Stavzor® Lamictal® tabs Tegretol® Lamictal® chewable tabs Trileptal® Lamictal® ODT PA Lithobid® lamotrigine tabs levetiracetam lithium carbonate lithium carbonate SA oxcarbazepine Proprietary & Confidential * Note that Covered agents not listed on PDL may be considered non-preferred Page 20 Revision Date: November 1, 2014 Effective Date: November 1, 2014 Magellan Health Services TennCare Preferred Drug List Preferred Drugs Non-Preferred Drugs IV. CENTRAL NERVOUS SYSTEM Sedative Hypnotic Agents QL zaleplon QL zolpidem QL Ambien® QL Rozerem® QL Ambien CR® QL Silenor® PA, QL eszopiclone QL Sonata® QL EdluarTM PA, QL temazepam PA, QL estazolam PA, QL triazolam PA, QL flurazepam PA, QL zolpidem ER QL Halcion® PA, QL Zolpimist® PA, QL Intermezzo® QL Lunesta® QL Restoril® PA, QL Skeletal Muscle Relaxants baclofen methocarbamol Amrix® QL cyclobenzaprine tizanidine tablets carisoprodol/ASA PA, QL Robaxin® carisoprodol/ASA/codeine PA Skelaxin® cyclobenzaprine 7.5mg Soma® PA, QL Flexeril® tizanidine capsules Lorzone® Zanaflex® chlorzoxazone orphenadrine/ASA/caffeine dantrolene carisoprodol orphenadrine Parafon Forte® PA, QL metaxalone Preferred Drugs Non-Preferred Drugs V. DERMATOLOGICS Topical Antipruritics/Antihistamines Prudoxin® PA, QL N/A acyclovir 5% ointment Denavir® cream QL silver sulfadiazine Thermazene® Zonalon® PA, QL Topical Antivirals Xerese® PA QL Zovirax® ointment QL Zovirax® cream QL Topical Agents for Burns SSD® mefanide Sulfamylon® Silvadene® Proprietary & Confidential * Note that Covered agents not listed on PDL may be considered non-preferred Page 21 Revision Date: November 1, 2014 Effective Date: November 1, 2014 Magellan Health Services Preferred Drugs TennCare Preferred Drug List Non-Preferred Drugs V. DERMATOLOGICS Antiseborrheic Agents Mexar® wash Carmol® 10% Scalp lotion selenium sulfide/pyrithione zinc in urea Ovace® SelenosTM sulfacetamide sodium 10% wash Ovace®Plus Selsun® Rosula® NS Pads sodium sulfacetamide 10% shampoo Seb-PrevTM sulfacetamide sodium/urea pads selenium sulfide shampoo TL TrisebTM selenium sulfide 2.5% lotion 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 benzoyl peroxide (2.5%, 5%, 10% excluding cleanser, gel, microspheres, and towlettes) clindamycin phosphate (excluding foam and lotion) erythromycin (excluding swab) sodium sulfacetamide (excluding suspension) benzoyl peroxide (cleanser, gel, microspheres, towlettes, and all strengths not listed as preferred) benzoyl peroxide kits and other dermatological kits PA clindamycin phosphate foam and lotion clindamycin/benzoyl peroxide gel erythromycin swab erythromycin/benzoyl peroxide sulfacetamide suspension sodium sulfacetamide/sulfur All branded single agent and combination products of: benzoyl peroxide, clindamycin, erythromycin, and sodium sulfacetamide Topical Agents for Rosacea (Covered for recipients < 21 years old only) Finacea® 15% gel metronidazole 0.75% cream QL metronidazole 0.75% gel QL metronidazole 0.75% lotion QL metronidazole gel 1% QL Finacea® Plus gel PA MetroLotion® QL Metrocream® QL Mirvaso® MetroGel® 1% QL Noritate® 1% cream MetroGel® 1% Kit RosadanTM Kit Proprietary & Confidential * Note that Covered agents not listed on PDL may be considered non-preferred Page 22 Revision Date: November 1, 2014 Effective Date: November 1, 2014 Magellan Health Services Preferred Drugs TennCare Preferred Drug List Non-Preferred Drugs V. DERMATOLOGICS Topical Antifungal Agents ciclopirox econazole Bensal HP® Luzu® PA Ciclodan® Kit PA Loprox® clotrimazole nystatin ciclopirox nail kit PA Lotrisone® clotrimazole/betamethasone Mentax® CNL 8 Nail Kit® PA Naftin® Ertaczo® Nizoral® Exelderm® Nystatin/triamcinolone Extina® Oxistat® Jublia® PA Pediaderm® AF Ketocon Kit PA Pedipirox-4® Nail PA ketoconazole foam Penlac® PA Ketodan® Kit PA Vusion® PA ciclopirox solution 8% PA ketoconazole (shampoo and cream) Lamisil® Topical Antipsoriatics Class PA calcipotriene cream PA calcipotriene scalp solution PA Vectical® PA Tazorac® PA calcipotriene ointment PA Dovonex® Scalp Solution PA calcitriol ointment PA Sorilux® PA calcipotriene/betamethasone PA Taclonex® PA Dovonex® PA Genital Wart Agents imiquimod Aldara® podofilox Veregen® Condylox® Immunomodulators Aldara® imiquimod ammonium lactate LacLotion® N/A Emollients lactic acid lactic acid with vitamin E Lac-Hydrin® Retinoids, Oral acitretin PA, QL Myorisan® PA Absorica® PA Sotret® PA Amnesteem® PA Soriatane® QL Claravis® PA Zenatane® PA Proprietary & Confidential * Note that Covered agents not listed on PDL may be considered non-preferred Page 23 Revision Date: November 1, 2014 Effective Date: November 1, 2014 Magellan Health Services Preferred Drugs TennCare Preferred Drug List Non-Preferred Drugs V. DERMATOLOGICS Retinoids, Topical Class PA Tazorac® PA tretinoin PA adapalene PA Retin-A® PA Atralin® PA Retin-A Micro® PA Differin® PA tretinoin microsphere gel PA Epiduo® PA VeltinTM PA FabiorTM Ziana® PA Pediculocides/Scabicides QL NatrobaTM QL permethrin QL Sklice® QL Elimite® QL Ovide® QL Eurax® QL spinosad QL lindane PA, QL UlesfiaTM QL malathion QL Keratolytic Agents all generic urea products all generic salicylic acid products All brand urea products Regranex® PA Santyl® lidocaine QL lidocaine viscous All brand salicylic acid products Enzyme Preps and Wound Healing N/A Topical Anesthetics All brand lidocaine products Lidoderm® PA lidocaine/prilocaine QL EMLA® QL Pliaglis® Carac® Panretin® diclofenac 3% gel Valchlor® PA Efudex® Zyclara® fluorouracil Targretin® Picato® lidocaine HC Fluoroplex® Topical Antineoplastics Solaraze® hydrocortisone 1% cream and ointment hydrocortisone 2.5% cream, lotion and ointment Topical Steroids: Least Potent Alcortin® A Aqua Glycolic HC® Kit hydrocortisone acetate-aloe vera 2% gel Pediaderm HC® 2% Kit Texacort® 2.5% solution U-cort® 1% cream Proprietary & Confidential * Note that Covered agents not listed on PDL may be considered non-preferred Page 24 Revision Date: November 1, 2014 Effective Date: November 1, 2014 Magellan Health Services Preferred Drugs TennCare Preferred Drug List Non-Preferred Drugs V. DERMATOLOGICS Topical Steroids: Mild aclomethasone 0.05% cream and ointment Derma-Smoothe/FS® Oil desonide 0.05% cream desonide 0.05% ointment Desonate® 0.05% gel betamethasone valerate 0.1% lotion fluocinolone acetonide 0.01% cream, oil and solution Synalar® 0.01% solution Verdeso® 0.05% foam Topical Steroids: Lower Mid-Strength betamethasone dipropionate 0.05% lotion Capex® shampoo Derma-Top® 0.1% ointment Cloderm® 0.1% cream hydrocortisone butyrate 0.1% solution Derma-Top® 0.1% cream betamethasone valerate 0.1% cream clocortolone 0.1% cream and pump fluticasone proprionate 0.05% cream Cutivate® 0.05% cream and lotion desonide 0.05% lotion Desowen® 0.05% lotion Diprolene® 0.05% lotion fluocinolone acetonide 0.01% shampoo fluocinolone acetonide 0.025% cream fluticasone proprionate 0.05% lotion hydrocortisone butyrate 0.1% cream and ointment hydrocortisone valerate 0.2% cream Pandel® 0.1% cream prednicarbate 0.1% cream and ointment Topical Steroids: Mid-Strength hydrocortisone valerate 0.2% ointment Elocon® 0.1% cream and lotion triamcinolone acetonide 0.1% cream Kenalog® aerosol spray mometasone furoate 0.1% cream and solution (lotion) fluocinolone acetonide 0.025% ointment Pediaderm TA® Kit Proprietary & Confidential * Note that Covered agents not listed on PDL may be considered non-preferred Page 25 Revision Date: November 1, 2014 Effective Date: November 1, 2014 Magellan Health Services Preferred Drugs TennCare Preferred Drug List Non-Preferred Drugs V. DERMATOLOGICS Topical Steroids: Upper Mid-Strength fluocinonide 0.05% emulsified base cream amcinonide 0.1% cream and lotion triamcinolone acetonide 0.025% cream, lotion and ointment betamethasone valerate 0.1% ointment triamcinolone acetonide 0.5% cream and ointment desoximetasone 0.05% cream fluticasone proprionate 0.005% ointment betamethasone dipropionate 0.05% cream triamcinolone acetonide 0.1% lotion and ointment betamethasone valerate 0.12% foam Diprolene AF® 0.05% cream Luxiq® 0.12% foam Topicort® 0.05% cream Trianex® 0.05% ointment Topical Steroids: Potent betamethasone dipropionate, augmented 0.05% cream amcinonide 0.1% ointment mometasone furoate 0.1% ointment betamethasone dipropionate, augmented 0.05% lotion fluocinonide 0.05% cream, gel, ointment and solution Apexicon E® 0.05% cream betamethasone dipropionate 0.05% ointment desoximetasone 0.05% gel and ointment desoximetasone 0.25% cream and ointment diflorasone diactetate 0.05% cream and ointment Elocon® 0.1% ointment Halog® 0.1% ointment and cream Topicort® 0.05% gel and ointment Topicort® 0.25% cream and ointment Proprietary & Confidential * Note that Covered agents not listed on PDL may be considered non-preferred Page 26 Revision Date: November 1, 2014 Effective Date: November 1, 2014 Magellan Health Services Preferred Drugs TennCare Preferred Drug List Non-Preferred Drugs V. DERMATOLOGICS Topical Steroids: Super Potent clobetasol propionate 0.05% cream, gel, ointment, and solution betamethasone dipropionate, augmented 0.05% gel, and ointment halobetasol propionate 0.05% cream and ointment clobetasol propionate emollient base 0.05% foam clobetasol propionate emollient base 0.05% cream clobetasol propionate 0.05% foam, lotion and shampoo Clobex® 0.05% lotion and shampoo Clobex® 0.05% spray ClodanTM ClodanTM Kit PA Cordran® tape Diprolene® 0.05% ointment fluocinonide 0.1% cream Olux® 0.05% aerosol Olux-E® 0.05% aerosol Temovate® 0.05% cream and ointment Temovate E® 0.05% cream Ultravate® 0.05% cream and ointment Vanos® 0.1% cream Preferred Drugs Non-Preferred Drugs VI. DIABETIC SUPPLIES Diabetic Supplies: Blood Glucose Meters Abbott Diabetes Care Products (Covered Meters Include: Freestyle InsuLinx Meter, FreeStyle Lite Meter, FreeStyle Freedom Lite Meter, Precision Xtra Meter) Abbott Test Strips QL (Covered Strips Include: Precision Xtra Test Strips, FreeStyle Test Strips, FreeStyle Lite Test Strips, Freestyle InsuLinx Test Strips) AgaMatrix Products PA LifeScan Products PA Bayer Healthcare Products PA Roche Diagnostics Products PA Home Diagnostics Products PA Diabetic Supplies: Blood Glucose Test Strips AgaMatrix Products PA, QL LifeScan Products PA, QL Bayer Healthcare Products PA, QL Roche Diagnostics Products PA, QL Home Diagnostics Products PA, QL Proprietary & Confidential * Note that Covered agents not listed on PDL may be considered non-preferred Page 27 Revision Date: November 1, 2014 Effective Date: November 1, 2014 Magellan Health Services Preferred Drugs TennCare Preferred Drug List Non-Preferred Drugs VII. ENDOCRINE AND METABOLIC AGENTS Agents for Gout allopurinol probenecid Colcrys® PA Uloric® PA Zyloprim® probenecid/colchicine Anabolic Steroids Class PA Anadrol-50® PA N/A Oxandrin® PA oxandrolone PA Androgens Androgel® packets PA Testim® PA Androderm® PA Testred® PA Androgel® pump PA Android® PA testosterone (generic Androgel®, Fortesta®, Testim®) PA Danazol Axiron® PA testosterone cypionate PA, QL Depo-testosterone® PA, QL (200 mg/mL 1 mL vial) Androxy® PA testosterone enanthate PA, QL Delatestryl® PA, QL Striant® PA Depo-testosterone® PA, QL (excluding 200 mg/mL 1 mL vial) VogelxoTM PA Fortesta® PA Methitest® PA Antidiuretic/Vasopressor Agents DDAVP desmopressin tabs Stimate® PA desmopressin nasal spray Bone: Bisphosphonates Actonel® solution PA alendronate QL Actonel® QL Fosamax® QL Atelvia® QL Fosamax Plus D® QL Binosto® QL ibandronate QL Boniva® QL risedronate QL Didronel® Skelid® QL etidronate Bone: Calcitonin Class PA, QL calcitonin nasal spray PA, QL Miacalcin® nasal spray PA, QL raloxifene QL N/A Fortical® PA, QL Miacalcin® injection PA, QL Bone: SERMs Evista® QL Bone: Parathyroid Hormone Forteo® PA Proprietary & Confidential * Note that Covered agents not listed on PDL may be considered non-preferred Page 28 Revision Date: November 1, 2014 Effective Date: November 1, 2014 Magellan Health Services Preferred Drugs TennCare Preferred Drug List Non-Preferred Drugs VII. ENDOCRINE AND METABOLIC AGENTS Contraceptives, Non-Oral Depo SubQ Provera® QL medroxyprogesterone acetate inj. QL Altavera® Leena® Apri® Amethia Lo® Aranelle® Aviane® Beyaz® Brevicon® Camila® Cesia® Cryselle® Cyclessa® DeblitaneTM Desogen® Drosperinone/ ethinyl estradiol Elinest® Ella® Enpresse® Errin® Estrostep FE® Femcon FE® Gildagia® Gildess® Heather® Jolivette® Junel® Junel FE® Kelnor 1/35® Kurvelo® Depo-Provera® QL Nuvaring® PA Xulane TM PA Ortho Evra® PA Contraceptives, Oral Ortho Tri-Cyclen Lo® Balziva® Seasonale® Ortho-Cept® Generess FE® Seasonique® Levonorgestrel/ethinyl Ortho-Cyclen® Jolessa® Tilia FE® estradiol Kariva® Tri-Legest® FE Levora® Ortho-Novum® Lybrel® Zenchent® Lo/Ovral® Ovcon-50® Philith® Ogestrel® Plan B® Quasense® Lessina® Loestrin® Loestrin 24 FE® Loestrin FE® Lo Loestrin FE® Low-Ogestrel® Lutera® Microgestin® Microgestin FE® Mircette® Modicon® Mononessa® Necon® Natazia® Next Choice® Nikki® Nor-QD® Nora-BE® Nordette® Norinyl® Nortrel® Ortho Micronor® Ortho Tri-Cyclen® Plan B® One-Step Portia® Previfem® Reclipsen® Safyral® Solia® Sprintec® Sronyx® Tri-Linyah® Tri-Norinyl® Tri-Previfem® Tri-Sprintec® Trinessa® Trivora® Velivet® Vesturna® Wymza Fe® Yasmin® YAZ® Zovia® Proprietary & Confidential * Note that Covered agents not listed on PDL may be considered non-preferred Page 29 Revision Date: November 1, 2014 Effective Date: November 1, 2014 Magellan Health Services TennCare Preferred Drug List Preferred Drugs Non-Preferred Drugs VII. ENDOCRINE AND METABOLIC AGENTS Diabetes: Alpha-Glucosidase Inhibitors acarbose Precose® Glyset® Diabetes: Amylin Analogs Symlin® PA N/A Diabetes: Biguanides QL metformin QL metformin ER QL Fortamet® QL Glumetza® QL Glucophage® QL metformin ER osmotic QL Glucophage XR® QL Riomet® PA, QL Diabetes: DPP-4 Inhibitors and Combinations Class PA, QL Januvia® PA, QL Janumet® PA, QL Juvisync® PA, QL KombiglyzeTM XR PA, QL Onglyza® PA, QL Byetta® PA, QL Nesina® PA, QL JentaduetoTM PA, QL Oseni® PA, QL Kazano® PA, QL TradjentaTM PA, QL Diabetes: GLP-2 Analogs Gattex® PA N/A Bydureon® vials PA, QL Janumet XR® PA, QL Diabetes: Incretin Mimetics Class PA, QL Bydureon® Pen Victoza® PA, QL PA, QL Diabetes: Insulins Humalog® vials Humulin 70/30® Pen PA Apidra® Humalog 50/50® vials Levemir® vials Lantus® OptiClick PA Humalog 75/25® vials Humalog® Kwikpen PA Lantus® vials Apidra® Solostar PA Novolin N® Lantus® Solostar PA Humalog Mix 50/50® Kwikpen PA Novolin R® Levemir® FlexPen PA Humalog Mix 75/25® Kwikpen PA Novolin 70/30® Humulin N® Novolog® vials Humulin R® Novolog Mix 70/30® vials Humulin N® Pen PA Humulin® R U-500 Humulin 70/30® vials nateglinide QL Novolog® Flex Pen PA Novolog Mix 70/30® Flex Pen PA Diabetes: Meglitinides and CombinationQL Prandin® QL PrandimetTM QL Proprietary & Confidential * Note that Covered agents not listed on PDL may be considered non-preferred repaglinide QL Starlix® QL Page 30 Revision Date: November 1, 2014 Effective Date: November 1, 2014 Magellan Health Services Preferred Drugs TennCare Preferred Drug List Non-Preferred Drugs VII. ENDOCRINE AND METABOLIC AGENTS Diabetes: Sulfonylureas and Combination glimepiride QL glipizide glipizide ER/XL glyburide micronized glyburide/metformin glipizide/metformin glyburide Amaryl® QL Glucovance® chlorpropamide Glynase PresTab® Diabeta® Metaglip® Glucotrol® tolazamide Glucotrol XL® Diabetes: SGLT2 Inhibitors and Combinations N/A tolbutamide Class PA FarxigaTM PA, QL InvokanaTM PA, QL InvokametTM PA, QL Jardiance® PA, QL Diabetes: Thiazolidinediones Class PA, QL pioglitazone PA, QL Actos® PA, QL Avandia® PA, QL Diabetes: Thiazolidinedione Combinations Class PA, QL pioglitazone-metformin PA, QL ACTOplus Met® PA, QL Avandaryl® PA, QL ACTOplus Met® XR PA, QL DuetAct® PA, QL Avandamet® PA, QL pioglitazone-glimepiride PA, QL Disease Modifying Anti-Rheumatic Drugs hydroxychloroquine Ridaura® Arava® Depen® Azulfidine® QL Plaquenil® methotrexate sulfasalazine EC QL Azulfidine EN® QL Rheumatrex® Note: Injectable agents for the treatment of RA are located under Immunomodulators Cuprimine® Trexall® N/A XelJanz® PA, QL leflunomide sulfasalazine QL Anti-Rheumatic: Kinase Inhibitors Glucocorticoids, Oral Celestone® Orapred® Cortef® Orapred® ODT PA dexamethasone Dexpak® Pediapred® hydrocortisone Entocort® EC PA Rayos® methylprednisolone Medrol® Uceris® PA, QL prednisolone Millipred® budesonide capsules PA cortisone Genotropin® PA Norditropin® PA prednisone Growth Hormone Agents Veripred® Class PA Humatrope® PA Saizen® PA Nutropin® PA Serostim® PA Nutropin AQ® PA Tev-Tropin® PA Omnitrope® PA Zorbtive® PA Proprietary & Confidential * Note that Covered agents not listed on PDL may be considered non-preferred Page 31 Revision Date: November 1, 2014 Effective Date: November 1, 2014 Magellan Health Services Preferred Drugs TennCare Preferred Drug List Non-Preferred Drugs VII. ENDOCRINE AND METABOLIC AGENTS Hematopoietic Agents Class PA Aranesp® PA Epogen® PA N/A Procrit® PA Hormones: Adrenocorticotropic H.P. Acthar® PA, QL N/A Hormones: Anti-Thyroid methimazole propylthiouracil leuprolide PA Synarel® Cenestin® estropipate Activella® PremPhase® QL estradiol FemHRT® Low Dose PreFest® medroxyprogesterone megestrol QL Premarin® Tapazole® Hormones: LHRH N/A Hormones: Oral Estrogens EnJuvia® Femtrace® Estrace® Menest® Hormones: Oral Estrogen/Progestins PremPro® QL Angeliq® JinteliTM estradiol/norethindrone MimveyTM FemHRT® 1/5 Hormones: Oral Progestins progesterone Aygestin® Prometrium® Megace® QL Provera® Megace ES® PA, QL norethindrone acetate PA Hormones: Thyroid Cytomel® liothyronine Armour Thyroid® levothyroxine Unithroid® Thyrolar® Levothroid® Levoxyl® Synthroid® Thyroid® Tirosint® Hormones: Transdermal Estrogens Alora® QL Divigel® Estrasorb® Elestrin® Evamist® Vivelle-Dot® QL Estraderm® QL Menostar® QL estradiol TDS QL Minivelle® QL Climara® QL Hormones: Transdermal Estrogen/Progestins QL Combipatch® QL Climara Pro® QL Proprietary & Confidential * Note that Covered agents not listed on PDL may be considered non-preferred Page 32 Revision Date: November 1, 2014 Effective Date: November 1, 2014 Magellan Health Services Preferred Drugs TennCare Preferred Drug List Non-Preferred Drugs VII. ENDOCRINE AND METABOLIC AGENTS Hormones: Vaginal Estrogens Estring® Premarin Vaginal Cream® QL Estrace® Vagifem® Femring® Insulin-Like Growth Factor-1 Class PA N/A Increlex® PA Mineralocorticoids, Oral N/A fludrocortisone Progesterone Receptor Antagonists Korlym® PA N/A Somatostatic Agents octreotide PA Sandostatin® PA Somatuline Depot® Signifor® PA, QL Somavert® Preferred Drugs Non-Preferred Drugs VIII. GASTROINTESTINAL 5-ASA Derivatives, Oral QL AprisoTM QL Pentasa® QL Asacol HD® QL Dipentum® QL Azulfidine® QL Giazo® QL balsalazide QL sulfasalazine EC QL sulfasalazine QL Azulfidine EN® QL Sulfazine EC® QL Colazal® QL Asacol® QL Delzicol® QL Lialda® QL Canasa® Sulfazine® QL mesalamine enema 5-ASA Derivatives, Rectal mesalamine kit Rowasa® Rowasa kit® 5HT-3 Receptor Antagonists (IBS) Class PA Lotronex® PA, QL N/A diphenoxylate with atropine Lofene® Antidiarrheals Lonox® loperamide Lomotil® opium tincture Motofen® paregoric Fulyzaq®PA Anti-Emetics: A-9-THC Derivatives Class PA N/A Cesamet® PA Marinol® PA dronabinol® PA Proprietary & Confidential * Note that Covered agents not listed on PDL may be considered non-preferred Page 33 Revision Date: November 1, 2014 Effective Date: November 1, 2014 Magellan Health Services Preferred Drugs TennCare Preferred Drug List Non-Preferred Drugs VIII. GASTROINTESTINAL Anti-Emetics: Anticholinergics meclizine prochlorperazine trimethobenzamide Transderm Scōp® PA, QL Antivert® Tigan® Compro® Phenergan ® PA promethazine PA Anti-Emetics: 5-HT3 Antagonists Class PA ondansetron tabs and ODT PA, QL Anzemet® PA, QL Zofran ODT® PA, QL granisetron PA, QL Zofran® Solution PA Kytril® PA, QL Zofran® PA, QL ondansetron oral soln PA Zuplenz® PA, QL Sancuso® PA, QL Anti-Emetics: NK-1 Antagonists Class PA Emend® PA, QL N/A Anti-Emetics: Miscellaneous Diclegis® PA, QL N/A Antispasmodics/Anticholinergics Anaspaz® methscopolamine Bentyl® Pamine® Cantil® Pamine Forte® hyoscyamine chlordiazepoxide/clidinium Robinul® Hyosyne® Cuvposa® PA Robinul Forte® NuLev® Levsin® Sal-Tropine® propantheline Librax® dicyclomine glycopyrrolate HyoMax® N/A N/A Symax Fastabs® Symax-SL® Miscellaneous Agents for IBS Amitiza® PA, QL Linzess® PA, QL Combination Products for H. pylori Class PA Helidac® PA Prevpac® PA, QL lansoprazole/amoxicillin/ clarithromycin PA, QL Pylera® PA, QL Omeclamox® PA Gallstone Solubilizing Agents ursodiol QL Actigall® QL Urso® QL ChenodalTM Urso Forte® QL Proprietary & Confidential * Note that Covered agents not listed on PDL may be considered non-preferred Page 34 Revision Date: November 1, 2014 Effective Date: November 1, 2014 Magellan Health Services Preferred Drugs TennCare Preferred Drug List Non-Preferred Drugs VIII. GASTROINTESTINAL H2 Receptor Antagonists cimetidine famotidine ranitidine syrup Enulose® generlac ranitidine capsules nizatidine Zantac® Pepcid® ranitidine tablets Constulose® Axid® Laxatives PEG 3350 powder PEG 3350 electrolyte solution lactulose CoLyte® PEG 3350 with flavor packs GoLYTELY® PEG 3350 solution HalfLytely® Prepopik® Kristalose® Suclear® MoviPrep® Suprep® NuLYTELY® Trilyte® OsmoPrep® Visicol® Motility Agents Metozolv® ODT PA metoclopramide Reglan® Mucosal Protectants misoprostol sucralfate tablets Creon® ZenPep® Carafate® sucralfate suspension PA Cytotec® Pancreatic Enzymes (all strengths) Pancreaze® Ultresa® PertzyeTM Viokace® pancrelipase (all strengths) Proton Pump Inhibitors pantoprazole QL Aciphex® QL Prevacid® QL Aciphex® sprinkles PA Prevacid® SoluTabTM PA, QL omeprazole® OL Dexilant® QL Prilosec® QL esomeprazole QL Protonix® QL lansoprazole QL rabeprazole QL lansoprazole ODT PA, QL Zegerid® QL Protonix® suspension Nexium® QL Saliva Stimulating Agents pilocarpine PA, QL cevimeline PA, QL Salagen® PA, QL Evoxac® PA, QL Proprietary & Confidential * Note that Covered agents not listed on PDL may be considered non-preferred Page 35 Revision Date: November 1, 2014 Effective Date: November 1, 2014 Magellan Health Services Preferred Drugs TennCare Preferred Drug List Non-Preferred Drugs IX. IMMUNOLOGIC AGENTS Immunomodulators Class PA, QL Cimzia® PA, QL Humira® PA, QL Enbrel® PA, QL Actemra® PA, QL Simponi® PA, QL Kineret® PA, QL Stelara® PA, QL Orencia® PA, QL Immunosuppressants azathioprine Gengraf® Astagraf XL® PA Neoral® PA Azasan® PA Prograf® PA cyclosporine microemulsion tacrolimus Cellcept® PA Rapamune® PA Hecoria® PA Sandimmune® PA Imuran® PA sirolimus PA Myfortic® PA Zortress® PA cyclosporine mycophenolate mofetil mycophenolic acid PA Multiple Sclerosis Agents QL Avonex® QL Avonex Administration Pack® QL Betaseron® QL Ampyra® QL Copaxone®20 mg/mL QL Copaxone® 40 mg/mL PA, QL Extavia® QL Rebif® QL Multiple Sclerosis Agents: Potassium Channel Blockers N/A Multiple Sclerosis Agents: Oral Disease Modifying Agents Aubagio® PA N/A Gilenya® PA, QL Tecfidera® PA, QL Topical Immunomodulators Class PA Elidel® PA Preferred Drugs Protopic® PA Non-Preferred Drugs X. MISCELLANEOUS Gaucher’s Disease Agents Zavesca® Orfadin® N/A CerdelgaTM QL Hereditary Tyrosinemia Agents N/A Oral Iron Chelators Class PA Exjade® PA Proprietary & Confidential * Note that Covered agents not listed on PDL may be considered non-preferred Ferriprox® PA Page 36 Revision Date: November 1, 2014 Effective Date: November 1, 2014 Magellan Health Services Preferred Drugs TennCare Preferred Drug List Non-Preferred Drugs XI. ONCOLOGY AGENTS Afinitor® Inlyta® Stivarga® Afinitor Disperz® PA anastrozole Jakafi® Tafinlar® Aromasin® Tarceva® Casodex® Tasigna® Hydrea® Thalomid® Purixan® PA Alkeran® bicalutamide Bosulif® Caprelsa® Cometriq® cyclophosphamide Droxia® Eligard® PA Emcyt® Erivedge® etoposide exemestane Fareston® flutamide Gilotrif® Gleevec® Hexalen® Hycamtin® hydroxyurea Imbruvica® Iressa® leucovorin Leukeran® leuprolide PA letrozole lomustine Lysodren® Matulane® Mekinist® Tabloid® Arimidex® tamoxifen capicitabine Targretin® Femara® temozolamide Purinethol® tretinoin Temodar® Tykerb® mercaptopurine VotrientTM Mesna® Xalkori® methotrexate Xeloda® Myleran® Xtandi® Nexavar® Zelboraf® Nilandron® Zolinza® OfortaTM Zydelig® Pomalyst® Zykadia® Revlimid® Zytiga® Sprycel® Sutent® Effective March 1, 2014, the initial fill of oncology products will be limited to a 14 days supply. If the initial 14 days supply is tolerated, the member is eligible to receive the remainder of the first months supply without additional copay by the pharmacy submitting a Submission Clarification Code (NCPDP D.0 field 42Ø-DK) of 2. After the initial month, members may continue to receive up to a 31 days supply of oncology products per fill. Preferred Drugs Non-Preferred Drugs XII. OPHTHALMICS Ophthalmic Antibiotic/Steroid Combinations neomycin/BAC/poly B/HC neomycin/poly B/dexameth sulfacetamide/prednisolone Pred-G® TobraDex® suspension Blephamide® tobramycin/dexamethasone susp Maxitrol® TobraDex® ointment neomycin/poly B/HC TobraDex® ST suspension Poly-Pred® Zylet® PA Proprietary & Confidential * Note that Covered agents not listed on PDL may be considered non-preferred Page 37 Revision Date: November 1, 2014 Effective Date: November 1, 2014 Magellan Health Services TennCare Preferred Drug List Preferred Drugs Non-Preferred Drugs XII. OPHTHALMICS Ophthalmic Antibiotics AK-Poly-BACTM ofloxacin AzaSite® Ocuflox® bacitracin Polysporin® ciprofloxacin polymyxin B/TMP Romycin® Besivance® Polytrim® sulfacetamide sodium drops Bleph-10® sulfacetamide ointment tobramycin Ciloxan® Tobrex® solution Tobrasol® Garamycin® Zymaxid® Tobrex® ointment gatifloxacin 0.5% solution Vigamox® levofloxacin 0.5% solution bacitracin/poly B erythromycin Gentak® gentamicin Moxeza® neomycin/bac/poly B neomycin/poly B/gramicidin Ophthalmic Antifungals Natacyn® PA N/A Ophthalmic Antivirals Viroptic® trifluridine BepreveTM QL ketotifen QL Neosporin® Ophthalmic Antihistamines Pataday® QL ZirganTM PA > 5yr old QL azelastine QL LastacaftTM QL Elestat® QL Optivar® QL Emadine® QL Patanol® QL epinastine QL Zaditor® QL Ophthalmic Alpha-2 Agonists apraclonidine brimonidine tartrate 0.2% carteolol levobunolol brimonidine tartrate 0.15% Alphagan P® Iopidine® Ophthalmic Beta Blockers timolol maleate Betagan® OptiPranolol® betaxolol timolol gel solution Betimol® Timoptic® Betoptic-S® Timpoptic Occudose® Istalol® Timoptic-XE® metipranolol Ophthalmic Carbonic Anhydrase Inhibitors QL Azopt® QL dorzolamide QL naphazoline dorzolamide/timolol QL Cosopt® QL Trusopt® QL Cosopt PF® QL Ophthalmic Decongestants phenylephrine Neo-Synephrine® Proprietary & Confidential * Note that Covered agents not listed on PDL may be considered non-preferred Page 38 Revision Date: November 1, 2014 Effective Date: November 1, 2014 Magellan Health Services Preferred Drugs TennCare Preferred Drug List Non-Preferred Drugs XII. OPHTHALMICS Ophthalmic Mast Cell Stabilizers Alocril® Alamast® cromolyn sodium Alomide® Mydriatics and Mydriatic Combos atropine AK-PentolateTM Isopto® Homatropine Atropine CareTM Cyclogyl® Isopto Hyoscine® cyclopentolate CyclomydrilTM Mydriacyl® tropicamide Isopto Atropine® Ophthalmic NSAIDs Class PA diclofenac PA Acular® PA Ilevro® PA Acular LS® PA Nevanac® PA ketorolac PA AcuvailTM PA Ocufen® PA BromdayTM PA Voltaren® PA flurbiprofen PA bromfenac PA Ophthalmic Prostaglandin Agonists QL latanoprost QL Lumigan® QL Rescula® QL Xalatan® QL Travatan Z® QL Zioptan® QL Travoprost QL Ophthalmic Steroids Alrex® fluorometholone FML® ointment prednisolone acetate Pred Mild® Lotemax® Susp dexamethasone Lotemax® Ointment Durezol® Maxidex® Flarex® prednisolone sodium phosphate FML Forte® Pred Forte® FML Liquifilm® Vexol® Lotemax® Gel Glaucoma Direct Acting Miotics Isopto® Carbachol pilocarpine Pilopine HS® Isopto® Carpine Glaucoma Combinations Combigan® PA Restasis® PA, QL AK-Dilate® 2.5%, 10% naphazoline Simbrinza® PA Ophthalmic Immunomodulators Class PA, QL N/A Ophthalmic Vasoconstrictors NeofrinTM 2.5%, 10% phenylephrine 2.5%, 10% Albalon® Mydfrin® Proprietary & Confidential * Note that Covered agents not listed on PDL may be considered non-preferred Page 39 Revision Date: November 1, 2014 Effective Date: November 1, 2014 Magellan Health Services Preferred Drugs TennCare Preferred Drug List Non-Preferred Drugs XII. OPHTHALMICS Ophthalmic Lubricants and Artificial Tears Lacrisert® PA N/A N/A Miscellaneous Ophthalmics Cystaran® PA Preferred Drugs Non-Preferred Drugs XIII. OTICS Otic Quinolones CiproDex® QL ofloxacin otic QL Cipro HC® QL ciprofloxacin otic Otic Steroid/Antibiotic Combinations Cortisporin® Otic Cortomycin® Otic Coly-Mycin® S Cortisporin®-TC Otic HC/neomycin/polymyxinB Miscellaneous Otics acetic acid acetic acid/antipyrine/benzo/ polycosonal RE Benzotic® acetic acid/aluminum Acetasol HC® RE Chlorphenylcaine® acetic acid/HC Aurax Treagan® benzocaine/antipyrine DermOtic® TriOxin chloroxylenol/pramoxine fluocinolone acetonide VoSol® Neotic® VoSol® HC Otic Edge® Zinotic® Pramotic® Zinotic ES® PR Otic® Preferred Drugs Non-Preferred Drugs XIV. RENAL AND GENITOURINARY Alpha Blockers for BPH doxazosin prazosin tamsulosin QL terazosin alfuzosin QL Minipress® Cardura® Rapaflo® Cardura XL® QL Uroxatral® QL Flomax® QL Androgen Hormone Inhibitors finasteride QL Avodart® QL Proprietary & Confidential * Note that Covered agents not listed on PDL may be considered non-preferred Proscar® QL Page 40 Revision Date: November 1, 2014 Effective Date: November 1, 2014 Magellan Health Services Preferred Drugs TennCare Preferred Drug List Non-Preferred Drugs XIV. RENAL AND GENITOURINARY Combination Agents for BPH Jalyn®PA, QL N/A Phosphorus Depleters calcium acetate Phoslyra® EliphosTM Renvela® tablets Fosrenol® Renvela® powder for suspension PA PhosLo® sevelamer Renagel® Velphoro® PA Urinary Tract Antispasmodics oxybutynin Toviaz® QL tolterodine QL VESIcare® QL Detrol® QL oxybutynin ER QL Ditropan XL® QL Oxytrol® QL Detrol LA® QL Sanctura XR® QL Enablex® QL tolterodine ER QL flavoxate QL trospium QL GelniqueTM QL trospium XR QL Myrbetriq® Urinary Alkalizing Agents citric acid/sodium citrate Cytra-3® Citrolith® Polycitra-K® Cytra-K® crystals Urocit-K® Cytra-2® potassium citrate/citric acid Ora-Cit® Tricitrates® acetic acid K-Phos MF® Renacidin® PA K-Phos #2® Phospha Neutral® Cytra-K® solution K-Phos Original® potassium citrate Urinary Acidifying Agents K-Phos Neutral® Phenazo® phenazopyridine Elmiron® Fem pHTM Urinary Analgesics Pyridium® Urinary Interstitial Cystitis Agents RIMSO-50® N/A Vaginal Antiseptics N/A Preferred Drugs Non-Preferred Drugs XV. RESPIRATORY Anaphylaxis Therapy Agents Epipen® QL Epipen, Jr.® QL Adrenaclick® QL epinephrine injectable QL Auvi-QTM PA, QL Proprietary & Confidential * Note that Covered agents not listed on PDL may be considered non-preferred Page 41 Revision Date: November 1, 2014 Effective Date: November 1, 2014 Magellan Health Services Preferred Drugs TennCare Preferred Drug List Non-Preferred Drugs XV. RESPIRATORY Anticholinergics, Inhaled QL albuterol/ipratropium QL Combivent Respimat® QL Combivent MDI® QL Spiriva® QL Atrovent® HFA QL ipratropium 0.3%, 0.6% QL ipratropium solutionQL DuoNeb® QL Tudorza® QL Anticholinergics, Nasal QL Atrovent 0.3%, 0.6%® QL Antihistamines, First Generation (Covered for recipients < 21 years old only) brompheniramine maleate Dytuss syrup all formulations of brompheniramine tannate carbinoxamine maleate LoHist-12 all formulations of diphenhydramine tannate Bromspiro chlorpheniramine maleate clemastine hydroxyzine all formulations of chlorpheniramine tannate promethazine Aldex AN® Palgic® dexchlorpheniramine Vazol® Doxytex® Vistaril® cyproheptadine hydrochloride diphenhydramine HCl J-Tan PD Antihistamines, Non-Sedating (Covered for recipients < 21 years old only) Allegra® QL Clarinex-D 24 Hr® QL Allegra-D 12 Hr® QL desloratadine QL cetirizine syrup Allegra-D 24 Hr® QL desloratadine ODT PA, QL cetirizine/PSE QL Allegra ODT® PA, QL fexofenadine loratadine QL Claritin® QL fexofenadine/PSE QL loratadine RDT PA, QL Claritin® chewable PA, QL levocetirizine QL loratadine/PSE QL Claritin-D 12 Hr® QL Semprex®-D QL Claritin-D 24 Hr® QL Xyzal® QL Claritin RediTabs® PA, QL Zyrtec® QL Clarinex® QL Zyrtec® chewable PA, QL Clarinex RediTabs® PA, QL Zyrtec® ODT PA, QL Clarinex-D 12 Hr® QL Zyrtec-D® QL cetirizine chewable cetirizine tabs QL PA, QL QL Antihistamines, Nasal QL Astepro® PA, QL Patanase® QL Dymista® PA, QL azelastine PA, QL Beta Agonists: Combination Products Class PA, QL Advair Diskus® PA, QL Advair HFA® PA, QL Dulera® PA, QL Symbicort® PA, QL Anoro Ellipta® PA, QL Breo Ellipta® PA, QL Proprietary & Confidential * Note that Covered agents not listed on PDL may be considered non-preferred Page 42 Revision Date: November 1, 2014 Effective Date: November 1, 2014 Magellan Health Services Preferred Drugs TennCare Preferred Drug List Non-Preferred Drugs XV. RESPIRATORY Beta Agonists: Long Acting MDI Class PA, QL Serevent Diskus® PA, QL Foradil® PA, QL Arcapta® QL Striverdi ® Respimat QL Beta Agonists: Nebulizer albuterol inhalation solution QL AccuNeb® QL Perforomist® PA, QL Brovana® PA, QL Xopenex® PA, QL levalbuterol PA, QL Beta Agonists: Short Acting MDI QL Proventil HFA® QL Maxair Autohaler® QL Ventolin HFA® QL ProAir® HFA QL Xopenex HFA® PA, QL Beta Agonist: Oral albuterol syrup albuterol ER Bethkis® PA,QL Pulmozyme® PA, QL albuterol tabs terbutaline VoSpire ER® metaproterenol Cystic Fibrosis Agents QL TOBI® inhalation solution PA, QL Cayston® PA, QL Tobi Podhaler® PA, QL Kalydeco® PA, QL tobramycin solution 300mg/5mL PA, QL 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 cromolyn QL acetylcysteine benzonatate PA N/A Mucolytics N/A Non-Narcotic Antitussives Class PA Tessalon® PA Zonatuss® PA Tessalon Perles® PA Proprietary & Confidential * Note that Covered agents not listed on PDL may be considered non-preferred Page 43 Revision Date: November 1, 2014 Effective Date: November 1, 2014 Magellan Health Services Preferred Drugs TennCare Preferred Drug List Non-Preferred Drugs XV. RESPIRATORY Steroids, Orally Inhaled QL Asmanex® QL QVAR® QL Flovent HFA® QL Aerospan® QL Pulmicort Respules® PA, QL Alvesco® QL Flovent Diskus® QL budesonide respules PA, QL Pulmicort Flexhaler® QL Steroids, Intranasal QL fluticasone propionate QL Beconase AQ® QL Omnaris® QL budesonide nasal spray QL Rhinocort Aqua® QL Qnasl® QL Flonase® QL triamcinolone acetonide QL flunisolide QL Veramyst® QL Nasacort® AQ QL Zetonna® QL Nasonex® QL Xanthine Derivatives aminophylline Dyphylline GG® Difil®-G DG 200 Jay-Phyl Lufyllin®-GG COPD Difil®-G Forte Dy-G® Elixophyllin® Dilex-G Lufyllin® Theochron® Theo-24® Dylix® theophylline ER Daliresp® PA N/A Adrenalin® Phosphodiesterase 4 Inhibitor Vasoconstrictors, Intranasal N/A Tyzine® Preferred Drugs Non-Preferred Drugs XVI. SMOKING CESSATION AGENTS Smoking Cessation Agents QL bupropion SR QL Chantix® QL nicotine polacrilex lozenge QL nicotine polacrilex gum QL nicotine transdermal patch QL Commit® QL Nicotrol® inhaler QL Nicoderm® CQ QL Nicotrol® nasal spray QL Nicorette® gum QL Zyban® QL Preferred Drugs Non-Preferred Drugs XVII. VITAMINS AND ELECTROLYTES Cystine Depleting Agent Cystagon® Procysbi® PA Proprietary & Confidential * Note that Covered agents not listed on PDL may be considered non-preferred Page 44 Revision Date: November 1, 2014 Effective Date: November 1, 2014 Magellan Health Services Preferred Drugs TennCare Preferred Drug List Non-Preferred Drugs XVII. VITAMINS AND ELECTROLYTES Fluoride Products Denta 5000® Phos-flur® Epiflur® SF Dentagel® Fluor-a-day® Fluoritab® Renaf® drops Ludent® Fluor-a-day® Chewable Luride® Gel-Kam® Prevident® SF 5000 Plus sodium fluoride Folic Acid Preparations folic acid Deplin® PA l-methylfolate PA FalessaTM PA Q-Tabs® PA Kidney Stone Agents Lithostat® N/A Thiola® Multivitamins with Fluoride (Covered for recipients < 21 years old only) All generic prescription products (various manufacturers) All brand prescription products (various manufacturers) All generic OTC and prescription products All brand OTC and prescription products Multivitamins with Iron (Covered for recipients < 21 years old only) Kalexate Kionex® Effer-K® Kaon-CL® Klor-Con® Klor-Con/EF® Klor-Con M® Potassium Depletors sodium polystyrene sulfonate Kayexalate® SPS® Potassium Supplements K-Effervescent® Epiklor® Micro K® K-tabs® potassium chloride caps potassium bicarbonate Klor-Con® K-Vescent® powder potassium chloride tabs and solution potassium chloride, microencapsulated Prenatal Vitamins All generic OTC and prescription products (various manufacturers) All brand OTC and prescription products (various manufacturers) All OTC and generic prescription products (various manufacturers) All brand prescription products (various manufacturers) calcitriol doxercalciferol PA paricalcitol PA Hectorol® PA Zemplar® PA Renal Vitamins Vitamin D / Vitamin D-Analogs ergocalciferol Vitamin D Drisdol® Proprietary & Confidential * Note that Covered agents not listed on PDL may be considered non-preferred Rocaltrol® Page 45 Revision Date: November 1, 2014 Effective Date: November 1, 2014 Magellan Health Services Preferred Drugs TennCare Preferred Drug List Non-Preferred Drugs XVII. VITAMINS AND ELECTROLYTES Vitamin K Products Mephyton® zinc sulfate N/A Zinc Supplements Zincate® Galzin® PA Proprietary & Confidential * Note that Covered agents not listed on PDL may be considered non-preferred Page 46 Revision Date: November 1, 2014
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