1. No category

TennCare Preferred Drug List (PDL)
Effective January 8, 2015
PA – Prior Authorization required, subject to specific PA criteria, QL – Quantity Limit (PA and NP agents require a PA before dispensing)
Approval of NP agents requires trial and failure, contraindication or intolerance of 2 preferred agents, unless otherwise indicated.
Please note: With the exception of the “Branded Drugs Classified as Generics” list, TennCare is a mandatory generic program in accordance with state law (TCA 53-10-205).
Approval of a branded product when a generic is available requires documentation of a serious adverse reaction from the generic via a FDA MedWatch form OR
contraindication to an inactive ingredient in the AB-rated generic equivalent. Therapeutic Failure of an AB-rated generic equivalent may be considered for approval of
branded products in the following high-risk medication classes: Anticonvulsants, Atypical Antipsychotics, HIV antivirals, Immunosuppressants, and Oncology Agents.
Preferred Drugs
Non-Preferred Drugs
I. Analgesics
Agents for Opiate Detoxification
ReVia® PA
naltrexone PA
Suboxone®
film
Buprenorphine and Buprenorphine/Naloxone
Bunavail® PA, QL
PA, QL
buprenorphine/naloxone
tablets PA, QL
buprenorphine PA, QL
Zubsolv® 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
MS Contin® PA, QL
Butrans® PA, QL
Nucynta® ER PA,QL
ConZipTM PA, QL
Opana ER® PA, QL
Dolophine® PA, QL
OxyContin® PA, QL
Duragesic® PA, QL
oxymorphone ER PA, QL
ExalgoTM PA, QL
oxycodone 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
morphine sulfate SR 24hr PA, QL
* Note that Covered agents not listed on PDL may be considered non-preferred
Proprietary & Confidential
© 2015, Magellan Health Services, Inc. All Rights Reserved.
Effective Date: January 8, 2015
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
hydrocodone/ibuprofen QL
Tylenol® with Codeine QL
hydromorphone suppositories
Tylox® QL
Levorphanol QL
Ultracet® QL
Lorcet® QL
Ultram® QL
Lortab® QL
Vicodin® QL
Maxidone® QL
Vicodin HP QL
Magnacet® QL
Vicoprofen® QL
meperidine QL
XartemisTM XR
Meperitab® QL
Xodol® QL
morphine suppositories QL
Zamicet® QL
Endocet® QL
hydromorphone QL (excluding
suppositories)
Ibudone® 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: January 8, 2015
Effective Date: January 8, 2015
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: January 8, 2015
Effective Date: January 8, 2015
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: January 8, 2015
Effective Date: January 8, 2015
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
Sulfatrim®
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: January 8, 2015
Effective Date: January 8, 2015
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: January 8, 2015
Effective Date: January 8, 2015
Magellan Health Services
Preferred Drugs
TennCare Preferred Drug List
Non-Preferred Drugs
II. ANTI-INFECTIVES
Antivirals: Cytomegalovirus Agents
valganciclovir
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
Harvoni® PA, QL
VictrelisTM PA, QL
Sovaldi® PA, QL
OlysioTM PA, QL
Antivirals: Hepatitis C Ribavirins
Ribasphere® 200 mg tablets
ribavirin tablets
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 QL
Intelence® PA, QL
Famvir® QL
Sustiva® 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: January 8, 2015
Effective Date: January 8, 2015
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
benazepril
captopril
enalapril
prazosin
Cardura®
Minipress®
ACE Inhibitors
lisinopril
ramipril QL
Accupril®
perindopril QL
Aceon® QL
Prinivil®
Altace® QL
Quinapril
Epaned® PA
trandolapril QL
Proprietary & Confidential
* Note that Covered agents not listed on PDL may be considered non-preferred
Page 8
Revision Date: January 8, 2015
Effective Date: January 8, 2015
Magellan Health Services
TennCare Preferred Drug List
Preferred Drugs
Non-Preferred Drugs
III. CARDIOVASCULAR
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
amlodipine/valsartan/HCTZ PA, QL
TribenzorTM PA, QL
Azor® PA, QL
Twynsta® PA, QL
telmisartan/amlodipine PA, QL
valsartan/amlodipine PA, QL
Angiotensin II Receptor Blockers + Diuretic
losartan/HCTZ® QL
Atacand HCT®
Hyzaar®
Avalide®
irbesartan/HCTZ
Benicar HCT® QL
Micardis HCT® QL
candesartan/HCTZ
QL
telmisartan/ HCTZ QL
Diovan HCT® QL
Teveten HCT®
Edarbyclor® QL
valsartan/ HCTZ QL
Anti-Anginal Agents: Miscellaneous
N/A
Ranexa® PA
Proprietary & Confidential
* Note that Covered agents not listed on PDL may be considered non-preferred
Page 9
Revision Date: January 8, 2015
Effective Date: January 8, 2015
Magellan Health Services
Preferred Drugs
TennCare Preferred Drug List
Non-Preferred Drugs
III. CARDIOVASCULAR
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: January 8, 2015
Effective Date: January 8, 2015
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
metoprolol succinate PA, QL
Betapace®
pindolol
betaxolol
propranolol solution PA
bisoprolol fumarate PA
propranolol ER
Bystolic®
Sectral®
Corgard®
Sorine®
Hemangeol TM PA
Tenormin®
Inderal LA®
timolol maleate
InnoPran XL® QL
Toprol XL® PA, QL
Levatol® QL
Zebeta®
Lopressor®
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: January 8, 2015
Effective Date: January 8, 2015
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: January 8, 2015
Effective Date: January 8, 2015
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
niacin ER PA
Niaspan® PA
Lipotropics: Omega-3 Fatty Acids Class PA
Lovaza® PA
N/A
Vascepa® PA
omega-3 acid ethyl esters PA
Lipotropics: Standard Potency Statins QL
lovastatin QL
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: January 8, 2015
Effective Date: January 8, 2015
Magellan Health Services
Preferred Drugs
TennCare Preferred Drug List
Non-Preferred Drugs
III. CARDIOVASCULAR
Oral Anticoagulants
Coumadin®
Eliquis® PA, QL
warfarin
Jantoven®
Xarelto® PA, QL
Pradaxa® PA, QL
Oral Thrombopoietin Agonists
Promacta® PA, QL
N/A
Peripheral Vasodilators
ergoloid mesylates
Pheochromocytoma Agents
Demser® PA
N/A
Platelet Inhibitors
Aggrenox®
dipyridamole
anagrelide
ticlopidine
cilostazol
Agrylin®
Persantine®
Brilinta® PA, QL
Plavix®
clopidogrel 300 mg
Pletal®
Effient® PA
clopidogrel 75 mg
Pulmonary Arterial Hypertension Agents Class PA, QL
Adcirca® PA, QL
Tracleer® PA, QL
Adempas® PA, QL
Revatio® PA, QL
Opsumit® PA, QL
Revatio® suspension PA, QL
sildenafil PA, QL
Ventavis® PA, QL
Orenitram® ER PA, QL
Letairis® PA, QL
Tyvaso® PA, QL
Vasopressors
N/A
midodrine
Vasodilator/Nitrate Combinations
BiDil® PA
N/A
Preferred Drugs
Non-Preferred Drugs
IV. CENTRAL NERVOUS SYSTEM
Agents for Neuropathic Pain
gabapentin capsules
QL
Cymbalta® PA, QL
lidocaine patch PA
duloxetine QL
Lidoderm® PA
gabapentin solution PA, QL
Lyrica® PA
gabapentin tablets QL
Neurontin® QL
Gralise® PA, QL
Neurontin® solution PA, QL
Horizant® PA, QL
Proprietary & Confidential
* Note that Covered agents not listed on PDL may be considered non-preferred
Page 14
Revision Date: January 8, 2015
Effective Date: January 8, 2015
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: January 8, 2015
Effective Date: January 8, 2015
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: January 8, 2015
Effective Date: January 8, 2015
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
Zyprexa Zydis® PA, QL
Class PA
fluoxetine/olanzapine PA, QL
N/A
butalbital/APAP/caff QL
Invega® SustennaTM PA, QL
Symbyax® PA, QL
Anti-Migraine: Combination Agents
Cafergot®
Margesic® QL
butalbital/ASA/caff QL
Fiorinal® with codeine QL
butalbital/APAP/caff/codeine QL
isomethept/caffeine/APAP QL
butalbital/ASA/caff/codeine QL
Migergot®
Fioricet® with codeine QL
Anti-Migraine: 5-HT1 Receptor Agonists QL
Imitrex Nasal® QL
Relpax® 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: January 8, 2015
Effective Date: January 8, 2015
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
Intuniv® PA, QL
guanfacine ER PA, QL
KapvayTM 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: January 8, 2015
Effective Date: January 8, 2015
Magellan Health Services
Preferred Drugs
TennCare Preferred Drug List
Non-Preferred Drugs
IV. CENTRAL NERVOUS SYSTEM
Anticonvulsants
carbamazepine
lamotrigine tabs
Aptiom® PA
Lamictal® ODT PA
Banzel® PA
Lamictal® XR
Carbatrol®
lamotrigine chewable tabs
levetiracetam
carbamazepine ER (generic for
Carbatrol® only)
lamotrigine ER
levetiracetam ER
Celontin®
Lyrica® PA
oxcarbazepine
clonazepam (tabs & ODT) PA, QL
Mysoline®
phenobarbital PA
Depakene®
Neurontin® QL
Phenytek®
Depakote®
Neurontin® solution PA, QL
phenytoin
Depakote® ER
Onfi®PA
primidone
Depakote® Sprinkles
Oxtellar XR®
topiramate
diazepam rectal gel PA, QL
Peganone®
Tegretol-XR® 100mg
Dilantin-125®
Potiga® PA
valproic acid
Dilantin Kapseal® 100 mg
QudexyTM XR PA, QL
Vimpat® PA
Epitol®
Sabril® PA
zonisamide
felbamate PA
Felbatol® PA
Stavzor®
FycompaTM PA, QL
Tegretol-XR® (200 & 400mg)
gabapentin solution PA, QL
tiagabine
gabapentin tablets QL
Topamax®
Gabitril®
topiramate ER PA, QL
Keppra®
Trileptal®
Keppra® XR
Trokendi XR® PA, QL
Klonopin® PA, QL
Zarontin®
Lamictal® (tabs & chewable tabs)
Zonegran®
carbamazepine 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®
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: January 8, 2015
Effective Date: January 8, 2015
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: January 8, 2015
Effective Date: January 8, 2015
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
Lunesta® QL
Ambien CR® QL
Restoril® PA, QL
Belsomra® QL
Rozerem® QL
eszopiclone QL
Silenor® PA, QL
EdluarTM PA, QL
Sonata® QL
estazolam PA, QL
temazepam PA, QL
flurazepam PA, QL
triazolam PA, QL
Halcion® PA, QL
zolpidem ER QL
Hetlioz® PA, QL
Zolpimist® PA, QL
Intermezzo® QL
Skeletal Muscle Relaxants
baclofen
methocarbamol
Amrix® QL
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: January 8, 2015
Effective Date: January 8, 2015
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: January 8, 2015
Effective Date: January 8, 2015
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: January 8, 2015
Effective Date: January 8, 2015
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
lidocaine/hydrocortisone
All brand salicylic acid products
Enzyme Preps and Wound Healing
N/A
Topical Anesthetics
lidocaine/prilocaine QL
All brand lidocaine products
Lidoderm® PA
EMLA® QL
Pliaglis®
lidocaine/hydrocortisone/aloe
Topical Antineoplastics
Carac®
Panretin®
diclofenac 3% gel
Picato®
Efudex®
Valchlor® PA
fluorouracil
Targretin®
fluorouracil 5% cream
Zyclara®
Fluoroplex®
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: January 8, 2015
Effective Date: January 8, 2015
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
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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
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Effective Date: January 8, 2015
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
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Effective Date: January 8, 2015
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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
Androderm® PA
Testred® PA
Androgel® pump PA
Android® PA
testosterone (generic Androgel®,
Fortesta®, Testim®) PA
Danazol
Axiron® PA
testosterone cypionate PA, QL
Depo-testosterone® PA, QL
(200 mg/mL 1 mL vial)
Androxy® PA
testosterone enanthate PA, QL
Delatestryl® PA, QL
Striant® PA
Depo-testosterone® PA, QL
(excluding 200 mg/mL
1 mL vial)
Testim® PA
Fortesta® PA
VogelxoTM PA
Methitest® PA
Antidiuretic/Vasopressor Agents
DDAVP
desmopressin tabs
Stimate® PA
desmopressin nasal spray
Bone: Bisphosphonates
Actonel® solution PA
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
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Effective Date: January 8, 2015
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
Beyaz®
Brevicon®
Camila®
Cesia®
Cryselle®
Cyclessa®
DeblitaneTM
Desogen®
drosperinone/
ethinyl estradiol
Elinest®
Ella®
Enpresse®
Errin®
estradiol
Estrostep FE®
Femcon FE®
Gildagia®
Gildess®
Heather®
Jolivette®
Junel®
Junel FE®
Kelnor 1/35®
Kurvelo®
Contraceptives, Oral
Ortho-Cyclen®
Generess FE®
Seasonique®
levonorgestrel/ethinyl Ortho-Novum®
estradiol
Jolessa®
Tilia FE®
Levora®
Kariva®
Tri-Legest® FE
Lo/Ovral®
Ovcon-50®
Lybrel®
Zenchent®
Loestrin®
Philith®
Plan B®
Ogestrel®
Plan B® One-Step
Quasense®
Apri®
Aviane®
Ortho Evra® PA
Seasonale®
Leena®
Aranelle®
Xulane TM PA
Balziva®
Altavera®
Amethia Lo®
Depo-Provera® QL
Nuvaring® PA
Lessina®
Loestrin 24 FE®
Lomedia 24 FE®
Lo Loestrin FE®
Low-Ogestrel®
Lutera®
Microgestin®
Microgestin FE®
Mircette®
Modicon®
Mononessa®
Necon®
Natazia®
Next Choice®
Nikki®
Nor-QD®
Nora-BE®
Nordette®
Ortho-Cept®
Portia®
Previfem®
Reclipsen®
Safyral®
Solia®
Sprintec®
Sronyx®
Tarina-FE®
Tri-Linyah®
Tri-Norinyl®
Tri-Previfem®
Tri-Sprintec®
Trinessa®
Trivora®
Velivet®
Vesturna®
norethindrone/ethinyl Wymza Fe®
estradiol - FE
Norinyl®
Yasmin®
Ortho Micronor®
Zovia®
Nortrel®
Ortho Tri-Cyclen®
Ortho Tri-Cyclen Lo®
YAZ®
Proprietary & Confidential
* Note that Covered agents not listed on PDL may be considered non-preferred
Page 29
Revision Date: January 8, 2015
Effective Date: January 8, 2015
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
Tanzeum® 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
Trulicity® PA, QL
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
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Magellan Health Services
Preferred Drugs
TennCare Preferred Drug List
Non-Preferred Drugs
VII. ENDOCRINE AND METABOLIC AGENTS
Diabetes: Sulfonylureas and Combination
glimepiride QL
glyburide micronized
glipizide
glyburide/metformin
glipizide ER/XL
glipizide/metformin
Amaryl® QL
Glucovance®
chlorpropamide
Glynase PresTab®
Diabeta®
Metaglip®
Glucotrol®
tolazamide
Glucotrol XL®
glyburide
tolbutamide
Diabetes: SGLT2 Inhibitors and Combinations
N/A
Class PA
FarxigaTM PA, QL
Jardiance® PA, QL
InvokametTM PA, QL
Xigduo® XR PA, QL
InvokanaTM PA, QL
Diabetes: Thiazolidinediones Class PA, QL
Actos® PA, QL
pioglitazone PA, QL
Avandia® PA, QL
Diabetes: Thiazolidinedione Combinations
pioglitazone-metformin
PA, QL
Class 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
budesonide capsules
cortisone
dexamethasone
hydrocortisone
methylprednisolone
Genotropin® PA
Norditropin® PA
Glucocorticoids, Oral
PA
prednisolone
prednisone
Celestone®
Orapred®
Cortef®
Orapred® ODT PA
Dexpak®
Pediapred®
Medrol®
Rayos®
Millipred®
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
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Effective Date: January 8, 2015
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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
LopreezaTM
FemHRT® 1/5
MimveyTM
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
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Effective Date: January 8, 2015
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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
SERM/Estrogen Combinations
Duavee® PA
N/A
Somatostatic Agents
octreotide PA
Sandostatin® PA
Somatuline Depot®
Signifor® PA, QL
Somavert®
Preferred Drugs
Non-Preferred Drugs
VIII. GASTROINTESTINAL
5-ASA Derivatives, Oral QL
AprisoTM QL
Pentasa® QL
Asacol HD® QL
Dipentum® QL
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
Proprietary & Confidential
* Note that Covered agents not listed on PDL may be considered non-preferred
Page 33
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Effective Date: January 8, 2015
Magellan Health Services
Preferred Drugs
TennCare Preferred Drug List
Non-Preferred Drugs
VIII. GASTROINTESTINAL
Anti-Emetics: A-9-THC Derivatives Class PA
Cesamet® PA
N/A
Marinol® PA
dronabinol PA
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
N/A
Diclegis® PA, QL
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
Symax Fastabs®
Symax-SL®
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: January 8, 2015
Effective Date: January 8, 2015
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®
Miscellaneous Agents for Irritable Bowel Syndrome
N/A
Amitiza® PA, QL
Miscellaneous Agents for Inflammatory Bowel Disease
Entocort® EC PA
N/A
Uceris® PA, QL
Motility Agents
Metozolv® ODT PA, QL
metoclopramide QL
misoprostol
Linzess® PA, QL
Reglan® QL
Mucosal Protectants
sucralfate tablets
Carafate®
sucralfate suspension PA
Cytotec®
Pancreatic Enzymes
Creon® (all strengths)
ZenPep®
Pancreaze®
Ultresa®
PertzyeTM
Viokace®
pancrelipase (all strengths)
Proton Pump Inhibitors
pantoprazole QL
Aciphex® QL
Prevacid® QL
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
Proprietary & Confidential
* Note that Covered agents not listed on PDL may be considered non-preferred
Page 35
Revision Date: January 8, 2015
Effective Date: January 8, 2015
Magellan Health Services
Preferred Drugs
TennCare Preferred Drug List
Non-Preferred Drugs
VIII. GASTROINTESTINAL
Saliva Stimulating Agents
cevimeline PA, QL
pilocarpine PA, QL
Salagen® PA, QL
Evoxac® PA, QL
Preferred Drugs
Non-Preferred Drugs
IX. IMMUNOLOGIC AGENTS
Anti-inflammatory: PDE-4 Inhibitors
Otezla® PA, QL
N/A
Cimzia® PA, QL
Enbrel® PA, QL
Immunomodulators Class PA, QL
Humira® PA, QL
Actemra® PA, QL
Simponi® PA, QL
Kineret® PA, QL
Stelara® PA, QL
Orencia® PA, QL
Immunosuppressants
azathioprine
Gengraf®
Astagraf XL® PA
mycophenolic acid PA
Azasan® PA
Neoral® PA
cyclosporine
tacrolimus
Cellcept® (excluding suspension) PA Prograf® PA
Cellcept® suspension
cyclosporine microemulsion
mycophenolate mofetil
Hecoria® PA
Rapamune® PA
Imuran® PA
Sandimmune® PA
Myfortic® PA
sirolimus PA
mycophenolatemofetil suspension Zortress® PA
Multiple Sclerosis Agents QL
Avonex® QL
Avonex Administration Pack® QL
Betaseron® QL
Ampyra® QL
N/A
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
Gilenya® PA, QL
Tecfidera® PA, QL
Topical Immunomodulators Class PA
Elidel® PA
Protopic® PA
Proprietary & Confidential
* Note that Covered agents not listed on PDL may be considered non-preferred
tacrolimus ointment PA
Page 36
Revision Date: January 8, 2015
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Magellan Health Services
Preferred Drugs
TennCare Preferred Drug List
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 37
Revision Date: January 8, 2015
Effective Date: January 8, 2015
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®
tobramycin/dexamethasone
suspension
Blephamide®
TobraDex® ointment
Maxitrol®
TobraDex® suspension
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
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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
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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® Carpine
pilocarpine
Pilopine HS®
phospholine iodide
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
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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
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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
calcium acetate
EliphosTM
Phosphorus Depleters
Phoslyra®
Renvela® tablets
ferric citrate
Renvela® powder for suspension PA
Fosrenol®
sevelamer
PhosLo®
Velphoro® PA
Renagel®
Urinary Tract Antispasmodics
oxybutynin
tolterodine QL
Toviaz® 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®
Cytra-K® solution
potassium citrate
Urinary Acidifying Agents
Renacidin® PA
acetic acid
K-Phos
K-Phos #2®
Phospha Neutral®
K-Phos Original®
MF®
K-Phos Neutral®
Phenazo®
phenazopyridine
Elmiron®
Fem pHTM
Urinary Analgesics
Pyridium®
Urinary Interstitial Cystitis Agents
RIMSO-50®
N/A
Vaginal Antiseptics
N/A
Proprietary & Confidential
* Note that Covered agents not listed on PDL may be considered non-preferred
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Magellan Health Services
Preferred Drugs
TennCare Preferred Drug List
Non-Preferred Drugs
XV. RESPIRATORY
Anaphylaxis Therapy Agents
Epipen® QL
Adrenaclick® QL
Epipen, Jr.® QL
epinephrine injectable QL
Auvi-QTM PA, QL
Anticholinergics, Inhaled QL
albuterol/ipratropium QL
Combivent Respimat® QL
DuoNeb® QL
Combivent MDI® QL
Spiriva® QL
Spiriva Respimat® QL
Atrovent® HFA QL
ipratropium 0.3%, 0.6% QL
ipratropium solutionQL
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
cyproheptadine hydrochloride
diphenhydramine HCl
hydroxyzine
all formulations of chlorpheniramine tannate
promethazine
Aldex AN®
Palgic®
dexchlorpheniramine
Vazol®
Doxytex®
Vistaril®
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
Patanase® QL
Astepro® PA, QL
Dymista® PA, QL
azelastine PA, QL
olopatadine QL
Proprietary & Confidential
* Note that Covered agents not listed on PDL may be considered non-preferred
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Magellan Health Services
Preferred Drugs
TennCare Preferred Drug List
Non-Preferred Drugs
XV. RESPIRATORY
Beta Agonists: Combination Products Class PA, QL
Advair Diskus® PA, QL
Advair HFA® PA, QL
Serevent Diskus® PA, QL
Anoro Ellipta® PA, QL
Dulera® PA, QL
Symbicort® PA, QL
Breo Ellipta® PA, QL
Foradil® PA, QL
Arcapta® QL
Beta Agonists: Long Acting MDI Class PA, 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
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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
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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®
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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
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