TennCare Preferred Drug List (PDL) Effective February 1, 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 Buprenorphine and Buprenorphine/Naloxone Suboxone® film PA, QL Bunavail® PA, QL Zubsolv® PA, QL buprenorphine PA, QL buprenorphine/naloxone tablets PA, QL COX-II Inhibitors Class PA Celebrex® PA, QL N/A celecoxib PA, QL 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 oxycodone ER PA, QL Hysingla® 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 Proprietary & Confidential © 2015 Magellan Health Services Preferred Drugs Non-Preferred Drugs I. Analgesics Short-Acting Narcotics codeine/APAP QL morphine IR QL (excluding suppositories) butalbital/APAP/caff/codeine QL Nucynta® QL Endocet® QL oxycodone QL butalbital/ASA/caff/codeine QL Opana® QL hydrocodone/APAP QL (excluding generic for Xodol) oxycodone/APAP QL Capital with Codeine® QL Oxecta® QL hydromorphone QL (excluding suppositories) tramadol QL codeine QL oxymorphone QL Endodan® QL oxycodone/ASA QL Demerol® QL oxycodone/IBU QL dihydrocodeine/APAP/codeine QL Panlor® SS QL dihydrocodeine/ASA/codeine QL Percocet® QL Dilaudid® QL Percodan® QL Fioricet® with Codeine QL Reprexain® 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 Ibudone® QL Norco® QL NSAID/Anti-Ulcer Agents N/A Page 2 | TennCare Preferred Drug List (PDL) Arthrotec® PA Duexis® PA diclofenac/misoprostol PA Vimovo® PA Effective Date: February 1, 2015 QL Preferred Drugs Non-Preferred Drugs I. Analgesics Salicylates and Non-Narcotic Combination Agents Be-Flex Plus® QL Ed-Flex® QL Acuflex® QL Flextra DS® QL choline mag trisalicylate QL RhinoflexTM QL Alpain® QL Flextra-650® QL diflunisal QL salsalate QL Anabar® QL Lagesic® QL Dologesic® 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 Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) diclofenac potassium ketorolac QL Anaprox® diclofenac sodium meloxicam tablets Anaprox DS diclofenac sodium ER nabumetone CambiaTM Motrin® flurbiprofen naproxen Cataflam® Nalfon® ibuprofen piroxicam Clinoril® Naprelan® indomethacin 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 ketoprofen meloxicam suspension Mobic® ® Preferred Drugs Non-Preferred Drugs II. ANTI-INFECTIVES Antibiotics: Cephalosporins First Generation cefadroxil capsules cephalexin capsules cefadroxil tablets cefadroxil suspension cephalexin suspension cephalexin tablets Keflex® Antibiotics: Cephalosporins Second Generation cefaclor capsules cefprozil cefuroxime tabs PA cefaclor suspension Ceftin® suspension PA cefaclor ER Ceftin® tabs Effective Date: February 1, 2015 TennCare Preferred Drug List (PDL) | Page 3 Preferred Drugs Non-Preferred Drugs II. ANTI-INFECTIVES Antibiotics: Cephalosporins Third Generation cefdinir Suprax® Cedax® ceftibuten Cefditoren Spectracef® cefpodoxime Antibiotics: Ketolides Ketek® PA N/A Antibiotics: Macrolides azithromycin QL erythromycin/sulfisoxazole azithromycin suspension Biaxin® Biaxin XL PA erythromycin brand products ® QL clarithromycin clarithromycin ER/XL QL erythromycin generic products Dificid® PA, QL Zithromax® QL Zmax® QL Antibiotics: Methenamine and Combo all generic combinations of methenamine, phenylsalicylate, hyoscyamine, atropine, etc. 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 neomycin N/A Neo-Fradin® Antibiotics: Oral Anti-Tuberculosis ethambutol pyrazinamide cycloserine Rifadin® isoniazid rifabutin PA Isonarif® PA Rifamate® PA Mycobutin® PA rifampin Myambutol® Rifater® PA Paser® Seromycin® Pulvules Priftin® Trecator® Antibiotics: Oral Glycopeptides vancomycin caps PA N/A Antibiotics: Oral Lincosamines clindamycin caps Cleocin® Cleocin® Pediatric granules PA clindamycin pediatric solution PA Antibiotics: Oral Nitrofurans nitrofurantoin capsules nitrofurantoin suspension PA Furadantin® PA Macrobid® Page 4 | TennCare Preferred Drug List (PDL) Effective Date: February 1, 2015 Macrodantin® Preferred Drugs Non-Preferred Drugs II. ANTI-INFECTIVES Antibiotics: Oxazolidinones Zyvox® PA, QL N/A Antibiotics: Penicillins amoxicillin dicloxacillin all brand penicillins amoxicillin/clavulanate penicillin amoxicillin/clavulanic acid XR amoxicillin ER Antibiotics: Quinolones ciprofloxacin 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 Sulfatrim® Bactrim® Primsol® Bactrim DS® Septra DS® Antifungals: Oral clotrimazole troches nystatin Ancobon® PA ketoconazole PA fluconazole suspension PA terbinafine PA, QL Diflucan® suspension PA Lamisil® PA, QL fluconazole tablets QL Diflucan® tablets QL Noxafil® PA griseofulvin suspension flucytosine PA Onmel® PA, QL Gris-Peg® Grifulvin V® Sporanox® PA, QL griseofulvin microsize Terbinex® PA, QL griseofulvin ultramicrosize Vfend® PA itraconazole PA, QL voriconazole PA Effective Date: February 1, 2015 TennCare Preferred Drug List (PDL) | Page 5 Preferred Drugs Non-Preferred Drugs II. ANTI-INFECTIVES Antifungals: Vaginal miconazole-3 kit terconazole nystatin AVCTM cream miconazole-3 vaginal supp Gynazole-1 Terazol® ® Anti-Infectives: Amebicides N/A paromomycin Anti-Infectives: Antimalarials atovaquone/proguanil mefloquine Aralen® Malarone® chloroquine primaquine Coartem® Qualaquin® dapsone quinine sulfate Daraprim ® Anti-Infectives: Anthelmintics Albenza® N/A Stromectol® Biltricide® 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 metronidazole 0.75% gel Cleocin® cream clindamycin phos 2% cream Vandazole® Clindesse® vaginal cream MetroGel® Vaginal Antivirals: Cytomegalovirus Agents valganciclovir Valcyte® Antivirals: Hepatitis B Baraclude® Epivir-HBV® QL adefovir PA lamivudine-HBV QL entecavir Tyzeka® PA Hepsera® PA Antivirals: Hepatitis C Non-Pegylated Interferons Alferon® N Intron-A® Infergen® PA Antivirals: Hepatitis C Pegylated Interferons Pegasys® ProClick PA, QL Pegasys Conv. Pack® PA, QL Pegasys® syringes PA, QL Pegasys® vials PA, QL Page 6 | TennCare Preferred Drug List (PDL) PEG-Intron® QL Effective Date: February 1, 2015 PEG-Intron Redipen® QL Preferred Drugs Non-Preferred Drugs II. ANTI-INFECTIVES Antivirals: Hepatitis C Antivirals Harvoni® PA, QL VictrelisTM PA, QL Sovaldi® PA, QL OlysioTM PA, QL Antivirals: Hepatitis C Ribavirins Ribasphere® 200 mg tablets Copegus® ribavirin tablets Moderiba ribavirin capsules TM dose pack Ribapak® Rebetol® capsules Ribasphere® 200mg capsules Rebetol® solution PA Ribasphere® 400 & 600 mg tablets Antivirals: Herpes acyclovir valacyclovir QL famciclovir QL Famvir® 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 N/A Tivicay® PA, QL Antivirals: HIV NNRTIs Edurant® nevirapine QL nevirapine ER QL Viramune® QL Intelence® PA, QL Sustiva® QL Rescriptor® QL Viramune® XR QL Antivirals: HIV NRTIs abacavir QL stavudine QL Retrovir® QL didanosine capsules QL Videx® solution QL Zerit® QL Emtriva® QL Viread® QL Epivir® QL Ziagen® QL lamivudine QL zidovudine QL Videx® capsules QL Antivirals: HIV NRTI Combos abacavir/lamivudine/ zidovudine PA, QL lamivudine/zidovudine QL Atripla® QL Stribild® Combivir® QL Triumeq® QL Complera® Trizivir® PA, QL Epzicom® QL Truvada® QL N/A Effective Date: February 1, 2015 TennCare Preferred Drug List (PDL) | Page 7 Preferred Drugs Non-Preferred Drugs II. ANTI-INFECTIVES Antivirals: HIV Protease Inhibitors Crixivan® QL Aptivus® PA, QL Prezista® QL Invirase® QL Prezista® QL Kaletra® QL Reyataz® caps and powderQL Lexiva® QL Viracept® QL Norvir® QL Antivirals: Influenza Relenza® PA, QL N/A Preferred Drugs Tamiflu® PA, QL Non-Preferred Drugs III. CARDIOVASCULAR Alpha/Beta Blockers labetalol Coreg® QL carvedilol QL Trandate® Coreg CR® QL Alpha-Blockers doxazosin Cardura® prazosin Minipress® terazosin ACE Inhibitors benazepril lisinopril Accupril® perindopril QL captopril ramipril Aceon Prinivil® ® QL QL enalapril Altace® QL Quinapril Epaned trandolapril QL fosinopril Univasc® QL Lotensin® Vasotec® Mavik Zestril® ® PA ® QL 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 enalapril/HCTZ Accuretic® quinapril/HCTZ captopril/HCTZ lisinopril/HCTZ fosinopril/ HCTZ Uniretic® Lotensin HCT® Vaseretic® moexipril/HCTZ Zestoretic® Prinzide® Angiotensin II Receptor Blockers losartan Page 8 Atacand® QL QL | TennCare Preferred Drug List (PDL) Effective Date: February 1, 2015 eprosartan QL Preferred Drugs Non-Preferred Drugs III. CARDIOVASCULAR Avapro® QL Benicar® QL Cozaar® QL candesartan® QL Diovan® QL EdarbiTM QL irbesartan QL Micardis® QL telmisartan QL Teveten® QL valsartan QL Angiotensin II Receptor Blockers + Calcium Channel Blocker Class PA, QL Exforge® PA, QL amlodipine/valsartan/HCTZ PA, QL TribenzorTM PA, QL Exforge HCT® 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 Ranexa® PA N/A Anti-Anginal Agents: Nitrates Isochron® nitroglycerin (excluding spray) amyl nitrite Monoket® isosorbide dinitrate (excluding 10 mg tabs and SL tabs) Nitrolingual® Dilatrate-SR® Nitro-Bid® isosorbide mononitrate Nitrostat® Imdur® Nitro-Dur® Isordil® nitroglycerin spray Isosorbide dinitrate 10 mg tabs NitroMistTM Minitran® isosorbide dinitrate, sublingual Anti-Arrhythmics, Oral amiodarone quinidine sulfate Betapace® Pacerone® disopyramide sotalol Betapace AF® propafenone ER flecainide sotalol AF Cordarone Rythmol® mexiletine Tikosyn® QL Multaq® PA Rythmol SR® propafenone Norpace® Sorine® quinidine gluconate Norpace CR® Tambocor® ® Anti-Hypertensives, Miscellaneous Catapres® NexiclonTM XR clonidine clonidine weekly TD patch QL reserpine guanfacine Clorpres Tenex® Catapres-TTS® QL methyldopa/HCTZ Effective Date: February 1, 2015 ® TennCare Preferred Drug List (PDL) | Page 9 Preferred Drugs Non-Preferred Drugs III. CARDIOVASCULAR hydralazine guanabenz methyldopa minoxidil PA Vecamyl® PA, QL Beta Blockers atenolol propranolol (excluding solution) acebutolol metoprolol succinate PA, QL metoprolol tartrate sotalol 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® nadolol Lopressor® Beta Blockers + Diuretic Corzide® nadolol/bendroflumethiazide bisoprolol HCT Dutoprol® PA, QL Tenoretic® metoprolol HCT Lopressor HCT® Ziac® atenolol/chlorthalidone propranolol HCT 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 verapamil ER PM Cardizem CD Verelan® Cardizem LA® QL Verelan PM® ® QL Dilacor XR® Cardiac Glycosides Lanoxin® digoxin Page 10 | TennCare Preferred Drug List (PDL) Effective Date: February 1, 2015 Preferred Drugs 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 acetazolamide Diamox® Sequels methazolamide Diuretics: Combination Diuretics amiloride/HCTZ Aldactazide® triamterene/HCTZ Maxzide® Dyazide® spironolactone/HCTZ Diuretics: Loop bumetanide furosemide Demadex® Edecrin® torsemide Lasix® Diuretics: Potassium Sparing amiloride Aldactone® spironolactone Inspra® PA eplerenone PA Diuretics: Thiazide and Related Diuretics chlorothiazide indapamide Diuril® Microzide® chlorthalidone metolazone hydrochlorothiazide 12.5mg tab PA Thalitone® methyclothiazide Zaroxolyn® hydrochlorothiazide (excluding 12.5mg tab) Hemostatics, Oral aminocaproic acid tranexamic acid PA, QL Amicar® Lysteda® PA, QL Intermittent Claudication cilostazol Pletal® pentoxifylline PA Trental® PA Lipotropics: Bile Acid Sequestrants Colestid® Questran Light® cholestyramine light colestipol WelChol® packets PA Prevalite® Questran® cholestyramine WelChol® tablets Lipotropics: Cholesterol Absorption Inhibitors N/A Zetia® PA, QL Effective Date: February 1, 2015 TennCare Preferred Drug List (PDL) | Page 11 Preferred Drugs Non-Preferred Drugs III. CARDIOVASCULAR Lipotropics: Fibric Acid Derivatives fenofibrate (excluding generic for Antara®) PA gemfibrozil fenofibrate (generic for TriCor®) PA 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 Kynamro Juxtapid® PA, QL ® 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 simvastatin (5 mg, 10 mg, 20 mg, 40 mg) QL pravastatin QL Altoprev® QL Livalo® QL fluvastatin QL Mevacor® QL Lescol® QL Pravachol® QL Lescol XL® QL Zocor® (5 mg, 10 mg, 20 mg, 40 mg) Lipotropics: High Potency Statins atorvastatin QL simvastatin 80 mg PA, QL QL QL Lipitor® QL Zocor® 80 mg PA, QL Crestor® 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 Caduet® PA, QL Injectable Anticoagulants fondaparinux Lovenox® Fragmin heparin ® Arixtra® enoxaparin Oral Anticoagulants Coumadin® Page 12 warfarin | TennCare Preferred Drug List (PDL) Eliquis® PA, QL Effective Date: February 1, 2015 Xarelto® PA, QL Preferred Drugs Non-Preferred Drugs III. CARDIOVASCULAR Pradaxa® PA, QL Jantoven® Oral Thrombopoietin Agonists Promacta® PA, QL N/A Peripheral Vasodilators ergoloid mesylates Pheochromocytoma Agents Demser® PA N/A Platelet Inhibitors Aggrenox® dipyridamole Agrylin® Persantine® anagrelide ticlopidine Brilinta® PA, QL Plavix® cilostazol clopidogrel 300 mg Pletal® clopidogrel 75 mg Effient® PA Pulmonary Arterial Hypertension Agents Class PA, QL Adcirca® PA, QL Tracleer® PA, QL Adempas® PA, QL Revatio® PA, QL Letairis® PA, QL Tyvaso® PA, QL Opsumit® PA, QL Revatio® suspension PA, QL sildenafil PA, QL Ventavis® PA, QL Orenitram® ER PA, QL 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 Alzheimer’s: Cholinesterase Inhibitors donepezil QL (excluding 23 mg) Exelon® Patch QL Aricept® ODT PA, QL galantamine solution donepezil ODT PA, QL galantamine tablets Aricept® QL galantamine ER QL Aricept® 23 mg tablet PA, QL Razadyne® donepezil 23 mg PA, QL Razadyne ER® QL Effective Date: February 1, 2015 TennCare Preferred Drug List (PDL) | Page 13 Preferred Drugs Non-Preferred Drugs IV. CENTRAL NERVOUS SYSTEM Exelon® rivastigmine Alzheimer’s: NMDA Receptor Antagonists Namenda® PA, QL N/A Namenda XR® PA, QL Antiparkinson’s Agents: Anticholinergics benztropine N/A trihexyphenidyl Antiparkinson’s Agents: Decarboxylase Inhibitors Lodosyn® carbidopa Antiparkinson’s Agents: Dopamine Precursors/Decarboxylase Inhibitors carbidopa/levodopa carbidopa/levodopa ER/SR Parcopa® Sinemet® CR Sinemet® Antiparkinson’s Agents: COMT Inhibitors and Combos carbidopa/levodopa/entacapone Comtan® Stalevo® Tasmar® entacapone 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 Brintellix® PA, QL N/A Antidepressants: SNRIs Class PA, QL venlafaxine PA, QL Cymbalta® PA, QL Fetzima® PA, QL venlafaxine ER caps 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 budeprion XL QL mirtazapine rapdis PA OleptroTM QL trazodone 300 mg Page 14 | TennCare Preferred Drug List (PDL) Effective Date: February 1, 2015 Preferred Drugs Non-Preferred Drugs IV. CENTRAL NERVOUS SYSTEM Forfivo XL® Wellbutrin® bupropion XL QL nefazodone Wellbutrin SR® maprotiline Remeron® Wellbutrin XL® QL bupropion IR/SR trazodone (excluding 300 mg) 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® fluphenazine thioridazine Loxitane® haloperidol thiothixene Moban® loxapine trifluoperazine Navane® Orap® Antipsychotics: Atypical Class PA Abilify® PA, QL quetiapine PA, QL Abilify MaintenaTM PA, QL Risperdal® PA, QL Abilify Discmelt® PA, QL risperidone PA, QL Clozaril® PA Risperdal Consta® PA, QL clozapine PA risperidone ODT PA, QL clozapine ODT PA Risperdal M-tab® PA, QL Fanapt® PA, QL Saphris® PA, QL FazaClo ODT® PA, QL Zyprexa® PA, QL Latuda® PA, QL Seroquel® XR PA, QL Geodon® PA, QL Seroquel® PA, QL olanzapine PA, QL ziprasidone PA, QL Invega® PA Versacloz® suspension PA Invega® SustennaTM PA, QL olanzapine ODT PA, QL Atypical Antipsychotic and SSRI Combinations fluoxetine/olanzapine PA, QL N/A Zyprexa Zydis® PA, QL Class PA Symbyax® PA, QL Anti-Migraine: Combination Agents butalbital/APAP/caff QL Cafergot® butalbital/ASA/caff QL Fiorinal® with codeine QL Margesic® QL butalbital/APAP/caff/codeine QL isomethept/caffeine/APAP QL butalbital/ASA/caff/codeine QL Migergot® Fioricet® with codeine QL Effective Date: February 1, 2015 TennCare Preferred Drug List (PDL) | Page 15 Preferred Drugs Non-Preferred Drugs IV. CENTRAL NERVOUS SYSTEM Anti-Migraine: 5-HT1 Receptor Agonists QL Imitrex Nasal® QL rizatriptan QL Alsuma® QL naratriptan QL Relpax® 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 Migranal® PA, QL N/A Antihyperkinesis: Stimulants Adderall XR® QL Methylin® tabs Adderall® QL Methylin® solution & chewables amphetamine salt IR combo QL methylphenidate amphetamine salt ER combo QL methylphenidate ER QL (generic for Ritalin LA®) dextroamphetamine QL methylphenidate ER QL (excluding generic for Ritalin LA®) Concerta® QL methylphenidate CR QL dextroamphetamine solution QL methylphenidate SA OSM QL Daytrana® QL methylphenidate solution Focalin® ProCentra® QL Desoxyn® QL methylphenidate SR 24hr QL Focalin XR® QL Quillivant XR® QL dexmethylphenidate Ritalin LA® QL Metadate ER® QL Ritalin ® dexmethylphenidate XR QL Ritalin SR® methamphetamine QL Vyvanse® QL Dexedrine Spansule® QL Zenzedi® Methylin ER® QL Antihyperkinesis: Non-Stimulants Strattera ® QL clonidine ER PA, QL Intuniv® PA, QL guanfacine ER PA, QL KapvayTM PA, QL Agents for Narcolepsy modafinil PA, QL Provigil® PA, QL Nuvigil® PA, QL Page 16 | TennCare Preferred Drug List (PDL) Effective Date: February 1, 2015 Xyrem® PA, QL Preferred Drugs Non-Preferred Drugs IV. CENTRAL NERVOUS SYSTEM Anticonvulsants Aptiom® PA Lamictal® ODT PA carbamazepine ER (excluding generic lamotrigine chewable tabs Carbatrol) Banzel® PA Lamictal® XR Carbatrol® levetiracetam carbamazepine ER (generic for Carbatrol® only) lamotrigine ER Diastat® PA, QL levetiracetam ER Celontin® Lyrica® PA Dilantin Kapseal® 30 mg oxcarbazepine clonazepam (tabs & ODT) PA, QL Mysoline® Dilantin® Infatabs® phenobarbital PA Depakene® Neurontin® QL divalproex Phenytek® Depakote® Neurontin® solution PA, QL divalproex DR sprinkles phenytoin Depakote® ER Onfi®PA divalproex extended release primidone Depakote® Sprinkles Oxtellar XR® Equetro® topiramate diazepam rectal gel PA, QL Peganone® ethosuximide Tegretol-XR® 100mg Dilantin-125® Potiga® PA gabapentin capsules QL valproic acid Dilantin Kapseal® 100 mg QudexyTM XR PA, QL Vimpat® PA Epitol® Sabril® PA zonisamide felbamate PA Stavzor® Felbatol® PA Tegretol® 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 lamotrigine tabs Agents for RLS (Restless Leg Syndrome) pramipexole QL ropinirole Horizant® PA, QL Neupro® PA Mirapex® QL Requip® Amyotrophic Lateral Sclerosis (ALS) Rilutek® riluzole Effective Date: February 1, 2015 TennCare Preferred Drug List (PDL) | Page 17 Preferred Drugs Non-Preferred Drugs IV. CENTRAL NERVOUS SYSTEM Anti-Anxiety Agents alprazolam PA, QL diazepam PA, QL alprazolam ER PA, QL oxazepam PA, QL buspirone (excluding 30 mg) lorazepam PA, QL alprazolam ODT PA, QL Niravam PA, QL chlordiazepoxide PA, QL Ativan PA, QL Tranxene-T PA, QL clorazepate PA, QL Buspar® Valium PA, QL buspirone 30 mg Xanax PA, QL Meprobamate Xanax ER PA, QL Cholinergic Muscle Stimulants Mestinon® syrup pyridostigmine 60 mg tab Mytelase® Prostigmin® Mestinon® 60 mg tab Mestinon® 180mg ER tab Non-Ergot Dopamine Receptor Agonists pramipexole QL ropinirole bromocriptine Parlodel® Cyloset® Requip® Mirapex® QL Requip® XL Mirapex® ER QL ropinirole ER Neupro® PA MAOI-Bs selegiline Azilect® N/A Zelapar® PA Eldepryl® Miscellaneous CNS Agents Nuedexta® PA, QL N/A Mood Stabilizers carbamazepine lithium citrate Depakote® Lamictal® XR lamotrigine tabs oxcarbazepine Depakene® lamotrigine ER lamotrigine chewable tabs valproic acid Keppra Stavzor® ® levetiracetam Lamictal® tabs Tegretol® lithium carbonate Lamictal® chewable tabs Trileptal® lithium carbonate SA Lamictal® ODT PA Lithobid® Page 18 | TennCare Preferred Drug List (PDL) Effective Date: February 1, 2015 Preferred Drugs Non-Preferred Drugs IV. CENTRAL NERVOUS SYSTEM Sedative Hypnotic Agents QL zaleplon QL Ambien® QL Lunesta® QL zolpidem 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 orphenadrine chlorzoxazone orphenadrine/ASA/caffeine carisoprodol PA, QL Parafon Forte® cyclobenzaprine tizanidine tablets carisoprodol/ASA PA, QL Robaxin® carisoprodol/ASA/codeine PA Skelaxin® cyclobenzaprine 7.5mg Soma® PA, QL Flexeril® tizanidine capsules Lorzone® Zanaflex® dantrolene metaxalone Preferred Drugs Non-Preferred Drugs V. DERMATOLOGICS Topical Antipruritics/Antihistamines Prudoxin® PA, QL N/A Zonalon® PA, QL Topical Antivirals acyclovir 5% ointment QL Xerese® PA Zovirax® ointment QL Denavir® cream QL Zovirax® cream QL Topical Agents for Burns silver sulfadiazine Thermazene® SSD® mefanide Sulfamylon® Silvadene® Effective Date: February 1, 2015 TennCare Preferred Drug List (PDL) | Page 19 Preferred Drugs Non-Preferred Drugs V. DERMATOLOGICS Antiseborrheic Agents Mexar® wash Carmol® 10% Scalp lotion selenium sulfide/pyrithione zinc in urea selenium sulfide 2.5% lotion 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 Topical Antibiotic Agents for Skin and Soft Tissue Infections gentamicin mupirocin ointment Altabax® Centany® Bactroban® cream mupirocin cream Bactroban® ointment Topical Antibiotic Agents for Acne (Covered for recipients < 21 years old only) Azelex® 20% cream clindamycin phosphate (excluding benzoyl peroxide (cleanser, gel, microspheres, towlettes, and all foam and lotion) strengths not listed as preferred) benzoyl peroxide (2.5%, 5%, 10% excluding cleanser, gel, microspheres, and towlettes) erythromycin (excluding swab) sodium sulfacetamide (excluding suspension) 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® Plus gel PA MetroLotion® QL metronidazole 0.75% cream QL Metrocream® QL Mirvaso® metronidazole 0.75% gel QL MetroGel® 1% QL Noritate® 1% cream metronidazole 0.75% lotion QL MetroGel® 1% Kit RosadanTM Kit Finacea® 15% gel Page 20 | metronidazole gel 1% QL TennCare Preferred Drug List (PDL) Effective Date: February 1, 2015 Preferred Drugs Non-Preferred Drugs V. DERMATOLOGICS Topical Antifungal Agents Bensal HP® Luzu® PA ciclopirox econazole ciclopirox solution 8% PA ketoconazole (shampoo and cream) Ciclodan® Kit PA clotrimazole nystatin Loprox® 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 Lamisil® Topical Antipsoriatics Class PA calcipotriene ointment PA Dovonex® Scalp Solution PA calcipotriene scalp solution PA calcitriol ointment PA Sorilux® PA Tazorac® PA calcipotriene/betamethasone PA Taclonex® PA calcipotriene cream PA Vectical® PA Dovonex® PA Genital Wart Agents imiquimod Aldara® podofilox Veregen® Condylox® Immunomodulators Aldara® imiquimod Emollients ammonium lactate lactic acid LacLotion® lactic acid with vitamin E Lac-Hydrin® Retinoids, Oral N/A acitretin PA, QL Myorisan® PA Absorica® PA Sotret® PA Amnesteem® PA Soriatane® QL Claravis® PA Zenatane® PA Effective Date: February 1, 2015 TennCare Preferred Drug List (PDL) | Page 21 Preferred Drugs 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 Pediculocides/Scabicides NatrobaTM QL Sklice® QL permethrin QL Ziana® PA 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 All brand salicylic acid products Enzyme Preps and Wound Healing Regranex® PA N/A Santyl® Topical Anesthetics lidocaine QL lidocaine viscous All brand lidocaine products Lidoderm® PA lidocaine/hydrocortisone lidocaine/prilocaine QL EMLA® QL Pliaglis® lidocaine/hydrocortisone/aloe Topical Antineoplastics Carac® Panretin® diclofenac 3% gel Picato® Fluoroplex® Solaraze® Efudex® Valchlor® PA fluorouracil Targretin fluorouracil 5% cream Zyclara® ® Topical Steroids: Least Potent hydrocortisone 1% cream and ointment Alcortin® A hydrocortisone 2.5% cream, lotion and ointment Aqua Glycolic HC® Kit hydrocortisone acetate-aloe vera 2% gel Pediaderm HC® 2% Kit Texacort® 2.5% solution U-cort® 1% cream Page 22 | TennCare Preferred Drug List (PDL) Effective Date: February 1, 2015 Preferred Drugs Non-Preferred Drugs V. DERMATOLOGICS Topical Steroids: Mild aclomethasone 0.05% cream and ointment Derma-Smoothe/FS® Oil betamethasone valerate 0.1% lotion Desonate® 0.05% gel desonide 0.05% cream desonide 0.05% ointment 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 betamethasone valerate 0.1% cream clocortolone 0.1% cream and pump Derma-Top® 0.1% ointment Cloderm® 0.1% cream fluticasone proprionate 0.05% cream Cutivate® 0.05% cream and lotion hydrocortisone butyrate 0.1% solution Derma-Top® 0.1% cream 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 mometasone furoate 0.1% cream and solution (lotion) fluocinolone acetonide 0.025% ointment triamcinolone acetonide 0.1% cream Kenalog® aerosol spray Pediaderm TA® Kit Effective Date: February 1, 2015 TennCare Preferred Drug List (PDL) | Page 23 Preferred Drugs Non-Preferred Drugs V. DERMATOLOGICS Topical Steroids: Upper Mid-Strength fluocinonide 0.05% emulsified base cream amcinonide 0.1% cream and lotion fluticasone proprionate 0.005% ointment betamethasone dipropionate 0.05% cream triamcinolone acetonide 0.025% cream, lotion and ointment betamethasone valerate 0.1% ointment triamcinolone acetonide 0.1% lotion and ointment betamethasone valerate 0.12% foam triamcinolone acetonide 0.5% cream and ointment desoximetasone 0.05% cream 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 fluocinonide 0.05% cream, gel, ointment and solution Apexicon E® 0.05% cream mometasone furoate 0.1% ointment betamethasone dipropionate, augmented 0.05% lotion betamethasone dipropionate 0.05% ointment desoximetasone 0.05% gel and ointment desoximetasone 0.25% cream and ointment diflorasone 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 Page 24 | TennCare Preferred Drug List (PDL) Effective Date: February 1, 2015 Preferred Drugs 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 clobetasol propionate emollient base 0.05% cream clobetasol propionate 0.05% foam, lotion, shampoo, and spray halobetasol propionate 0.05% cream and ointment clobetasol propionate emollient base 0.05% foam Clobex® 0.05% lotion and shampoo Clobex® 0.05% spray 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 AgaMatrix Products PA LifeScan Products PA (Covered Meters Include: Freestyle InsuLinx Meter, FreeStyle Lite Meter, FreeStyle Freedom Lite Meter, Precision Xtra Meter) Bayer Healthcare Products PA Roche Diagnostics Products PA Home Diagnostics Products PA Diabetic Supplies: Blood Glucose Test Strips Abbott Test Strips QL AgaMatrix Products PA, QL LifeScan Products PA, QL (Covered Strips Include: Precision Xtra Test Strips, FreeStyle Test Strips, FreeStyle Lite Test Strips, Freestyle InsuLinx Test Strips) Bayer Healthcare Products PA, QL Roche Diagnostics Products PA, QL Home Diagnostics Products PA, QL Preferred Drugs Non-Preferred Drugs VII. ENDOCRINE AND METABOLIC AGENTS Agents for Gout allopurinol probenecid Colcrys® PA probenecid/colchicine Uloric® PA Effective Date: February 1, 2015 Zyloprim® TennCare Preferred Drug List (PDL) | Page 25 Preferred Drugs Non-Preferred Drugs VII. ENDOCRINE AND METABOLIC AGENTS 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 Actonel® QL Fosamax® QL alendronate 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 Fortical® PA, QL PA, QL Miacalcin® injection PA, QL Miacalcin® nasal spray PA, QL Bone: SERMs Evista® QL raloxifene QL Bone: Parathyroid Hormone Forteo® PA N/A Contraceptives, Non-Oral Depo SubQ Provera® QL Nuvaring® PA medroxyprogesterone acetate inj. QL Page 26 | TennCare Preferred Drug List (PDL) Depo-Provera® QL Ortho Evra® PA Effective Date: February 1, 2015 Xulane TM PA Preferred Drugs Non-Preferred Drugs VII. ENDOCRINE AND METABOLIC AGENTS Contraceptives, Oral Altavera® Leena® Ortho-Cept® Balziva® Seasonale® Amethia Lo® Lessina® Ortho-Cyclen® Generess FE® Seasonique® Apri® levonorgestrel/ethinyl estradiol Ortho-Novum® Jolessa® Tilia FE® Aranelle® Levora® Ovcon-50® Kariva® Tri-Legest® FE Aviane® Lo/Ovral® Philith® Lybrel® Zenchent® Beyaz® Loestrin® Plan B® Ogestrel® Brevicon® Loestrin 24 FE® Plan B® One-Step Quasense® Camila® Lomedia 24 FE® Portia® Cesia® Lo Loestrin FE® Previfem® Cryselle® Low-Ogestrel® Reclipsen® Cyclessa® Lutera® Safyral® DeblitaneTM Microgestin® Solia® Desogen® Microgestin FE® Sprintec® drosperinone/ ethinyl Mircette® estradiol Sronyx® Elinest® Modicon® Tarina-FE® Ella® Mononessa® Tri-Linyah® Enpresse® Necon® Tri-Norinyl® Errin® Natazia® Tri-Previfem® estradiol Next Choice® Tri-Sprintec® Estrostep FE® Nikki® Trinessa® Femcon FE® Nor-QD® Trivora® Gildagia® Nora-BE® Velivet® Gildess® Nordette® Vesturna® Heather® norethindrone/ethinyl estradiol - FE Wymza Fe® Jolivette® Norinyl® Yasmin® Junel® Nortrel® YAZ® Junel FE® Ortho Micronor® Zovia® Kelnor 1/35® Ortho Tri-Cyclen® Kurvelo® Ortho Tri-Cyclen Lo® Effective Date: February 1, 2015 TennCare Preferred Drug List (PDL) | Page 27 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 Fortamet® QL Glumetza® QL metformin ER 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 KombiglyzeTM XR PA, QL Janumet XR® PA, QL Nesina® PA, QL Janumet® PA, QL Onglyza® PA, QL JentaduetoTM PA, QL Oseni® PA, QL Kazano® PA, QL TradjentaTM PA, QL Juvisync® PA, QL Diabetes: GLP-2 Analogs Gattex® PA N/A Diabetes: Incretin Mimetics Class PA, QL Bydureon® vials PA, QL Bydureon® Pen Victoza® PA, QL PA, QL Trulicity® PA, QL Tanzeum® PA, QL Byetta® PA, QL Diabetes: Insulins Humalog® vials Humulin 70/30® Pen PA Apidra® Humalog 75/25® vials Lantus® vials Apidra® Solostar PA Humalog 50/50® vials Levemir® vials Lantus® OptiClick PA Humalog® Kwikpen 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 N® Pen PA Novolog® Flex Pen PA Humulin R® Novolog Mix 70/30® vials Humulin® R U-500 Novolog Mix 70/30® Flex Pen PA Humulin 70/30® vials Diabetes: Meglitinides and CombinationQL nateglinide QL Page 28 | TennCare Preferred Drug List (PDL) Prandin® QL repaglinide QL PrandimetTM QL Starlix® QL Effective Date: February 1, 2015 Preferred Drugs Non-Preferred Drugs VII. ENDOCRINE AND METABOLIC AGENTS Diabetes: Sulfonylureas and Combination glimepiride QL glyburide micronized Amaryl® QL Glucovance® glipizide glyburide/metformin chlorpropamide Glynase PresTab® glipizide ER/XL Diabeta® Metaglip® glipizide/metformin Glucotrol® tolazamide glyburide Glucotrol XL® Diabetes: SGLT2 Inhibitors and Combinations N/A tolbutamide 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 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® leflunomide sulfasalazine QL Azulfidine® QL Plaquenil® methotrexate sulfasalazine EC QL Azulfidine EN® QL Rheumatrex® Cuprimine® Trexall® Note: Injectable agents for the treatment of RA are located under Immunomodulators Anti-Rheumatic: Kinase Inhibitors XelJanz® PA, QL N/A Glucocorticoids, Oral Celestone® Orapred® ODT PA cortisone Cortef® Pediapred® dexamethasone Dexpak® prednisolone ODT PA hydrocortisone Medrol® Rayos® methylprednisolone Millipred® Veripred® prednisolone Orapred® budesonide capsules PA prednisone Growth Hormone Agents Class PA Genotropin® PA Humatrope® PA Saizen® PA Norditropin® PA Nutropin® PA Serostim® PA Nutropin AQ® PA Tev-Tropin® PA Omnitrope® PA Zorbtive® PA Effective Date: February 1, 2015 TennCare Preferred Drug List (PDL) | Page 29 Preferred Drugs Non-Preferred Drugs VII. ENDOCRINE AND METABOLIC AGENTS Hematopoietic Agents Class PA Aranesp® PA N/A Procrit® PA Epogen® PA Hormones: Adrenocorticotropic H.P. Acthar® PA, QL N/A Hormones: Anti-Thyroid methimazole Tapazole® propylthiouracil Hormones: LHRH leuprolide PA N/A Synarel® Hormones: Oral Estrogens Cenestin® estropipate EnJuvia® Femtrace® estradiol Premarin® Estrace® Menest® Hormones: Oral Estrogen/Progestins Activella® PremPhase® QL Angeliq® JinteliTM FemHRT® Low Dose PremPro® QL estradiol/norethindrone LopreezaTM FemHRT® 1/5 MimveyTM PreFest® Hormones: Oral Progestins medroxyprogesterone progesterone megestrol QL Aygestin® Prometrium® Megace® QL Provera® Megace ES® PA, QL norethindrone acetate PA Hormones: Thyroid Cytomel® liothyronine Armour Thyroid® Levothroid® Synthroid® Thyroid® levothyroxine Unithroid® Thyrolar® Tirosint® Levoxyl® Hormones: Transdermal Estrogens Alora® QL Divigel® Estrasorb® Climara® QL Elestrin® Evamist® Vivelle-Dot® QL Estraderm® QL Menostar® QL estradiol TDS QL Hormones: Transdermal Estrogen/Progestins Climara Pro® QL Combipatch® QL Page 30 | Minivelle® QL QL TennCare Preferred Drug List (PDL) Effective Date: February 1, 2015 Preferred Drugs Non-Preferred Drugs VII. ENDOCRINE AND METABOLIC AGENTS Hormones: Vaginal Estrogens Estring® Estrace® Vagifem® Femring® Premarin Vaginal Cream® QL 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 Asacol® QL sulfasalazine EC QL Azulfidine® QL Giazo® QL balsalazide QL sulfasalazine QL Azulfidine EN® QL Delzicol® QL Sulfazine EC® QL Colazal® QL Lialda® QL Sulfazine® QL 5-ASA Derivatives, Rectal Canasa® mesalamine enema mesalamine kit Rowasa® Rowasa kit® 5HT-3 Receptor Antagonists (IBS) Class PA Lotronex® PA, QL N/A Antidiarrheals diphenoxylate with atropine Lonox® Lomotil® opium tincture Lofene® loperamide Motofen® paregoric Fulyzaq®PA Anti-Emetics: A-9-THC Derivatives Class PA N/A Cesamet® PA Marinol® PA dronabinol PA Effective Date: February 1, 2015 TennCare Preferred Drug List (PDL) | Page 31 Preferred Drugs Non-Preferred Drugs VIII. GASTROINTESTINAL Anti-Emetics: Anticholinergics meclizine trimethobenzamide Antivert® prochlorperazine Transderm Scōp® PA, QL Compro® Tigan® 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 dicyclomine Symax Fastabs® Anaspaz® methscopolamine glycopyrrolate Symax-SL Bentyl Pamine® ® ® HyoMax® Cantil® Pamine Forte® hyoscyamine chlordiazepoxide/clidinium Robinul® Hyosyne® Cuvposa® PA Robinul Forte® NuLev® Levsin® Sal-Tropine® propantheline Librax® Combination Products for H. pylori Class PA N/A 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 H2 Receptor Antagonists Axid® ranitidine capsules famotidine nizatidine Zantac® ranitidine tablets Pepcid® cimetidine Page 32 ranitidine syrup | TennCare Preferred Drug List (PDL) Effective Date: February 1, 2015 Preferred Drugs Non-Preferred Drugs VIII. GASTROINTESTINAL Laxatives Constulose® PEG 3350 powder CoLyte® PEG 3350 with flavor packs Enulose® PEG 3350 electrolyte solution GoLYTELY® PEG 3350 solution generlac HalfLytely® Prepopik® lactulose Kristalose® Suclear® MoviPrep® Suprep® NuLYTELY® Trilyte® OsmoPrep® Visicol® Miscellaneous Agents for Irritable Bowel Syndrome Amitiza® PA, QL N/A Linzess® PA, QL Miscellaneous Agents for Inflammatory Bowel Disease Entocort® EC PA N/A Uceris® PA, QL Motility Agents Metozolv® ODT PA, QL metoclopramide QL Reglan® QL Mucosal Protectants misoprostol 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 Protonix® suspension 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 Nexium® QL Saliva Stimulating Agents pilocarpine PA, QL cevimeline PA, QL Salagen® PA, QL Evoxac® PA, QL Effective Date: February 1, 2015 TennCare Preferred Drug List (PDL) | Page 33 Preferred Drugs Non-Preferred Drugs IX. IMMUNOLOGIC AGENTS Anti-inflammatory: PDE-4 Inhibitors Otezla® PA, QL N/A 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 mycophenolic acid PA Cellcept® suspension mycophenolate mofetil Azasan® PA Neoral® PA cyclosporine tacrolimus Cellcept® (excluding suspension) PA Prograf® PA cyclosporine microemulsion Hecoria® PA Rapamune® PA Imuran® PA Sandimmune® PA Myfortic® PA sirolimus PA mycophenolatemofetil suspension Zortress® PA Multiple Sclerosis Agents QL Avonex® QL Copaxone®20 mg/mL QL Avonex Administration Pack® QL Rebif® QL Copaxone® 40 mg/mL PA, QL Extavia® QL Betaseron® QL Multiple Sclerosis Agents: Potassium Channel Blockers N/A Ampyra® QL Multiple Sclerosis Agents: Oral Disease Modifying Agents Aubagio® PA N/A Gilenya® PA, QL Tecfidera® PA, QL Topical Immunomodulators Class PA Elidel® PA tacrolimus ointment PA Protopic® PA Preferred Drugs Non-Preferred Drugs X. MISCELLANEOUS Gaucher’s Disease Agents CerdelgaTM QL Zavesca® Hereditary Tyrosinemia Agents N/A Orfadin® Oral Iron Chelators Class PA Exjade® PA N/A Page 34 | TennCare Preferred Drug List (PDL) Effective Date: February 1, 2015 Ferriprox® PA Preferred Drugs Non-Preferred Drugs XI. ONCOLOGY AGENTS Afinitor® Inlyta® Stivarga® Afinitor Disperz® PA Alkeran® Iressa® Tabloid® Arimidex® anastrozole Jakafi® Tafinlar® Aromasin® bicalutamide leucovorin tamoxifen capicitabine Bosulif Leukeran Tarceva Casodex® Caprelsa® leuprolide PA Targretin® Femara® Cometriq® letrozole Tasigna® Hydrea® cyclophosphamide lomustine temozolamide Purinethol® Droxia® Lysodren® Thalomid® Purixan® PA Eligard® PA Matulane® tretinoin Temodar® Emcyt® Mekinist® Tykerb® Erivedge® mercaptopurine VotrientTM etoposide Mesna® Xalkori® exemestane methotrexate Xeloda® Fareston® Myleran® Xtandi® flutamide Nexavar® Zelboraf® Gilotrif® Nilandron® Zolinza® Gleevec® OfortaTM Zydelig® Hexalen® Pomalyst® Zykadia® Hycamtin® Revlimid® Zytiga® hydroxyurea Sprycel® Imbruvica® 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 Blephamide® TobraDex® ointment neomycin/poly B/dexameth Maxitrol® TobraDex® suspension sulfacetamide/prednisolone neomycin/poly B/HC TobraDex® ST suspension Pred-G® Poly-Pred® Zylet® PA neomycin/BAC/poly B/HC tobramycin/dexamethasone suspension Effective Date: February 1, 2015 TennCare Preferred Drug List (PDL) | Page 35 Preferred Drugs Non-Preferred Drugs XII. OPHTHALMICS Ophthalmic Antibiotics AK-Poly-BACTM ofloxacin AzaSite® Ocuflox® bacitracin/poly B polymyxin B/TMP bacitracin Polysporin® ciprofloxacin Romycin® Besivance® Polytrim® erythromycin sulfacetamide sodium drops Bleph-10® sulfacetamide ointment Gentak® tobramycin Ciloxan® Tobrex® solution gentamicin Tobrasol® Garamycin® Zymaxid® Moxeza® Tobrex® ointment gatifloxacin 0.5% solution neomycin/bac/poly B Vigamox® levofloxacin 0.5% solution Neosporin® neomycin/poly B/gramicidin Ophthalmic Antifungals Natacyn® PA N/A Ophthalmic Antivirals Viroptic® trifluridine Ophthalmic Antihistamines BepreveTM QL Pataday® QL ketotifen 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 0.15% Alphagan P® Iopidine® brimonidine tartrate 0.2% Ophthalmic Beta Blockers carteolol timolol maleate levobunolol Betagan® OptiPranolol® betaxolol timolol gel solution Betimol Timoptic® ® Betoptic-S® Timpoptic Occudose® Istalol® Timoptic-XE® metipranolol Ophthalmic Carbonic Anhydrase Inhibitors QL Azopt® QL dorzolamide/timolol QL Cosopt® QL Trusopt® QL Cosopt PF® QL dorzolamide QL Ophthalmic Decongestants naphazoline Neo-Synephrine® phenylephrine Ophthalmic Mast Cell Stabilizers Alocril® Page 36 cromolyn sodium | TennCare Preferred Drug List (PDL) Alamast® Effective Date: February 1, 2015 Alomide® Preferred Drugs Non-Preferred Drugs XII. OPHTHALMICS 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 flurbiprofen PA Acular LS® PA Nevanac® PA ketorolac PA AcuvailTM PA Ocufen® PA BromdayTM PA Voltaren® 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® prednisolone acetate dexamethasone Lotemax® Ointment fluorometholone Pred Mild® Durezol® Maxidex® FML® ointment Flarex® prednisolone sodium phosphate Lotemax® Susp FML Forte® Pred Forte® FML Liquifilm® Vexol® Lotemax® Gel Glaucoma Direct Acting Miotics Isopto® Carpine pilocarpine Pilopine HS® phospholine iodide Glaucoma Combinations Simbrinza® PA Combigan® PA Ophthalmic Immunomodulators Class PA, QL N/A Restasis® PA, QL Ophthalmic Vasoconstrictors AK-Dilate® 2.5%, 10% NeofrinTM 2.5%, 10% Albalon® naphazoline phenylephrine 2.5%, 10% Mydfrin® Ophthalmic Lubricants and Artificial Tears N/A Lacrisert® PA Effective Date: February 1, 2015 TennCare Preferred Drug List (PDL) | Page 37 Preferred Drugs Non-Preferred Drugs XII. OPHTHALMICS Miscellaneous Ophthalmics Cystaran® PA N/A Preferred Drugs Non-Preferred Drugs XIII. OTICS Otic Quinolones CiproDex® QL Cipro HC® QL ofloxacin otic QL ciprofloxacin otic Otic Steroid/Antibiotic Combinations Cortomycin® Otic Cortisporin® Otic HC/neomycin/polymyxinB Cortisporin®-TC Otic Coly-Mycin® S Miscellaneous Otics acetic acid acetic acid/antipyrine/benzo/ polycosonal RE Benzotic® acetic acid/aluminum Acetasol HC® RE Chlorphenylcaine® acetic acid/HC Aurax Treagan® 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 tamsulosin QL alfuzosin QL Minipress® prazosin terazosin Cardura® Rapaflo® Cardura XL® QL Uroxatral® QL Flomax® QL Androgen Hormone Inhibitors Avodart® QL finasteride QL Combination Agents for BPH Jalyn®PA, QL N/A Page 38 | TennCare Preferred Drug List (PDL) Effective Date: February 1, 2015 Proscar® QL Preferred Drugs Non-Preferred Drugs XIV. RENAL AND GENITOURINARY Phosphorus Depleters calcium acetate Phoslyra® ferric citrate Renvela® powder for suspension PA EliphosTM Renvela® tablets Fosrenol® sevelamer PhosLo® Velphoro® PA Renagel® Urinary Tract Antispasmodics oxybutynin Toviaz® QL Detrol® QL oxybutynin ER QL tolterodine QL VESIcare® 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 potassium citrate Citrolith® Tricitrates® Cytra-K® solution potassium citrate/citric acid Cytra-K® crystals Urocit-K® Cytra-2® Ora-Cit® Virtrate-3® Cytra-3® Polycitra-K® Urinary Acidifying Agents Renacidin® PA acetic acid K-Phos MF® K-Phos Original® K-Phos Neutral® K-Phos #2® Phospha Neutral® Urinary Analgesics Phenazo® phenazopyridine Pyridium® Urinary Interstitial Cystitis Agents Elmiron® RIMSO-50® N/A Vaginal Antiseptics N/A Fem pHTM Preferred Drugs Non-Preferred Drugs XV. RESPIRATORY Anaphylaxis Therapy Agents Epipen® QL Epipen, Jr.® QL Adrenaclick® QL epinephrine injectable QL Auvi-QTM PA, QL Effective Date: February 1, 2015 TennCare Preferred Drug List (PDL) | Page 39 Preferred Drugs Non-Preferred Drugs XV. RESPIRATORY Anticholinergics, Inhaled QL albuterol/ipratropium QL Combivent Respimat® QL DuoNeb® QL Spiriva Respimat® QL Atrovent® HFA QL ipratropium solutionQL Incruse Ellipta® QL Combivent MDI® QL Spiriva® QL Tudorza® QL Anticholinergics, Nasal QL Atrovent 0.3%, 0.6%® QL ipratropium 0.3%, 0.6% QL Antihistamines, First Generation (Covered for recipients < 21 years old only) brompheniramine maleate Dytuss syrup all formulations of brompheniramine tannate Bromspiro hydroxyzine all formulations of chlorpheniramine tannate carbinoxamine maleate LoHist-12 all formulations of diphenhydramine tannate chlorpheniramine maleate promethazine Aldex AN® Palgic® clemastine dexchlorpheniramine Vazol® cyproheptadine hydrochloride Doxytex® Vistaril® diphenhydramine HCl J-Tan PD Antihistamines, Non-Sedating (Covered for recipients < 21 years old only) cetirizine chewable PA, QL Allegra® QL Clarinex-D 24 Hr® QL cetirizine tabs 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 Antihistamines, Nasal QL Astepro® PA, QL Patanase® QL Dymista® PA, QL azelastine PA, QL Beta Agonists: Combination Products olopatadine QL Class PA, QL Advair Diskus® PA, QL Dulera® PA, QL Anoro Ellipta® PA, QL Advair HFA® PA, QL Symbicort® PA, QL Breo Ellipta® PA, QL Page 40 | TennCare Preferred Drug List (PDL) QL Effective Date: February 1, 2015 Preferred Drugs 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 terbutaline albuterol tabs VoSpire ER® metaproterenol Cystic Fibrosis Agents QL Bethkis® PA,QL Cayston® PA, QL TOBI® Podhaler® and inhalation solution PA, QL Pulmozyme® PA, QL Kalydeco® PA, QL tobramycin solution 300mg/5mL PA, QL Expectorants SSKI N/A 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 N/A Mucolytics acetylcysteine N/A Non-Narcotic Antitussives Class PA benzonatate PA Tessalon® PA Zonatuss® PA Tessalon Perles® PA Effective Date: February 1, 2015 TennCare Preferred Drug List (PDL) | Page 41 Preferred Drugs Non-Preferred Drugs XV. RESPIRATORY Steroids, Orally Inhaled QL Asmanex Twisthaler® QL Aerospan® QL budesonide respules PA, QL Flovent HFA® QL Alvesco® QL Pulmicort Respules® PA, QL Pulmicort Flexhaler® QL Arnuity Ellipta® QL Flovent Diskus® QL QVAR® QL Asmanex HFA® QL Steroids, Intranasal QL fluticasone propionate QL Beconase AQ® QL Omnaris® QL Nasonex® QL budesonide nasal spray QL Rhinocort Aqua® QL Qnasl® QL Flonase® QL triamcinolone acetonide QL flunisolide QL Veramyst® QL Nasacort® AQ QL Zetonna® QL Xanthine Derivatives aminophylline Dyphylline GG® Difil®-G COPD Elixophyllin® Dilex-G DG 200 Jay-Phyl Lufyllin®-GG Difil®-G Forte Lufyllin® Theochron® Dy-G® Theo-24® Dylix® theophylline ER Phosphodiesterase 4 Inhibitor Daliresp® PA N/A Vasoconstrictors, Intranasal Adrenalin® N/A Tyzine® Preferred Drugs Non-Preferred Drugs XVI. SMOKING CESSATION AGENTS Smoking Cessation Agents QL bupropion SR QL nicotine polacrilex lozenge QL Commit® QL Nicotrol® inhaler QL Chantix® QL nicotine transdermal patch QL Nicoderm® CQ QL Nicotrol® nasal spray QL Nicorette® gum QL Zyban® QL nicotine polacrilex gum QL Preferred Drugs Non-Preferred Drugs XVII. VITAMINS AND ELECTROLYTES Cystine Depleting Agent Procysbi® PA Cystagon® Page 42 | TennCare Preferred Drug List (PDL) Effective Date: February 1, 2015 Preferred Drugs Non-Preferred Drugs XVII. VITAMINS AND ELECTROLYTES Fluoride Products Denta 5000® Phos-flur® Fluor-a-day® Chewable Luride® Dentagel® Renaf® Gel-Kam® Prevident® Epiflur® SF Fluor-a-day® drops SF 5000 Plus Fluoritab® sodium fluoride Ludent® 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 brand prescription products (various manufacturers) All generic prescription products (various manufacturers) Multivitamins with Iron (Covered for recipients < 21 years old only) All brand OTC and prescription products All generic OTC and prescription products Potassium Depletors Kalexate sodium polystyrene sulfonate Kayexalate® SPS® Kionex® Potassium Supplements Effer-K® K-Effervescent® Epiklor® Micro K® Kaon-CL® K-Vescent® K-tabs® potassium chloride caps Klor-Con® potassium bicarbonate Klor-Con® powder Klor-Con/EF® potassium chloride tabs and solution Klor-Con M® potassium chloride, microencapsulated Prenatal Vitamins All generic OTC and prescription products (various manufacturers) All brand OTC and prescription products (various manufacturers) Renal Vitamins All OTC and generic prescription products (various manufacturers) All brand prescription products (various manufacturers) Vitamin D / Vitamin D-Analogs calcitriol ergocalciferol Vitamin D doxercalciferol PA paricalcitol PA Drisdol® Rocaltrol® Hectorol® PA Zemplar® PA Effective Date: February 1, 2015 TennCare Preferred Drug List (PDL) | Page 43 Preferred Drugs Non-Preferred Drugs XVII. VITAMINS AND ELECTROLYTES Vitamin K Products Mephyton® N/A Zinc Supplements zinc sulfate Page 44 Zincate® | TennCare Preferred Drug List (PDL) Galzin® PA Effective Date: February 1, 2015
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