TennCare AutoExempt List
March 1, 2015
This is a current list of the drugs and supplies that do not count toward an enrollee’s monthly drug limit.
This list is subject to change. Go to the following link to see the most current version:
https://tenncare.magellanhealth.com/static/docs/Program_Information/TennCare_AutoExempt_List.pdf
CARDIOVASCULAR DISEASE (ORAL FORMULATIONS ONLY)
Note: Brand names in this category are provided for reference only. Only generic cardiovascular medications are exempt from the script limit. If classified
as a brand in Medispan, the product will not be exempt from the script limit.
acebutolol (Sectral)
felodipine ER
nifedipine ER/SA/XL
(Adalat CC, Procardia XL)
acetazolamide (Diamox)
fosinopril (Monopril)
nifedipine IR (Adalat, Procardia)
amiloride/HCTZ (Moduretic)
fosinopril/HCTZ (Monopril-HCT)
pindolol (Visken)
amiloride (Midamor)
furosemide (Lasix)
propranolol (Inderal)
amlodipine (Norvasc)
HCTZ (Microzide, Oretic)
propranolol LA (Inderal LA)
atenolol (Tenormin)
indapamide
propranolol/HCTZ (Inderide)
atenolol/chlorthalidone (Tenoretic)
isradipine (DynaCirc)
quinapril (Accupril)
benazepril (Lotensin)
labetalol (Trandate)
quinapril/HCTZ (Accuretic)
benazepril/HCTZ (Lotensin HCT)
lisinopril (Prinivil, Zestril)
ramipril (Altace)
betaxolol (Kerlone)
lisinopril/HCTZ (Prinzide, Zestoretic)
sotalol (Betapace, Sorine)
bisoprolol fumarate (Zebeta)
losartan (Cozaar)
sotalol AF (Betapace AF)
bisoprolol/HCTZ (Ziac)
losartan/HCTZ (Hyzaar)
spironolactone (Aldactone)
bumetanide (Bumex)
methyclothiazide (Enduron)
spironolactone/HCTZ (Aldactazide)
captopril (Capoten)
metolazone (Zaroxolyn)
telmisartan (Micardis)
captopril/HCTZ (Capozide)
metoprolol succinate (Toprol XL)
telmisartan/HCTZ (Micardis HCT)
carvedilol (Coreg)
metoprolol tartrate (Lopressor)
timolol maleate (Blocadren)
chlorothiazide (Diuril)
metoprolol/HCTZ (Lopressor HCT)
torsemide (Demadex)
chlorthalidone (Hygroton)
moexipril (Univasc)
trandolapril (Mavik)
diltiazem ER/SR/XR (Cardizem CD, Cardizem
LA, Cartia XT, Dilacor XR, Dilt-CD, Taztia XT,
Tiazac)
moexipril/HCTZ (Uniretic)
triamterene/HCTZ (Dyazide, Maxzide)
diltiazem IR (Cardizem)
nadolol (Corgard)
valsartan (Diovan)
enalapril (Vasotec)
nadolol/bendroflumethiazide (Corzide)
verapamil ER (Covera-HS, Isoptin SR,
Verelan)
enalapril/HCTZ (Vasoretic)
nicardipine (Cardene)
verapamil HCl (Calan, Isoptin)
Proprietary & Confidential
© 2015, Magellan Health Services. All Rights Reserved.
DIABETES AGENTS – ORAL HYPOGLYCEMICS
Note: Brand names in this category are provided for reference only. Only generic oral hypoglycemic medications are exempt from the script limit. If
classified as a brand in Medispan the product will not be exempt from the script limit.
acarbose (Precose)
glipizide ER/XL (Glucotrol XL)
pioglitazone (Actos)
acetohexamide (Dymelor)
glyburide (Diabeta, Micronase)
pioglitazone/glimepiride (DuetAct)
chlorpropamide (Diabinese)
glyburide, micronized (Glynase, PresTab)
pioglitazole/metformin (ACTOplus Met)
glimepiride (Amaryl)
glyburide/metformin (Glucovance)
tolazamide (Tolinase)
glipizide/metformin (Metaglip)
metformin (Glucophage)
tolbutamide (Orinase)
glipizide (Glucotrol)
metformin ER (Glucophage XR)
DIABETES AGENTS – INSULINS
®
®
human insulin NPH (Humulin N, Novolin N )
insulin detemir vials (Levemir vials)
®
human insulin NPH/Regular (Humulin 70/30, Novolin 70/30 )
insulin lispro (Humalog and Novolog – all dosage forms)
human insulin Regular (Humulin R, Novolin R®, Humulin R U-500)
insulin lispro protamine/lispro
(Humalog and Novolog mix– all dosage forms)
insulin glargine (Lantus vials)
RESPIRATORY
Note: Brand names in this category, with the exception of Proventil HFA, are provided for reference only. Only generic respiratory medications are exempt
from the script limit. TennCare considers Proventil HFA a generic medication. All other medications classified as brand products in Medispan will not be
exempt from the script limit.
albuterol (Proventil HFA)
albuterol sulfate inhalation solution
(Accuneb, Proventil)
ipratropium inhalation solution (Atrovent)
ANTINEOPLASTICS
abiraterone acetate (Zytiga)
dasatinib (Sprycel)
ixabepilone (Ixempra)
rituximab (Rituxan)
afatinib (Gilotrif)
daunorubicin (Cerubidine)
lapatinib (Tykerb)
romadepsin (Istodax)
anastrazole (Arimidex)
daunorubicin citrate liposomal
(DaunoXome)
lenalidomide (Revlimid)
ruxolitinib (Jakafi)
arsenic trioxide (Trisenox)
decitabine (Dacogen)
letrozole (Femara)
samarium SM 153 lexidronam
(Quadramet)
asparaginase (Elspar, Erwinaze)
degarelix (Firmagon)
leucovorin (Wellcovorin)
siltuximab (Sylvant)
axitinib (Inlyta)
denileukin diftitox (Ontak)
leuprolide (Eligard, Lupron,
Lupron Depot, Viadur)
sorafenib (Nexavar)
azacitidine (Vidaza)
Dexrazoxane
(Zinecard, Totect)
lomustine (CeeNU)
streptozocin (Zanosar)
bcg vaccine (TheraCys, TICE BCG)
docetaxel (Taxotere)
mechlorethamine (Mustargen)
strontium-89 chloride
(Metastron)
bendamustine (Treanda)
Doxorubicin
(Adriamycin, Rubex)
melphalan (L-PAM) (Alkeran)
sunitinib (Sutent)
bevacizumab (Avastin)
doxorubicin, liposomal (Doxil)
mercaptopurine (6-MP)
(Purinethol)
talc powder, sterile (Sclerosol)
Effective Date: March 1, 2015
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ANTINEOPLASTICS
bexarotene (Targretin)
enzalutamide (Xtandi)
mesna (Mesnex)
bicalutamide (Casodex)
epirubicin (Ellence)
methotrexate
(Mexate, Trexall, Abitrexate,
Folex, Otrexup)
tamoxifen and oral solution
(Nolvadex)
bleomycin (Blenoxane)
erlotinib (Tarceva)
mitomycin (MTC) (Mutamycin)
temozolomide (Temodar)
bortezomib (Velcade)
estramustine (Emcyt)
mitotane (Lysodren)
temsirolimus (Torisel)
bosutinib (Bosulif)
etoposide (VP-16-213,
Toposar, VePesid, Etopophos)
mitoxantrone (Novantrone)
teniposide (VM-26, Vumon)
brentuximab (Adcetris)
everolimus (Afinitor)
nelarabine (Arranon)
thalidomide (Thalomid)
busulfan (Busulfex, Myleran)
exemestane (Aromasin)
nilotinib (Tasigna)
thioguanine (TG, Tabloid)
cabazitaxel (Jevtana)
floxuridine (FUDR)
nintedanib (Ofev)
thiotepa (TSPA, Thioplex)
cabozantanib (Cometriq)
fludarabine phosphate
(Fludara, Oforta)
nilutamide (Nilandron)
topotecan (Hycamtin)
capecitabine (Xeloda)
fluorouracil (Adrucil, Carac)
ofatumumab (Arzerra)
toremifene citrate (Fareston)
carboplatin (Paraplatin)
flutamide (Eulexin)
omacetaxine (Synribo)
tositumomab (Bexxar)
cafilzomib (Kyprolis)
fulvestrant (Faslodex)
oxaliplatin (Eloxatin)
trametinib (Mekinist )
carmustine (BCNU, BiCNU, Gliadel)
gallium nitrate (Ganite)
Paclitaxel (Onxol, Abraxane,
Taxol)
trastuzumab (Herceptin)
ceritinib (Zykadia)
gefitinib (Iressa)
panitumumab (Vectibix)
tretinoin
cetuximab (Erbitux)
gemcitabine (Gemzar)
pazopanib (Votrient)
triptorelin pamoate (Trelstar)
chlorambucil (Leukeran)
gemtuzumab (Mylotarg)
pegaspargase (Oncaspar)
uracil mustard
(Uracil Mustard)
cisplatin (Platinol)
goserelin (Zoladex)
pembrolizumab (Keytruda)
valrubicin (Valstar)
cladribine (CdA) (Leustatin)
Hydroxyurea
(Droxia, Hydrea, Mylocel)
pemetrexed (Alimta)
vandetanib (Caprelsa)
clofarabine (Clolar)
ibritumomab tiuxetan
(Zevalin)
pentostatin (DCF) (Nipent)
vemurafenib (Zelboraf)
crizotinib (Xalkori)
ibrutinib (Imbruvica)
pertuzumab (Perjeta)
vinblastine (Velban, Velsar)
Cyclophosphamide
(Cytoxan, Neosar)
idarubicin (Idamycin PFS)
plicamycin (Mithracin)
Vincristine(Oncovin, Vincasar
PFS)
cytarabine, conventional (CytosarU, Tarabine PFS)
idelalisib (Zydelig)
pomalidomide (Pomalyst)
vinorelbine tartrate (Navelbine)
cytarabine, liposomal (DepoCyt)
ifosfamide (Ifex)
porfimer sodium (Photofrin)
vismodegib (Erivedge)
dabrafenib (Tafinlar)
imatinib mesylate (Gleevec)
pralatrexate (Fotolyn)
vorinostat (Zolinza)
dacarbazine (DTIC-Dome)
ipilimumab (Yervoy)
procarbazine (Matulane)
ziv-aflibercept (Zaltrap)
dactinomycin
(actinomycin D, Cosmegen)
irinotecan (Camptosar)
ramucirumab (Cyramza)
Effective Date: March 1, 2015
regorafinib (Stivarga)
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ANTIPARKINSONIAN AGENT
benztropine (Cogentin)
carbidopa (Lodosyn)
ANTITUBERCULAR AGENTS
aminosalicylic acid
(PAS, Paser)
ethionamide (Trecator-SC)
rifampin (Rifadin)
capreomycin
(Capastat Sulfate)
isoniazid (INH, Isohydrazide,
Niazid, Nydrazid, Niazid-B6)
rifampin/isoniazid (Rifamate)
cycloserine
(Seromycin Pulvules)
Pyrazinamide
rifampin/pyrazinamide /
isoniazid (Rifater)
ethambutol (Myambutol)
rifabutin (Mycobutin)
rifapentine (Priftin)
streptomycin sulfate
ANTIVIRALS
abacavir (Ziagen)
emtricitabine (Emtriva)
nevirapine (Viramune, Viramune XR)
abacavir/lamivudine (Epzicom)
emtricitabine/rilpivirine/tenofovir
(Complera)
raltegravir (Isentress)
abacavir/lamivudine/zidovudine (Trizivir)
emtricitabine/tenofovir (Truvada)
rilpivirine (Edurant)
adefovir (Hepsera)
enfuvirtide (Fuzeon)
ritonavir (Norvir)
amprenavir (Agenerase)
entecavir (Baraclude)
ritonavir/lopinavir (Kaletra)
atazanavir (Reyataz)
etravirine (Intelence)
saquinavir (Fortovase, Invirase)
cidofovir (Vistide)
fomivirsen (Vitravene)
stavudine (d4T, Zerit)
cobicistat/elvitegravir/emtricitabine/tenofov
ir (Stribild)
fosamprenavir calcium (Lexiva)
telbivudine (Tyzeka)
darunavir ethanolate (Prezista)
foscarnet (Foscavir)
tenofovir disoproxil fumarate (Viread)
delavirdine mesylate (Rescriptor)
ganciclovir (DHPG, Cytovene IV)
tipranavir (Aptivus)
didanosine (ddl) (Videx)
indinavir sulfate (Crixivan)
valganciclovir (Valcyte)
doutegravir (Tivicay)
lamivudine (3TC, Epivir, Epivir HBV)
zalcitabine (ddC, Hivid)
dolutegravir/abacavir/lamivudine (Triumeq)
lamivudine/zidovudine (Combivir)
zidovudine (AZT, Retrovir)
efavirenz (Sustiva)
maraviroc (Selzentry)
efavirenz/emtricitabine/tenofovir (Atripla)
nelfinavir (Viracept)
CONTRACEPTIVES
All oral contraceptives
All non-oral contraceptives
Effective Date: March 1, 2015
Intra-uterine Devices (IUDs):
Skyla, Mirena, Paragard
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CLOTTING FACTORS
antihemophilic factor, human (Alphanate, Hemofil-M, Humate-P,
Koate, Melate, Monarc-M, Monoclate-P, Nybcen, Profilate)
factor IX, human recombinant (Benefix)
antihemophilic factor, human recombinant (Advate, Bioclate,
Genarc, Helixate, Kogenate, Recombinate, Refacto, Xyntha)
factor IX (Alphanine, Mononine)
antihemophilic factor/Von Willebrand factor complex (Humate-P,
Wilate)
factor IX complex, human
(Bebulin, Konyne, Profilnine, Proplex)
anti-inhibitor coagulant complex (Autoplex T, Feiba VH Immuno)
factor IX, recombinant (Alprolix)
factor VIIa, recombinant (NovoSeven, NovoSeven RT)
factor XIII (Corifact)
factor VIII, recombinant (Obizur)
Fc fusion protein, recombinant (Eloctate)
DIALYSIS MEDICATIONS
calcium acetate (PhosLo, Eliphos)
ferric citrate
calcium acetate/ magnesium carbonate (MagneBind)
lanthanum carbonate (Fosrenol)
cinacalcet (Sensipar)
sevelamer (Renvela tablets, Renagel)
FA/vitamin B complex with C (B-Plex, Dialyvite, Folbee Plus,
Nephronex, renal caps, Renal Multivitamin Formula, Renaphro)
sodium polystyrene sulfonate
(Kayexalate, Kionex, Marlexate, SPS)
FLU VACCINE – INJECTABLE FORMULATIONS ONLY
influenza (Fluvirin, Fluzone, Fluarix, Influenza A H1N1)
HEMATOPOIETIC AGENTS
darbepoetin alfa (Aranesp)
pegfilgrastim (Neulasta)
epoetin alfa, recombinant (Epogen, Procrit)
plerixafor (Mozobil)
filgrastim (Neupogen)
sargramostim (Leukine, Prokine)
oprelvekin (Neumega)
HEPATITIS C
boceprevir (Victrelis)
interferon alfacon-1 (Infergen)
ribivirin / interferon alfa-2b (Rebetron)
dasabuvir/ombitasvir/paritaprevir/ ritonavir
(Viekira)
peg-interferon alfa-2a (Pegasys)
simprevir (Olysio)
interferon alfa-2a (Roferon-A)
peg-interferon alfa-2b (PEG-Intron)
sofosbuvir (Sovaldi)
interferon alfa-2b (Intron A, Sylatron)
Ribavirin
(Copegus, Rebetol, Ribasphere, Ribapak)
telaprevir (Incivek)
Effective Date: March 1, 2015
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IMMUNOSUPPRESSIVES
azathioprine (Azasan, Imuran)
daclizumab (Zenapax)
sirolimus (Rapamune)
basiliximab (Simulect)
muromonab-CD3 (Orthoclone OKT3)
Tacrolimus
(FK506, Prograf, Hecoria, Astagraf XL)
Cyclosporine
(Sandimmune, Gengraf, Neoral, Sangcya)
mycophenolate (Cellcept, Myfortic)
IRON PREPARATIONS
iron dextran complex
(DexFerrum, Imferon, Infed, Proferdex)
sodium ferric gluconate complex/sucrose
(Ferrlecit)
iron sucrose complex (Venofer)
LONG-ACTING ANTIPSYCHOTICS
fluphenazine (Prolixin Decanoate)
haloperidol decanoate (Haldol Decanoate)
TRANSPLANT
hepatitis B immune globulin (Bayhep-B, H-Big, Hyperhep, NABI-HB, HepaGam B)
OTHER COVERED ITEMS
Antidiarrheals – Fulyzaq
Asthma Supplies – Spacers, Peak Flow Meters, and NaCl for
inhalation
Diabetic Supplies – Test strips; Lancets; Lancet Devices; Acetone
®
Urine Test (i.e., Ketostix ); Alcohol Pads; Glucose Control Solution;
®
Glucagon injection, Meters; Syringes: Pen Needles
Prenatal vitamins – Brands such as Prenate, Zenate, etc.
Large Volume Parenterals – IV fluids : quantities Products ≥ 50mL,
(Generic Name: Dextrose; Lactated Ringers; Sodium Chloride;
Sterile Water)
Saline Flush – Coded up to 30mL vials
Total Parenteral Nutrition (TPN) – Coded by Amino Acid, all
additives will be covered Heplock 10u/mL or 100u/mL
Effective Date: March 1, 2015
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