TennCare Preferred Drug List (PDL)

Effective November 1, 2014

PA Prior Authorization required, subject to specific PA criteria, QL Quantity Limit (PA and NP agents require a PA before dispensing)
Approval of NP agents requires trial and failure, contraindication or intolerance of 2 preferred agents, unless otherwise indicated.
Please note: With the exception of the Branded Drugs Classified as Generics list, TennCare is a mandatory generic program in accordance with state law (TCA 53-10-205).
Approval of a branded product when a generic is available requires documentation of a serious adverse reaction from the generic via a FDA MedWatch form OR
contraindication to an inactive ingredient in the AB-rated generic equivalent. Therapeutic Failure of an AB-rated generic equivalent may be considered for approval of
branded products in the following high-risk medication classes: Anticonvulsants, Atypical Antipsychotics, HIV antivirals, Immunosuppressants, and Oncology Agents.

Preferred Drugs

Non-Preferred Drugs

I. Analgesics
Agents for Opiate Detoxification
ReVia PA

naltrexone PA
Suboxone

film

Zubsolv PA, QL

Buprenorphine and Buprenorphine/Naloxone

buprenorphine PA, QL

PA, QL

buprenorphine/naloxone
tablets PA, QL

COX-II Inhibitors Class PA

Celebrex PA, QL

N/A

Transmucosal Fentanyl Products

fentanyl lozenge PA, QL

Abstral PA, QL

Fentora PA, QL

Actiq PA, QL

Subsys PA, QL

Narcotics Agonist/Antagonists
butorphanol NS PA, QL

nalbuphine PA, QL

pentazocine/naloxone PA, QL

pentazocine/APAP PA, QL

Narcotics, Long Acting Narcotics

fentanyl patch PA, QL

morphine sulfate SA PA(100 mg), QL

Kadian PA (100 mg), QL

Avinza PA, QL

morphine sulfate SR 24hr PA, QL

Butrans PA, QL

MS Contin PA, QL

ConZipTM PA, QL

Nucynta ER PA,QL

Dolophine PA, QL

Opana ER PA, QL

Duragesic PA, QL

OxyContin PA, QL

ExalgoTM PA, QL

oxymorphone ER PA, QL

hydromorphone ER PA, QL

tramadol ER PA, QL

methadone PA, QL

tramadol ER 24 hr PA, QL

Methadose PA, QL

Ultram ER PA, QL

morphine sulfate ER capsules PA, QL Zohydro ER PA, QL

* Note that Covered agents not listed on PDL may be considered non-preferred
Proprietary & Confidential
2014, Magellan Health Services, Inc. All Rights Reserved.

Effective Date: November 1, 2014

Magellan Health Services

Preferred Drugs

TennCare Preferred Drug List

Non-Preferred Drugs

I. Analgesics
Short-Acting Narcotics
codeine/APAP QL

morphine IR QL (excluding
suppositories)

butalbital/APAP/caff/codeine QL

Norco QL

butalbital/ASA/caff/codeine QL

Nucynta QL

hydrocodone/APAP QL
(excluding generic for Xodol)

oxycodone QL

oxycodone/APAP QL

Capital with Codeine QL

Opana QL

tramadol QL

codeine QL

Oxecta QL

Endodan QL

oxymorphone QL

Demerol QL

oxycodone/ASA QL

dihydrocodeine/APAP/codeine QL

oxycodone/IBU QL

dihydrocodeine/ASA/codeine QL

Panlor SS QL

Dilaudid QL

Percocet QL

Fioricet with Codeine QL

Percodan QL

Fiorinal with Codeine QL

Roxicet QL

Hycet QL

Roxicodone QL

hydrocodone/APAP 5/300

Synalgos-DC QL

hydrocodone/APAP 10/300

tramadol/APAP QL

Endocet QL

hydrocodone/ibuprofen
5/200 mg QL

hydromorphone QL (excluding
suppositories)
Ibudone QL

hydrocodone/ibuprofen (excluding Tylenol with Codeine QL

5/200 mg) QL
hydromorphone suppositories

Tylox QL

Levorphanol QL

Ultracet QL

Lorcet QL

Ultram QL

Lortab QL

Vicodin QL

Maxidone QL

Vicodin HP QL

Magnacet QL

Vicoprofen QL

meperidine QL

XartemisTM XR

Meperitab QL

Xodol QL

morphine suppositories QL

Zamicet QL

QL

NSAID/Anti-Ulcer Agents
N/A

Arthrotec PA

Duexis PA

diclofenac/misoprostol PA

Vimovo PA

Proprietary & Confidential

* Note that Covered agents not listed on PDL may be considered non-preferred

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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

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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

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Magellan Health Services

Preferred Drugs

TennCare Preferred Drug List

Non-Preferred Drugs

II. ANTI-INFECTIVES
Antibiotics: Oral Nitrofurans
nitrofurantoin capsules

nitrofurantoin suspension PA

Furadantin PA

Macrodantin

Macrobid

Antibiotics: Oxazolidinones
Zyvox PA, QL

N/A
amoxicillin

amoxicillin/clavulanate
ciprofloxacin

Antibiotics: Penicillins
all brand penicillins

dicloxacillin
penicillin

amoxicillin ER

amoxicillin/clavulanic acid XR

Antibiotics: Quinolones

levofloxacin tabs

Avelox PA

Levaquin tabs

Avelox ABC Pack PA

Levaquin solution PA

Cipro tablets

levofloxacin solution PA

Cipro suspension PA

moxifloxacin PA

ciprofloxacin suspension PA

Noroxin PA

ciprofloxacin ER QL

ofloxacin

Factive PA

Antibiotics: Tetracyclines
doxycycline monohydrate 50 and 100 mg caps

Adoxa

minocycline ER PA, QL

doxycycline hyclate 50 and 100mg

demeclocycline PA

minocycline tablets

minocycline capsules

minocycline capsules

Morgidox

tetracycline

doxycycline hyclate DR particles

OcudoxTM Kit

doxycycline hyclate 20mg PA, QL

Oracea

doxycycline monohydrate 75 mg
and 150 mg caps

Periostat PA, QL

doxycycline monohydrate tabs

Solodyn PA, QL

Doryx

Vibramycin

Dynacin

Antibiotics: Sulfonamides, Folate Antagonist

sulfadiazine PA

trimethoprim (TMP)
TMP/sulfamethoxazole

Bactrim

Primsol

Bactrim DS

Septra DS

Proprietary & Confidential

* Note that Covered agents not listed on PDL may be considered non-preferred

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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

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Magellan Health Services

Preferred Drugs

TennCare Preferred Drug List

Non-Preferred Drugs

II. ANTI-INFECTIVES
Antivirals: Cytomegalovirus Agents
N/A

Valcyte
Baraclude

Antivirals: Hepatitis B
Epivir-HBV QL

adefovir PA

lamivudine-HBV QL

entecavir

Tyzeka PA

Hepsera PA

Antivirals: Hepatitis C Non-Pegylated Interferons

Intron-A
Pegasys ProClick PA, QL
Pegasys syringes PA, QL

Alferon N

Infergen PA

Antivirals: Hepatitis C Pegylated Interferons

Pegasys Conv. Pack PA, QL

PEG-Intron QL

PEG-Intron Redipen QL

Pegasys vials PA, QL

Antivirals: Hepatitis C Antivirals

OlysioTM PA, QL

IncivekTM PA, QL

VictrelisTM PA, QL

Ribasphere 200 mg tablets

ribavirin tablets

Sovaldi PA, QL

Antivirals: Hepatitis C Ribavirins

Copegus

ribavirin capsules

ModeribaTM dose pack

Ribapak

Rebetol capsules

Ribasphere 200mg capsules

Rebetol solution PA

Ribasphere 400 & 600 mg tablets

Antivirals: Herpes
acyclovir

famciclovir QL

valacyclovir QL

Valtrex QL

Sitavig buccal tabs QL

Zovirax

Antivirals: HIV CCR5 Antagonists

N/A

Selzentry PA, QL

Antivirals: HIV Fusion Inhibitors

N/A

Fuzeon PA, QL

Antivirals: HIV Integrase Inhibitors

Isentress PA, QL

Tivicay PA, QL

Edurant

nevirapine

Intelence PA, QL

Famvir QL

Sustiva QL

QL

N/A

Antivirals: HIV NNRTIs

nevirapine ER QL

Viramune QL

Rescriptor QL

Viramune XR QL

Proprietary & Confidential

* Note that Covered agents not listed on PDL may be considered non-preferred

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Magellan Health Services

Preferred Drugs

TennCare Preferred Drug List

Non-Preferred Drugs

II. ANTI-INFECTIVES
Antivirals: HIV NRTIs
abacavir QL

stavudine QL

Emtriva QL

Viread QL

didanosine capsules QL
Epivir QL

lamivudine QL

Retrovir QL
Zerit QL

Videx solution QL
Ziagen QL

zidovudine QL

Antivirals: HIV NRTI Combos

abacavir/lamivudine/
zidovudine PA, QL

lamivudine/zidovudine QL

Combivir QL

Triumeq QL

Atripla QL

Complera

Epzicom QL

Trizivir PA, QL
Truvada QL
Prezista QL

Kaletra QL

Reyataz QL

Lexiva QL

Norvir QL
N/A

N/A

Stribild

Aptivus PA, QL
Invirase QL

Videx capsules QL

Antivirals: HIV Protease Inhibitors

Crixivan QL

Prezista QL

Viracept QL

Antivirals: Influenza
Relenza PA, QL

Preferred Drugs

Tamiflu PA, QL

Non-Preferred Drugs

III. CARDIOVASCULAR
Alpha/Beta Blockers
labetalol

carvedilol QL

Coreg QL

Trandate

Coreg CR QL

Alpha-Blockers
doxazosin
terazosin

prazosin

Cardura

Proprietary & Confidential

* Note that Covered agents not listed on PDL may be considered non-preferred

Minipress

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TennCare Preferred Drug List

Preferred Drugs

Non-Preferred Drugs

III. CARDIOVASCULAR
ACE Inhibitors
benazepril
captopril
enalapril

lisinopril

ramipril QL

Accupril

perindopril QL

Aceon QL

Prinivil

Altace QL

Quinapril

Epaned PA

trandolapril QL

fosinopril

Univasc QL

Lotensin

Vasotec

Mavik QL

Zestril

moexipril QL

ACEI + Calcium Channel Blocker Combo

N/A

benazepril/amlodipine QL, PA

Tarka QL, PA

Lotrel QL, PA

trandolapril/verapamil QL, PA

ACEI + Diuretic Combination

benazepril/HCTZ
captopril/HCTZ

enalapril/HCTZ

lisinopril/HCTZ

Accuretic

quinapril/HCTZ

fosinopril/ HCTZ

Uniretic

Lotensin HCT

Vaseretic

moexipril/HCTZ

Zestoretic

Prinzide

Angiotensin II Receptor Blockers

losartan QL

Atacand QL
Avapro QL
Benicar QL
Cozaar QL
candesartan QL
Diovan QL
EdarbiTM QL

eprosartan QL
irbesartan QL
Micardis QL
telmisartan QL
Teveten QL
valsartan QL

Angiotensin II Receptor Blockers + Calcium Channel Blocker Class PA, QL

Exforge PA, QL

Exforge HCT PA, QL

losartan/HCTZ QL

Azor PA, QL

TribenzorTM PA, QL

telmisartan/amlodipine PA, QL

Twynsta PA, QL

Angiotensin II Receptor Blockers + Diuretic

Atacand HCT

Hyzaar

Avalide

irbesartan/HCTZ

Benicar

HCT QL

candesartan/HCTZ

Micardis HCT QL
QL

telmisartan/ HCTZ QL

Diovan HCT QL

Teveten HCT

Edarbyclor QL

valsartan/ HCTZ QL

Proprietary & Confidential

* Note that Covered agents not listed on PDL may be considered non-preferred

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Magellan Health Services

Preferred Drugs

TennCare Preferred Drug List

Non-Preferred Drugs

III. CARDIOVASCULAR
Anti-Anginal Agents: Miscellaneous
Ranexa PA

N/A

Anti-Anginal Agents: Nitrates

Isochron

nitroglycerin (excluding spray)

amyl nitrite

Monoket

Nitrolingual

Dilatrate-SR

Nitro-Bid

isosorbide mononitrate

Nitrostat

Imdur

Nitro-Dur

Isordil

nitroglycerin spray

Isosorbide dinitrate 10 mg tabs

NitroMistTM

isosorbide dinitrate
(excluding 10 mg tabs
and SL tabs)
Minitran

isosorbide dinitrate, sublingual

Anti-Arrhythmics, Oral
amiodarone

quinidine sulfate

Betapace

Pacerone

Betapace AF

propafenone ER

flecainide

sotalol

sotalol AF

Cordarone

Rythmol

Tikosyn QL

Multaq PA

Rythmol SR

Norpace

Sorine

Norpace CR

Tambocor

disopyramide
mexiletine

propafenone

quinidine gluconate

Anti-Hypertensives, Miscellaneous
Catapres

NexiclonTM XR

clonidine weekly TD patch QL

reserpine

guanfacine

Clorpres

Tenex

guanabenz

Vecamyl PA, QL

methyldopa

minoxidil PA

Catapres-TTS QL
clonidine

hydralazine

methyldopa/HCTZ

Proprietary & Confidential

* Note that Covered agents not listed on PDL may be considered non-preferred

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Preferred Drugs

TennCare Preferred Drug List

Non-Preferred Drugs

III. CARDIOVASCULAR
Beta Blockers
atenolol

metoprolol tartrate
nadolol

propranolol (excluding solution)

sotalol

acebutolol

Lopressor

Betapace

metoprolol succinate PA, QL

betaxolol

pindolol

bisoprolol fumarate PA

propranolol solution PA

Bystolic

propranolol ER

Cartrol

Sectral

Corgard

Sorine

Inderal LA

Tenormin

InnoPran XL QL

timolol maleate

Kerlone

Toprol XL PA, QL

Levatol QL

Zebeta

Beta Blockers + Diuretic

atenolol/chlorthalidone
bisoprolol HCT

metoprolol HCT

propranolol HCT

Corzide

nadolol/bendroflumethiazide

Dutoprol PA, QL

Tenoretic

Lopressor HCT

Ziac

Calcium Channel Blockers (DHP)

amlodipine QL

Adalat CC QL

Norvasc QL

felodipine ER

Cardene SR QL

Nymalize PA

nicardipine

isradipine QL

Procardia

nifedipine ER/SA/XL QL

nifedipine IR

Procardia XL QL

nimodipine PA

Sular QL

nisoldipine QL

Calcium Channel Blockers (Non-DHP)

diltiazem ER/SR/XR

Calan

diltiazem ER (generic for

Cardizem LA) QL

diltiazem IR

Calan SR

Tiazac

verapamil

Cardizem

verapamil ER PM

verapamil ER QL

Cardizem CD

Verelan

Cardizem LA QL

Verelan PM

Dilacor XR

Cardiac Glycosides
digoxin

Lanoxin

Proprietary & Confidential

* Note that Covered agents not listed on PDL may be considered non-preferred

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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

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Preferred Drugs

TennCare Preferred Drug List

Non-Preferred Drugs

III. CARDIOVASCULAR
Lipotropics: Fibric Acid Derivatives
fenofibrate (excluding generic
for Antara) PA
fenofibrate (generic
for TriCor) PA

gemfibrozil

Antara PA

Lipofen PA

fenofibric acid PA

Lofibra PA

Fenoglide PA

Lopid

fenofibrate (generic for

Antara) PA

TriCor PA

fenofibrate capsules (generic for

Lipofen) PA

Triglide PA

Fibricor PA

TriLipix PA

Lipotropics: Miscellaneous
Juxtapid PA, QL

Kynamro PA, QL

Lipotropics: Niacin Derivatives Class PA

Niacor PA

Niaspan PA

Lipotropics: Omega-3 Fatty Acids Class PA

Lovaza PA

N/A

niacin ER PA
Vascepa PA

omega-3 acid ethyl esters PA

Lipotropics: Standard Potency Statins QL

lovastatin QL

pravastatin QL

simvastatin (5 mg, 10 mg, 20 mg, Altoprev QL

40 mg) QL

Livalo QL

fluvastatin QL

Mevacor QL

Lescol QL

Pravachol QL

Lescol XL QL

Zocor (5 mg, 10 mg, 20 mg, 40

mg) QL

Lipotropics: High Potency Statins QL

atorvastatin QL
Crestor QL

simvastatin 80 mg PA, QL

Lipitor QL

Zocor 80 mg PA, QL

Lipotropics: Combination Antihyperlipidemics QL

N/A

Advicor PA QL

Simcor QL

Liptruzet PA

Vytorin PA, QL

Lipotropics: Statin + CCB Combination

amlodipine/atorvastatin PA, QL

N/A
fondaparinux
Fragmin

Caduet PA, QL

Injectable Anticoagulants
Lovenox

Arixtra

enoxaparin

heparin

Proprietary & Confidential

* Note that Covered agents not listed on PDL may be considered non-preferred

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Preferred Drugs

TennCare Preferred Drug List

Non-Preferred Drugs

III. CARDIOVASCULAR
Oral Anticoagulants
Coumadin
Jantoven

Eliquis PA

warfarin

Pradaxa PA

Oral Thrombopoietin Agonists

Promacta PA, QL

N/A

Peripheral Vasodilators

ergoloid mesylates

Pheochromocytoma Agents
Demser PA

N/A
Aggrenox
anagrelide
cilostazol

clopidogrel 75 mg

Platelet Inhibitors
dipyridamole
ticlopidine

Agrylin

Persantine

Brilinta PA, QL

Plavix

clopidogrel 300 mg

Pletal

Effient PA

Pulmonary Arterial Hypertension Agents Class PA, QL

Adcirca PA, QL

Tracleer PA, QL

Adempas PA, QL

Orenitram PA, QL

Ventavis PA, QL

Revatio PA, QL

Letairis PA, QL

sildenafil PA, QL

Tyvaso PA, QL

Opsumit PA, QL
Revatio suspension PA, QL

Vasopressors
N/A

midodrine
N/A

Xarelto PA, QL

Vasodilator/Nitrate Combinations
BiDil PA

Preferred Drugs

Non-Preferred Drugs

IV. CENTRAL NERVOUS SYSTEM

Agents for Neuropathic Pain
gabapentin capsules QL

Cymbalta PA, QL

lidocaine patch PA

duloxetine QL

Lidoderm PA

gabapentin solution PA, QL

Lyrica PA

gabapentin tablets QL

Neurontin QL

Gralise PA, QL

Neurontin solution PA, QL

Horizant PA, QL

Proprietary & Confidential

* Note that Covered agents not listed on PDL may be considered non-preferred

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Effective Date: November 1, 2014

Magellan Health Services

Preferred Drugs

TennCare Preferred Drug List

Non-Preferred Drugs

IV. CENTRAL NERVOUS SYSTEM

Alzheimers: 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

Alzheimers: NMDA Receptor Antagonists

Namenda PA, QL

N/A

Namenda XR PA, QL

Antiparkinsons Agents: Anticholinergics

benztropine
carbidopa
carbidopa/levodopa

N/A

trihexyphenidyl

Antiparkinsons Agents: Decarboxylase Inhibitors

Lodosyn

Antiparkinsons Agents: Dopamine Precursors/Decarboxylase Inhibitors

carbidopa/levodopa ER/SR

Parcopa

Sinemet CR

Sinemet

Antiparkinsons 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

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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

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Effective Date: November 1, 2014

Magellan Health Services

Preferred Drugs

TennCare Preferred Drug List

Non-Preferred Drugs

IV. CENTRAL NERVOUS SYSTEM

Antipsychotics: Atypical Class PA
Abilify PA, QL

quetiapine PA, QL

Abilify MaintenaTM PA, QL

Risperdal PA, QL

Clozaril PA

Risperdal Consta PA, QL

clozapine PA

risperidone PA, QL

risperidone ODT PA, QL

clozapine ODT PA

Risperdal M-tab PA, QL

Saphris PA, QL

FazaClo ODT PA, QL

Zyprexa PA, QL

Seroquel XR PA, QL

Geodon PA, QL

Seroquel PA, QL

ziprasidone PA, QL

Invega PA

Versacloz suspension PA

Abilify Discmelt PA, QL

Fanapt PA, QL
Latuda PA, QL

olanzapine PA, QL

olanzapine ODT PA, QL

Atypical Antipsychotic and SSRI Combinations

butalbital/ASA/caff/codeine QL
butalbital/APAP/caff QL
Imitrex Nasal QL
Relpax QL

Zyprexa Zydis PA, QL

Class PA

fluoxetine/olanzapine PA, QL

N/A
butalbital/APAP/caff/codeine QL

Invega SustennaTM PA, QL

Symbyax PA, QL

Anti-Migraine: Combination Agents

Cafergot

Margesic QL

butalbital/ASA/caff QL

isomethept/caffeine/APAP QL

Fioricet with codeine QL

Migergot

Fiorinal with codeine QL

Anti-Migraine: 5-HT1 Receptor Agonists QL

rizatriptan QL

Alsuma QL

naratriptan QL

rizatriptan ODT QL

Amerge QL

sumatriptan kits QL

sumatriptan vials QL

Axert PA, QL

sumatriptan nasal QL

sumatriptan tabs QL

Frova QL

Sumavel DoseProTM QL

Imitrex Injectable QL

Treximet QL

Imitrex Kit QL

Zomig QL

Imitrex tablets QL

Zomig Spray QL

Maxalt QL

Zomig ZMT QL

Maxalt MLT QL

Anti-Migraine: Ergotamine Derivatives

N/A

Migranal PA, QL

Proprietary & Confidential

* Note that Covered agents not listed on PDL may be considered non-preferred

Page 17
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Magellan Health Services

Preferred Drugs

TennCare Preferred Drug List

Non-Preferred Drugs

IV. CENTRAL NERVOUS SYSTEM

Antihyperkinesis: Stimulants
Adderall QL

Methylin solution & chewables

methylphenidate

amphetamine salt ER combo QL

methylphenidate ER QL (generic for

Ritalin LA)

methylphenidate SA OSM QL

Daytrana QL

methylphenidate solution

ProCentra QL

Desoxyn QL

methylphenidate SR 24hr QL

Quillivant XR QL

dexmethylphenidate

Ritalin LA QL

Ritalin

dexmethylphenidate XR QL

Ritalin SR

Vyvanse QL

Dexedrine Spansule QL

Zenzedi

Adderall XR QL

Methylin tabs

dextroamphetamine QL

methylphenidate ER QL (excluding Concerta QL

generic for Ritalin LA)

amphetamine salt IR combo QL

dextroamphetamine solution QL
Focalin

Focalin XR QL

Metadate ER QL

methamphetamine QL
Methylin ER QL
Strattera QL

methylphenidate CR QL

Antihyperkinesis: Non-Stimulants
clonidine ER PA, QL

KapvayTM PA, QL

Intuniv PA, QL

Agents for Narcolepsy

Provigil PA, QL

modafinil PA, QL

Xyrem PA, QL

Nuvigil PA, QL

Proprietary & Confidential

* Note that Covered agents not listed on PDL may be considered non-preferred

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Revision Date: November 1, 2014

Effective Date: November 1, 2014

Magellan Health Services

TennCare Preferred Drug List

Preferred Drugs

Non-Preferred Drugs

IV. CENTRAL NERVOUS SYSTEM

Anticonvulsants
carbamazepine

lamotrigine tabs

Aptiom PA

Lamictal (tabs & chewable

tabs)

Banzel PA

Lamictal ODT PA

Carbatrol

lamotrigine chewable tabs

levetiracetam

carbamazepine ER (generic for

Carbatrol only)

Lamictal XR

levetiracetam ER

Celontin

lamotrigine ER

oxcarbazepine

clonazepam (tabs & ODT) PA, QL

Lyrica PA

phenobarbital PA

Depakene

Mysoline

Phenytek

Depakote

Neurontin QL

phenytoin

Depakote ER

Neurontin solutionPA, QL

primidone

Depakote Sprinkles

OnfiPA

topiramate

diazepam rectal gel PA, QL

Oxtellar XR

Tegretol-XR 100mg

Dilantin-125

Peganone

valproic acid

Dilantin Kapseal 100 mg

Potiga PA

Vimpat PA

Epitol

Sabril PA

zonisamide

felbamate PA
Felbatol PA

Stavzor

FycompaTM PA, QL

Tegretol-XR (200 & 400mg)

carbamazepine ER (excluding
generic Carbatrol)
Diastat PA, QL

Dilantin Kapseal 30 mg
Dilantin Infatabs
divalproex

divalproex DR sprinkles

divalproex extended release

Equetro

ethosuximide

gabapentin capsules QL

Tegretol

gabapentin solution PA, QL

tiagabine

gabapentin tablets

Topamax

QL

Gabitril

Trileptal

Keppra

Trokendi XR PA

Keppra XR

Zarontin

Klonopin PA, QL

Zonegran

Agents for RLS (Restless Leg Syndrome)

pramipexole QL

ropinirole

Horizant PA, QL

Neupro PA

Mirapex QL

Requip

Amyotrophic Lateral Sclerosis (ALS)

Rilutek

riluzole

Proprietary & Confidential

* Note that Covered agents not listed on PDL may be considered non-preferred

Page 19
Revision Date: November 1, 2014

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Magellan Health Services

Preferred Drugs

TennCare Preferred Drug List

Non-Preferred Drugs

IV. CENTRAL NERVOUS SYSTEM

Anti-Anxiety Agents
alprazolam PA, QL

buspirone (excluding 30 mg)

chlordiazepoxide PA, QL

diazepam PA, QL

lorazepam PA, QL

clorazepate PA, QL

alprazolam ER PA, QL

oxazepam PA, QL

alprazolam ODT PA, QL

Niravam PA, QL

Ativan PA, QL

Tranxene-T PA, QL

Buspar

Valium PA, QL

buspirone 30 mg

Xanax PA, QL

Meprobamate

Xanax ER PA, QL

Cholinergic Muscle Stimulants

Mestinon syrup

Mestinon 180mg ER tab

pramipexole QL

pyridostigmine 60 mg tab

Mytelase

Prostigmin

Mestinon 60 mg tab

Non-Ergot Dopamine Receptor Agonists

ropinirole

bromocriptine

Parlodel

Cyloset

Requip

Mirapex QL

Requip XL

Mirapex ER QL

ropinirole ER

Neupro PA

MAOI-Bs
selegiline

N/A

Azilect

Zelapar PA

Eldepryl

Miscellaneous CNS Agents

Nuedexta PA, QL

N/A

Mood Stabilizers

carbamazepine

lithium citrate

Depakote

Lamictal XR

Depakene

lamotrigine ER

lamotrigine chewable tabs

valproic acid

Keppra

Stavzor

Lamictal tabs

Tegretol

Lamictal chewable tabs

Trileptal

Lamictal ODT PA

Lithobid

lamotrigine tabs
levetiracetam

lithium carbonate

lithium carbonate SA

oxcarbazepine

Proprietary & Confidential

* Note that Covered agents not listed on PDL may be considered non-preferred

Page 20
Revision Date: November 1, 2014

Effective Date: November 1, 2014

Magellan Health Services

TennCare Preferred Drug List

Preferred Drugs

Non-Preferred Drugs

IV. CENTRAL NERVOUS SYSTEM

Sedative Hypnotic Agents QL
zaleplon QL

zolpidem QL

Ambien QL

Rozerem QL

Ambien CR QL

Silenor PA, QL

eszopiclone QL

Sonata QL

EdluarTM PA, QL

temazepam PA, QL

estazolam PA, QL

triazolam PA, QL

flurazepam PA, QL

zolpidem ER QL

Halcion PA, QL

Zolpimist PA, QL

Intermezzo QL
Lunesta QL
Restoril PA, QL

Skeletal Muscle Relaxants

baclofen

methocarbamol

Amrix QL

cyclobenzaprine

tizanidine tablets

carisoprodol/ASA PA, QL

Robaxin

carisoprodol/ASA/codeine PA

Skelaxin

cyclobenzaprine 7.5mg

Soma PA, QL

Flexeril

tizanidine capsules

Lorzone

Zanaflex

chlorzoxazone

orphenadrine/ASA/caffeine

dantrolene

carisoprodol

orphenadrine
Parafon Forte

PA, QL

metaxalone

Preferred Drugs

Non-Preferred Drugs

V. DERMATOLOGICS
Topical Antipruritics/Antihistamines
Prudoxin PA, QL

N/A
acyclovir 5% ointment
Denavir cream QL
silver sulfadiazine
Thermazene

Zonalon PA, QL

Topical Antivirals
Xerese PA

QL

Zovirax ointment QL

Zovirax cream QL

Topical Agents for Burns

SSD

mefanide

Sulfamylon

Silvadene

Proprietary & Confidential

* Note that Covered agents not listed on PDL may be considered non-preferred

Page 21
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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

OvacePlus

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
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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
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Effective Date: November 1, 2014

Magellan Health Services

Preferred Drugs

TennCare Preferred Drug List

Non-Preferred Drugs

V. DERMATOLOGICS
Retinoids, Topical Class PA
Tazorac PA

tretinoin PA

adapalene PA

Retin-A PA

Atralin PA

Retin-A Micro PA

Differin PA

tretinoin microsphere gel PA

Epiduo PA

VeltinTM PA

FabiorTM

Ziana PA

Pediculocides/Scabicides QL
NatrobaTM QL

permethrin QL

Sklice QL

Elimite QL

Ovide QL

Eurax QL

spinosad QL

lindane PA, QL

UlesfiaTM QL

malathion QL

Keratolytic Agents
all generic urea products

all generic salicylic acid products All brand urea products

Regranex PA

Santyl

lidocaine QL

lidocaine viscous

All brand salicylic acid products

Enzyme Preps and Wound Healing

N/A

Topical Anesthetics
All brand lidocaine products

Lidoderm PA

lidocaine/prilocaine QL

EMLA QL

Pliaglis

Carac

Panretin

diclofenac 3% gel

Valchlor PA

Efudex

Zyclara

fluorouracil

Targretin

Picato

lidocaine HC
Fluoroplex

Topical Antineoplastics

Solaraze

hydrocortisone 1% cream and ointment

hydrocortisone 2.5% cream, lotion and ointment

Topical Steroids: Least Potent

Alcortin A
Aqua Glycolic HC Kit
hydrocortisone acetate-aloe vera 2% gel
Pediaderm HC 2% Kit
Texacort 2.5% solution
U-cort 1% cream

Proprietary & Confidential

* Note that Covered agents not listed on PDL may be considered non-preferred

Page 24
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Effective Date: November 1, 2014

Magellan Health Services

Preferred Drugs

TennCare Preferred Drug List

Non-Preferred Drugs

V. DERMATOLOGICS
Topical Steroids: Mild
aclomethasone 0.05% cream and ointment

Derma-Smoothe/FS Oil

desonide 0.05% cream

desonide 0.05% ointment

Desonate 0.05% gel

betamethasone valerate 0.1% lotion

fluocinolone acetonide 0.01% cream, oil and solution

Synalar 0.01% solution
Verdeso 0.05% foam

Topical Steroids: Lower Mid-Strength

betamethasone dipropionate 0.05% lotion

Capex shampoo

Derma-Top 0.1% ointment

Cloderm 0.1% cream

hydrocortisone butyrate 0.1% solution

Derma-Top 0.1% cream

betamethasone valerate 0.1% cream

clocortolone 0.1% cream and pump

fluticasone proprionate 0.05% cream

Cutivate 0.05% cream and lotion

desonide 0.05% lotion
Desowen 0.05% lotion
Diprolene 0.05% lotion
fluocinolone acetonide 0.01% shampoo
fluocinolone acetonide 0.025% cream
fluticasone proprionate 0.05% lotion
hydrocortisone butyrate 0.1% cream and ointment
hydrocortisone valerate 0.2% cream
Pandel 0.1% cream
prednicarbate 0.1% cream and ointment

Topical Steroids: Mid-Strength

hydrocortisone valerate 0.2% ointment

Elocon 0.1% cream and lotion

triamcinolone acetonide 0.1% cream

Kenalog aerosol spray

mometasone furoate 0.1% cream and solution (lotion)

fluocinolone acetonide 0.025% ointment

Pediaderm TA Kit

Proprietary & Confidential

* Note that Covered agents not listed on PDL may be considered non-preferred

Page 25
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Effective Date: November 1, 2014

Magellan Health Services

Preferred Drugs

TennCare Preferred Drug List

Non-Preferred Drugs

V. DERMATOLOGICS
Topical Steroids: Upper Mid-Strength
fluocinonide 0.05% emulsified base cream

amcinonide 0.1% cream and lotion

triamcinolone acetonide 0.025% cream, lotion and ointment

betamethasone valerate 0.1% ointment

triamcinolone acetonide 0.5% cream and ointment

desoximetasone 0.05% cream

fluticasone proprionate 0.005% ointment

betamethasone dipropionate 0.05% cream

triamcinolone acetonide 0.1% lotion and ointment

betamethasone valerate 0.12% foam

Diprolene AF 0.05% cream
Luxiq 0.12% foam
Topicort 0.05% cream
Trianex 0.05% ointment

Topical Steroids: Potent

betamethasone dipropionate, augmented 0.05% cream

amcinonide 0.1% ointment

mometasone furoate 0.1% ointment

betamethasone dipropionate, augmented 0.05% lotion

fluocinonide 0.05% cream, gel, ointment and solution

Apexicon E 0.05% cream

betamethasone dipropionate 0.05% ointment
desoximetasone 0.05% gel and ointment
desoximetasone 0.25% cream and ointment
diflorasone diactetate 0.05% cream and ointment
Elocon 0.1% ointment
Halog 0.1% ointment and cream
Topicort 0.05% gel and ointment
Topicort 0.25% cream and ointment

Proprietary & Confidential

* Note that Covered agents not listed on PDL may be considered non-preferred

Page 26
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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

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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

Testim PA

Androderm PA

Testred PA

Androgel pump PA

Android PA

testosterone (generic Androgel,

Fortesta, Testim) PA

Danazol

Axiron PA

testosterone cypionate PA, QL

Depo-testosterone PA, QL
(200 mg/mL 1 mL vial)

Androxy PA

testosterone enanthate PA, QL

Delatestryl PA, QL

Striant PA

Depo-testosterone PA, QL
(excluding 200 mg/mL
1 mL vial)

VogelxoTM PA

Fortesta PA
Methitest PA

Antidiuretic/Vasopressor Agents
DDAVP

desmopressin tabs

Stimate PA

desmopressin nasal spray

Bone: Bisphosphonates
Actonel solution PA
alendronate QL

Actonel QL

Fosamax QL

Atelvia QL

Fosamax Plus D QL

Binosto QL

ibandronate QL

Boniva QL

risedronate QL

Didronel

Skelid QL

etidronate

Bone: Calcitonin Class PA, QL

calcitonin nasal spray

PA, QL

Miacalcin nasal spray PA, QL

raloxifene QL
N/A

Fortical PA, QL
Miacalcin injection PA, QL

Bone: SERMs
Evista QL

Bone: Parathyroid Hormone

Forteo PA

Proprietary & Confidential

* Note that Covered agents not listed on PDL may be considered non-preferred

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Preferred Drugs

TennCare Preferred Drug List

Non-Preferred Drugs

VII. ENDOCRINE AND METABOLIC AGENTS

Contraceptives, Non-Oral
Depo SubQ Provera QL
medroxyprogesterone
acetate inj. QL
Altavera

Leena

Apri

Amethia Lo
Aranelle
Aviane
Beyaz

Brevicon
Camila
Cesia

Cryselle

Cyclessa

DeblitaneTM
Desogen

Drosperinone/
ethinyl estradiol
Elinest
Ella

Enpresse
Errin

Estrostep FE
Femcon FE
Gildagia
Gildess

Heather

Jolivette
Junel

Junel FE

Kelnor 1/35
Kurvelo

Depo-Provera QL

Nuvaring PA

Xulane TM PA

Ortho Evra PA

Contraceptives, Oral
Ortho Tri-Cyclen Lo Balziva

Seasonale

Ortho-Cept

Generess FE

Seasonique

Levonorgestrel/ethinyl Ortho-Cyclen

Jolessa

Tilia FE

estradiol

Kariva

Tri-Legest FE

Levora

Ortho-Novum

Lybrel

Zenchent

Lo/Ovral

Ovcon-50
Philith

Ogestrel

Plan B

Quasense

Lessina

Loestrin

Loestrin 24 FE
Loestrin FE

Lo Loestrin FE
Low-Ogestrel
Lutera

Microgestin

Microgestin FE
Mircette

Modicon

Mononessa
Necon

Natazia

Next Choice
Nikki

Nor-QD

Nora-BE

Nordette
Norinyl
Nortrel

Ortho Micronor

Ortho Tri-Cyclen

Plan B One-Step
Portia

Previfem

Reclipsen
Safyral
Solia

Sprintec
Sronyx

Tri-Linyah

Tri-Norinyl

Tri-Previfem
Tri-Sprintec
Trinessa
Trivora
Velivet

Vesturna

Wymza Fe
Yasmin
YAZ

Zovia

Proprietary & Confidential

* Note that Covered agents not listed on PDL may be considered non-preferred

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TennCare Preferred Drug List

Preferred Drugs

Non-Preferred Drugs

VII. ENDOCRINE AND METABOLIC AGENTS

Diabetes: Alpha-Glucosidase Inhibitors
acarbose

Precose

Glyset

Diabetes: Amylin Analogs

Symlin PA

N/A

Diabetes: Biguanides QL

metformin QL

metformin ER QL

Fortamet QL

Glumetza QL

Glucophage QL

metformin ER osmotic QL

Glucophage XR QL

Riomet PA, QL

Diabetes: DPP-4 Inhibitors and Combinations Class PA, QL

Januvia PA, QL

Janumet PA, QL

Juvisync PA, QL

KombiglyzeTM XR PA, QL
Onglyza PA, QL

Byetta PA, QL

Nesina PA, QL

JentaduetoTM PA, QL

Oseni PA, QL

Kazano PA, QL

TradjentaTM PA, QL

Diabetes: GLP-2 Analogs

Gattex PA

N/A
Bydureon vials PA, QL

Janumet XR PA, QL

Diabetes: Incretin Mimetics Class PA, QL

Bydureon Pen

Victoza PA, QL

PA, QL

Diabetes: Insulins

Humalog vials

Humulin 70/30 Pen PA

Apidra

Humalog 50/50 vials

Levemir vials

Lantus OptiClick PA

Humalog 75/25 vials

Humalog Kwikpen PA

Lantus vials

Apidra Solostar PA

Novolin N

Lantus Solostar PA

Humalog Mix 50/50 Kwikpen PA Novolin R

Levemir FlexPen PA

Humalog Mix 75/25 Kwikpen PA Novolin 70/30

Humulin N

Novolog vials

Humulin R

Novolog Mix 70/30 vials

Humulin N Pen PA
Humulin R U-500

Humulin 70/30 vials

nateglinide QL

Novolog Flex Pen PA

Novolog Mix 70/30 Flex Pen PA

Diabetes: Meglitinides and CombinationQL

Prandin QL
PrandimetTM QL

Proprietary & Confidential

* Note that Covered agents not listed on PDL may be considered non-preferred

repaglinide QL
Starlix QL

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Preferred Drugs

TennCare Preferred Drug List

Non-Preferred Drugs

VII. ENDOCRINE AND METABOLIC AGENTS

Diabetes: Sulfonylureas and Combination
glimepiride QL
glipizide

glipizide ER/XL

glyburide micronized

glyburide/metformin

glipizide/metformin
glyburide

Amaryl QL

Glucovance

chlorpropamide

Glynase PresTab

Diabeta

Metaglip

Glucotrol

tolazamide

Glucotrol XL

Diabetes: SGLT2 Inhibitors and Combinations

N/A

tolbutamide
Class PA

FarxigaTM PA, QL

InvokanaTM PA, QL

InvokametTM PA, QL

Jardiance PA, QL

Diabetes: Thiazolidinediones Class PA, QL

pioglitazone PA, QL

Actos PA, QL

Avandia PA, QL

Diabetes: Thiazolidinedione Combinations Class PA, QL

pioglitazone-metformin PA, QL

ACTOplus Met PA, QL

Avandaryl PA, QL

ACTOplus Met XR PA, QL

DuetAct PA, QL

Avandamet PA, QL

pioglitazone-glimepiride PA, QL

Disease Modifying Anti-Rheumatic Drugs

hydroxychloroquine

Ridaura

Arava

Depen

Azulfidine QL

Plaquenil

methotrexate

sulfasalazine EC QL

Azulfidine EN QL

Rheumatrex

Note: Injectable agents for the treatment of RA are located under

Immunomodulators

Cuprimine

Trexall

N/A

XelJanz PA, QL

leflunomide

sulfasalazine QL

Anti-Rheumatic: Kinase Inhibitors

Glucocorticoids, Oral
Celestone

Orapred

Cortef

Orapred ODT PA

dexamethasone

Dexpak

Pediapred

hydrocortisone

Entocort EC PA

Rayos

methylprednisolone

Medrol

Uceris PA, QL

prednisolone

Millipred

budesonide capsules PA
cortisone

Genotropin PA

Norditropin PA

prednisone

Growth Hormone Agents

Veripred
Class PA

Humatrope PA

Saizen PA

Nutropin PA

Serostim PA

Nutropin AQ PA

Tev-Tropin PA

Omnitrope PA

Zorbtive PA

Proprietary & Confidential

* Note that Covered agents not listed on PDL may be considered non-preferred

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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

MimveyTM

FemHRT 1/5

Hormones: Oral Progestins

progesterone

Aygestin

Prometrium

Megace QL

Provera

Megace ES PA, QL
norethindrone acetate PA

Hormones: Thyroid
Cytomel

liothyronine

Armour Thyroid

levothyroxine

Unithroid

Thyrolar

Levothroid
Levoxyl

Synthroid

Thyroid
Tirosint

Hormones: Transdermal Estrogens

Alora QL

Divigel

Estrasorb

Elestrin

Evamist

Vivelle-Dot QL

Estraderm QL

Menostar QL

estradiol TDS QL

Minivelle QL

Climara QL

Hormones: Transdermal Estrogen/Progestins QL

Combipatch QL

Climara Pro QL

Proprietary & Confidential

* Note that Covered agents not listed on PDL may be considered non-preferred

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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

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

FulyzaqPA

Anti-Emetics: A-9-THC Derivatives Class PA

N/A

Cesamet PA

Marinol PA

dronabinol PA

Proprietary & Confidential

* Note that Covered agents not listed on PDL may be considered non-preferred

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Preferred Drugs

TennCare Preferred Drug List

Non-Preferred Drugs

VIII. GASTROINTESTINAL
Anti-Emetics: Anticholinergics
meclizine

prochlorperazine

trimethobenzamide

Transderm Scp PA, QL

Antivert

Tigan

Compro
Phenergan PA

promethazine PA

Anti-Emetics: 5-HT3 Antagonists Class PA

ondansetron tabs and ODT PA, QL

Anzemet PA, QL

Zofran ODT PA, QL

granisetron PA, QL

Zofran Solution PA

Kytril PA, QL

Zofran PA, QL

ondansetron oral soln PA

Zuplenz PA, QL

Sancuso PA, QL

Anti-Emetics: NK-1 Antagonists Class PA

Emend PA, QL

N/A

Anti-Emetics: Miscellaneous
Diclegis PA, QL

N/A

Antispasmodics/Anticholinergics
Anaspaz

methscopolamine

Bentyl

Pamine

Cantil

Pamine Forte

hyoscyamine

chlordiazepoxide/clidinium

Robinul

Hyosyne

Cuvposa PA

Robinul Forte

NuLev

Levsin

Sal-Tropine

propantheline

Librax

dicyclomine

glycopyrrolate
HyoMax

N/A
N/A

Symax Fastabs
Symax-SL

Miscellaneous Agents for IBS

Amitiza PA, QL

Linzess PA, QL

Combination Products for H. pylori Class PA

Helidac PA

Prevpac PA, QL

lansoprazole/amoxicillin/
clarithromycin PA, QL

Pylera PA, QL

Omeclamox PA

Gallstone Solubilizing Agents

ursodiol QL

Actigall QL

Urso QL

ChenodalTM

Urso Forte QL

Proprietary & Confidential

* Note that Covered agents not listed on PDL may be considered non-preferred

Page 34
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Preferred Drugs

TennCare Preferred Drug List

Non-Preferred Drugs

VIII. GASTROINTESTINAL
H2 Receptor Antagonists
cimetidine

famotidine

ranitidine syrup

Enulose
generlac

ranitidine capsules

nizatidine

Zantac

Pepcid

ranitidine tablets
Constulose

Axid

Laxatives
PEG 3350 powder

PEG 3350 electrolyte solution

lactulose

CoLyte

PEG 3350 with flavor packs

GoLYTELY

PEG 3350 solution

HalfLytely

Prepopik

Kristalose

Suclear

MoviPrep

Suprep

NuLYTELY

Trilyte

OsmoPrep

Visicol

Motility Agents
Metozolv ODT PA

metoclopramide

Reglan

Mucosal Protectants

misoprostol

sucralfate tablets

Creon

ZenPep

Carafate

sucralfate suspension PA

Cytotec

Pancreatic Enzymes
(all strengths)

Pancreaze

Ultresa

PertzyeTM

Viokace

pancrelipase (all strengths)

Proton Pump Inhibitors

pantoprazole QL

Aciphex QL

Prevacid QL

Aciphex sprinkles PA

Prevacid SoluTabTM PA, QL

omeprazole OL

Dexilant QL

Prilosec QL

esomeprazole QL

Protonix QL

lansoprazole QL

rabeprazole QL

lansoprazole ODT PA, QL

Zegerid QL

Protonix suspension

Nexium QL

Saliva Stimulating Agents

pilocarpine PA, QL

cevimeline PA, QL

Salagen PA, QL

Evoxac PA, QL

Proprietary & Confidential

* Note that Covered agents not listed on PDL may be considered non-preferred

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Preferred Drugs

TennCare Preferred Drug List

Non-Preferred Drugs

IX. IMMUNOLOGIC AGENTS

Immunomodulators Class PA, QL
Cimzia PA, QL

Humira PA, QL

Enbrel PA, QL

Actemra PA, QL

Simponi PA, QL

Kineret PA, QL

Stelara PA, QL

Orencia PA, QL

Immunosuppressants
azathioprine

Gengraf

Astagraf XL PA

Neoral PA

Azasan PA

Prograf PA

cyclosporine microemulsion

tacrolimus

Cellcept PA

Rapamune PA

Hecoria PA

Sandimmune PA

Imuran PA

sirolimus PA

Myfortic PA

Zortress PA

cyclosporine

mycophenolate mofetil

mycophenolic acid PA

Multiple Sclerosis Agents QL

Avonex QL

Avonex Administration Pack QL

Betaseron QL
Ampyra QL

Copaxone20 mg/mL QL

Copaxone 40 mg/mL PA, QL

Extavia QL

Rebif QL

Multiple Sclerosis Agents: Potassium Channel Blockers

N/A

Multiple Sclerosis Agents: Oral Disease Modifying Agents

Aubagio PA

N/A

Gilenya PA, QL
Tecfidera PA, QL

Topical Immunomodulators Class PA

Elidel PA

Preferred Drugs

Protopic PA

Non-Preferred Drugs

X. MISCELLANEOUS
Gauchers 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

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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 42-DK) of 2. After the initial month, members may continue to receive up to a 31 days supply of oncology
products per fill.

Preferred Drugs

Non-Preferred Drugs

XII. OPHTHALMICS
Ophthalmic Antibiotic/Steroid Combinations
neomycin/BAC/poly B/HC

neomycin/poly B/dexameth

sulfacetamide/prednisolone
Pred-G

TobraDex suspension

Blephamide

tobramycin/dexamethasone susp

Maxitrol

TobraDex ointment

neomycin/poly B/HC

TobraDex ST suspension

Poly-Pred

Zylet PA

Proprietary & Confidential

* Note that Covered agents not listed on PDL may be considered non-preferred

Page 37
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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

Page 38
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Preferred Drugs

TennCare Preferred Drug List

Non-Preferred Drugs

XII. OPHTHALMICS
Ophthalmic Mast Cell Stabilizers
Alocril

Alamast

cromolyn sodium

Alomide

Mydriatics and Mydriatic Combos

atropine

AK-PentolateTM

Isopto Homatropine

Atropine CareTM

Cyclogyl

Isopto Hyoscine

cyclopentolate

CyclomydrilTM

Mydriacyl

tropicamide

Isopto Atropine

Ophthalmic NSAIDs Class PA

diclofenac PA

Acular PA

Ilevro PA

Acular LS PA

Nevanac PA

ketorolac PA

AcuvailTM PA

Ocufen PA

BromdayTM PA

Voltaren PA

flurbiprofen PA

bromfenac PA

Ophthalmic Prostaglandin Agonists QL

latanoprost QL

Lumigan QL

Rescula QL

Xalatan QL

Travatan Z QL

Zioptan QL

Travoprost QL

Ophthalmic Steroids
Alrex

fluorometholone
FML ointment

prednisolone acetate
Pred Mild

Lotemax Susp

dexamethasone

Lotemax Ointment

Durezol

Maxidex

Flarex

prednisolone sodium phosphate

FML Forte

Pred Forte

FML Liquifilm

Vexol

Lotemax Gel

Glaucoma Direct Acting Miotics

Isopto Carbachol

pilocarpine

Pilopine HS

Isopto Carpine

Glaucoma Combinations
Combigan PA
Restasis PA, QL
AK-Dilate 2.5%, 10%
naphazoline

Simbrinza PA

Ophthalmic Immunomodulators Class PA, QL

N/A

Ophthalmic Vasoconstrictors
NeofrinTM 2.5%, 10%

phenylephrine 2.5%, 10%

Albalon
Mydfrin

Proprietary & Confidential

* Note that Covered agents not listed on PDL may be considered non-preferred

Page 39
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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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Preferred Drugs

TennCare Preferred Drug List

Non-Preferred Drugs

XIV. RENAL AND GENITOURINARY

Combination Agents for BPH
JalynPA, QL

N/A

Phosphorus Depleters

calcium acetate

Phoslyra

EliphosTM

Renvela tablets

Fosrenol

Renvela powder for suspension PA

PhosLo

sevelamer

Renagel

Velphoro PA

Urinary Tract Antispasmodics

oxybutynin

Toviaz QL

tolterodine QL

VESIcare QL

Detrol QL

oxybutynin ER QL

Ditropan XL QL

Oxytrol QL

Detrol LA QL

Sanctura XR QL

Enablex QL

tolterodine ER QL

flavoxate QL

trospium QL

GelniqueTM QL

trospium XR QL

Myrbetriq

Urinary Alkalizing Agents

citric acid/sodium citrate

Cytra-3

Citrolith

Polycitra-K

Cytra-K crystals

Urocit-K

Cytra-2

potassium citrate/citric acid

Ora-Cit

Tricitrates

acetic acid

K-Phos MF

Renacidin PA

K-Phos #2

Phospha Neutral

Cytra-K solution

K-Phos Original

potassium citrate

Urinary Acidifying Agents

K-Phos Neutral

Phenazo

phenazopyridine
Elmiron
Fem pHTM

Urinary Analgesics
Pyridium

Urinary Interstitial Cystitis Agents

RIMSO-50

N/A

Vaginal Antiseptics
N/A

Preferred Drugs

Non-Preferred Drugs

XV. RESPIRATORY
Anaphylaxis Therapy Agents
Epipen QL

Epipen, Jr. QL

Adrenaclick QL

epinephrine injectable QL

Auvi-QTM PA, QL

Proprietary & Confidential

* Note that Covered agents not listed on PDL may be considered non-preferred

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Preferred Drugs

TennCare Preferred Drug List

Non-Preferred Drugs

XV. RESPIRATORY
Anticholinergics, Inhaled QL
albuterol/ipratropium QL

Combivent Respimat QL

Combivent MDI QL

Spiriva QL

Atrovent HFA QL

ipratropium 0.3%, 0.6% QL

ipratropium solutionQL

DuoNeb QL
Tudorza QL

Anticholinergics, Nasal QL
Atrovent 0.3%, 0.6% QL

Antihistamines, First Generation (Covered for recipients < 21 years old only)

brompheniramine maleate

Dytuss syrup

all formulations of brompheniramine tannate

carbinoxamine maleate

LoHist-12

all formulations of diphenhydramine tannate

Bromspiro

chlorpheniramine maleate
clemastine

hydroxyzine

all formulations of chlorpheniramine tannate

promethazine

Aldex AN

Palgic

dexchlorpheniramine

Vazol

Doxytex

Vistaril

cyproheptadine hydrochloride
diphenhydramine HCl

J-Tan PD

Antihistamines, Non-Sedating (Covered for recipients < 21 years old only)

Allegra QL

Clarinex-D 24 Hr QL

Allegra-D 12 Hr QL

desloratadine QL

cetirizine syrup

Allegra-D 24 Hr QL

desloratadine ODT PA, QL

cetirizine/PSE QL

Allegra ODT PA, QL

fexofenadine

loratadine QL

Claritin QL

fexofenadine/PSE QL

loratadine RDT PA, QL

Claritin chewable PA, QL

levocetirizine QL

loratadine/PSE QL

Claritin-D 12 Hr QL

Semprex-D QL

Claritin-D 24 Hr QL

Xyzal QL

Claritin RediTabs PA, QL

Zyrtec QL

Clarinex QL

Zyrtec chewable PA, QL

Clarinex RediTabs PA, QL

Zyrtec ODT PA, QL

Clarinex-D 12 Hr QL

Zyrtec-D QL

cetirizine chewable
cetirizine tabs QL

PA, QL

QL

Antihistamines, Nasal QL
Astepro PA, QL

Patanase QL

Dymista PA, QL

azelastine PA, QL

Beta Agonists: Combination Products Class PA, QL

Advair Diskus PA, QL
Advair HFA PA, QL

Dulera PA, QL

Symbicort PA, QL

Anoro Ellipta PA, QL

Breo Ellipta PA, QL

Proprietary & Confidential

* Note that Covered agents not listed on PDL may be considered non-preferred

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Magellan Health Services

Preferred Drugs

TennCare Preferred Drug List

Non-Preferred Drugs

XV. RESPIRATORY
Beta Agonists: Long Acting MDI Class PA, QL
Serevent Diskus PA, QL

Foradil PA, QL

Arcapta QL

Striverdi Respimat QL

Beta Agonists: Nebulizer

albuterol inhalation solution QL

AccuNeb QL

Perforomist PA, QL

Brovana PA, QL

Xopenex PA, QL

levalbuterol PA, QL

Beta Agonists: Short Acting MDI QL

Proventil HFA QL

Maxair Autohaler QL

Ventolin HFA QL

ProAir HFA QL

Xopenex HFA PA, QL

Beta Agonist: Oral

albuterol syrup
albuterol ER

Bethkis PA,QL

Pulmozyme PA, QL

albuterol tabs

terbutaline

VoSpire ER

metaproterenol

Cystic Fibrosis Agents QL

TOBI inhalation solution PA, QL

Cayston PA, QL

Tobi Podhaler PA, QL

Kalydeco PA, QL

tobramycin solution
300mg/5mL PA, QL

Expectorants
N/A

SSKI

Leukotriene Receptor Antagonists QL

montelukast tabs
and chewables PA, QL

Accolate QL

zafirlukast QL

montelukast granules PA, QL

Zyflo QL

Singulair tabs and

chewables PA, QL

Zyflo CR QL

Singulair granules PA, QL

Mast Cell Stabilizers

cromolyn

QL

acetylcysteine
benzonatate PA

N/A

Mucolytics
N/A

Non-Narcotic Antitussives Class PA

Tessalon PA

Zonatuss PA

Tessalon Perles PA

Proprietary & Confidential

* Note that Covered agents not listed on PDL may be considered non-preferred

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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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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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