tenncare preferred drug list (pdl)

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  • *NotethatagentsnotlistedonPDLmaybeconsiderednonpreferred

    Proprietary&Confidential2018MagellanHealthServices

    TennCarePreferredDrugList(PDL)EffectiveFebruary1,2018

    PAPriorAuthorizationrequired,subjecttospecificPAcriteria; QL QuantityLimit(PA &NPagentsrequireaPAbeforedispensing);BBudgetaryReductioneditforutilizationcontrol(StandardNPPAcriteriadoesnotapply);IDClassPAforpatientswithIntellectualorDevelopmentalDisabilityPleasenotethefollowing: ApprovalofNPagentsrequirestrialandfailure,contraindication,orintoleranceof2preferredagents,unlessotherwiseindicated WiththeexceptionoftheBrandedDrugsClassifiedasGenericslist,TennCareisamandatorygenericprograminaccordancewithstatelaw(TCA5310205).

    ApprovalofabrandedproductwhenagenericisavailablerequiresdocumentationofaseriousadversereactionfromthegenericviaaFDAMedWatchformORcontraindicationtoaninactiveingredientintheABratedgenericequivalent.TherapeuticFailureofanABratedgenericequivalentmaybeconsideredforapprovalofbrandedproductsinthefollowinghighriskmedicationclasses:Anticonvulsants,AtypicalAntipsychotics,HIVantivirals,Immunosuppressants,andOncologyAgents.

    Unlessotherwisenoted,allagentslistedonthePDLarereferencinglegenddrugswhichareprescriptionrequiredagents.CoverageofOvertheCounter(OTC)Productsislistedat:https://tenncare.magellanhealth.com/static/docs/Program_Information/TennCare_Covered_OTC_Products.pdf

    PreferredDrugs NonPreferredDrugs

    I.Analgesics AgentsforOpiateDetoxification

    naltrexonePA ReViaPA BuprenorphineandBuprenorphine/Naloxone

    BunavailPA,QL buprenorphinePA,QL SuboxonefilmPA,QL buprenorphine/naloxonetabletsPA,QLZubsolvPA,QL

    COXIIInhibitorsPAcelecoxib(50,100,&200mg)QL CelebrexQL celecoxib400mgPA,QL

    TransmucosalFentanylProductsN/A AbstralPA,QL FentoraPA,QL ActiqPA,QL LazandaPA,QL fentanyllozengePA,QL SubsysPA,QL

    NaloxoneProductsNarcannasalsprayPA,QL n/a

    NarcoticsAgonist/AntagonistsnalbuphinePA,QL butorphanolNSPA,QL pentazocine/naloxonePA,QL pentazocine/APAPPA,QL

    Narcotics,LongActingNarcoticsEmbedaPA,QL NucyntaERPA,QL ArymoERPA,QL MorphabondER PA,QLfentanylpatch(excluding37.5mcg/hr,62.5mcg/hr,and87.5mcg/hr)PA,QL

    AvinzaPA,QL morphinesulfateERcapsPA,QL

    BelbucaPA,QL morphinesulfateSA PA, QL buprenorphinepatchPA,QL morphinesulfateSR24hr(generic

    forAvinza)PA,QL ButransPA,QL MSContinPA,QL ConZipPA,QL OpanaERPA,QL DolophinePA,QL OxyContinPA,QL DuragesicPA,QL oxymorphoneERPA,QL ExalgoPA,QL oxycodoneERPA,QL fentanylpatch(37.5mcg/hr,

    62.5mcg/hr,and87.5mcg/hr)PA,QLtramadolERPA,QL

    hydromorphoneER PA,QL tramadolER24hrPA,QL HysinglaER PA,QL tramadolERPA, QL(genericfor

    Conzip) KadianPA(100mg),QL UltramERPA,QL methadonePA,QL XtampzaERPA,QL MethadosePA,QL ZohydroERPA,QL

    https://tenncare.magellanhealth.com/static/docs/Program_Information/TennCare_Covered_OTC_Products.pdfhttps://tenncare.magellanhealth.com/static/docs/Preferred_Drug_List_and_Drug_Criteria/Criteria_PDL.pdf#nameddest=agents_for_opiate_detoxificationhttps://tenncare.magellanhealth.com/static/docs/Preferred_Drug_List_and_Drug_Criteria/Criteria_PDL.pdf#nameddest=buprenorphine_naloxonehttps://tenncare.magellanhealth.com/static/docs/Preferred_Drug_List_and_Drug_Criteria/Criteria_PDL.pdf#nameddest=cox_inhibitorshttps://tenncare.magellanhealth.com/static/docs/Preferred_Drug_List_and_Drug_Criteria/Criteria_PDL.pdf#nameddest=trans_fentanyl_productshttps://tenncare.magellanhealth.com/static/docs/Preferred_Drug_List_and_Drug_Criteria/Criteria_PDL.pdf#nameddest=naloxone_productshttps://tenncare.magellanhealth.com/static/docs/Preferred_Drug_List_and_Drug_Criteria/Criteria_PDL.pdf#nameddest=narcotics_agonist_antagonistshttps://tenncare.magellanhealth.com/static/docs/Preferred_Drug_List_and_Drug_Criteria/Criteria_PDL.pdf#nameddest=analgesicshttps://tenncare.magellanhealth.com/static/docs/Preferred_Drug_List_and_Drug_Criteria/Criteria_PDL.pdf#nameddest=narcotics_long_acting

  • *NotethatagentsnotlistedonPDLmaybeconsiderednonpreferred

    EffectiveDate:February1,2018 TennCarePreferredDrugList(PDL) | Page2

    PreferredDrugs NonPreferredDrugs

    I.Analgesics ShortActingNarcoticsQL

    codeine/APAPPA(

  • *NotethatagentsnotlistedonPDLmaybeconsiderednonpreferred

    EffectiveDate:February1,2018 TennCarePreferredDrugList(PDL) | Page3

    PreferredDrugs NonPreferredDrugs

    I.Analgesics NonSteroidalAntiInflammatoryDrugs(NSAIDs)

    diclofenac1%gel(genericforVoltarengel)QL

    indomethacin Anaprox Motrin

    diclofenacpotassium ketorolacQL AnaproxDS Nalfondiclofenacsodium meloxicamtablets Cambia NaprelandiclofenacsodiumER nabumetone Cataflam naproxentabsandsuspensionibuprofen sulindac Clinoril naproxensodiumER Daypro Naprosyn diclofenacsodium1.5%PA NaproxenCR ECNaprosyn PennsaidPA etodolac piroxicam etodolacER Ponstel Feldene oxaprozin fenoprofen SprixPA,QL FlectorPA,QL TivorbexPA flurbiprofen tolmetin indomethacinER ToradolQL ketoprofen VivlodexPA,QL ketoprofenER Voltaren meclofenamate VoltarengelQL mefenamicacid VoltarenXR meloxicamsuspension VOPACMDSKitPA Mobic Zipsor ZorvolexPA

    PreferredDrugs NonPreferredDrugs

    II.ANTIINFECTIVES Antibiotics:CephalosporinsFirstGeneration

    cefadroxilcapsules cephalexincapsules cefadroxiltablets Daxbiacefadroxilsuspension cephalexinsuspension cephalexintablets Keflex

    Antibiotics:CephalosporinsSecondGenerationcefaclorcapsules cefuroximetabsPA cefaclorsuspension CeftinsuspensionPAcefprozil cefaclorER Ceftintabs

    Antibiotics:CephalosporinsThirdGenerationcefdinir Suprax Cedax cefpodoxime cefditoren ceftibuten cefiximesuspension Spectracef

    Antibiotics:KetolidesN/A KetekPA

    Antibiotics:MacrolidesazithromycinQL erythromycin/sulfisoxazole Biaxin erythromycinbasetabletsazithromycinsuspensionPA BiaxinXLQL erythromycinbrandproductsclarithromycin clarithromycinER/XLQL ZithromaxQLerythromycingenericproducts(excludingerythromycinbasetabs)

    DificidPA,QL ZmaxQL

    https://tenncare.magellanhealth.com/static/docs/Preferred_Drug_List_and_Drug_Criteria/Criteria_PDL.pdf#nameddest=nsaidshttps://tenncare.magellanhealth.com/static/docs/Preferred_Drug_List_and_Drug_Criteria/Criteria_PDL.pdf#nameddest=analgesicshttps://tenncare.magellanhealth.com/static/docs/Preferred_Drug_List_and_Drug_Criteria/Criteria_PDL.pdf#nameddest=antiinfectiveshttps://tenncare.magellanhealth.com/static/docs/Preferred_Drug_List_and_Drug_Criteria/Criteria_PDL.pdf#nameddest=cepha_second_generationhttps://tenncare.magellanhealth.com/static/docs/Preferred_Drug_List_and_Drug_Criteria/Criteria_PDL.pdf#nameddest=ketolideshttps://tenncare.magellanhealth.com/static/docs/Preferred_Drug_List_and_Drug_Criteria/Criteria_PDL.pdf#nameddest=macrolides

  • *NotethatagentsnotlistedonPDLmaybeconsiderednonpreferred

    EffectiveDate:February1,2018 TennCarePreferredDrugList(PDL) | Page4

    PreferredDrugs NonPreferredDrugs

    II.ANTIINFECTIVES Antibiotics:MethenamineandCombo

    allgenericcombinationsofmethenamine,phenylsalicylate,hyoscyamine,atropine,etc.

    methenaminemandelate allbrandcombinationsofmethenamine,phenylsalicylate,hyoscyamine,atropine,etc.

    Hiprexmethenaminehippurate UroqidAcid#2

    Antibiotics:MiscellaneousAgentsforUTIN/A MonurolQL,PA

    Antibiotics:NonAbsorbableRifamycinN/A XifaxanPA,QL

    Antibiotics:OralAminoglycosidesneomycin NeoFradin N/A

    Antibiotics:OralAntiTuberculosisethambutol pyrazinamide cycloserine Rifadinisoniazid rifabutinPA IsonarifPA RifamatePAMycobutinPA rifampin Myambutol RifaterPA Paser SeromycinPulvules Priftin Trecator

    Antibiotics:OralGlycopeptidesN/A vancomycincapsPA

    Antibiotics:OralLincosaminesclindamycincaps Cleocin clindamycinpediatricsolutionPA CleocinPediatricgranulesPA

    Antibiotics:OralNitrofuransnitrofurantoincapsules nitrofurantoinsuspensionPA FuradantinPA Macrodantin Macrobid

    Antibiotics:OxazolidinonesN/A linezolidsuspensionQL SivextroPA,QL linezolidtabsPA,QL ZyvoxPA,QL

    Antibiotics:Penicillinsamoxicillin dicloxacillin allbrandpenicillins amoxicillinERamoxicillin/clavulanate penicillin amoxicillin/clavulanicacidXR

    Antibiotics:Quinolonesciprofloxacin levofloxacintabs AveloxPA Levaquintabs AveloxABCPackPA LevaquinsolutionPA Ciprotablets levofloxacinsolutionPA CiprosuspensionPA moxifloxacinPA ciprofloxacinsuspensionPA NoroxinPA ciprofloxacinERQL ofloxacin FactivePA

    https://tenncare.magellanhealth.com/static/docs/Preferred_Drug_List_and_Drug_Criteria/Criteria_PDL.pdf#nameddest=misc_agents_utihttps://tenncare.magellanhealth.com/static/docs/Preferred_Drug_List_and_Drug_Criteria/Criteria_PDL.pdf#nameddest=nonabsorbable_rifamycinhttps://tenncare.magellanhealth.com/static/docs/Preferred_Drug_List_and_Drug_Criteria/Criteria_PDL.pdf#nameddest=oral_antituberculosishttps://tenncare.magellanhealth.com/static/docs/Preferred_Drug_List_and_Drug_Criteria/Criteria_PDL.pdf#nameddest=glycopeptideshttps://tenncare.magellanhealth.com/static/docs/Preferred_Drug_List_and_Drug_Criteria/Criteria_PDL.pdf#nameddest=lincosamideshttps://tenncare.magellanhealth.com/static/docs/Preferred_Drug_List_and_Drug_Criteria/Criteria_PDL.pdf#nameddest=nitrofuranshttps://tenncare.magellanhealth.com/static/docs/Preferred_Drug_List_and_Drug_Criteria/Criteria_PDL.pdf#nameddest=oxazolidinoneshttps://tenncare.magellanhealth.com/static/docs/Preferred_Drug_List_and_Drug_Criteria/Criteria_PDL.pdf#nameddest=antiinfectiveshttps://tenncare.magellanhealth.com/static/docs/Preferred_Drug_List_and_Drug_Criteria/Criteria_PDL.pdf#nameddest=quinolones

  • * NotethatagentsnotlistedonPDLmaybeconsiderednonpreferred

    EffectiveDate:February1,2018 TennCarePreferredDrugList(PDL) | Page5

    PreferredDrugs NonPreferredDrugs

    II. ANTIINFECTIVESAntibiotics:Tetracyclines

    doxycyclinemonohydrate50and100mgcaps Adoxa minocyclineERPA,QLdoxycyclinehyclate50and100mg demeclocyclinePA minocycline

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